Fluoroscopy-assisted ultrasound guidance for mini-percutaneous nephrolithotomy (mini-PCNL) procedures in children is a safer and more effective approach than fluoroscopy alone, researchers have found.
The results suggest that there's a way to treat children with kidney stones with lower radiation doses, wrote a team led by Dr. Amr Salama of the Alexandria School of Medicine in Egypt. The group's research was published on 13 March in Urology.
"[Our study shows that] fluoroscopy-assisted ultrasonography guidance for access for PCNL seems to be an acceptable if not better option than plain fluoroscopy guidance to limit radiation exposure," the investigators noted.
The incidence of kidney stones is increasing, particularly among children, the authors explained, a trend that translates into more hospitalizations, surgeries, and healthcare costs. One of the ways the condition is treated is through percutaneous nephrolithotomy -- which is considered a first-line treatment for removing kidney stones greater than 20 mm in children; it has stone clearance success rates of 90% or higher and replaces open stone surgery. "Mini"-PCNL is a version of the procedure that further decreases bleeding, postoperative pain, and complication rates.
But PCNL does impart radiation, and clinicians have sought to mitigate this exposure, especially to pediatric patients. Using ultrasound to guide PCNL shows promise for not only identifying soft tissues and arteries and increasing accuracy of access to the stone but also conferring less radiation.
Salama and colleagues assessed whether and how much fluoroscopy-assisted, ultrasound-guided mini-PCNL could reduce radiation exposure compared to traditional fluoroscopy via a study that included 50 children who underwent the procedure between July 2022 and August 2023. Patients were divided into two groups: group A (mean age, 7 years) underwent fluoroscopy-only guided mini-PCNL, while group B (mean age, 8 years) received fluoroscopy-assisted ultrasound-guided mini-PCNL. The investigators tracked complication rate and fluoroscopy time.
The group reported the following:
| Performance of fluoroscopy alone compared with fluoroscopy with ultrasound for guiding mini-PCNL procedures | |||
|---|---|---|---|
| Measure | Fluoroscopy alone (group A) | Fluoroscopy with ultrasound guidance (group B) | p-value |
| Fluoroscopy duration (seconds) | 158 | 29 | p < 0.05 |
| Radiation dose | 32.4 mGy | 6.1 mGy | p < 0.05 |
| Time to puncture (seconds) | 136.6 | 52.2 | p < 0.05 |
| Complications rate | 16% | 12% | p = 0.65 |
| Hospital stay (days) | 2.8 | 2.2 | p = 0.16 |
The team also found an overall stone-free success rate of 96% for both patient groups.
Using ultrasound for mini-PCNL offers a promising alternative to fluoroscopy alone, according to the authors.
"The most often used access approach [for kidney stone removal] worldwide is still fluoroscopy, [but] our study findings show that [fluoroscopy and ultrasound guided] PCNL is a useful method that significantly cuts down on time and radiation exposure," they concluded.
The complete study can be found here.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
