JOURNAL OF ENDOUROLOGYVolume 6, Number 1, 1992Mary Ann I.¡chert. Inc., Publishers

Suprapubic Percutaneous Cystolitholapaxy in Children

HAMDY EL-KAPPANY, M.D.

ABSTRACT

Bladder stones of 10 male children were removed via the percutaneous suprapubic route. The mean age was3.5 years, and the mean stone size was 1.2 cm. As in the percutaneous nephrolithotomy technique, the bladderwas punctured under fluoroscopy followed by tract dilation to 32F using Amplatz dilators and sheath. Then thebladder stones were inspected and removed with an adult nephroscope. A 1-day hospital stay was recorded forall patients with no morbidity or deaths.

INTRODUCTION

STONES OF THE URINARY BLADDER, although muchless frequently seen than those of the upper tract are still not

uncommon in the developing countries,' especially in children.The small urethra in children and young adolescents precludesany endoscopie trials for lithotripsy or litholapaxy.

With the development of endourologic methods to remove

renal calculi using the percutaneous route,2'3 a similar approachwas designed to remove bladder stone as an alternative to opencystolithotomy. This study evaluates our experience with thistechnique.

PATIENTS AND METHODS

Ten children with an age range from 1.5 to 13 years (mean3.5) were subjected to this technique. The stone size was be¬tween 0.8 cm and 1.7 cm in diameter (mean 1.2 cm). Twopatients presented with urine retention as the stones were im¬pacted in the posterior urethra; for them, a preliminary suprapu¬bic lOFcystocath was inserted.

The patients were placed in the lithotomy position undergeneral anesthesia. Under fluoroscopy, preliminary panendos-copy was performed to exclude any infravesical obstruction, toexamine the bladder mucosa, and to push up the stone in thetwo patients with retention. An 8F urethral catheter was in¬serted to fill the bladder with diluted contrast until it becamefully distended. After creation of a 1-cm skin incision approxi¬mately 4 to 5 cm above the mid-pubic symphysis, the bladder

was punctured suprapubically in-the midline using an 18-gaugeneedle, and a 0.038-inch J-tip guidewire was inserted throughit. Over the wire, gradual dilatation was performed using theTeflon fasciai and coaoxial dilators to 30F followed by insertionof 32F Amplatz sheath for tract temponade and security. Theadult nephroscope was passed through this sheath to identify thestone. For stones less than 1.0 cm in diameter, mechanicalextraction was possible, while larger stones were broken up byultrasound and mechanically retrieved. Further endoscopie ex¬amination was performed to identify any vesical laceration andto inspect the bladder neck. This step was followed by fixationof a 22F Nelaton suprapubic catheter that was passed throughthe Amplatz sheath. The sheath and the urethral catheter were

then removed. Radiological monitoring of puncture, dilation,and insertion of the Amplatz sheath as well as after fixation ofthe suprapubic catheter have revealed little or no leak. One daylater after a satisfactory voiding stream had been documented,the tube was removed, and the patient became ready for dis¬charge.

The hospital stay for all the patients was 1 day postopera-tively. No complications developed regarding fever, infection,or abdominal pain.

DISCUSSION

The traditional endoscopie transurethral litholapaxy for theadult is not feasible at all for children, and the only way was a

suprapubic surgical approach. In children, the urethra is used

Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

59

60 EL-KAPPANY ET AL.

only for the initial assessment, to push impacted urethralstones, and for filling the bladder before the procedure.

A dilated secured tract through the anterior abdominal andbladder wall for visual extraction, of the vesical stone has beenshown to be rapid, safe, and effective. The tract proved to bestable around the Amplatz sheath, securing manipulation of thestone by the nephroscope and its accessories even with ultra¬sonic disintegration for larger calculi. Once the instrument was

removed, the tract closed rapidly around the suprapubic tubewith no extravasation. The hospital stay for all patients was 1day, with no morbidity or death, and when the tube was re¬

moved, the patient was left with 1.5-cm scar with no abdominaldiscomfort. The operating time in percutaneous suprapubic cys-tolitholapaxy is much shorter than that of open cystolithotomy,which also has a longer hospitalization and possible morbidity.4

By this simple, quick method, using generally available en¬

doscopie instruments, the approach to some difficult problemsmay now be considered. McNicholas et al5 have used a similartechnique in adults for placement of larger-bore suprapubiccatheters and removal of bladder calculi followed by transure-thral resection of the prostate, dilatation of impassible urethralstricture, and coagulation of the prostatic cavity after resectionof prostatic cancer. Antegrade identification and fulguration ofurethral valves was carried out through a 12F suprapubic cysto-catheter set with a trocar sheath.6

Other endourologic modalities could be considered to frag¬ment pediatrie bladder stones using a transurethrál ureteroscope(9.5F) with ultrasonic or laser lithotripsy. However, the longertime needed to fragment and remove the stone per urethra maycarry a great possibility of injury to the bladder mucosa andurethra, with subsequent stricture. Vandeursén and Baret use

extracorporeal lithotripsy to treat bladder calculi in adults with a

success rate of 100%.7 This approach may not be useful in

pediatrics for fear of urethral obstruction by stone fragments,especially in the small urethra of young boys.

In conclusion, this suprapubic percutaneous cystolitholapaxytechnique can be helpful in situations where transurethrál access

is inadequate, difficult, or not feasible, such as for bladderstone removal in children.

REFERENCES

1. Van Reen: Geographical and nutritional aspects of endemic stones.In: Brockis JG, Finlayson (eds): Urinary Lithiasis. Littleton,Mass: PSG Publishing, 1981

2. Fernström I, Johannson B: Percutaneous pyelolithotomy: a new

extraction technique. Scand J Urol Nephrol 1976; 10:2573. Segura JW, Patterson DE, LeRoy AJ, et al: Percutaneous removal of

kidney stones: review of 1,000 cases. J Urol 1985; 134:1077-10814. Branes RW, Bergman RT, Worten E: Litholapaxy vs. cystolithot¬

omy. J Urol 1983; 89:680-6815. McNicholas TA, Ramsay JWA, Carter SStC, Miller RA: Suprapu¬

bic endoscopy: a percutaneous approach. Br J Urol 1988; 61:221-223

6. Zaontz MR, Firlit CF: Percutaneous antegrade ablation of posteriorurethral valves in infants with small caliber urethras: an alternativeto urinary diversion." J Urol 1986; 136:247-248

7. Vandeursen H. Baret L: Extracorporeal shock wave lithotripsy forbladder stone with second generation lithotriptors. J Urol 1990;143:18-19

Address reprint requests to:Hamdy El-Kappany, M.D.

Urology and Nephrology CenterMansoura University

Mansoura, Egypt