Çocuklarda perkütan suprapubik sistolitotripsi

Özet

Erişkindeki mesane taşları transüretral girişimle tedavi edilmesine karşın, çocuklarda bu işlem üretra kalibresinin dar olmasından dolayı çoğunlukla yapılamamakta ve yapıldığı takdirde ciddi üretra darlıklarına yol açabilmektedir. Bu nedenden dolayı perkütan suprapubik sistolitotripsi çocuklar için seçilebilecek güvenli ve etkili bir işlemdir. Nisan 2004 ile Haziran 2004 tarihleri arasında kliniğimizde 6 hastaya perkütan suprapubik sistolitotripsi yapıldı. İşlem genel anestezi altında uygulandı. İşlem esnasında floroskopi kullanılmadı. Mesane izotonik ile şişirilerek ve kolayca giriş sağlandı. Traktın dilatasyonunu takiben yerleştirilen amplaz kılıftan girilerek 24 F nefroskop ve pnömotik litötriptör yardımıyla taşlar kırılarak dışarı alındı. Transüretral ve suprapubik kateter konulmasını takiben işlem sonlandırıldı. 24 saat sonra suprapubik kateter, 48 saat sonra transüretral kateter alınarak hastalar hastaneden çıkarıldı. Hastaların yaşları 3 yıl ile 10 yıl arasında (ortalama 5.7 yıl) değişmekteydi. Taş büyüklüğü 8 mm ile 30 mm arasında (ortalama 19 mm) arasında değişmekteydi. Bütün hastaların taş yükü tek seansta tamamen temizlendi. İşlem 15 ile 30 dakika arasında (ortalama 22.5 dakika) tamamlandı. Hiçbir olguda açık ameliyata geçilmedi. Hastaların hastanede kalış süreleri 2 ile 3 gün arasında (ortalama 2.5 gün) değişmekteydi. Tecrübelerimize göre perkütan suprapubik sistolitotripsi çocuk hastalarda mesane taşlarının tedavisinde kullanılabilecek etkili ve güvenilir bir yöntemdir.

Abstract

Introduction: Primary vesical stones are common in the children in underdeveloped and developing countries. The treatment options available for managing bladder calculi include transurethral cystolithotripsy, open cystolithotomy and shock wave lithotripsy (SWL). Although the majority of vesical calculi in adults can be treated by transurethral lithotripsy, this procedure is restricted in children due to the narrow caliber of the urethra. For this reason, percutaneous suprapubic lithotripsy is a good choice as a safe and effective method for the treatment of bladder stones in children. Materials and Methods: Between April 2004 and June 2005, percutaneous suprapubic lithotripsy was applied to 6 children in our clinic under general anesthesia. The procedure was done without fluoroscopy. The bladder was distended with saline and a suprapubic puncture made easily. The instrument was an adult 24F rigid nephroscope, similar to that used for percutaneous nephrolithotripsy. Pneumatic disintegration was performed for stones of >10 mm. Suprapubic and urethral catheters were removed on the 1st and 2nd postoperative day, respectively. Results: The patients' ages ranged from 3 to 10 years (average: 5.7 years). All of the patients were males. Stone size was detected on plain film. The stone size ranged from 8 to 30 mm (average: 19 mm). The patients had the complaints such as, hematuria, pelvic pain and urinary retention. All the patients were assessed clinically and biochemically with relevant investigations including urine culture and sensitivity. In urine cultures of 3 patients Escherichia coli and in urine culture of 1 patient Proteus mirabilis were detected. In these patients, after suitable antimicrobial treatment, cystolithotripsy procedure was performed. Each patient was cleared from the stone burden with a single session. The average operating time was 22.5 min (15-30 min). Abdominal distention developed in a patient. Minimal fluid was determined intraabdominally by ultrasound and resolved spontaneously. All patients were discharged from hospital at postoperative 2nd to 3rd days (average: 2.5 days). Conclusion: In developing and underdeveloped countries, endemic bladder stone is still common disease in the childhood. Nutritional etiology is dominant in pediatric urinary bladder stone formation in these countries. Although the main component of the urinary bladder stones is struvite in developed countries, this component is generally ammonium acid urate in the developing and underdeveloped countries. The majority of bladder calculi in adults can now be treated transurethrally with the use of ultrasonic or pneumatic lithotripsy. Despite this variety of operative approaches and modalities of lithotripsy, the management of large calculi can sometimes be challenging and time consuming. In spite of the improvement of endourologic instruments, open surgical removal of primary bladder calculi in children is still the mainstay of therapy. The established approach for endoscopically treating bladder calculi are either transuretral or percutaneous. Transuretral lithotripsy has become an alternative method to open cystolithotomy in adulthood, not in childhood. Transurethral lithotripsy procedure is restricted in children due to the narrow caliber of the urethra. SWL treatment for bladder stones is a technically easy method; however, because of the difficulty in passing the stone fragments, its application in children usually is not suitable. Based on our experience, we can conclude that percutaneous suprapubic lithotripsy is a safe and effective method for the treatment of bladder stones in children. Because this procedure is safe, effective and minimally invasive method, it can be more popular choice of the treatment of bladder calculi in children.