Tamsulosin for the management of distal ureteral stones in children: a prospective randomized study

Assessing safety and tolerability of super selective alpha-1 adrenergic blockers in infants under 3 years: Insights from a single-center study on lower urinary tract obstruction (LUTO)

BACKGROUND

Little is known about alpha blocker use in young children, particularly in those with lower urinary tract obstruction (LUTO). Therefore, we aimed to assess the safety and tolerability of selective alpha-blockers in children under 3 years of age with LUTO.

METHODS

A prospectively-collected database captured 93 patients born between 12/2005 and 01/2023. Assessed data included baseline characteristics, ultrasound features, blood pressure (BP), side effects and creatinine values. Primary outcome was side effects or discontinuation of alpha-blockers. Secondary outcomes were BP parameters, growth, and kidney function. Data are shown as median with interquartile range (IQR), Odds Ratio (OR) with 95% CI and mean value with standard deviation (SD).

RESULTS

A total of 33 patients less than 3 years of age were started on alpha-blockers at 16.8 ± 11.8 months and followed for 48.9 ± 40.5 months. At last follow-up, no significant effect on systolic/diastolic BP percentiles (p > 0.9 and p > 0.9), creatinine levels (p > 0.9). Weight percentiles increased to the last follow-up (37.8 ± 33.2 vs. 53.6 ± 32.9, p = 0.0133) while height percentiles increased from 28 to 100 days to last follow-up (12.9 ± 18.3 vs. 39.6 ± 35.2, p=0.001). Four patients discontinued alpha-blockers; however, no side-effects were reported during the study period.

CONCLUSIONS

No severe clinical or systemic side effects were observed, demonstrating safety and tolerability in young children with LUTO. Although alpha-blockers did not significantly improve kidney function in short term follow-up, and failure to thrive was not observed in these children. Additional studies with more patients are required to assess the optimal dosing and timing leading to maximal benefits for these infants.

Standardization of the management of pediatric urolithiasis in the emergency department

INTRODUCTION

The incidence of urolithiasis in the pediatric population is rising and medical expulsive therapy (MET) using alpha-adrenergic antagonists has been found to be effective in aiding in the passage of ureteral stones in children. A prior review of patients presenting to our quaternary children's hospital with urolithiasis found only 54 % were prescribed MET and these patients had increased rates of spontaneous stone passage. Thus, an ED urolithiasis management protocol was created to standardize evaluation and care of children with suspected urolithiasis.

OBJECTIVE

To compare management of children with urolithiasis presenting to the ED before and after urolithiasis management protocol implementation.

METHODS

This is a retrospective review of patients with urolithiasis who presented to our children's ED from 2011 to 2022. The primary outcome was rate of MET prescribing before and after pathway implementation in July 2017, thus the pre-implementation group comprises patients who presented to the ED from July 2011 to July 2017, and the post-protocol group includes those who presented from August 2017 to April 2022. Secondary outcomes included CT utilization in the ED, surgical intervention rate, proportion with spontaneous stone passage, and frequency of urology consultation. Two-sample t-test and Fisher's exact test were used to compare the outcomes of interest before and after protocol implementation.

RESULTS

Of 337 patients who presented to the ED after protocol implementation, 120 met inclusion criteria. When comparing outcomes before and after implementation of the protocol, there was significantly decreased use of CT scans (79 % vs 50 %, p < 0.0001) and increased prescribing of MET (54 % vs 82 %, p < 0.0001). There was a significant decrease in opioids prescribed (44 % vs 26.7 %, p = 0.0040), and an increased rate of spontaneous stone passage (34 % vs 46 %, p = 0.0483). Lastly, there was a significant reduction in the rate of surgery for stone management after the implementation of protocol (35 % vs 17 %, p = 0.0020) DISCUSSION: As the ED is the primary site of presentation for many children with urolithiasis, standardization of evaluation and management provides an opportunity to improve outcomes in this population. We found that implementation of an ED urolithiasis management protocol was associated with decreased use of CT scans, decreased opioid prescribing, increased spontaneous stone passage, and decreased rate of surgical management for children with ureteral stones.

CONCLUSIONS

This study demonstrates the positive impact of standardizing care for children presenting to the ED with urolithiasis.

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Management of Pediatric Urolithiasis in an Italian Tertiary Referral Center: A Retrospective Analysis

Background and Objectives: In recent years, the prevalence of pediatric urolithiasis has increased in North America and Western countries, though it is endemic in developing countries. The aim of this study is to describe the experience of a tertiary pediatric referral center in the surgical management of pediatric urolithiasis. Materials and Methods: We retrospectively reviewed the experience of patients ≤ 16 years old affected by urinary stones who underwent surgery. Results: From April 2021 to September 2023, 31 pediatric patients underwent surgical procedures for stone diseases at our department: 13 preschool-aged (1-5 years) and 18 school-aged (6-16 years) children. During this period, 12 URSs, 17 RIRSs, and 2 PCNLs were recorded. Five patients had residual fragments at first, so three of them underwent a second endourological lithotripsy (2 RIRSs and 1 URS). Complete clearance was finally achieved in 27 patients. The stone composition was evaluated in 25 cases. Conclusions: Numerous innovations in the surgical treatment of pediatric urolithiasis have resulted from the development of smaller devices and new technology. Our results show how, in experienced centers, retrograde and percutaneous lithotripsy are safe and effective procedures for use in pediatric populations.

Pediatric Stone Disease: Current Trends and Future Directions

Pediatric nephrolithiasis is less common in children than in adults but the incidence has been rising rapidly, and it is now a public health and economic burden in the United States. There are challenges unique to children that should be taken into consideration when evaluating and managing pediatric stone disease. In this review, we present the current research on risk factors, emerging new technologies for treatment of stones and recent investigations on prevention of stones in this population.

Medical Expulsive Therapy for Pediatric Ureteral Stones: A Meta-Analysis of Randomized Clinical Trials

To evaluate the efficacy and safety of medical expulsive therapy (MET) for ureteral stones in pediatric patients, Cochrane, PubMed, Web of Science, Scopus, and the reference list of retrieved studies were searched up to September 2022 to identify RCTs on the efficacy of MET. The protocol was prospectively registered at PROSPERO (CRD42022339093). Articles were reviewed, data were extracted by two reviewers, and the differences were resolved by the third reviewer. The risk of bias was assessed using the RoB2. The outcomes, including the stone expulsion rate (SER), stone expulsion time (SET), episode of pain, analgesic consumption, and adverse effects, were evaluated. Six RCTs enrolling 415 patients were included in the meta-analysis. The duration of MET ranged from 19 to 28 days. The investigated medications included tamsulosin, silodosin, and doxazosin. The stone-free rate after 4 weeks in the MET group was 1.42 times that of the control group (RR: 1.42; 95% CI: 1.26-1.61, p < 0.001). The stone expulsion time also decreased by an average of 5.18 days (95% CI: -8.46/-1.89, p = 0.002). Adverse effects were more commonly observed in the MET group (RR: 2.18; 95% CI: 1.28-3.69, p = 0.004). The subgroup analysis evaluating the influence of the type of medication, the stone size, and the age of patients failed to reveal any impact of the aforementioned factors on the stone expulsion rate or stone expulsion time. Alpha-blockers as medical expulsive therapy among pediatric patients are efficient and safe. They increase the stone expulsion rate and decrease the stone expulsion time; however, this included a higher rate of adverse effects, which include headache, dizziness, or nasal congestion.

Meta-analysis of the efficacy and adverse drug reactions of adrenergic alpha-antagonists in treating children with ureteral calculi

This meta-analysis investigated the efficacy and adverse drug reactions (ADRs) of three different adrenergic alpha-antagonists during the treatment of pediatric ureteral stones. Studies were retrieved from MEDLINE, EMBASE, and the Cochrane Controlled Trial Registry until January 2022. We identified 7 articles, including six RCTs and one cohort study. 610 children received either adrenergic alpha-antagonists or placebo. The results confirmed that the three different adrenergic alpha-antagonists could significantly increase the ureteral calculi expulsive rate and shorten the ureteral calculi expulsive time, regardless of the size of the stone "<5 mm" or "5-10 mm". Subgroup analysis suggested that all three adrenergic alpha-antagonists increased the ureteral calculi expulsive rate. Tamsulosin and silodosin also have the effect of shortening ureteral calculi expulsive time, while doxazosin has an insignificant effect on ureteral calculi expulsive time. Besides, tamsulosin and silodosin obviously reduced the number of pain episodes caused by ureteral calculi in children. We analyzed the treatment-emergent adverse events (TEAEs) caused by the treatment of three different adrenergic alpha-antagonists to explore their ADRs. The probability of ADRs was increased after treatment with adrenergic alpha-antagonists. Further subgroup analysis revealed the application of tamsulosin was positively correlated with ADRs in children with ureteral calculi, while the application of doxazosin and silodosin had no statistically significant effect on the probability of TEAEs. In a conclusion, this article systematically analyzed the efficacy and ADRs of three different adrenergic alpha-antagonists, and provided reference and guidance for the application of adrenergic alpha-antagonists to treat children ureteral calculi.

Diagnosis and Management of Nephrolithiasis in Children

The incidence of kidney stones in children is increasing. Approximately two-thirds of pediatric cases have a predisposing cause. Children with recurrent kidney stones have an increased higher risk of developing chronic kidney. A complete metabolic workup should be performed. Ultrasound examination is the initial imaging modality recommended for all children with suspected nephrolithiasis. A general dietary recommendation includes high fluid consumption, dietary salt restriction, and increased intake of vegetables and fruits. Depending on size and location of the stone, surgical intervention may be necessary. Multidisciplinary management is key to successful treatment and prevention.

Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway

INTRODUCTION/BACKGROUND

Urolithiasis is an increasingly common condition seen in children with an annual incidence of 2-3% in children under 18, and up to 10% in adolescents. Treatment of stones varies including observation, IV hydration, pain management, medical expulsive therapy (MET), or surgery. Though well-studied and often used in adults, MET (alpha-adrenergic antagonists to facilitate passage of ureteral stones), is not routinely prescribed in pediatric patients.

OBJECTIVE

The goals of this study were to review a quaternary children's hospital's emergency room frequency of MET utilization for ureterolithiasis as well as evaluate the clinical outcomes of children who were prescribed MET compared to those treated with pain control alone.

STUDY DESIGN

A retrospective review was performed of children 2 months to 18 years with ureterolithiasis who presented to a quaternary children's hospital ED from 2011 to 2017. The primary outcome was the frequency of MET prescribed. Secondary outcomes included the following comparisons in patients who received MET and analgesics with those who received analgesics alone: hospital admission rate, length of hospitalization, emergency room re-presentation rate, surgical intervention, spontaneous stone passage, urology consultation, how the urology consult affected MET utilization, referral to outpatient urology and nephrology clinics, and CT utilization in the ED. Comparisons were performed utilizing Fischer's exact and t-tests.

RESULTS

139 patients were included with a mean age of 14 years (SD 4.14), 42% male. There was no difference between age, gender, stone size, return to the ED, serum creatinine, or length of hospitalization (if admitted) between patients who were and were not placed on MET. The rate of stone passage was significantly higher for those placed on MET (45%) versus not (20%) (p = 0.0022). Urology was consulted for 93% of the cases where children were prescribed MET, compared with only 52% of cases where MET was not prescribed (p = <0.0001).

DISCUSSION

In our experience MET was significantly underutilized in patients where urology was not involved. This is similar to a study by Itano et al. which found urology consultation in the ED significantly increased use of tamsulosin for ureterolithiasis in adults. Children with ureterolithiasis placed on MET had a significantly higher rate of stone passage compared to children managed by pain control alone.

CONCLUSION

Given the benefits of MET to increase the rate of spontaneous stone passage it may be considered first line therapy for treatment of children with ureterolithiasis.

Paediatric stone management: innovations and standards

PURPOSE OF REVIEW

The aim of this study was to discuss current trends and recent developments in the surgical management of paediatric urolithiasis.

RECENT FINDINGS

Medical expulsive therapy (MET) is considered as an option for the treatment of children with ureter stones. Extracorporeal shockwave lithotripsy (SWL) remains as a first option for majority of kidney stones and upper ureter stones. Advances in endourology have led to increased adoption of retrograde intrarenal surgeries (RIRS) and percutaneous nephrolithotomy (PCNL/mini-PCNL/ultra-mini-PCNL/micro-PCNL).

SUMMARY

Management of paediatric stone disease has developed significantly in the past decade. However, the evidence in the literature remains disproportional to these advances. Well designed multicentric studies are still needed to compare effectiveness and safety of these procedures.

Meta-Analysis of the Safety and Efficacy of α-Adrenergic Blockers for Pediatric Urolithiasis in the Distal Ureter

OBJECTIVE

Pediatric urolithiasis is a common condition, and medical expulsive therapy has grown to be accepted by many parents. We carried out a meta-analysis to identify the efficacy and safety of α-adrenergic blockers for the treatment of pediatric urolithiasis.

METHODS

We identified related articles from the PubMed, Embase, and Cochrane Library databases. All published randomized controlled trials (RCTs) describing the use of α-adrenergic blockers and placebo treatment for pediatric distal urolithiasis were involved. The outcomes included stone expulsion rate, stone expulsion time, pain episodes, need for analgesia, adverse events, and related subgroup analyses.

RESULTS

A total of nine RCTs were involved in our study, including 586 patients. We found that α-adrenergic blockers could significantly increase the rate of stone expulsion [odds ratio (OR), 3.49; 95% confidence interval (CI), 2.38-5.12; p < 0.00001], reduce the stone expulsion time [mean difference (MD), -5.15; 95% CI, -8.51 to -1.80; p = 0.003], and decrease pain episodes (MD, -1.02; 95% CI, -1.33 to -0.72; p < 0.00001) and analgesia demand (MD, -0.92; 95% CI, -1.32 to -0.53; p < 0.00001) but had a higher incidence of side effects (MD, 2.83; 95% CI, 1.55 to 5.15; p = 0.0007). During subgroup analyses, different medications (tamsulosin, doxazosin, and silodosin) also exhibited better efficiencies than placebo, except for doxazosin, which showed no difference in expulsion time (MD, -1.23; 95% CI, -2.98 to 0.51; p = 0.17). The three kinds of α-adrenergic blockers also appeared to be better tolerated, except for tamsulosin with its greater number of adverse events (MD, 2.85; 95% CI, 1.34 to 6.03; p = 0.006). Silodosin led to a better expulsion rate than tamsulosin (OR, 0.42; 95% CI, 0.20 to 0.92; p = 0.03). In addition, α-adrenergic blockers increased the stone expulsion rate regardless of stone size and decreased the expulsion time of stones measuring <5 mm (MD, -1.71; 95% CI, -2.91 to -0.52; p = 0.005), which was not the case for stones measuring >5 mm in expulsion time (MD, -3.61; 95% CI, -10.17 to 2.96; p = 0.28).

CONCLUSION

Our review suggests that α-adrenergic blockers are well-tolerated and efficient for treating pediatric distal urolithiasis. We also conclude that silodosin is the best choice of drug, offering a better expulsion rate, but it remains to be evaluated further by future studies.

Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study

AIM

To compare the efficacy and safety of silodosin versus tamsulosin as medical expulsive therapy for stones of lower-third ureter in children.

PATIENTS AND METHODS

This prospective single-blind placebo-controlled randomized study included 167 pediatric patients who presented with distal ureteric stone (DUS) less than 1 cm. Patients were randomized into 3 groups; group I received silodosin 4 mg once daily, and group II received tamsulosin 0.4 mg while those in group III had placebo. The side effects of the used drugs, both rate and time of stone expulsion, and number of pain episodes were compared among the study groups for a maximum of 4 weeks.

RESULTS

Follow-up data of our patients after treatment revealed that the stone expulsion rate was significantly higher and the time to stone expulsion was significantly shorter in group I (89.3%, 12.4 ± 2.3 days) and group II (74.5%, 16.2 ± 4.2 days) compared to group III (51.8%, 21.2 ± 5.6). However, a statistically significant difference between silodosin and tamsulosin groups in favor of the former one was reported regarding the 2 studied items. Meanwhile, pain episodes requiring analgesia were statistically fewer in group I and II in contrast to placebo group. Adverse events were comparable among all groups.

CONCLUSION

Silodosin provides significantly better stone expulsion rate and shorter expulsion time than tamsulosin for treatment of DUS. Both medications showed good safety profiles in children. However, further studies are required on a larger scale to confirm our results. Assessment of drug safety on younger age-group is still needed.

Evaluation of Preoperative Tamsulosin Role in Facilitating Ureteral Orifice Navigation for School-Age Pediatric Ureteroscopy

Purpose

To address whether preoperative tamsulosin increases the rate of successful ureteral orifice navigation for ureteroscopy (URS) without prestenting in school-age pediatric patients.

Methods

We retrospectively reviewed all pediatric patients who had undergone ureteroscopy (URS) at our institution from 2013 to 2020. Patients were divided into two groups: those who had received tamsulosin 0.4 mg daily ≥48 hours preoperatively and those who had not. Statistical analysis was done using independent-sample t-tests and Mann–Whitney U tests for continuous variables, and χ² and Fisher’s exact tests were used for categorical variables. Multivariate analysis was done using binary logistic regression test.

Results

Overall, successful ureteral orifice navigation occurred in 44 of 50 patients (88%) who had received tamsulosin and 17 of 26 (65.4%) who had not (p=0.019). On further subanalysis based on stone location and instrumentation used, successful ureteral orifice navigation had occurred in 21 of 24 patients (87.5%) in the tamsulosin group and one of five (20%) in the no-tamsulosin group for semirigid ureteroscopy for mid–distal ureterolithiasis (p=0.007). For proximal ureteral and renal stones, successful ureteral orifice navigation with a flexible ureteroscope or ureteral access sheath had occurred in 23 of 26 patients (88.5%) in the tamsulosin group and 16 of 21 (76.2%) in the no-tamsulosin group (p=0.437). Multivariate analysis showed no significant difference between success rates in the two groups after controlling for patient weight, height, BMI, and stone location. We did not observe any adverse effects from tamsulosin.

Conclusion

This is the first study to evaluate preoperative tamsulosin on successful ureteral orifice navigation in school-age pediatric patients. Although not reaching statistical significance, further evaluation should be done on larger cohorts. Patient height was found to be an independent predictor of successful ureteral orifice navigation.

Surgical Management of Urolithiasis of the Upper Tract - Current Trend of Endourology in Africa

Urolithiasis is a global pathology with increasing prevalence rate. The lifetime recurrence of urolithiasis ranges from 10–75% creating a public health crisis in affected regions. The epidemiology of urolithiasis in most parts of Africa and Asia remains poorly documented as incidence and prevalence rates in these settings are extrapolated from hospital admissions. The surgical management of kidney and ureteral stones is based on the stone location, size, the patient’s preference and the institutional capacity. To date, the available modalities in the management of urolithiasis includes external shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy (URS) including flexible and semirigid ureteroscopy. However, regarding the lack of endourological equipment and expertise in most parts of Sub-Saharan Africa (SSA), most urological centers in these regions still consider open surgery for kidney and ureteral stones. This review explores the current trend and surgical management of upper tract urolithiasis in SSA with insight on the available clinical guidelines.

What predicts spontaneous passage of ≤1 cm ureteral stones in children?

PURPOSE

The aim of this study is to determine what factors predict spontaneous passage of ≤1 cm ureteral stones in children.

METHODS

Files of the patients diagnosed with a single ureteral stone on a given side between 2008 and 2017 were retrospectively reviewed. Patients with congenital obstructive uropathy, neurogenic bladder, vesicoureteral reflux and those with a stone diameter of >1 cm were excluded. Detection of ureteral stones was done using ultrasonography (US) primarily, and computed tomography when US findings were inconclusive. Patients were treated either conservatively or surgically. Conservative treatment included adequate hydration and pain management whereas surgical treatment included ureteroscopic intervention. Apart from those who required urgent intervention, patients were referred for surgical treatment after 2-4 weeks of follow-up with no spontaneous passage. Factors analyzed for association of spontaneous passage included age, gender, type of hematuria, stone localization, laterality, presence of concomitant kidney stone, degree of hydronephrosis, stone size and stone composition.

RESULTS

A total of 70 patients (38 males, 32 females); median age 4.7 years had a ≤ 1 cm ureteral stone (median diameter 7 mm). US was able to diagnose the ureteric stone in 47 patients while computed tomography was required in 23 patients. Spontaneous passage was observed in 40 patients (57.1%). Median time for stone passage was 8 days (3-34 days). Stone size and presence of hematuria (macroscopic and microscopic combined) were factors associated with spontaneous passage and 6.7 mm was found to be the cut-off (AUC = 0.953; 95% CI 0.905-1.000; sensitivity 96.7%, specificity 82.5%, p < 0.001). Moreover, age, degree of hydronephrosis or stone location were not associated with spontaneous passage.

CONCLUSION

Patients with a ureteric stone size <6.7 mm can safely be followed conservatively, with a spontaneous passage rate of 82.5%. Type of Study Case series with no comparison group. Level of Evidence IV.

Guideline-adherence in the treatment of symptomatic urolithiasis in children and adolescents in southwestern Germany

BACKGROUND

Approximately 1% of urolithiasis cases in Germany affect children. Interdisciplinary groups have agreed on national and international guidelines for children to recommend appropriate treatment pathways. The aim of this retrospective and preliminary study is to analyze whether adherence to current guidelines for pediatric stone disease in southwestern Germany is feasible.

METHODS

During 2014 to 2017 24 children and adolescents (nine female, 15 male, median age 9.7 years), were treated for symptomatic urolithiasis in our institutions. We retrospectively collected clinical and operative courses. Clinical pathways were compared to previous guideline recommendations of the EAU 2014 and the German S2k guideline 2015.

RESULTS

17 of the 24 patients were treated according to guideline recommendations (71%). Non-adherency was based on parental decisions in two and technical/medical considerations in five cases. In 11 children (45.8%) secondary or adjunctive treatments were necessary, in three of the seven non-adherently treated (43%) and in eight of the 17 adherently treated children (47%).

CONCLUSION

Our daily treatment approach seems to comply well with current pediatric stone guidelines. Nevertheless, guideline-non-adherent decision making emphasizes their strength and limitations, as specific clinical situations in children may require an individual treatment plan, as non-predictable conditions may occur.

Reprint - Medical and surgical interventions for the treatment of urinary stones in children: A Cochrane Review

INTRODUCTION

We performed systematic review to assess the effects of different medical and surgical management of urinary stones in children.

METHODS

We performed a comprehensive search using multiple databases (MEDLINE, EMBASE, Cochrane Register of Controlled Trials), trials registries (World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov), and abstract proceedings of major urological and pediatric urology meetings, with no restrictions on the language of publication or publication status, up until December 2017. We included all randomized controlled trials (RCTs) and quasi-RCTs. Two review authors independently assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias in accordance with the Cochrane "Risk of bias" tool. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to GRADE.

RESULTS

We included 14 studies with a total of 978 randomized participants in our review, informing seven comparisons with shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy (regardless of the type of lithotripsy), open stone surgery, and medical expulsive therapy. There was very low quality of evidence in the most comparisons with regards to the effectiveness and adverse events for the treatment of pediatric upper renal tract stone disease.

CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children. There is a critical need for better-quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Medical and surgical interventions for the treatment of urinary stones in children

BACKGROUND

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

OBJECTIVES

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of percutaneous nephrolithotripsy on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

AUTHORS' CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Is tamsulosin effective for the passage of symptomatic ureteral stones: A systematic review and meta-analysis

BACKGROUND

Some trials have stated that there is no benefit to tamsulosin administration for clearing ureteral stones, which is contrary to previous studies. To confirm the efficacy of tamsulosin for treating symptomatic ureteral stones, we performed this review.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases to identify all studied variables, including tamsulosin, urinary stones, expulsion, and side effects. In addition, for all patients and different stone sizes, the treatment efficacy, expulsion rate, and expulsion time were also recorded for this treatment.

RESULTS

Forty-nine studies involving 6436 patients met the inclusion criteria. The data synthesized from these studies indicated that tamsulosin improved the renal stone clearance rate (80.5% vs 70.5%; mean difference (MD), 1.16; 95% confidence interval (CI), 1.13-1.19; P <.00001) and reduced the expulsion time (MD, -3.61; 95% CI, -3.77 to -3.46; P ≤.00001). Regarding complications, no significant difference was found between the 2 groups in terms of the total side effects (MD, 1.15; 95% CI, 0.97-1.35; P = .10) or divided complications, including retrograde ejaculation (P = .01), hypotension (P = .52), dizziness (P = .07), diarrhea (P = .58), vomiting (P = .88), headache (P = .84), nausea (P = .91), and fatigue (P = .10).

CONCLUSIONS

Tamsulosin should be strongly recommended for patients with ureteral stones to increase treatment efficacy. The side effects were not significantly different between the tamsulosin and control treatments.

Cost-Effectiveness Analysis of the Management of Distal Ureteral Stones in Children

OBJECTIVE

To determine the most cost-effective approach to the management of distal ureteral stones in children given the potential for recurrent renal colic during a trial of passage versus potential stent discomfort and complications of ureteroscopy.

METHODS

We developed a decision tree to project costs and clinical outcomes associated with observation, medical explusive therapy (MET), and ureteroscopy for the management of an index patient with a 4-mm-distal ureteral stone. We determined which strategy would be least costly and offer the most pain-free days within 30days of diagnosis. We performed a one-way sensitivity analysis on the probability of successful stone passage with MET. We obtained probabilities from the literature and costs from the 2016 Pediatric Health Information System Database.

RESULTS

Ureteroscopy was the costliest strategy but maximized the number of pain-free days within 30days of diagnosis ($5282/29 pain-free days). MET was less costly than ureteroscopy but also less effective ($615/21.8 pain-free days). Observation cost more than MET and was also less effective ($2139/15.5 pain-free days). The one-way sensitivity analysis on the probability of successful stone passage with MET demonstrated that ureteroscopy always has the highest net monetary benefits value and is therefore the recommended strategy given a fixed willingness-to-pay.

DISCUSSION

Using a rigorous decision-science approach, we found that ureteroscopy is the recommended strategy in children with small distal ureteral stones. Although it costs more than MET, it resulted in more pain-free days in the first 30days following diagnosis given the faster resolution of the stone episode.

Approach to the Child with Hematuria

The causes of macroscopic and microscopic hematuria overlap; both are often caused by urinary tract infections or urethral/bladder irritation. Coexistent hypertension and proteinuria should prompt investigation for glomerular disease. The most common glomerulonephritis in children is postinfectious glomerulonephritis. In most patients, and especially with isolated microscopic hematuria, the diagnostic workup reveals no clear underlying cause. In those cases whereby a diagnosis is made, the most common causes of persistent microscopic hematuria are thin basement membrane nephropathy, immunoglobulin A nephropathy, or idiopathic hypercalciuria. Treatment and long-term prognosis varies with the underlying disease.

Safety of Tamsulosin: A Systematic Review of Randomized Trials with a Focus on Women and Children

INTRODUCTION

Although tamsulosin is indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH), it has also been assessed in clinical studies for other conditions/symptoms and in other populations such as women and children. In this systematic review of randomized studies, the overall safety of tamsulosin was assessed, focusing on these understudied populations.

METHODS

Literature searches were conducted using Embase, Medline, and PubMed (inception-December 2015). A study was included if patients were randomized to receive treatment with any dose of tamsulosin capsules, tablets, or an oral controlled absorption system and numerical safety results were reported.

RESULTS

Overall, 160 articles involving 46,072 participants met the inclusion criteria. Of these, four studies included women only and three included children. The mean [standard deviation (SD)] age ranged from 7.3 (4.2) to 76.8 (7.1) years. The studies (n; %) evaluated healthy subjects (18; 11%) or patients with lower urinary tract symptoms/BPH (90; 56%), ureteral stones/renal colic (42; 26%), prostatitis (4; 3%), or other conditions (6; 4%). Patients discontinued tamsulosin primarily because of adverse events (AEs) or insufficient response. AEs in women and children were abdominal pain, asthenia, constipation, dizziness, dry mouth, drowsiness, dyspepsia, headache, incontinence, nasal congestion, nausea, orthostatic hypotension, and somnolence. Due to heterogeneity across studies, statistical analysis could not be conducted.

DISCUSSION

No unexpected AEs were observed in an all-comers population treated with tamsulosin for various conditions/symptoms. The overall safety profile in women and children seemed to be generally consistent with the profile in men, the indicated population.

Medical and surgical interventions for the treatment of urinary stones in children

BACKGROUND

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

OBJECTIVES

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

AUTHORS' CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Use of medical expulsive therapy in children: An assessment of nationwide practice patterns and outcomes

INTRODUCTION

Early data support the use of medical expulsive therapy (MET) in children. However, little is known regarding use or outcomes associated with MET outside of pediatric-specific practices. Using a national administrative dataset, we sought to characterize utilization patterns of MET as well as assess outcomes associated with MET exposure.

STUDY DESIGN

We interrogated the MarketScan Commercial Claims and Encounters database to identify children under the age of 18 presenting to the emergency department (ED) with any diagnosis of upper urinary tract calculi (UUTC, including renal and ureteral calculi). MET exposure was defined as having a prescription filled for a MET agent within 1 week of the ED encounter. Characteristics of children receiving MET were defined and outcomes compared between children with and without MET exposure.

RESULTS

Of 1325 children included in the study, 13.2% received MET, including 15.4% of children with a diagnosis of "calculus of the ureter." MET use increased significantly throughout the study period (p = 0.004), although only 30.4% of children considered potential MET candidates received MET in the final year of the study (2013). Among all patients, receipt of MET was associated with male gender, presence of comorbidity, provider-type (urologist), and year of diagnosis, although among those with a specific diagnosis of "calculus of the ureter," only year of diagnosis remained a significant factor. Rates of unplanned physician visits and surgical interventions were similar between groups. Children receiving MET were more likely to receive follow-up imaging, although only 46% of children with ureteral calculi had appropriate follow-up imaging within 90 days, regardless of MET exposure. Odds ratios of factors and outcomes associated with MET exposure are shown in the Table.

DISCUSSION

Although early data support safety and efficacy MET in children, nationwide use in children is low among potential candidates for MET. For children with ureteral calculi, only year of diagnosis was a significant factor associated with MET use. No difference in unplanned physician visits or surgical interventions was noted. Most notable, however, was the low rate of follow-up imaging within 90 days for children presenting acutely with UUTC.

CONCLUSIONS

Use of MET for children with ureteral calculi is increasing, although still fewer than a third of children considered potential candidates receive this treatment. Follow-up imaging is not obtained for many children with ureteral calculi. Future work is needed to standardize management and follow-up protocols for children with acute renal colic.

Silodosin in the treatment of distal ureteric stones in children: A prospective, randomised, placebo-controlled study

Objectives

To evaluate the possible role of silodosin (a highly selective α_1A-adrenoceptor antagonist) in facilitating the passage of distal ureteric stones (DUS) in children, as the role of α-blockers as medical expulsive therapy is well known in adults.

Patients and methods

In all, 40 paediatric patients (27 boys and 13 girls) diagnosed with unilateral, single, radiopaque DUS of <10 mm were included in the study. Their mean (SD, range) age was 8.1 (2.7, 5–17) years. The patients were randomly divided into two groups: Group A, received silodosin 4 mg as a single bedtime dose; and Group B, received placebo as a single bedtime dose. Ibuprofen was prescribed to both groups on-demand for pain episode relief. Patients were followed up biweekly for 4 weeks. The stone expulsion time and rate, pain episodes, analgesic use, and any adverse effects were recorded.

Results

The mean (SD) stone size in Group A was 6.6 (1.7) mm and in Group B was 6.7 (1.4) mm (P = 0.4). Two patients were lost to follow-up (one from each group), and one patient in Group A refused to complete the study. The stone-free rate at end of the 4-week treatment period was 88.8% in Group A vs 73.6% in Group B (P = 0.4). The mean (SD) stone expulsion time was 7.0 (4.3) vs 10.4 (4.7) days in groups A and B, respectively (P = 0.02). The mean (SD) number of pain episodes requiring ibuprofen was 2.3 (1.4) vs 4.7 (2.6) episodes in groups A and B, respectively (P < 0.001). Adverse effects (headache and dizziness) were recorded in three patients (16.7%) in Group A, which were mild and none of them discontinued treatment, whilst no adverse effects were recorded in Group B.

Conclusions

The data in the present study show that silodosin can be safely used in the treatment of DUS in children for decreasing time to stone expulsion, pain episodes, and analgesic requirement.

[S2k guidelines on diagnostics, therapy and metaphylaxis of urolithiasis (AWMF 043/025) : Compendium]

Every tenth German citizen will suffer from at least one urinary calculus during the lifetime. The diagnostics, treatment and follow-up treatment of urolithiasis are, therefore, part of the daily routine practice for all urologists in hospitals and private practices as well as in many other disciplines, such as general practitioners, internists, nephrologists and pediatricians. Although the diagnostics and therapy have experienced substantial alterations over the last 10 years, the possibilities of metabolic diagnostics and secondary prevention for patients at risk are, unfortunately and unjustly, in many places very poorly represented. The present S2k guidelines, which for the first time were established in an interdisciplinary consensus process, represent the current practical recommendations and, whenever possible, use tables and algorithms in order to facilitate easy reference in the routine daily work. Last but not least, this greatly simplifies the measures for metaphylaxis.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

The efficacy and safety of adrenergic alpha-antagonists in treatment of distal ureteral stones in pediatric patients: A systematic review and meta-analysis

OBJECTIVE

We carried out a systematic review and meta-analysis to evaluate the efficacy and safety of adrenergic alpha-antagonists as a medical expulsive therapy for ureteral stones in pediatric patients.

METHODS

The PubMed, EMBASE and Cochrane Controlled Trials Register databases were searched up to January 2016. All randomized controlled trials and all cohort studies in which patients were randomized to receive either adrenergic alpha-antagonists or placebo for ureteral stones were identified. The outcome measures assessed were overall stone expulsion rate (primary), expulsion time (secondary), and treatment-emergent adverse events.

RESULTS

Five trials with a total of 406 pediatric patients met the inclusion criteria. According to the doses of adrenergic alpha-antagonists, the pooling effects of adrenergic alpha-antagonists were analyzed, with a higher expulsion rate obtained than in controls, the stone expulsion rate (OR=2.70, 95% CI 1.49 to 4.91, P=0.001). Adrenergic alpha-antagonists statistically did not significantly decrease the number of the stone expulsion time with the placebo, the stone expulsion time (SMD=-4.65, 95% CI -9.76 to 0.45, P=0.07). Safety assessments included common treatment-emergent adverse events (TEAEs) (OR=2.01, 95% CI 0.74 to 5.48, P=0.17). Compared with placebos, there was a higher stone expulsion rate with the adrenergic alpha-antagonists; in addition, fewer adverse effects were observed.

CONCLUSIONS

This meta-analysis may suggest that adrenergic alpha-antagonists are a safe and effective medical expulsive therapy choice for ureteral stones in pediatric patients. As the level of classification of evidence-based medicine, the level of evidence of our article is Ia. But it remains to need a large-scale multicenter randomized controlled study to be further confirmed.

LEVEL OF EVIDENCE

The level of evidence of our study is V.

Clinical effectiveness in the diagnosis and acute management of pediatric nephrolithiasis

The incidence of pediatric nephrolithiasis has risen over the past few decades leading to a growing public health burden. Children and adolescents represent a unique patient population secondary to their higher risks from radiation exposure as compared to adults, high risk of recurrence, and longer follow up time given their longer life expectancies. Ultrasound imaging is the first-line modality for diagnosing suspected nephrolithiasis in children. Although data is limited, the best evidence based medicine supports the use of alpha-blockers as first-line MET in children, especially when stones are small and in a more distal ureteral location. Surgical management of pediatric nephrolithiasis is similar to that in adults with ESWL and URS first-line for smaller stones and PCNL reserved for larger renal stone burden. Clinical effectiveness in minimizing risks in children and adolescents with nephrolithiasis centers around ED pathways that limit CT imaging, strict guidance to ALARA principles or use of US during surgical procedures, and education of both patients and families on the risks of repeat ionizing radiation exposures during follow up and acute colic events.

Pediatric Kidney Stones - Avoidance and Treatment

Pediatric stone disease is increasing in incidence and healthcare costs. With more years at-risk for stone recurrence during their lifetimes, children with nephrolithiasis constitute a high-risk patient population that requires focused intervention through both medical and surgical means. Through high-quality future studies to compare methods of stone prevention and treatment, the burden of stone disease on the youngest members of society may be ameliorated.

An Evaluation of the Efficacy of Selective Alpha-Blockers in the Treatment of Children with Neurogenic Bladder Dysfunction--Preliminary Findings

The aim of this study was to assess the usefulness of selective α1-blockers in children with neurogenic urinary tract dysfunctions and increased leak point pressure (LPP). 14 children from age 6 to 16 years with neurogenic urinary tract dysfunctions (neurogenic bladder) and LPP > 40 cm H₂O were enrolled in the study. All patients received a selective α1-blocker (doxazosin) for 6-8 weeks with an initial dosage of 0.03 mg/kg. During the observation period the continuation of oral anticholinergics, Clean Intermittent Catheterization (CIC), observation of "urinary dryness" and urinary incontinence periods were recommended. Patients were scheduled for a follow-up visit and urodynamic investigation after 6-8 weeks after the doxazosin therapy was started. In 4 patients, urine leakage occurred at lower pressures; in 9 patients, no significant changes in urine leak point pressures were detected; in 3 patients, there was a significant increase in the bladder capacity; in one patient, deterioration in continence was noted. The differences both in LPP and LPV before and after the treatment were not statistically significant. Our observations are consistent with the conclusions from other studies and showed no evident efficacy of doxazosin in children with neurogenic bladder.

Is Tamsulosin Effective after Shock Wave Lithotripsy for Pediatric Renal Stones? A Randomized, Controlled Study

PURPOSE

We assessed the effect of tamsulosin as an adjunctive therapy after shock wave lithotripsy for pediatric single renal pelvic stones.

MATERIALS AND METHODS

A total of 120 children with a unilateral single renal pelvic stone were included in a prospective randomized, controlled study. All children were randomized to 2 equal groups. Group 1 received tamsulosin (0.01 mg/kg once daily) as adjunctive therapy after shock wave lithotripsy in addition to paracetamol while group 2 received paracetamol only. Stone clearance was defined as no renal stone fragments or fragments less than 3 mm and no pelvicalyceal system dilatation.

RESULTS

Our study included 69 boys and 51 girls with a median age of 3.5 years and a median stone size of 1.2 cm. There was no statistically significant difference between groups 1 and 2 in stone or patient criteria. Of the children 99 (82.5%) achieved stone clearance after the first session, including 50 in group 1 and 49 in group 2. All children in each group were cleared of stones after the second session. The overall complication rate was 14.2%. There was no statistically significant difference between single session stone clearance rates (p = 0.81) and complications rates (p = 0.432) in either group. On multivariate analysis using logistic regression smaller stone size (p = 0.016) and radiopaque stones (p = 0.019) were the only predictors of stone clearance at a single shock wave lithotripsy session. Tamsulosin therapy did not affect stone clearance (p = 0.649).

CONCLUSIONS

Tamsulosin does not seem to improve renal stone clearance. Smaller and radiopaque renal stones have more chance of clearance after shock wave lithotripsy for pediatric single renal pelvic stones.

Outcomes of Ureteroscopic Management of Pediatric Urolithiasis: A Comparative Analysis of Prepubertal and Adolescent Patients

OBJECTIVE

To compare the outcomes of ureteroscopic intervention in terms of both the stone-free rate and complications in both prepubertal and adolescent patients. Although safety of pediatric ureteroscopic intervention is well established, a comparative outcome of prepubertal and adolescent patients is lacking.

MATERIALS AND METHODS

Pediatric patients who underwent ureteroscopic treatment of a renal or ureteral stone at our institution from July 2005 to August 2014 were retrospectively identified. Patients were classified by age either as prepubertal (≤11 years) or adolescent (>11 years) for purposes of comparison. Demographic and intraoperative variables as well as 30-day postoperative complication rates were compared between groups. Data were analyzed using χ(2) and Fisher's exact tests as appropriate.

RESULTS

A total of 104 patients were identified, of whom 64 (62%) were prepubertal and 40 (38%) were adolescent. Ureteroscopic failure occurred in a minority of patients (5% vs 4.7%, P > .9). Complication rates including ureteral perforation (0% vs 1.6%, P > .9), postoperative urinary tract infection (2.5% vs 4.7%, P > .9), hematuria with clot passage (0% vs 7.8%, P = .15), and persistent flank pain (15% vs 17%, P = .85) were not significantly different between adolescent and prepubertal patients, respectively.

CONCLUSION

In spite of small size and small body habitus, the ureteroscopic management of pediatric urolithiasis can be performed successfully in both the prepubertal and adolescent patients with acceptable and equivalent morbidity as well as successful clearance of stone.

Medical expulsive therapy for pediatric urolithiasis: Systematic review and meta-analysis

OBJECTIVE

Kidney stone disease has become more common among children and young adults. Despite its well-documented success in adults, published success rates of medical expulsive therapy (MET) for pediatric urolithiasis vary widely. Our objective was to determine whether the aggregated evidence supports the use of MET in children.

METHODS

We searched the Cochrane Controlled Trials Register, clinicaltrials.gov, MEDLINE, and EMBASE databases, and recently presented meeting abstracts for reports in any language. In addition, the bibliographies of included studies were then hand-searched. The protocol was prospectively registered at PROSPERO (CRD42013005960). Inclusion criteria were children (aged ≤ 18 years) with urolithiasis treated with medications with the specific goal of increasing spontaneous stone passage rate, including but not limited to alpha-adrenergic blockers (e.g., tamsulosin or doxazosin), calcium channel blockers (e.g., nifedipine), or other adjuvant medications (e.g., steroids or tolterodine). Manuscripts were then assessed and data abstracted in duplicate, with differences resolved by the senior author. Risk of bias was assessed using standardized instruments. Descriptive statistical analyses were performed as appropriate.

RESULTS

We identified 11,197 studies, five of which (3 randomized controlled trials, 2 retrospective cohorts) were included in the pooled meta-analysis. Although we found little evidence of significant publication bias, we were unable to assess the likelihood of other forms of bias (allocation, selection) for most included studies due to reporting limitations. The pooled results demonstrate that MET significantly increased the odds of spontaneous stone passage (OR 2.21, 95% CI 1.40-3.49). Between-study heterogeneity was not statistically significant (I(2) = 14%, p = 0.36). Bivariate meta-regression models revealed no significant association between the likelihood of stone passage and study COI (p = 0.9), study country (p = 0.7), patient age (p = 0.4), patient gender (p = 0.4), duration of follow-up (p = 0.3), or stone size (p = 0.7). Side effects of MET were reported to be minimal. Relatively few patients reported any adverse effects at all; the most commonly reported issue was somnolence. Concerns about biases affecting the published outcomes of the included studies exist due to the low quality of the randomized controlled trials reviewed for analysis. However, there was little visual evidence of publication bias noted on the funnel plot, as confirmed by the Begg test (p = 0.5).

CONCLUSIONS

Consistent with the adult literature, pediatric studies demonstrate that treatment with MET results in increased odds of spontaneous ureteral stone passage and a low rate of adverse events. Although the accumulated literature is limited by inconsistent and/or incomplete reporting, there is nonetheless a clear, cumulative positive effect of MET on stone passage among children. The available evidence thus supports a prominent role for MET in treatment algorithms for pediatric urolithiasis.

The use of alpha-1 adrenergic blockers in children with distal ureterolithiasis: a systematic review and meta-analysis

INTRODUCTION

Urinary lithiasis is the main urologic cause of emergency treatment in adult patient. In the past years, the incidence in children population has increased. However, literature about the use of alpha-1 adrenergic blockers in pediatric population with distal ureterolithiasis is still scarce. The drug acts by decreasing ureter contractions, especially in the distal portion, facilitating calculus expulsion.

OBJECTIVE

This review has the objective to evaluate the use of alpha-1 adrenergic blockers as medical expulsive treatment in children with distal ureterolithiasis.

EVIDENCE ACQUISITION

An electronic literature search was performed using the MEDLINE, COCHRANE, and LILACS databases. We further searched manually the references of the primary studies. Searches were concluded on October 4th, 2014. Articles were selected, independently and in pairs, by the respective titles and summaries. Any divergence was resolved by consensus.

EVIDENCE SYNTHESIS

Alpha-1 adrenergic antagonists increased the probability of calculus expulsion by 27% (NNT=4). Calculi smaller than 5mm, increased by 33% (NNT=3). Larger than 5mm, increased by 34% (NNT=3).

CONCLUSION

Alpha-1 adrenergic blocker use is related with a greater incidence of expulsion of ureteral calculi, smaller or greater than 5mm, and fewer episodes of pain when compared to ibuprofen. However it is necessary larger samples to enhance the power analysis of the expulsion of ureteral calculi larger than 5mm and the episodes of pain.

PATIENT SUMMARY

This review analyzed the outcome of alpha adrenergic antagonist in children with ureteral calculi. We conclude that it is the best medicine for use, since it helps the expulsion of the stone.

Medical expulsive treatment in pediatric urolithiasis

The frequency of stone disease in childhood ranges between 0.1-5 percent. Stone disease occurs as a result of enviromental, metabolic, anatomical, infectious and nutritional factors. Percutaneous nephrolitotomy, uretherorenoscopy, laparoscopic surgery, open surgery and extracorporeal shock wave lithothripsy are treatment alternatives for stone disease during childhood. However, these methods are not completely innocent. Some complications may occur after these procedures. These procedures are generally not cost- effective. Even invasive procedures have high success rates, so medical expulsive treatment modalities have become an alternative for a group of patients. Nonsteroidal anti- inflammatory drugs, antimuscarinic drugs, phospodiesterase type 5 inhibitors, steroids, calcium channel blockers and alpha blockers are treatment alterneatives used for this modality in the literature. The drug is chosen according to the location, size, and composition of the stone, recent technology, cost, surgeon's experience and surgeon's and the parents' preferences. In this review article the following topics will be discussed such as "Why medical expulsive treatment is needed during childhood? Which drug should be chosen for which stone type? How long should a treatment of urolithiasis last?

Efficacy and safety of tamsulosin as a medical expulsive therapy for stones in children

OBJECTIVES

To evaluate the efficacy of tamsulosin for promoting ureteric stone expulsion in children, based on the confirmed efficacy of tamsulosin as a medical expulsive therapy in adults.

PATIENTS AND METHODS

From February 2010 to July 2013, 67 children presenting with a distal ureteric stone of <1 cm as assessed on unenhanced computed tomography were included in the study. The patients were randomised into two groups, with group 1 (33 patients) receiving tamsulosin 0.4 mg and ibuprofen, and group 2 (34) receiving ibuprofen only. They were followed up for 4 weeks. Endoscopic intervention was indicated for patients with uncontrolled pain, recurrent urinary tract infection, hypersensitivity to tamsulosin and failure of stone passage after 4 weeks of conservative treatment.

RESULTS

Sixty-three patients completed the study. There were no statistically significant differences between the groups in patient age, body weight and stone size, the mean (SD) of which was 6.52 (1.8) mm in group 1 vs. 6.47 (1.79) mm in group 2 (P = 0.9). The mean (SD) time to stone expulsion in group 1 was 7.7 (1.9) days, vs. 18 (1.73) days in group 2 (P < 0.001). The analgesic requirement (mean number of ketorolac injections) in group 1 was significantly less than in group 2, at 0.55 (0.8) vs. 1.8 (1.6) (P < 0.001). The stone-free rate was 87% in group 1 and 63% in group 2 (P = 0.025).

CONCLUSIONS

Tamsulosin used as a medical expulsive therapy for children with ureteric stones is safe and effective, as it facilitates spontaneous expulsion of the stone.

Ureteroscopy for treatment of upper urinary tract stones in children: technical considerations

The incidence of pediatric urolithiasis is increasing. While many smaller stones may pass spontaneously, surgical therapy is sometimes warranted. Surgical options include shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery. Ureteroscopy represents a minimally invasive approach, and it is increasingly being used to treat pediatric upper tract calculi. Ureteroscopy is performed under anesthesia and fluoroscopic guidance, with basket extraction or lithotripsy of the calculi. Technical considerations include active or passive ureteral dilatation, the use of ureteral access sheaths for larger stone burdens, and post-operative stent placement. The current pediatric literature suggests high success rates (equal to or surpassing shock wave lithotripsy) and low complication rates. However, concerns remain regarding feasibility in patients with variant anatomies and risk due to intra-operative radiation exposure.

Evaluation and medical management of kidney stones in children

PURPOSE

We review the current literature on the diagnostic evaluation and dietary and pharmacological management of children with nephrolithiasis.

MATERIALS AND METHODS

We searched MEDLINE(®), Embase(®) and the Cochrane Library from their inceptions to March 2014 for published articles in English on kidney stones and therapy in children 0 to 18 years old. Based on review of the titles and abstracts, 110 of the 1,014 articles (11%) were potentially relevant to the diagnostic evaluation and medical management of nephrolithiasis in children. We summarized this literature and drew on studies performed in adult populations to augment areas in which no studies of sufficient quality have been performed in children, and to highlight areas in need of research.

RESULTS

During the last 25 years the incidence of nephrolithiasis in children has increased by approximately 6% to 10% annually and is now 50 per 100,000 adolescents. Kidney stones that form during childhood have a similar composition to those that form in adulthood. Approximately 75% to 80% of stones are composed of predominantly calcium oxalate, 5% to 10% are predominantly calcium phosphate, 10% to 20% are struvite and 5% are pure uric acid. The recurrence rate of nephrolithiasis in patients with stones that form during childhood is poorly defined. Ultrasound should be used as the initial imaging study to evaluate children with suspected nephrolithiasis, with noncontrast computerized tomography reserved for those in whom ultrasound is nondiagnostic and the suspicion of nephrolithiasis remains high. Current treatment strategies for children with kidney stone disease are based largely on extrapolation of studies performed in adult stone formers and single institution cohort or case series studies of children. Tamsulosin likely increases the spontaneous passage of ureteral stones in children. Increased water intake and reduction of salt consumption should be recommended for all children with a history of kidney stones. Potassium citrate is a potentially effective medication for children with calcium oxalate stones and concomitant hypocitraturia, as well as children with uric acid stones. However, long-term compliance with therapy and the effect on decreasing stone recurrence in children are unknown. Based largely on efficacy in adult populations, thiazide diuretics should be considered in the treatment of children with calcium based stones and persistent hypercalciuria refractory to reductions in salt intake.

CONCLUSIONS

The incidence of kidney stone disease in children is increasing, yet few randomized clinical trials or high quality observational studies have assessed whether dietary or pharmacological interventions decrease the recurrence of kidney stones in children. Collaborative efforts and randomized clinical trials are needed to determine the efficacy and effectiveness of alternative treatments for children with nephrolithiasis, particularly those with calcium oxalate stones and concomitant hypercalciuria and hypocitraturia. Additional areas in need of study are the optimal length of time for a trial of stone passage in children, the cost-effectiveness of medical expulsive therapy vs analgesics alone, and the size and location of stones for which medical expulsive therapy is most effective.