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Re: Bhageria A, Nayak B, Seth A, Dogra PN, Kumar R. Pediatric percutaneous nephrolithotomy: Single-centre 10-year experience. J Pediatr Urol 2013;9:472–5

Published:September 30, 2013DOI:https://doi.org/10.1016/j.jpurol.2013.08.016
      We read the paper of Bagheria et al. with interest [
      • Bhageria A.
      • Nayak B.
      • Seth A.
      • Dogra P.N.
      • Kumar R.
      Pediatric percutaneous nephrolithotomy: single-centre 10-year experience.
      ]. The authors reported their 10 years of experience of percutaneous nephrolithotomy (PCNL) in children. Although the authors analyzed their database retrospectively in order to determine the patient characteristics and treatment outcomes, the efficacy and safety of this procedure in the pediatric population is already established [
      • Desai M.R.
      • Kukreja R.A.
      • Patel S.H.
      • Bapat S.D.
      Percutaneous nephrolithotomy for complex pediatric renal calculus disease.
      ,
      • Bilen C.Y.
      • Kocak B.
      • Kitirci G.
      • Ozkaya O.
      • Sarikaya S.
      Percutaneous nephrolithotomy in children: lessons learned in 5 years at a single institution.
      ]. Moreover, several pitfalls of the study must be addressed.
      First of all, the authors included 102 PCNL procedures during a 10-year period (approximately 10 procedures per year). Furthermore, they used adult instruments for a pediatric population. Although the authors claimed that the use of adult-sized nephroscopes in children allows faster stone clearance with no additional complications, there are many papers which demonstrate smaller instrument size does not significantly increase the operative time, and it is associated with lower complication rates [
      • Bilen C.Y.
      • Kocak B.
      • Kitirci G.
      • Ozkaya O.
      • Sarikaya S.
      Percutaneous nephrolithotomy in children: lessons learned in 5 years at a single institution.
      ,
      • Ozden E.
      • Sahin A.
      • Tan B.
      • Dogan H.S.
      • Eren M.T.
      • Tekgul S.
      Percutaneous renal surgery in children with complex stones.
      ]. Today, recent guidelines consistently recommend performing pediatric PCNL at high-volume centers where small caliber instruments are available in order to reduce the complications [
      • Turk C.
      • Knoll T.
      • Petrik A.
      • Sarica K.
      • Skolarikos A.
      • Straub M.
      • et al.
      Members of the European Association of Urology (EAU) Guidelines Office
      Guidelines on Urolithiasis, edition presented at 28th EAU Annual Congress, Milan.
      ]. Unfortunately, the authors' center does not seem to meet these criteria, thus their results should be evaluated with caution.
      Not performing metabolic evaluation and stone analysis properly for the patients in this age group is also problematic, considering the high incidence of pediatric metabolic disorders. Metabolic evaluation of a stone patient should be performed at least 3 weeks after complete clearance of stones in the collecting system. Performing the analysis before the stone treatment, as the authors did, does not provide any clinical benefit [
      • Turk C.
      • Knoll T.
      • Petrik A.
      • Sarica K.
      • Skolarikos A.
      • Straub M.
      • et al.
      Members of the European Association of Urology (EAU) Guidelines Office
      Guidelines on Urolithiasis, edition presented at 28th EAU Annual Congress, Milan.
      ]. The authors reported that six cases had clinically insignificant residual stone fragments; however, they omit to mention that the term clinically insignificant residual fragment is controversial in the pediatric age group as this group of patients are all in the high-risk group for stone recurrence [
      • Turk C.
      • Knoll T.
      • Petrik A.
      • Sarica K.
      • Skolarikos A.
      • Straub M.
      • et al.
      Members of the European Association of Urology (EAU) Guidelines Office
      Guidelines on Urolithiasis, edition presented at 28th EAU Annual Congress, Milan.
      ]. Finally, the authors did not provide their data as mean ± SD of stone size, which would give the readers more insight regarding the average stone burden of the study population.
      In our opinion, pediatric patients with kidney stones should be managed with special care considering the anatomical and metabolic differences in this age group. Instead of reporting the results of retrospective cohorts, researchers must focus on developing techniques and equipment to reduce the morbidity of stone removal surgeries as well as establishing treatment modalities to prevent the development of stones.

      Conflict of interest

      None.

      Funding

      None.

      References

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        Pediatric percutaneous nephrolithotomy: single-centre 10-year experience.
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        Guidelines on Urolithiasis, edition presented at 28th EAU Annual Congress, Milan.
        2013

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