Flexible ureteroscopy and lasertripsy (FURSL) for paediatric renal calculi: results from a systematic review

Factors effecting the success of retrograde intrarenal surgery in pediatric patients with renal stones: The experience of two tertiary centres with 368 renal units

INTRODUCTION AND OBJECTIVES

Currently, in the field of pediatric urology, the primary aim of surgical approaches for the treatment of renal stone disease is to provide a stoneless state through minimally invasive methods, and to prevent the damage that such stones may cause in the urinary system and stone recurrence. The aim of this study was to evaluate the efficacy and safety of RIRS and the factors affecting its success in the surgical treatment of renal stones in pediatric patients.

METHODS

Data from 357 pediatric and 368 renal units were collected retrospectively. The recorded parameters were age, gender, location and burden of the stone, and presence of postoperative residual stones.

RESULTS

The stone location was the upper pole in 28 (7.6 %) patients, the middle pole in 44 (12 %), the pelvis in 98 (26.6 %), the lower pole in 139 (37.8 %), and multiple locations in 59 (16 %) patients. A stoneless state was achieved in 277 (75.3 %) units, while 91 units (24.7 %) had residual stones at the end of the first month. In the multivariate analysis, the development of residual stones was found to be significantly associated with age (odds ratio [OR], 1.123; p = 0.012) and stone location (OR, 3.142; p = 0.018).

DISCUSSION

RIRS is an endourological procedure with a high success rate in the achievement of a stoneless state in both pediatric and adult age groups, with an 82-100 % success rate reported in various studies. A full stoneless state was achieved in 277 (75.3 %) units after the initial RIRS in the present study, and full stone clearance was achieved in 304 units after the second RIRS session, with a success rate of 82.6 %. A limitation of our study is that it was not performed by a single surgeon, and stone samples could not be taken from all patients for stone analysis.

CONCLUSION

RIRS has also been associated with a high success rate in the endoscopic treatment of renal stones and is an efficient and safe method with a minimal rate of complications, especially in the pediatric age group.

Urological Guidelines for Kidney Stones: Overview and Comprehensive Update

BACKGROUND

Evidence-based guidelines are published by urological organisations for various conditions, including urolithiasis. In this paper, we provide guidance on the management of kidney stone disease (KSD) and compare the American Urological Association (AUA) and European Association of Urologists (EAU) guidelines.

METHODS

We evaluate and appraise the evidence and grade of recommendation provided by the AUA and EAU guidelines on urolithiasis (both surgical and medical management).

RESULTS

Both the AUA and EAU guidelines provide guidance on the type of imaging, treatment options, and medical therapies and advice on specific patient groups, such as in paediatrics and pregnancy. While the guidelines are generally aligned and based on evidence, some subtle differences exist in the recommendations, but both are generally unanimous for the majority of the principles of management.

CONCLUSIONS

We recommend that the guidelines should undergo regular updates based on recently published material, and while these guidelines provide a framework, treatment plans should still be personalised, respecting patient preferences, surgical expertise, and various other individual factors, to offer the best outcome for kidney stone patients.

Role of Preoperative Ureteral Stent on Outcomes of Retrograde Intra-Renal Surgery (RIRS) in Children. Results From a Comparative, Large, Multicenter Series

OBJECTIVE

To assess outcomes of pre-stenting versus non-pre-stenting in children undergoing retrograde intrarenal surgery (RIRS) for intrarenal stones.

METHODS

Children/adolescent with kidney stones undergoing RIRS in 9 centers between 2015 and 2020 were retrospectively reviewed.

EXCLUSION CRITERIA

ureteral lithotripsy, bilateral procedures. Stone-free status was evaluated at 3-month and defined as a single residual fragment (RF) ≤2 mm/absence of multiple fragments. Patients were divided into two groups (Group 1 no-prestenting; Group 2 prestenting). Student's, Chi-square and Fisher's exact test was used to assess difference between groups. Univariable and multivariable logistic regression analysis were performed to predict RF. Statistical significance: P-value <0.05.

RESULTS

Three hundred eighty-nine children/adolescents were included (192 patients in Group 1). Prestented patients were younger compared with non-prestented (mean age 8.30 ± 4.93 vs 10.43 ± 4.30 years, P < 0.001). There were no differences in stone characteristics (number, size, locations). Lasing and total surgical time were similar. Urinary tract infections were more prevalent in Group 2 (10.7%) compared to Group 1 (3.7%, P = 0.016). Sepsis occurred in 2.1% of patients in Group 2 and no patient in Group 1 (P = 0.146). 30.7% patients in Group 1 and 26.4% in Group 2 had RF (P = 0.322). In univariate logistic regression analysis, stone size was associated with RF (OR 1.12 95%CI 1.06-1.18, P < 0.001), whereas Thulium fiber laser with a lower incidence (OR 0.24 95%CI 0.06-0.69, p=0.020). Multivariate logistic regression analysis showed that stone size was associated with RF (OR 1.20 95%CI 1.08-1.36, P = 0.001).

CONCLUSIONS

RIRS showed similar stone-free rate in pre and non-prestented children/adolescents, although prestented patients were younger. A higher risk of post-operative infections was reported in prestented patients.

Comparison of single-use flexible ureteroscopes with a reusable ureteroscope for the management of paediatric urolithiasis

INTRODUCTION

To compare the efficacy, side effects, and cost-effectiveness between a single-use digital flexible ureteroscope and a reusable flexible ureteroscope in the treatment of paediatric renal stones.

METHODS

This analytic, case-control, monocentric study included all patients undergoing flexible ureterosopies for stone treatment. Between April 2016 and February 2019, a reusable (Flex-X^C®, Karl Storz) flexible ureteroscope was used (control group), whereas a single-use (Uscope®, PUSEN Medical©) flexible ureteroscope was used in all procedures from March 2019 to April 2021. Clinical and procedural outcomes, operative times, complication rates, hospital stay, and costs per procedure were evaluated.

RESULTS

Forty-three cases using a reusable flexible ureteroscope and thirty-nine using a single-use flexible ureteroscope were included in the study. Demographic patient characteristics, stone burden, location and composition, preoperative presence of a double-J stent, procedural outcomes, mean length of postoperative hospital stay, and complications (4.6% versus 5%, p = 0.81) were comparable between the two groups. Median operative duration for stone removal was 93 min (20-170) with reusable versus 81 min (55-107) with the single-use scope (p = 0.18). Scope failure occurred four times with the reusable scope and in no case with the single-use. The total cost per procedure associated with the use of single-use scopes (798 Euros) was lower than a reusable scope (1483.23 Euros).

DISCUSSION

Single-use flexible ureteroscopes were created to bypass the problems incurred when reusable scopes were damaged and therefore not available for use in surgical procedures. Single-use flexible ureteroscopes are always immediately available and ready to be used, even in urgent cases, as they typically do not require maintenance or sterilization. Compared with their reusable counterparts, single-use flexible ureteroscopes have similar digital performance (270°), image quality and we found no difference in the success and complication rates. Cost analysis of a reusable flexible ureteroscope must consider the purchase price, maintenance and repair costs, and decontamination costs (including handling, detergent, bacterial culture, transportation, and storage costs). In contrast, only purchase price is included in cost analysis for single-use flexible ureteroscopes. Our study suggests that single-use flexible ureteroscopes may be associated with lower costs per procedure than their reusable counterparts.

CONCLUSION

Single-use flexible ureteroscopes are an interesting alternative to their reusable counterparts, particularly in terms of material resource management. Cost analyses conducted using a low volume of cases representative of a paediatric urology division favour the use of single-use ureteroscopes.

Outcomes of ureteroscopy for management of stone disease in early and late childhood over a 15-year period

Background

Although paediatric ureteroscopy is widely performed, there is still a lack of data and outcomes in early childhood. In this two-centre study, we compared the outcomes of ureteroscopy for stone disease management in early and late childhood and provide outcomes for the same.

Methods

Data was retrospectively collected on consecutive patients from two tertiary paediatric endo-urology European centres over a 15-year period (2006-2021). Patients were split into two groups, namely, early childhood (age ⩽ 9 years) and late childhood (age 9 to ⩽16 years). Outcomes including stone-free rate (SFR) and complications were compared between these two groups.

Results

A total of 148 patients underwent 184 procedures (1.2 procedure/patient) during the study period (66 in early childhood and 82 in late childhood). The mean age in early and late childhood groups were 5.6 and 13.3 years, and a male: female ratio of 1.6:1 and 1.1:1, respectively. The SFR and complications in early and late childhood groups were 87.8% and 90.2% (p = 0.64) and 5.7% and 4.1%, respectively.

Conclusion

Paediatric ureteroscopy and laser stone fragmentation achieves good results in both early and late childhood with comparable SFRs, although the complications and need for second procedure were marginally higher in the early childhood group. Our study would set up a new benchmark for patient counselling in future, and perhaps this needs to be reflected in the paediatric urolithiasis guidelines.

Role of Pediatric Ureteral Access Sheath and Outcomes Related to Flexible Ureteroscopy and Laser Stone Fragmentation: A Systematic Review of Literature

Context

Flexible ureteroscopy and laser lithotripsy (FURSL) represent a good treatment option for pediatric urolithiasis. Scarce evidence is available about the safety and efficacy of the concomitant use of a ureteral access sheath (UAS) in the setting of pediatric ureteroscopy (URS).

Objective

To acquire all the available evidence on UAS usage in pediatric FURSL, focusing on intra- and postoperative complications and stone-free rates (SFRs).

Evidence acquisition

We performed a systematic literature research using PubMed/MEDLINE, Embase, and Scopus databases. The inclusion criteria were cohorts of pediatric patients <18 yr old, submitted to URS for FURSL, reporting on more than ten cases of UAS placement. The primary outcomes were prestenting rates, operating time, ureteric stent placement rates after surgery, rates and grades of complications, ureteral injuries, and overall SFR. A total of 22 articles were selected.

Evidence synthesis

In total, 26 intraoperative and 130 postoperative complications following URS with UAS placement were reported (1.8% and 9.18% of the overall procedures, respectively). According to the Clavien-Dindo classification, 32 were classified as Clavien I, 29 as Clavien II, 43 as Clavien I or II, six as Clavien III, and one as Clavien IV. Twenty-one cases of ureteral injuries (1.59%) were noted in the whole cohort; most of them were ureteral perforation or extravasation, and were treated with a temporary indwelling ureteric stent. The overall SFR after a single URS procedure was 76.92%; after at least a second procedure, it was 84.9%.

Conclusions

FURSL is a safe and effective treatment option for pediatric urolithiasis. UAS use was associated with a low rate of ureteric injuries, mostly treated and resolved with a temporary indwelling ureteric stent.

Patient summary

We performed a systematic literature research on the utilization of a UAS during ureteroscopy for stone treatment in pediatric patients. We assessed the outcomes related to the rates of intra- and postoperative complications and the rates of efficacy of the procedure in the clearance of stones. The evidence shows a low rate and grade of complications associated with UAS placement and good stone-free outcomes. A ureteric injury may occur in 1.6% of cases, but it is usually managed and resolved with a temporary indwelling ureteric stent.

Retrograde Intrarenal Surgery (RIRS) for upper urinary tract stones in children below 12 years of age: A single centre experience

OBJECTIVE

Retrograde Intra Renal Surgery (RIRS) is a minimally invasive surgical modality for the treatment of renal stones. We evaluated the efficacy of RIRS in children below aged 12 years of age in the form of stone-free rate (SFR), complications and the feasibility of the procedure.

MATERIALS AND METHODS

This retrospective study included all children ≤ 12 years of age, with upper urinary tract stones single or multiple ≤ 15 mm in size who underwent RIRS between February 2019 to November 2021. RIRS was performed with 7.5 Fr flexible ureterorenoscope over the guidewire, the stones were dusted with Laser and the ureteral stent was left after RIRS. All patients had the post-procedure stent removed within 3 weeks after checking for residual stones with X-ray and ultrasonography of Kidney-Ureter-Bladder (USG-KUB). Follow-up USG KUB was done at 4 months.

RESULTS

15 patients included in our study met the inclusion criteria. The mean age was 8.7 ± 2.8 years, the mean stone size was 11.26 ± 2.14 mm and 26.6 % had multiple stones. Retrograde access failure was noted in 36.3 % in non stented patients. The mean operative time was 72.6 ± 20 minutes, fluoroscopy time was 4.4 ± 0.9 minutes and the mean LASER time was 26 ± 3.9 minutes. The mean hospital stay was 2.8 ± 0.9 days. Ureteral access sheath (UAS) was used in one patient. Conversion to mini PCNL was done in one pre stented patient due to access failure and one patient had a second look RIRS for residual stone. No major complications were noted except onr patient who had sepsis. The stone-free rates were 93.3% after primary RIRS and 100% after second look RIRS.

CONCLUSIONS

RIRS is a feasible, safe procedure for pediatric upper urinary stones with excellent stone-free rates and a low rate of complications.

Primary hyperoxaluria type 1: urologic and therapeutic management

While the surgical approaches available in primary hyperoxaluria (PH) are common to all patients requiring intervention for urolithiasis, the indications for treatment and their corresponding toxicities are unique. Being a rare disease, we are guided by case series. This review summarizes the available literature highlighting the important disease-specific considerations. Shockwave lithotripsy (SWL) is of particular interest. It is generally the first-line treatment for stones in children, but here the stones produced will be relatively resistant to fragmentation. In addition, there are concerning reports in children of sudden unilateral decline in function in the treated kidney as measured by nuclear renography. Percutaneous nephrostolithotomy might intuitively seem favorable given the shortest drain duration and the ability to treat larger stones efficiently but, similar to SWL, rapid chronic kidney disease (CKD) progression has been seen postoperatively. Ureteroscopy is therefore generally the safest option, but considerations regarding stent encrustation, the growth of residual fragments and the large volume of stone often faced may limit this approach. The surgeon must balance the above with consideration of the patient's CKD status when considering a plan of monitoring and treating stones in PH.

Factors associated with the stone-free status after retrograde intrarenal surgery in children

INTRODUCTION

Paediatric urolithiasis has a recurrent nature because it is frequently associated with metabolic or anatomical disorders or infectious conditions. The rising incidence of the disease with its recurrent nature emphasises the need for minimally invasive therapeutic options. In this study, we aimed to evaluate efficacy and factors affecting the success of retrograde intrarenal surgery (RIRS) in children.

MATERIALS AND METHODS

Patients who underwent RIRS were evaluated retrospectively. Two different flexible ureteroscopes (F-URS) were used (7.5F F-URS and 7.95F with a 4.9F bullet-shaped tip). Irrespective of size, all residual fragments were considered as failure. Age, stone size, stone localisation, Hounsfield Unit (HU), stone-free rate (SFR) and complications were evaluated.

RESULTS

Forty-six patients (29 boys and 17 girls) with a median age of 70.5 months (6-214 months) were treated with RIRS between August 2014 and November 2019. The median operative time was 60 minutes (45-120 minutes). The median follow-up was 26 months (3-65 months). Fourteen patients had lower pole and 10 patients had multiple stones. Ureteral access sheath (UAS) was used in 16 (35%) patients. SFR was 61%. The median number of general anaesthesia was 2 (min 1, max 5). Auxiliary semirigid URS, PCNL and repeat RIRS were required in 4, 6 and 5 patients, respectively. Two patients had postoperative febrile urinary tract infection (UTI) as a complication. Age was associated with post-operative febrile UTI. Presence of stones with HU lower than 700, being operated 4.9F F-URS and without UAS were associated with better SFR.

CONCLUSIONS

RIRS is a minimally invasive method with low complication rates in the treatment of childhood stone disease. Higher stone-free rates are obtained in low HU stones and cases in which we used 4.9 F tip F-URS.

Role and importance of ergonomics in retrograde intrarenal surgery (RIRS): outcomes of a narrative review

BACKGROUND

With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy (fURS) to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments, and outline future directions and recommendations in order to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists.

METHODS

This study was carried out according to the PRISMA guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy (URS), retrograde intrarenal surgery (RIRS), laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data was consolidated for analysis.

RESULTS

A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analysed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS.

CONCLUSION

Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.

Retrograde intrarenal surgery for renal stones in children <5 years of age

Introduction

There are very few studies in the literature describing retrograde intrarenal surgery (RIRS) in preschool children. We have evaluated the feasibility, stone-free rate, and complications of RIRS in children <5 years of age.

Methods

All children <5 years of age and stone size <2 cm (renal/proximal ureteric), who underwent RIRS at our hospital from February 2010 to May 2020 were included in this retrospective study. All children were prestented for the passive dilatation of ureter. A 7.5 Fr flexible ureterorenoscope was introduced over the ureteral access sheath (UAS) or over a guidewire. At 2 weeks, the stent was removed and at 2 months the child was evaluated for residual stones.

Results

A total of 62 children with 67 renal units met the inclusion criteria. The mean age was 42.11 months (4-60 months). Mean weight was 13.31 kg (6-16.3 kg). Mean stone size was 11.9 mm (7.3-18.2 mm). Majority of the stones were in pelvis (37.8%). UAS 9.5/11.5 Fr was placed in 40 (63.5%) children. Mean operative time was 55.2 min; mean hospitalization was 61 h. Four out of the 67 renal units (5.9%) required conversion to minipercutaneous nephrolithotomy in the same sitting, due to access failure. Two cases who developed post-operative fever required a change of antibiotics. Two cases required ureteroscopy for steinstrasse postoperatively. Stone-free rate at 2 months for stones size ≤2 mm was 76.3%.

Conclusion

Pediatric RIRS is a promising option in young children as it offers acceptable stone-free rates and a low incidence of high-grade complications. However, it requires expertise and should be offered in tertiary care centres.

Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in the pediatric population: the initial experience of two tertiary referral centers

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is the gold-standard for complex renal stones treatment in the pediatric population. While the miniaturization of PCNL reduces the risk of bleeding, it can hinder surgical and functional outcomes. The aim of the study was to assess the safety and feasibility of semi-closed-circuit vacuum-assisted Mini-PCNL (vmPCNL) in pediatric patients.

METHODS

From January 2017 to December 2018, we prospectively collected data on consecutive vmPCNLs from two European tertiary referral centers. The procedure was performed with the ClearPetra^® (Well Lead Medical Co., Ltd., Guangzhou, China) access sheath equipped with a lateral arm connected to the aspiration system (pressure setting ~120-150 cmH<inf>2</inf>O) by a 200 Ml plastic stone collector. Pre-, intra- and postoperative data and costs were analyzed. The stone-free rate (SFR) was defined as absence of residual fragments >4 mm with either ultrasound or kidney, ureter, and bladder X-ray.

RESULTS

Eighteen vmPCNLs were performed in 16 renal units of 13 children. The median age was 119 months (IQR: 97-160) and the weight was 29 Kg (IQR: 25-40). The median cumulative stone size was 32 mm (22-46) with 8 (44.4%) cases of staghorn stones. The OT was 128 min (IQR: 99-167). The basketing was unnecessary in 6/18 (33%) cases. Neither intra-operative complications nor blood transfusions occurred. Postoperative fever was observed in 5/18 (27.8%) cases; in one case a double J ureteral stent was placed for concomitant hydronephrosis. The SFR was 81.3% (13/16), rising to 93.8% (15/16) after ancillary procedures. The materials costs of a vmPCNL (734.8 €) were comparable to mini-PCNL using a reusable set (710.7 €).

CONCLUSIONS

The vmPCNL seems to be sustainable, safe and feasible for kidney stones treatment in the pediatric population.

Minimally Invasive Treatment of Urolithiasis in Children: Evaluation of the Use of Flexible Ureterorenoscopy and Laser Lithotripsy

Urolithiasis is a multifactorial disease; in recent years, its incidence has gradually increased in pediatric age. Among the factors involved in urolithiasis pathophysiology, urinary tract anomalies and metabolic diseases are the most relevant, although ethnicity and environmental factors may have an important role. The advances in technology and miniaturization of endoscopic devices have permitted the use of Retrograde Intrarenal Surgery (RIRS) to treat kidney and ureteral stones. Nowadays, flexible ureterorenoscopy and laser lithotripsy, which are techniques that have been applied in the management of adult upper urinary tract disorders, are also used in children as a minimally invasive treatment of urolithiasis with encouraging, effective and safe results. The Authors report a retrospective review of their record of cases considering 21 pediatric urolithiasis treatment procedures performed between October 2017 and April 2019 in a total of 17 patients (10 males and 7 females). Six procedures involved the use of the flexible ureterorenoscope (FURS) while in 15 procedures the application of the laser fiber was used (FURSL). A case of laser lithotripsy for bladder stone was included. The average age of patients was 10.5 years (2-18 years). The renal pelvis dilatation pretreatment was evaluated in post-operative follow-up. From the evaluation of the sample in analysis, the use of RIRS has good results in the treatment of paediatric urolithiasis, emerging as a valid option in the management of the paediatric population in terms of efficacy and safety, with an improvement in patient outcomes.

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.

Safety and efficacy of ureteroscopy and stone fragmentation for pediatric renal stones: a systematic review

Flexible ureteroscopy (FURS) is now commonly used for the treatment of paediatric renal stones. We conducted a systematic review of literature looking at the outcomes of flexible ureteroscopy and laser lithotripsy (FURSL) for paediatric stone disease. A systematic review was conducted in a Cochrane style and in accordance PRISMA checklist using MEDLINE, CINAHL, EMBASE, Scopus, and Cochrane library for all English language articles in patients ≤18 years from 1990-2018 who underwent FURSL. A total of 11 studies reported on 431 patients, with a mean age of 8.5 years (range, 0.25-17 years). The mean stone size was 13 mm (range, 1.5-30 mm). The overall stone free rate (SFR) was 87% (58-100%) with a mean complication rate of 12.6% (n=55) (range, 0-31.3%) and 76% needing a post-operative ureteric stent insertion. Of the complications, Clavien I/II complications included fever and urinary tract infection (UTI) (n=19), haematuria (n=7), stent discomfort/stent symptoms/post-operative pain (n=8), voiding disturbance (n=2) and post-operative nausea and vomiting (n=1). Clavien III complications included ureteral injury which included perforation (n=6), urinoma (n=1), and acute urinary retention secondary to stone fragmentation (n=1). Clavien IV complications were urinoma (n=2) and no Clavien V complications were noted. Our review suggests that ureteroscopy and laser stone fragmentation for paediatric population is a safe and effective treatment with good SFR and a low risk of complications.

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.

Treatment of upper urinary tract stones with flexible ureteroscopy in children

INTRODUCTION

This single-centre, retrospective study aimed to assess the efficacy and safety of flexible ureteroscopy (FURS) combined with holmium laser lithotripsy in treating children with upper urinary tract stones.

METHODS

From June 2014 to October 2015, a total of 100 children (74 boys and 26 girls) with upper urinary tract stones were treated using FURS. A 4.7 Fr double-J stent was placed two weeks before operation. Patients were considered stone-free when the absence of residual fragments was observed on imaging studies. The preoperative, operative, and postoperative data of the patients were retrospectively analyzed.

RESULTS

A total of 100 pediatric patients with a mean age of 3.51±1.82 years underwent 131 FURS and holmium laser lithotripsy. Mean stone diameter was 1.49±0.92 cm. Average operation time was 30.8 minutes (range 15-60). The laser power was controlled between 18 and 32 W, and the energy maintained between 0.6 and 0.8 J at any time; laser frequency was controlled between 30 and 40 Hz. Complications were observed in 69 (69.0 %) patients and classified according to the Clavien system. Postoperative hematuria (Clavien I) occurred in 64 (64.0 %) patients. Postoperative urinary tract infection with fever (Clavien II) was observed in 8/113 (7.1%) patients. No ureteral perforation and mucosa avulsion occurred. The overall stone-free rate of single operation was 89/100 (89%). Stone diameter and staghorn calculi were significantly associated with stone-free rate.

CONCLUSIONS

FURS and holmium laser lithotripsy is effective and safe in treating children with upper urinary tract stones.

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.

Risk factors for repeat surgical intervention in pediatric nephrolithiasis: A Pediatric Health Information System database study

INTRODUCTION

Successful surgical therapy for pediatric upper urinary tract calculi (UUTC) minimizes the need for repeat surgical interventions. However, staged procedures, whether planned or unplanned, are sometimes necessary. We assessed predictors of repeat intervention for children with UUTC using a nationwide administrative dataset.

METHODS

Using the Pediatric Health Information System (PHIS) dataset, we assessed children with UUTC undergoing shock wave lithotripsy (SWL) or ureteroscopy (URS) for an index stone from January 2010 to June 2015. Primary outcome was additional treatment for nephrolithiasis within 90 days. Patient and procedural variables were assessed as potential risks for retreatment. Multivariable logistic regression models were used to compare the risk of retreatment adjusting for potential confounding factors.

RESULTS

A total of 2788 patients undergoing URS (2,216, 79.5%) and SWL (572, 20.5%) were identified. SWL, stenting at the index operation without pre-index stenting, chronic comorbidities, renal calculi, and age <5 years were independent risk factors for retreatment. Use of ureteral stenting, most commonly employed in URS, was also a strong predictor of retreatment. Odds for reintervention, adjusted by multivariate modeling, are shown in the Figure.

CONCLUSIONS

Adjusting for measured confounders, SWL is associated with a 2.6-fold higher risk of repeat stone-related interventions. Additional patient-related factors also increase likelihood of retreatment. Intra-operative stent placement is a strong predictor of retreatment, perhaps serving as a marker for complex cases or planned staged procedures. Prospective studies are needed to assess comparative effectiveness of SWL and URS and improve mono-therapeutic success for children with UUTC.

Combined use of flexible ureteroscopic lithotripsy with micro-percutaneous nephrolithotomy in pediatric multiple kidney stones

BACKGROUND

We investigated the clinical value of treating pediatric multiple kidney stones with extensive distribution using flexible ureteroscopic lithotripsy (FUL) combined with micro-percutaneous nephrolithotomy (micro-PNL).

PATIENTS AND METHODS

In total, 21 pediatric patients with multiple renal calculi between May 2016 and June 2017 received FUL combined with micro-PNL. The group included 13 boys and eight girls; the patients' mean age was 3.8 years (range 1-8 years). The maximum stone diameter ranged from 1.0 to 1.5 cm. FUL was first performed in the lithotomy position to fragment stones that were located in the renal pelvis, and upper and mid-renal calyx. Patients were then moved to a prone position, and micro-PNL was performed to treat lower pole stones that could not be reached by the flexible ureteroscope during FUL. Percutaneous renal access to the lower calyx was achieved using a 4.8F "all-seeing needle" with ultrasound guidance, and stone fragmentation was performed with a 200-μm holmium laser at different settings to disintegrate 1- to 2-mm fragments.

RESULTS

All 21 pediatric patients with multiple kidney stones underwent combined FUL and micro-PNL. The stone free rate (SFR) was 85.7% (18/21). The mean surgical time was 45 min (range 30-70 min). The mean volume of irrigation fluid used was 480 mL (range 300-1200 mL). The mean surgical time for FUL and micro-PNL was 31 min and 14 min, respectively, and the mean volume of fluid used for FUL and micro-PNL was 360 mL and 120 mL, respectively. According to the modified Clavien classification, grade 1 and 2 postoperative complications occurred in five and one patients, respectively. The mean decrease in the level of hemoglobin was 0.4 g/dL (0-0.7 g/dL), and no patients required a transfusion. The average hospital stay was 3 days (range 2-5 days).

CONCLUSION

Combined FUL and micro-PNL is a safe, effective, and minimally invasive operation to remove multiple renal calculi with extensive distribution in children in selected cases.

Ureteroscopy for paediatric calculi: The twin-surgeon model

We describe our 'Tips and tricks' of ureteroscopy and lasertripsy (URSL) for paediatric ureteric calculi. All regional referrals directed to the paediatric urologist are discussed in a formal stone multidisciplinary team (MDT) meeting with urologists, radiologists, and biochemical pathologist. A paediatric urologist (SG) and an experienced adult endourologist (BS) do these stone procedures jointly as a twin-surgeon team approach for each patient.

Trends of intervention for paediatric stone disease over the last two decades (2000-2015): A systematic review of literature

OBJECTIVE

To ascertain the publication trends of interventions for paediatric kidney stone disease (KSD) we conducted a systematic review of literature over the last 16 years.

PATIENTS AND METHODS

With a rise of paediatric KSD and related interventions, a systematic review using PubMed was done over the last 16 years for all published papers on 'Paediatric stone disease intervention - ureteroscopy (URS), shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), open stone surgery, and laparoscopic stone surgery'. The search was limited to English language articles with a published abstract, whilst case reports, animal and laboratory studies, were excluded. We also analysed the data in two time periods, period-1 (2000-2007) and period-2 (2008-2015).

RESULTS

During the last 16-years, 339 papers were published on paediatric stone disease intervention on PubMed. This included papers on URS (95), PCNL (97), SWL (102), open stone surgery (34) and laparoscopic stone surgery (11). During period-1 and period-2 there were 30 and 65 papers on URS, 16 and 81 papers on PCNL, 33 and 60 papers on SWL, nine and 25 papers on open surgery, respectively. When comparing the two periods, there were 92 published papers for all interventions in period-1 and this had risen almost threefold to 247 papers in period-2.

CONCLUSIONS

Our systematic review shows that intervention for KSD in the paediatric age group has risen over the last 8 years. Whilst URS, SWL, open surgery and laparoscopic surgery have all doubled, PCNL has risen fivefold reflecting an increase in the new minimally invasive PCNL techniques.

Extracorporeal shock wave lithotripsy (ESWL) monotherapy in children: Predictors of successful outcome

INTRODUCTION AND OBJECTIVES

Although extracorporeal shock wave lithotripsy (ESWL) is the first choice for pediatric renal calculi <2 cm, the success rate after the first session is low. This is in contrast to other minimally invasive procedures like percutanous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS), which have higher rates of success. Therefore, the present study sought to identify predictors of success after one session of ESWL.

PATIENTS AND METHODS

A prospective study including 100 children with renal stone burden <2 cm who underwent ESWL at the present institution. The success rate after the first session was analyzed, and the predictors of success were investigated. The success of ESWL monotherapy was defined by absence of any residual fragments after 3 months, on non-contrast spiral computerized tomography (NCCT) scan, without need of any additional intervention.

RESULTS

Between January 2013 and October 2015, 100 children were treated with a Dornier Gemini lithotripter at the present institution. The mean patients age and stone size were 6 years (range: 1.8-14) and 13.1 mm (range: 6-20), respectively. After one session, 47% of patients showed complete clearance 3 months postoperative, those patients versus those who required an additional session or auxiliary procedures were younger in age, with smaller stone size and lower density. On multivariate analysis, only patient age was an independent predictor of success (odds ratio (OR) 0.9; P < 0.001).

CONCLUSION

Patient's age was an important predictor for response after ESWL monotherapy: not only did children respond better than adults, but age was also an independent predictor within the pediatric group.

Extracorporeal Shockwave Lithotripsy Versus Flexible Ureteroscopy for the Management of Upper Tract Urinary Stones in Children

OBJECTIVE

To compare the efficacy and morbidity of extracorporeal shockwave lithotripsy (SWL) and flexible ureteroscopy (F-URS) for the management of upper tract urinary stones in children.

METHODS

All SWL and F-URS performed in children in a single institution between 2000 and 2014 were reviewed retrospectively. Only procedures performed to treat upper tract urinary stones (upper ureter or kidney) were included in this study. Preoperative and perioperative outcomes were compared between the SWL and F-URS groups. Univariate and multivariate logistic regression analyses were used to evaluate predictors of stone-free (SF) status.

RESULTS

Over the study period, 100 SWL and 46 F-URS were conducted in 69 children. The SWL and F-URS groups were comparable in terms of stone size (14.6 vs 13.2 mm, p = 0.32), but there were more multiple stones (31% vs 57%; p = 0.003) and lower pole calculi (14% vs 37%; p = 0.003) in the F-URS group. The SF rate after one procedure was almost two times higher in the F-URS group compared with the SWL group (37% vs 21%; p = 0.04) without increasing the complication rate (21.7% vs 16%; p = 0.31). Similar results were observed in the subgroup of single renal stones <20 mm (SF rates: 78.6% vs 50%; p = 0.06). In multivariate analysis, the use of F-URS vs SWL was a predictor of an SF status (odds ratio = 3.7; p = 0.02).

CONCLUSION

F-URS provides a higher single-session SF rate, despite more complex urinary stones (multiple, lower pole, etc.) and without increasing morbidity.

Ureteroscopy for stone disease: expanding roles in the modern era

INTRODUCTION

The prevalence of urolithiasis is increasing worldwide and is causing significant morbidity and cost to the healthcare systems. While ureteroscopy (URS) has been established as a treatment option, our review highlights the expanding role of URS for the management of more complex stones and patients in the modern era.

MATERIAL AND METHODS

Ureteroscopy has shown to have good outcomes with stone free rates (SFR) comparable to other treatment modalities. Relevant publications have been identified. Their findings were critically appraised and used to formulate clinically oriented conclusions.

RESULTS

The use of URS has increased and now includes URS management for large stones, bilateral stone disease, obesity, pregnancy, pediatrics, solitary kidney, horseshoe kidney and patients with a bleeding diathesis.

CONCLUSIONS

With advances in URS technique and technology, its role has expanded to offer treatment in difficult clinical scenarios with good outcomes.

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.

Ureteroscopy and laser stone fragmentation (URSL) for large (≥1 cm) paediatric stones: Outcomes from a university teaching hospital

INTRODUCTION

The treatment of large renal stones (≥1 cm) in paediatric patients is challenging. The usual treatment options include percutaneous nephrolithotomy (PCNL) or shockwave lithotripsy (SWL). There is a rise in the use of ureteroscopy and laser stone fragmentation (URSL) for paediatric stones; however, outcomes of treatment for large renal stones in this age group are still largely unknown.

OBJECTIVE

To investigate the outcome of URSL for large paediatric renal stones ≥1 cm treated at the present institution over the last 5 years.

METHODS

A retrospective review was performed of outcomes from the prospectively maintained stone database. Only paediatric patients undergoing ureteroscopic (rigid or flexible ureteroscopy (URS)) procedures for stones ≥1 cm were included. Patient demographics, operative details, stone burden, hospital stay, complications and stone clearance were recorded and analysed.

RESULTS

From April 2010 to June 2015, 18 paediatric patients with a mean age of 10.4 years (range 3.6-15) underwent 35 ureteroscopic procedures for large stones (≥1 cm). The stone location was in the kidney (n = 14), ureter (n = 1), and in both the kidney and ureter for the remaining three patients. Nine patients had multiple stones. There was a preceding history of PCNL in four patients, with one patient having URS combined with a PCNL. The mean follow-up was 2.7 years (range 0-5). A postoperative stent was inserted in 21 (60%) patients. The overall stone-free rate (SFR) was 89% for a mean of 1.8 procedures per patient (range 1-4) - see Summary Table below. There was an inability to access stone within a lower pole calyx in one patient, despite maximum deflection of the ureteroscope. No intra- or post-operative complications were noted, and mean hospital stay was 1.1 days (range 0-5).

DISCUSSION

Published papers in adult literature have shown that ureteroscopy and laser fragmentation (URSL) is a viable alternative to PCNL. Newer equipment and improved techniques have resulted in SFRs being comparable with PCNL. A recent systematic review reported an SFR of 91% for large adult stones (>2 cm) for a mean 1.45 procedures per patient, and an overall complication rate of 8.6%. The present study has also demonstrated excellent outcomes in the use of ureteroscopy and laser fragmentation for the management of large paediatric stones with no complications.

CONCLUSION

The results show that paediatric URSL for large stones achieves a good SFR with minimal morbidity and is a good treatment option in established endourological units.

Percutaneous Nephrolithotomy in Rare Bleeding Disorders: A Case Report and Review of the Literature

Surgery in patients with congenital or acquired coagulation defects has always been challenging and requires special care with a multidisciplinary approach. Percutaneous nephrolithotomy (PCNL) is a standard procedure performed in patients with kidney stones. Although prone to bleeding more than most of the widely performed surgical procedures, there are not much data regarding PCNL in patients with bleeding disorders or coagulation defects. There are only case reports or series with a small number of patients for the patients with common coagulation defects, including hemophilias. Moreover, there are no reports about PCNL in rare bleeding disorders. In this study, we reported a case referred for kidney stone treatment and diagnosed as Factor VII deficiency during preoperative evaluation. Because it is one of the rare bleeding disorders, we also reviewed the literature in this field.

Postural therapy for renal stones in children: A Rolling Stones procedure

INTRODUCTION

Despite many advances, the management of renal stones - especially lower caliceal stones (LCS) - remains a challenge. The gravity-dependent location of the lower calices hinders the spontaneous clearance of fragments, which can be a nidus for future growth and symptomatic recurrence. Currently, there is no standard adjunctive therapy to facilitate fragment passage.

OBJECTIVES

To report the safety and effectiveness of mechanical percussion diuresis and inversion (PDI) therapy for eliminating renal stones in children.

PATIENTS AND METHODS

Since November 2013, children with residual fragments (after shock wave lithotripsy or flexible ureteroscopy) or native symptomatic renal stones were prospectively included in a protocol of four PDI sessions. After giving written consent, the children drank 10 ml/kg of water 30 min before therapy. They then laid in a prone Trendelenburg position on a couch angled at 45° and received continuous 10-min mechanical percussion applied over the affected flank by a physiotherapist (Figure summary). Tolerance stone burden reduction and stone clearance were documented with ultrasound 4 weeks after the last session.

RESULTS

Seventeen participants, with a median age of 10.8 years (range 18 months to 18 years), received 82 PDI sessions performed over 22 months. The median stone diameter was 5 mm (range 3-9). All children tolerated the PDI therapy well. Over a median follow-up of 11 months (range 3-18), no significant adverse effects were noted. The overall stone-free rate was 65%. Four of the six patients with residual fragment passed their fragments. The patients who did not become stone free by PDI experienced a decrease in fragment size of 57% (range 34-71). The observance rate was 100%.

DISCUSSION

Many studies have demonstrated that the gravity-dependent position of the lower calyces appears to be an important factor limiting the clearance of LCS. Positioning patients with a degree of inversion in order to put the collecting system beyond the horizontal plane affected the LCS through gravitational force. Complications were rare. PDI appeared to save costs and have similar success rates as shock wave lithotripsy for native small renal stones in children.

CONCLUSION

PDI is safe and effective for facilitating gravity-dependent drainage of renal stones and provides an opportunity to treat children in a quick, non-invasive, economic, painless, non-radiative and diverting fashion. This therapy is a valuable alternative in the pattern of stone management. In case of persistent fragments, it is recommend that the number of sessions be increased to six.

Flexible ureteroscopy: Technological advancements, current indications and outcomes in the treatment of urolithiasis

The last 3 decades have witnessed great improvements in the technology and clinical applications of many minimally invasive procedures in the urological field. Flexible ureteroscopy (fURS) has advanced considerably to become a widely utilized diagnostic and therapeutic tool for multiple upper urinary tract pathologies. The most common indication for fURS is the treatment of upper urinary tract stones with the aid of Holmium:Yttrium Aluminium Garnet (YAG) laser lithotripsy. Advancements in endoscope technologies and operative techniques have lead to a broader application of fURS in the management of urolithiasis to include larger and more complex stones. fURS has proved to be an effective and safe procedure with few contraindications. Continued progression in fURS may increase its clinical applicability and supplant other procedures as the first line treatment option for urolithiasis.

Ureteroscopy for Paediatric Renal Tract Stones - Outcomes from a Tertiary European Centre

Aims: The use of ureteroscopy in treating paediatric stone disease has risen in recent years. We retrospectively reviewed the results of ureteroscopic stone management for our regional paediatric stone service. Material and Methods: Between April 2010 and October 2013, consecutive patients undergoing ureteroscopy and stone fragmentation were identified. Data were recorded from electronic records for patient demographics, pre-operative assessment, stone characteristics, and intra- and post-operative complications. Results: Twenty-one patients (mean age 8.6 years; range: 1.4-16) had 32 procedures in our series (13 males and 8 females). Five (24%) had a metabolic abnormality and 8 (38%) had an anatomical abnormality. The mean initial stone size was 9.6 mm (range: 5-20) and 10 were left sided. Of the 32 procedures, 18 (56%) had a pre-operative stent. A positive pre-operative urine culture was seen in 4 (13%). CT was used in 6 (19%) with the rest having a combination of USS and/or plain KUB. Of these 21 patients, 13 (62%) were stone free after the first procedure, 17 (81%) after a second and 20 (95%) after a third (mean 1.5 procedures/patient). One patient with a 6-mm residual fragment chose to have surveillance. Eighteen (50%) had post-operative stent insertion. The mean length of stay was 1.5 days (range: 0-5). A minor complication (Clavien 1) was observed in 1 patient. No other complications were recorded. Conclusions: Ureteroscopy for stone disease in children is feasible with a low complication rate and high stone-free rate.