Transurethral Versus Percutaneous Endoscopic Management of Bladder Stones in Boys
Condition: Pediatric Bladder Stones
MeSH terms: Urinary Bladder Calculi
Study type: Interventional

Summary: 
      To compare safety and efficacy of trans urethral and per cutaneous approaches in endoscopic
      management of bladder stones in boys younger than 14 years
    

Detailed description: 
      Pediatric urolithiasis remains endemic in developing nations, affecting children at ages less
      than 1 year to adolescence. The prevalence rate is high at 5% to 15% compared with 1% to 5%
      in developed countries. Recent studies have shown that the percentage of bladder stones in
      pediatric urolithiasis is 30%.

      Open cystolithotomy has been the traditional modality to treat bladder stones. It has the
      inherent problems of a long scar, prolonged catheterization and hospitalization and risk of
      wound infection .The advent of improved endoscopic techniques in the form of gradual decrease
      in endoscopic sizes and the development of effective lithotripters have made trans urethral
      endoscopic management of bladder stones feasible. Excellent stone-free rates with trans
      urethral lithotripsy with minimal complications make it a preferred treatment option .
      However, in children especially boys, the small caliber of urethra raise concerns about the
      ability of stone fragments clearance and the possibility of iatrogenic urethral stricture
      occurrence. This renders trans urethral cystolithotripsy to be more difficult and unfavorable
      .

      Per cutaneous cystolithotomy (PCCL) can be a safe alternative with low morbidity and
      complication rate. It has been performed safely for bladder stones up to 5 cm in size. This
      procedure may carry many advantages in the form of short operative time, more feasible stone
      fragments retrieval and less need for stone disintegration with its possible sequel as
      mucosal perforation or stone escaping inside the bladder that prolong the operative time.

      On the other hand PCCL has important disadvantages such as the presence of an incision, the
      need to dilate a tract and the potential need for a urethral catheter or supra pubic tube.
      There are other reported complications including paralytic ileus, abdominal distention from
      escape of irrigating fluid into the abdominal cavity and urine leakage. It also carries a
      risk of bowel injury especially if there is a history of abdominal or pelvic surgery.

      To the best of our knowledge, no previous prospective studies compared between per cutaneous
      and trans urethral approaches for endoscopic management of bladder stones in male children.

      The aim of the study is to compare safety and efficacy of trans urethral and per cutaneous
      approaches in endoscopic management of bladder stones in boys younger than 14 years.
    

Intervention name(s): Transurethral extraction of bladder stone(s); percutaneous extraction of bladder stone(s)
Intervention type(s): Procedure; Procedure
Intervention description(s): Patients will have transurethral approach for management of their bladder stones. Either pneumatic or Holmium:YAG laser will be used for stone distentegration. Stone basket and/or Elics current evacuation will be used to retrieve stone fragments. Urethral catheter will be applied for 48 hours.; Patients will have percutaneous approach for management of their bladder stones. After initial cystoscopy a Foley's urethral catheter will be fixed for continuous irrigation. Then, the bladder will be filled to capacity with normal saline. Access to the distended bladder will be obtained by 10-gauge needle in the midline 1-2 cm above the pubic bone. Once suitable placement is confirmed with return of fluid, a guide wire will be passed through the needle into the bladder. Dilatation will be done using 8-10 Fr coaxial dilators then single fascial dilator with placement of 16 Fr Amplatz sheath as a working tract. No ultrasonic or fluoroscopic guidance will be used. Stone basket will be used to extract the stone. If the stones were larger than the used sheath, disintegration will be performed with a pneumatic lithotrite. Primary skin closure of the suprapubic stab wound by one stitch will be done and the urethral catheter will remain for 48 hours.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment