الفهرس 
AcknowledgmentsOnly 14 pages are availabe for public view
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Abstract
The aim of this work was to compare the operative outcomes (e.g. access duration, need for blood transfusion, radiation time, tract caliber and whole operative time), postoperative outcomes (mainly SFR, hospital stay and postoperative analgesia requirements) and complication rates of totally (solo) US guided PCNL versus fluoroscopic guided PCNL in pediatric age group. To achieve this purpose a total of 57 children (60 renal units) were included in this study from November 2018 until December 2020. All children had single or multiple renal stones and allocated according to our inclusion criteria Our study was a randomized clinical study that had been conducted prospectively in Urology and Nephrology Hospital of Assiut University. A written consent was taken from the parents of all. All preoperative, intraoperative and postoperative parameters, results and complications were recorded. The primary stone free rate was 75% (without any auxiliary maneuvers) with no significant difference could be elicited between pure US guidance and fluoroscopic guidance. We also did not find certain preoperative or intraoperative factors that could significantly affect the SFR (on multivariate analysis) in both groups of our study. The median whole operative time was 50 and 57.5 minutes (in the fluoroscopy and US groups respectively) with 66 minutes was a cutoff time after which complication rate increases. Postoperative Hb DROP was 0.2 and 0.5 gm/dl in the US and fluoroscopy groups respectively with no significant difference could be detected. Percentage of complications was 30%. (in total cohort), again without any significant difference between the two groups. Most of the complications were low grade complications (grade I according to modified Clavien grading system) and managed conservatively. Median radiation duration was 197 seconds in the fluoroscopy arm while was zero in the US arm. Median duration of hospital stay in the US group was 2.5 days while it was 2 days in the fluoroscopy group (significantly less than US group p value=.010). Hospital stay was the only postoperative outcome that had a significant difference between the two groups. PCNL is an effective and safe procedure for management of renal stones in pediatric patients with low morbidity and good success rate. Total US guidance during pediatric PCNL is safe and effective with success and complication rates comparable to the conventional fluoroscopic technique. The main advantages of total US guidance include: Absence (or marked reduction) of radiation whether to patients or medical team. Real time monitoring to the needle during puncture. Identification of surrounding organs and avoidance of their injury (e.g. bowel, liver or spleen) during tract establishment. Easy identification of the suitable posterior calyx on doing the puncture. Detection of residual radiolucent stones which cannot be discovered by the use of fluoroscopy. Detection of intraoperative complications e.g. marked perinephric or free intraperitoneal collections. The main disadvantages include: Cannot delineate the PCS anatomy especially in anomalous kidneys or recurrent cases (grade III according to Guy’s stone score). In these cases, it is better to combine fluoroscopy with US in pediatric PCNL. Cannot identify residual stone fragments along the ureter. Absence of real time monitoring during tract dilation with a higher possibility of guide wire slippage than with fluoroscopy. As a relatively new approach, it needs a learning curve and cumulative experience (especially in tract dilation) to improve results. The Guy’s Stone score [142] Grade I A solitary stone in the mid/lower pole with simple anatomy Or A solitary stone in the pelvis with simple anatomy Grade IIA solitary stone in the upper pole with simple anatomy Or Multiple stones in a patient with simple anatomy Or Any solitary stone in a patient with abnormal anatomyGrade IIIMultiple stones in a patient with abnormal anatomyOrStones in a caliceal diverticulumOrPartial staghorn calculusGrade IVStaghorn calculusOrAny stone in a patient with Spina Bifida or Spinal Injury