Recent management of urinary stone disease in a pediatric population

Factors related to the success rate of pediatric extracorporeal shock wave lithotripsy (ESWL) in Cipto Mangunkusumo Hospital: an 8-year single-center experience

Background

ESWL is still considered as the first favorable therapeutic option for urinary stone disease with acceptable effectivity. However, factors associated with favorable outcome have not been widely studied in pediatrics due to the small number of urinary stone prevalence. The aim of this study is to evaluate the factors associated with the success rate of pediatric ESWL in our center according to immediate stone-free rate and 3-month stone-free rates.

Methods

This is a retrospective cohort study of children less than 18 years who had ESWL for urolithiasis from January 2008 until August 2015. Patient’s characteristics including age, gender, BMI, stone location, stone length, stone burden, stone opacity, and number of ESWL sessions were gathered from the medical record. Nutritional status was determined according to the Centers for Disease Control and Prevention BMI curve. The outcome of this study was the factors related to the success rate in pediatric ESWL.

Results

Extracorporeal shock wave lithotripsy was done for 36 patients and 39 renal units (RUs) with mean age of 13.7 ± 4.3 years old, height of 1480 ± 16.0 cm, and BMI of 20.0 ± 3. Of 36 patients included, 39 renoureteral units (RUs) and 46 ESWL sessions were recorded. The mean overall treatment was 1.2 ± 0.5 sessions with mean stone length of 11.1 ± 6.3 mm and stone burden of 116.6 ± 130.3 mm2. Within 3 months of follow-up, we recorded that the overall 3-month success rate was 100%, while the overall 3-month stone-free rate was 66.7%. Stone length (p < 0.001 and p < 0.001), stone perpendicular length (p < 0.001 and p < 0.001), and stone burden (p < 0.001 and p = 0.001) were found to be significantly associated with immediate success and 3-month stone-free status, respectively.

Conclusions

ESWL is an effective and safe modality to treat pediatric urolithiasis cases. Stone length, stone perpendicular length, and stone burden were found to be associated with immediate success and 3-month stone-free status after pediatric ESWL treatment.

Mini PCNL: A viable single stage treatment for pediatric nephrolithiasis in resource limited countries

INTRODUCTION

There is increasing enthusiasm for the value of mini PCNL for pediatric stone clearance. In developing countries, it is important to arrange a single stage treatment as a significant proportion of patients do not comply with repeated treatments, such as SWL.

OBJECTIVE

To assess the safety, feasibility and outcomes of Mini PCNL in a pediatric cohort.

MATERIALS AND METHODS

Retrospective analysis was performed of all paediatric patients undergoing Mini-PCNL at our institute between December 2016 and December 2019. Data was collected on stone size, stone clearance rate, complications, fluoroscopic exposure, mean procedural time and length of hospital stay. Follow up data included imaging to assess stone free status at 1 and 3 months postoperatively.

RESULTS

Mini PCNL was performed in 113 pediatric patients, a total of 135 procedures, accounting for bilateral disease in 22. The age range was from 1 to 14 years with a mean age of 8.45 ± 3.14 years. The mean stone burden was 2.1 ± 0.4 cm. Partial and complete staghorn stones were observed in 7 and 3 patients, respectively. The mean operative time was 63.8 ± 13.2 min (range: 25 min to 116min) and mean length of stay was 4.3 ± 2.2 days. Primary stone clearance was achieved in 91.1% (123 patients). Ancillary procedures were undertaken in 10 patients resulting in a secondary clearance rate of 97.0% (131 patients) at 3 months. Complications occurred in 16.3% (22 patients) using the modified Clavien Classification. Metabolic abnormalities were seen in 56.7% of patients with hypocitraturia and hypercalciuria being the most common abnormalities.

DISCUSSION

Our study reports a clearance rate of 91.1%, whereas, Zeng et al. documented a stone clearance rate of 80.4%. This contrast may be attributed to the difference in followup imaging protocols of the two studies and the energy source used for fragmentation. The incidence of complications with PCNL ranges from 10.6% to 36.3%, we found complications in 16.3% of our cohort. Our study is limited due to its retrospective design with a short follow-up protocol. Computed tomography being gold standard for qualitative and quantitative assessment of stone burden was not used in all patients to assess the preoperative stone size. Furthermore, postoperatively stone clearance was determined on the basis of ultrasound and x-ray films that could limit the accuracy of our stone clearance rate.

CONCLUSION

Our study suggests that mini PNCL in pediatrics patients is an effective single stage treatment for definitive stone clearance with an acceptable complication risk.

Robot-assisted laparoscopic surgery for treatment of urinary tract stones in children: report of a multicenter international experience

This study aimed to report a multi-institutional experience with robot-assisted laparoscopic surgery (RALS) for treatment of urinary tract stones in children. The medical records of 15 patients (12 boys), who underwent RALS for urolithiasis in 4 international centers of pediatric urology over a 5-year period, were retrospectively collected. The median patient age was 8.5 years (range 4–15). Eleven/fifteen patients (73.3%) had concurrent uretero–pelvic junction obstruction (UPJO) and 2/15 patients (13.3%) had neurogenic bladder. Stones were in the renal pelvis in 8/15 (53.3%), in the lower pole in 3/15 (20%), in the bladder in 2/15 (13.3%), and in multiple locations in 2/15 (13.3%). One patient (6.6%) had bilateral multiple kidney stones. The median stone size was 10.8 mm (range 2–30) in upper tract location and 27 mm (range 21–33) into the bladder. Eleven patients with concomitant UPJO underwent simultaneous robot-assisted pyelolithotomy and pyeloplasty in 12 kidney units. Two patients with isolated staghorn stones received robot-assisted pyelolithotomy. Robot-assisted cystolithotomy was performed in two patients with bladder stones. The median operative time was 131.8 min (range 60–240). The stone-free rate was 80% following initial surgery and 100% after secondary treatment. Clavien 2 complications (hematuria, infections) were recorded in 5/15 patients (33.3%). Three/fifteen patients (20%) with residual renal stones were successfully treated using ureterorenoscopy (Clavien 3b). RALS was a feasible, safe and effective treatment option for pediatric urolithiasis in selected cases such as large bladder stones, bilateral kidney stones, staghorn stones or concomitant anomalies such as UPJO requiring simultaneous pyeloplasty.

Robotic Management of Urolithiasis in the Pediatric Population

A variety of surgical techniques exist for the management of urolithiasis. Minimally invasive techniques have replaced open surgery in the last few decades. For complex stone management, robotic-assisted laparoscopic surgery (RALS) has emerged as a safe and feasible alternative in adults. The literature for RALS for urolithiasis (RALS-UL) in the pediatric population is scarce. Herein, we present a review of the literature in both adult and pediatric patients as well as our experience using RALS-UL at our institutions. Special attention is given to the synchronous management of urolithiasis when surgery is performed for other conditions such as ureteropelvic junction obstruction (UPJO), and a supplemental video is provided.

Interest of URS-L in the Treatment of Ureterolithiasis in Preschool Children

Urolithiasis can affect all children even preschool ones. Diagnostic difficulties in the youngest children are due to the problems in locating pain and determining its character and severity. In keeping with the ALARA (As Low As Reasonably Achievable) protocol, the number of imaging tests possible to perform is very limited. Ultrasound is the first line exam of choice. After diagnosis of the presence of a stone, ESWL (Extracorporeal Shock Wave Lithotrypsy) should always be considered and offered to parents due to its high effectiveness and minimal invasiveness. If ESWL is contraindicated or not well-accepted by parents, authors suggest another minimal invasive approach: URS-L (Uretherorenoscopy-Lithotrypsy). Our study clinically analyzes 87 children, which were treated between 2009 and 2017 using the URS-L procedure. URS-L treatments were performed using Lithoclast until 2009, and after that time, using the holmium laser Ho:YAG. The overall effectiveness of treatments was 93.3%. There was no failure in the access to the stones. A macroscopic hematuria (Clavien-Dindo I grade) was observed through the second post-operative day in 9.2% of treated patients. No urosepsis was observed. Full metabolic evaluation was performed on all patients. Children remained under constant urological and nephrological observation. A recurrence of urolithiasis was observed in 35.6% of the cases. Treating ureteral lithiasis in young infants remains a big challenge. Our series shows that modern minimal invasive techniques used by very experienced pediatric urologists in high volume centers gives excellent results. In most cases, surgery should no longer need to be an option.

Therapeutic possibilities for urolithiasis in childhood

OBJECTIVES

We present our case studies on paediatric urolithiasis, the techniques employed in its treatment and its results.

MATERIAL AND METHODS

A retrospective study of paediatric urolithiasis of the upper urinary tract (UUT) treated at our centre between 2003 and 2014. We recorded demographic, clinical, diagnostic and therapeutic data and the complications. The therapeutic plan was recorded as isolated (extracorporeal lithotripsy, ureterorenoscopy, nephrolithotomy or surgery) or combined therapy.

RESULTS

We examined 41 renal/urethral units in 32 patients. The median age was 5 years (range, 11 months-14 years). The mean size was 12.9cm (±7.3mm). The locations were as follows: 23 (56%) in the renal pelvis (staghorn in 15 cases), 10 (24) in lower calyx and 8 (20%) in the urethra. We performed 80 procedures, with no differences in the age groups, which resulted in 12 complications (15%) but no septic condition secondary to lithotripsy. Stone removal from the urethra had a 100% success rate with the ureterorenoscopy. The overall cure rate was 90%.

CONCLUSION

The paediatric urolithiasis approach offers multiple alternatives. It is therefore important to tailor the procedure according to the size, location and composition of the stone. In our centre, the use of paediatric extracorporeal shock wave lithotripsy is safer. Ureterorenoscopy, semirigid or flexible, provides excellent results in ureters. Percutaneous nephrolithotomy with minimal access can be performed on small children and nursing infants.

[Impact of the acquisition of a flexible ureteroscope on the management of upper urinary tract stones in children]

INTRODUCTION

Firstly reported in the early 1990s for the treatment of upper urinary tract stones in adult patients, flexible ureteroscopy (F-URS) has been used in children during the past 10 years and is now considered as a viable, but still second-line alternative to extracorporeal shockwave lithotripsy in these patients (ESWL). The aim of this study was to assess the impact of the acquisition of a F-URS on the management of upper urinary tract stones in children.

PATIENTS AND METHODS

Data of all ESWL, F-URS and percutaneous nephrolithotomy performed for upper urinary tract stones in children from 0 to 18 years old in a single center from 2000 to 2014 have been collected retrospectively. Patients have been divided into two groups: group 1 before the acquisition of the F-URS (2000-2008) and group 2 after the acquisition of the F-URS (2008-2014). Preoperative data and peri-operative outcomes were compared between both groups using the χ(2) test and Fisher exact test for discrete variables and the Mann-Whitney test for continuous variables.

RESULTS

Thirty-seven children have been treated during the first era and 32 during the second one. The two groups were similar in terms of age (7.2 years vs 8.1 years; P=0.54), size of the largest stone (15 mm vs 16.2mm; P=0,56) and number of stones per patient (1.4 vs 2; P=0,07) but the sum of stone diameters was higher in group 2 (16.9 mm vs 24.2mm; P=0,048). The stone-free rates were comparable in both groups (28.1% vs 32.2% after the first procedure; P=0.72), as were the mean number of procedures per patient (2.4 vs 2.5; P=0.78), the total length of stay (2.7 days vs 2.9 days; P=0.77), and the number of patients who experienced at least one complication (37.8% vs 40.6%; P=0.87).

CONCLUSION

The acquisition of a F-URS allowed the treatment of more complex stones with a similar efficacy and without increasing morbidity. Further studies are needed to define the role of F-URS in the management of upper urinary tract stones in children.