Extracorporeal shockwave lithotripsy in infants

INTRODUCTION

Pediatric urolithiasis is relatively uncommon and limited information is available on the application of minimally invasive management modalities in young children. We present a single centre experience with extracorporeal shockwave lithotripsy (ESWL) for infants with upper urinary tract calculi.

MATERIAL AND METHODS

A total of 74 infants aged 3 months to 24 months with upper urinary tract calculi were treated with ESWL under general anesthesia using the Wolf 2500 and the 2501 Piezolith lithotriptors over a 14 and a half-year period. Patient and stone characteristics, risk factors for urolithiasis, treatment parameters, clinical outcomes and long-term follow-up were assessed and recorded.

RESULTS

The mean patient age was 14.5 (range 3 to 24) months. The mean renal stone size was 18.2 (range 7 to 32) mm while the mean ureteral stone size was 9.4 (range 5 to 14) mm. Metabolic abnormalities, structural anomalies and urinary tract infections were identified as contributory factors for stone formation in 34% of the infants. At the 3-month follow-up there was an overall successful outcome in 72 infants (97%) that included 65 (88%) who were rendered stone-free and 7 (9%) who had clinically insignificant stone fragments. Retreatment was required in 27 (35%) patients, auxiliary procedures after ESWL were needed in 5 (7%) and secondary operative procedures were required in 2 (3%). Major complications were encountered in 5 (7%) patients that included complete ureteral obstruction with sepsis in 2, partial ureteral obstruction in 1 and febrile urinary tract infection in 2 other children. Long-term follow-up was recorded in 39 infants: 8 developed recurrent stones, 2 had stone regrowth and 1 developed mild hypertension but none had significant deterioration of renal function.

CONCLUSIONS

ESWL is an effective treatment for upper urinary tract calculi in infants. In the short-term, complications are minimal but long-term follow-up is important.

Modified anatrophic nephrolithotomy: A useful treatment option for complete complex staghorn calculi

INTRODUCTION

Management of complete staghorn calculi represents a challenging problem for urologists. We describe our technique and clinical experience with modified anatrophic nephrolithotomy in patients harboring large, extensively branched staghorn calculi.

MATERIALS AND METHODS

From October 1996 to February 2005 twenty-six patients with complete staghorn calculi defined as filling the entire collecting system or at least 80% of it, were treated employing a modification of the classical anatrophic nephrolithotomy technique. The mean patient age was 46 (range 16-70) years and the mean stone size was 3150 (range 1375-4800) mm2. Intra-operative data, complications and stone-free rates were recorded. Long-term follow-up was completed in 22 patients with a mean duration of 38 (range 12-96) months. Renal function was evaluated by 99mTc dimercapto succinic acid renal scintigraphy before and 6 months after treatment.

RESULTS

The mean ischemia time was 36 (range 20-45) minutes, mean operative time was 195 (range 170-235) minutes and the mean blood loss was 475 (range 300-750) ml. Length of hospital stay averaged 8.8 days. One patient developed significant hematuria requiring renal angiography and embolization of a pseudoaneurysm. Overall, 22 patients (85%) were rendered stone-free at discharge while 23 patients (88%) were observed to be stone-free after 3 months. Long-term follow-up demonstrated recurrent stone fragments less than 4 mm in three patients. Isotope studies revealed that renal function remained unchanged in 55%, improved in 32% and became worse in the small number of remaining patients.

CONCLUSIONS

Modified anatrophic nephrolithotomy is a valuable treatment option for patients with complete staghorn calculi. Because of its efficacy, safety and simplicity we believe that the use of this surgical procedure is warranted in patients with a large, extensively branched, complex renal stone burden.

Holmium laser cystolithotripsy in children: initial experience

INTRODUCTION

Management of vesical calculi in children poses an interesting challenge to the urologist. The treatment options currently available include open surgery, transurethral pneumatic cystolithotripsy, percutaneous suprapubic cystolithotomy and shockwave lithotripsy (SWL). Holmium: YAG (Ho: YAG) laser cystolithotripsy represents a novel modality of treatment that is minimally invasive.

MATERIALS AND METHODS

From July 1999 to January 2003 we treated 23 children with vesical calculi using transurethral Ho: YAG laser lithotripsy. The indications for cystolithotripsy were stone size < or = 4 cm (N=19), or multiple stones with combined stone burden < or = 4 cm (N=4). The mean patient age was 7.8 (range 2-12) years and the mean stone size was 2.7 (range 0.9-4) cm. Access was obtained with an 8F ureteroscope and holmium laser energy (0.6-1.8 J/pulse at 5-12 Hz) was applied through a 550-mum. end-firing fibre under video guidance. The calculi were pulverized to tiny fragments about 2-3 mm in size. An 8F urinary catheter was placed for one night in all patients. Post-operatively the children were evaluated at 3 and 18 months with radiological imaging and uroflowmetry to confirm stone-free status and exclude urethral stricture formation.

RESULTS

The mean duration of the endoscopic procedure was 38 (range 19-62) minutes while the mean length of hospital stay was 2.2 (range 2-3) days. All the children were rendered stone-free following a single operative session. Laser-induced major complications were not observed in any of the children. At the mean follow-up of 42 (range 26-69) months none of the children developed stone recurrence, urinary tract infections or urethral strictures.

CONCLUSIONS

Transurethral Ho: YAG laser lithotripsy was found to be an efficient and safe modality for the treatment of vesical calculi in children.