• Sarwar Noori Mahmood Department of Surgery, College of Medicine, University of Sulaimani, Kurdistan Region, Iraq.
  • Hazhar Muhammad Rasul Urology Department, Sulaimani General Teaching Hospital, Sulaimani, Kurdistan Region, Iraq.
  • Hewa Mahmood Tawfeeq Urology Department, Sulaimani General Teaching Hospital, Sulaimani, Kurdistan Region, Iraq.




Renal stone, Pediatric percutaneous nephrolithotomy, Stone-free rate, Modified clavien classification system



Percutaneous nephrolithotomy (PCNL) is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.


To evaluate factors affecting the complications using the modified Clavien scoring system (MCCS) in children undergoing PCNL.

Patients and Methods

We performed prospective data analysis of 109 consecutive patients under the age of 17 years who underwent PCNL from September 2009 to January 2018. Stone complexity was determined according to certified Guy’s stone score (GSS). All PCNL procedures performed by a single experienced urologist under general anaesthesia and fluoroscopic guidance in a prone position. Complications recorded according to the MCCS.


The study comprises 109 patients who underwent 115 PCNL (six patients had bilateral PCNL), (65 boys and 44 girls), with a mean (range) age 6.57±4.51 (1-17) years and mean (range) stone burden was 2.341±1.105 (0.6-6) cm. The Stone-free rate after PCNL monotherapy was 93%, which heightened to 96.5% after shock wave lithotripsy. Thirty-nine children (33.9%) had operative complications; 95% were minor, Clavien grade I in 19(16.5%) patients, grade II in 18 (15.7%) patients, all were managed conservatively, while two (1.7%) patients have Grade IIIb Complications requiring surgical intervention. The Degree of hydronephrosis (moderate and severe), GSS, and operation duration were significantly associated with perioperative complications (P <0.05). 


PCNL in children is effective and safe for handling simple as well as complex renal calculi. Assignment of the modified clavien classification to all possible PCNL complications is a reproducible system for the improvement in reporting of detail perioperative complications. The distinguishing factors should be considered to reduce associated complication rates.


Smaldone MC, Docimo SG, Ost MC. Contemporary surgical management of pediatric urolithiasis. Urol Clin North Am .2010; 37: 253–67.

Hesse A, Brändle E, Wilbert D, Köhrmann KU, Alken P. Study on the prevalence and incidence of urolithiasis in Germany comparing the years 1979 vs. 2000. Eur Urol.2003; 44: 709–13.

Novak TE, Lakshmanan Y, Trock BJ, Gearhart JP, Matlaga BR. Sex prevalence of pediatric kidney stone disease in the United States: an epidemiologic investigation. Urology. 2009; 74: 104–7.

Lao M, Kogan BA, White MD, Feustel PJ. High recurrence rate at 5-year follow up in children after upper urinary tract stone surgery. J Urol. 2014; 191:440–4.

Ozden E, Mercimek MN, Yakupoglu YK, Ozkaya O, Sarikaya S. Modified Clavien classification in percutaneous nephrolithotomy: assessment of complications in children. J Urol.2011; 185: 264–8.

Holman E, Khan AM, Flasko T, Toth C, Salah MA. Endoscopic management of pediatric urolithiasis in a developing country. Urology .2004; 63: 159–62.

Sarwar Mahmood, Bryar Aziz, Hewa Tawfeeq, Saman Fakhralddin. Mini-versus standard percutaneous nephrolithotomy for treatment of pediatric renal stones: is smaller enough? Journal of Pediatric Urology (2019) 15, 664.e1e664.e6.

Samad L, Aquil S, Zaidi Z. Pediatric percutaneous nephrolithotomy: Setting new frontiers. BJU Int. 2006; 97: 359–63.

Nouralizadeh A, Basiri A, Javaherforooshzadeh A, Soltani MH, Tajali F. Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old. J Pediatr Urol. 2009; 5: 351– 4.

Dawaba MS, Shokeir AA, Hafez AT, Shoma AM, El-Sherbiny MT, Mokhtar A, et al. Percutaneous nephrolithotomy in children: early and late anatomical and functional results. J Urol. 2004; 172: 1078–81.

Wadhwa P, Aron M, Bal CS, Dhanpatty B, Gupta NP. Critical prospective appraisal of renal morphology and function in children undergoing shockwave lithotripsy and percutaneous nephrolithotomy. J Endourol.2007; 21(9):961-6.

Zeren S, Satar N, Bayazit Y, Bayazit AK, Payasli K, Ozkeçeli R. Percutaneous nephrolithotomy in the management of pediatric renal calculi. J Endourol.2002; 16: 75–8.

Desai MR, Kukreja RA, Patel SH, Bapat SD. Percutaneous nephrolithotomy for complex pediatric renal calculus disease. J Endourol .2004; 18(1):23-7.

Bilen CY, Gunay M, Ozden E, Inci K, Sarikaya S, Tekgul S. Tubeless mini-percutaneous nephrolithotomy in infants and preschool children: a preliminary report. J Urol. 2010; 184: 2498–503.

Tepeler A, Sancaktutar AA, Taskiran M, Silay MS, Bodakci MN, Akman T, et al. Preoperative evaluation of pediatric kidney stone prior to percutaneous nephrolithotomy: Is computed tomography really necessary? Urolithiasis. 2013; 41:505–10.

Penbegül N, Tepeler A, Sancaktutar AA, Bozkurt Y, Atar M, Yildirim K, et al. Safety and efficacy of ultrasound-guided percutaneous nephrolithotomy for treatment of urinary stone disease in children. Urology. 2012; 79:1015–9.

Bilen CY, Koçak B, Kitirci G, Ozkaya O, Sarikaya S. Percutaneous nephrolithotomy in children: lessons learned in 5 years at a single institution. J Urol.2007; 177: 1867–71.

Mor Y, Elmasry YE, Kellett MJ, Duffy PG. The role of percutaneous nephrolithotomy in the management of pediatric renal calculi.J Urol .1997; 158: 1319–21.

Gunes A, Ugras MY, Yilmaz U, Baydinc C, Soylu A. Percutaneous nephrolithotomy for pediatric stone disease: our experience with adult-sized equipment. Scand J Urol Nephrol.2003; 37: 477–81.

R Veeratterapillay, MBK Shaw, R Williams, P Haslam, A Lall, M De la Hunt, et al. Safety and efficacy of percutaneous nephrolithotomy for the treatment of pediatric urolithiasis. Ann R CollSurgEngl.2012; 94: 588–92.

Tefekli A, Ali Karadag M, Tepeler K, Sari E, Berberoglu Y, Baykal M, et al. Classification of percutaneous nephrolithotomy complications using the modified Clavien grading system: looking for a standard. Eur Urol.2008; 53: 184–90.

De la Rosette JJ, Opondo D, Daels FP, Giusti G, Serrano A, Kandasami SV, et al.; CROES PCNL Study Group. Categorization of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol.2012; 62: 246–55.

Thomas K, Smith NC, Hegarty N, Glass JM. The Guy’s stone score grading the complexity of percutaneous nephrolithotomy procedure. Urology 2011; 77: 277–81.

Stapleton FB. Clinical approach to children with Urolithiasis. Semin nephrology. 1996; 16: 389–97.

Tekin I, Tekgül S, Bakkaloglu M, Kendi S. Results of extracorporeal shock wave lithotripsy in children, using the Dornier MPL 9000 lithotriptor. J PediatrSurg.1998; 33: 1257– 9.

Demirkesen O, Tansu N, Yaycioglu O, Onal B, Yalcin V, Solok V. Extracorporeal shockwave lithotripsy in the pediatric population. J Endourol.1999; 13: 147–50.

Jackman SV, Hedican SP, Peters CA, Docimo SG. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. Urology. 1998; 52: 697– 701.

Badawy H, Salama A, Eissa M, Kotb E, Moro H, Shoukri I. Percutaneous management of renal calculi: experience with percutaneous nephrolithotomy in 60 children. J Urol.1999; 162: 1,710–13.

Ahmet Sahin, serdar Tekgül, Erim Erdem, Sinan Ekici, Metin Hascicek, Sezer kendi. Percutaneous nephrolithotomy in older children. J PediatrSurg.2000; 35: 1,336–38.

Boormans JL, Scheepe JR, Verkoelen CF, Verhagen PC. Percutaneous nephrolithotomy for treating renal calculi in children. BJU Int.2005; 95:631–34.

Raza A, Turna B, Smith G, Moussa S, David A.Pediatric urolithiasis: 15 years of local experience with minimally invasive endourological management of pediatric calculi. J Urol.2005; 174: 682–85.

Aron M, Yadav R, Goel R, Gupta NP. Percutaneous nephrolithotomy for complete staghorn calculi in preschool children. J Endourol.2005; 19: 968–72.

Kapoor R, Solanki F, Singhania P, Andankar M, Hemant R, Pathak. Safety and efficacy of percutaneous nephrolithotomy in the pediatric population. J Endourol.2008; 22: 637–40.

Unsal A, Resorlu B, Kara C, Bozkurt OF, Ozyuvali E. Safety and efficacy of percutaneous nephrolithotomy in infants, preschool age, and older children with different sizes of instruments. Urology. 2010; 76: 247–52.

Kumar R, Anand A, Saxena V, Seth A, Dogra PN, Gupta NP. Safety and efficacy of PCNL for management of staghorn calculi in pediatric patients. J Pediatr Urol.2011; 7: 248–51.

Goyal NK, Apul Goel, Sankhwar, Singh V, Singh BP, Sinha RJ, Dalela D, Yadav R. A critical appraisal of complications of percutaneous nephrolithotomy in pediatric patients using adult instruments. BJU Int. 2014; 113: 801–10.

Sarwar Noori Mahmood. Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis: a single center experience. JSMC, 2019;9:19-28.

Bulent Önal, Hasan Serkan Dogan, Nihat Satar, Cenk Y. Bilen, Ali G et al. Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society. J Urol.2014 Mar;191(3):777-82.

Guven S, Istanbulluoglu O, Gul U, Ozturk A, Celik H, Aygün C, et al. Successful percutaneous nephrolithotomy in children: multicenter study on current status of its use, efficacy, and complications using Clavien classification. J Urol.2011; 185: 1419–24.



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