PMC6034396_01
KUB radiograph in our 2-year-old patient. The arrow indicates the stone in the pyeloureteral junction of the right kidney. The dotted arrow indicates the large kidney stone with multiple stones in the upper and lower poles. KUB, kidney, ureter, and bladder.
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Imaging studies including kidney, ureter, and bladder (KUB) radiographs; ultrasonography (US); and computed tomography revealed a large stone measuring 2.0 x 1.2 cm (1043 Hounsfield units) in his right kidney at the pyeloureteral junction with mild hydronephrosis and a partial staghorn stone measuring 3.5 x 2.4 cm (1102 Hounsfield units), with multiple smaller stones in the left kidney (Fig. 1).
Fluoroscopic image obtained during the procedure using a 4.5F semi-rigid ureteroscope for placement of the ureteral catheter. The arrow indicates the 4.5F semi-rigid ureteroscope. The dotted arrow indicates the ureteral catheter.
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Additionally, we placed a 5F ureteral catheter to decrease the intrarenal pressure because of having some space in the ureter (Fig. 2).
Image of the Barts modified Valdivia position. The circle shows the pad used to fix the patient's shoulder. The dotted circle shows the thick cushion used to prevent movement toward the median.
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The patient was oriented in the Bart's modified Valdivia position under general anesthesia, which is characterized by a lateral position with the upper body elevated at a 45  angle and the lower body in the lithotomy position (Fig. 3).
Image of super ultra-mini percutaneous nephrolithotomy. The arrow indicates the 6F nephroscope. The dotted arrow indicates the 8.5F to 9.8F tract sheath.
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We then inserted a 6F miniaturized nephroscope (minimally invasive PCNL generation of nephroscopes; Karl Storz, Tuttlingen, Germany) through an 8.5F to 9.5F tract sheath (Fig. 4).