Treatment Of Pediatric Urolithiasis Research Articles

Efficacy of Different Surgical Methods in the Treatment of Pediatric Urolithiasis: Retrograde Intrarenal Surgery, Ekstracorporeal Shock Wave Lithotripsy and Open/Laparoscopic Surgery Approaches

Abstract Aims: To evaluate the stone-free success of retrograde intrarenal endoscopic surgery, extracorporeal shockwave lithotripsy and open/laparoscopic surgery methods that we applied to urinary system stones detected in the pediatric patient group in our clinic. Materials and Methods: In this study, we retrospectively analyzed the data of 302 pediatric patients who underwent RIRS and RIRS combined with ESWL, open stone surgery, laparoscopic stone surgery for urolithiasis between January 2013 and October 2020 in our clinic. The demographic data of the patients, the side and size of the stones detected by imaging methods, surgical stone interventions, stone-free results and the postoperative hydronephrosis status were evaluated. Results: Of the patients included in the study, 160 (53%) were boys and 142 (47%) were girls. The mean age was 89.719 months (SD 51.447, range 6–216). The mean size of the treated stones was 7.964 mm (SD 3.516, range 2.2-25). In the radiological examinations, stones were detected in 409 renal units. Side distribution of stones was 194 (47.43%) on the right and 215 (52.57%) on the left. Stone-free status was achieved in 262 (86.75%) of the patients in postoperative follow-up. No stones were found on imaging in 235 (77.81%) of these patients. In the follow-up, it was observed that hydronephrosis completely resolved in 278 (92.05%) patients. Conclusion:In conclusion, it is appropriate to prefer minimally invasive surgical methods, especially in pediatric cases. It should not be forgotten that open or laparoscopic surgery, especially laparoscopy, has a place in selected cases, according to the experience of the surgeon.

Outcome of Ultrasonography-Guided Percutaneous Nephrolithotomy for the Management of Pediatric Urolithiasis.

Objectives: This study aims to assess the outcomes of ultrasonography (US)-guided minimally invasive percutaneous nephrolithotomy (PCNL) in the treatment of pediatric urolithiasis. Methods: A retrospective analysis was conducted on 176 patients with pediatric renal and upper ureteral lithotripsy who underwent PCNL between August 2006 and July 2022. The cohort comprised 110 men and 66 women, with ages ranging from 6 months to 16 years. Postoperative stone clearance was evaluated using kidney, ureter, and bladder radiograph or US, categorizing stones less than 4 mm as clear. Postoperative complications were graded according to the Clavien-Dindo classification, with grades I and II considered minor and III and IV classified as major. Results: Among the patients, 152 underwent unilateral renal operation, whereas 24 underwent bilateral renal operation. The average operation duration was 67.41 minutes (range: 15-195 minutes). The mean duration of nephrostomy tube removal was 3.79 days, and the mean postsurgical hospital stay was 5.97 days. A total of 146 patients experienced a decrease in hemoglobin concentration post operation, with an average drop of 10.57 g/dL (range: 0.5-37.8 g/dL). Initial stone-free rate (SFR) was achieved in 85.5% (171/200) of cases, and the final SFR was 92.50% (185/200). The postoperative rate of minor complications was 8.54% (17/199), whereas major complications occurred in 12.06% (24/199) of cases. During the 6-month to 11-year follow-up period, 19 patients presented with combined stones, and of these 4 presented with ipsilateral stone recurrence who underwent PCNL treatment. Calcium oxalate was identified as the most common stone component. Conclusions: US-guided minimally invasive PCNL demonstrated excellent SFR and an acceptable complication rate in the management of pediatric urolithiasis. Furthermore, it offers the advantage of minimizing potential risks associated with radiation exposure during the procedure.

Clinical profile, diagnosis and treatment of pediatric urolithiasis: a single center experience in Kazakhstan

Objective: The aim of our study to present the results of the clinical profile, diagnosis and treatment of children with urolithiasis in the Pediatric Urology Department of the Scientific center of Pediatria and Pediatric surgery in Almaty, Kazakhstan. Materials and methods: A retrospective data from pediatric patients with urolithiasis admitted from January 2015 to December 2021. The data was obtained from medical records and included those with diagnosis confirmed by imaging and laboratory test, as 24-hour urine exams corrected for creatinine, stone composition. Results: We reviewed 204 children with urolithiasis. The male‐to‐female ratio was 1.34:1. Congenital anomalies of the urinary tract were found in 40 patients (19.6%).Urolithiasis was more common in adolescent girls, whereas in boys the frequency of observation is higher between 11 and 17 years old (p = 0.006). Majority of the patients were from southern regions (51%) in our country. Renal colic, urinary tract infection and macroscopic hematuria were the most common clinical manifestations. Urinary tract infection was diagnosed in 185 patients (90.6%). The most frequent metabolic disorders were hypercalciuria, hyperoxaluria. In 35% of cases there was a metabolic disorder and appropriate therapy was prescribed. In the remaining cases, surgical treatment was used. Conclusion: In this study we presented the prevalence of urolithiasis in the pediatric population in different regions of our country. We identified a high prevalence of infective stone as an etiological factor of pediatric urolithiasis. Clinical symptoms depending on the age and location of the stones. Bangladesh Journal of Medical Science Vol. 22 No. 02 April’23 Page : 297-304

Minimally invasive surgery for pediatric renal and ureteric stones: A therapeutic update.

The incidence of pediatric urolithiasis (PU) is growing worldwide. The corresponding therapeutic methods have become a research hot spot in pediatric urology. PU has the characteristics of abnormal metabolism, easy recurrence, and immature urinary system development, which make its treatment different from that of adults. Pediatric urologists should select the optimal treatment modality to completely remove the stones to prevent recurrence. Currently, the curative treatments of PU include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, retrograde intrarenal surgery, percutaneous nephrolithotomy (PCNL), laparoscopic, robot-assisted laparoscopic, and open surgery. This review aims to conduct a therapeutic update on the surgical interventions of both pediatric renal and ureteric stones. It accentuates that pediatric surgeons or urologists should bear in mind the pros and cons of various minimally invasive surgical treatments under different conditions. In the future, the treatment of PU will be more refined due to the advancement of technology and the development of surgical instruments. However, a comprehensive understanding of the affected factors should be taken into account by pediatric urologists to select the most beneficial treatment plan for individual children to achieve precise treatment.

The optimal settings of holmium YAG laser in treatment of pediatric urolithiasis.

The aim of this study is to present our experience on the use of the holmium:yttrium-aluminum-garnet (Ho:YAG) laser in pediatric patients for pediatric urolithiasis and describe the optimal settings. A total of 116 children who underwent urolithiasis treatment (percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS), retrograde intrarenal surgery (RIRS)) were included. The mean age of the patients was 8.4 ± 5.2 years (1-18). The mean follow-up was 26 ± 8.8 months (9-45). There was no difference between the mean stone sizes of PNL and RIRS patients (p = 0.816). Operations were performed with 200, 272, and 365-μm fibers. In mini-URS, stone fragmentation was achieved with the energy settings set between 0.5 and 1 J and frequency set to > 8 Hz. In RIRS, fragmentation was achieved with the setting of 0.5-0.8 J at 10-20 Hz. Stone fragmentation was performed with energy settings of 0.8 to 2 J between 5 and 15 Hz for PNL. There was no significant difference between the stone-free rates of the PNL and RIRS (p = 0.150). Four postoperative complications occurred (Clavien II), which included febrile urinary infections in two patients who underwent mini-URS, one patient who underwent PNL, and one patient who underwent RIRS. Our results confirmed that Ho-YAG laser can be effectively used in children for stone treatment by using low-energy high-frequency settings for URS and RIRS and a high energy setting for PNL.

Minimally Invasive Approaches in Pediatric Urolithiasis. The Experience of Two Italian Centers of Pediatric Surgery.

Background: Over the last 30 years, the incidence of pediatric urolithiasis (PU) has been increasing and the surgical management has evolved toward a minimally invasive approach (MIA). We reported the experience of two Centers of Pediatric Surgery in the management of PU, focusing on MIA as first choice in treatment.Methods: Data were retrospectively analyzed from October 2009 to October 2019 in children with urolithiasis who were admitted to two referral Italian Centers of Pediatric Surgery. Demographic and clinical data of the patients, features of the urolithiasis, type of surgery were considered.Results: Seventy patients (7.3 ± 5.0 years) with normal renal function were treated for calculi in the pyelocaliceal system (45.7%), ureter (34.3%), bladder (4.3%), urethra (1.4%), and multiple locations (14.3%). Size of calculi was >10 mm in 55.7% of cases (kidney>bladder/urethra>multiple>ureter, p = 0.01). Symptoms were present in 75.7% of patients. Family history was positive in 16.9% of cases. MIA was performed in 59 patients (84.3%): 11.8% shockwave lithotripsy (kidney>ureter>multiple); 32.2% ureteral retrograde surgery (ureteral>other localizations); 30.5% retrograde intrarenal surgery (kidney>other localizations); and 25.4% other procedures including percutaneous nephrolithotomy, cystoscopic bladder stone removal or laser cystolithotripsy (kidney>bladder>multiple). Preoperative stenting was necessary in 52.8% of cases. Four MIA procedures (6.9%, kidney>ureter/multiple) were converted to open surgery. Open surgery was required as first approach in 15.7% of patients (kidney>ureter>multiple) who needed urgent surgery or had associated congenital renal anomalies. In 18/70 of children (25.7%), with prevalence of stones in kidney and multiple location (p < 0.01), a second procedure completed the treatment (88.8% MIA). Intraoperative difficulties were recorded in 8.5% of cases, without difference between location and size of calculi. Late complications (5.7%) were related to displacement and infection of the ureteral stent.Conclusions: MIA resulted to be feasible in more than 75% of primary surgery and in more than 85% of cases requiring a second procedure. Preoperative stent was mandatory in more than 50% of children. The technological evolution allowed to overcome many of the technical difficulties related to the approach to the papilla and lower calyxes. Open surgery is reserved for selected cases and endoscopic surgery represents the best choice of treatment for PU.

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.

Use of Ultrasound in Pediatric Renal Stone Diagnosis and Surgery

Pediatric urolithiasis is on the rise globally and incidence rates have risen by 6-10% annually over the past couple of decades. Given the increasing incidence, high likelihood of recurrence, and long life expectancy of children, the use of ionizing radiation in the diagnosis, management, and follow up of pediatric urolithiasis has been scrutinized recently and many institutions and organizations have emphasized the use of non-ionizing imaging modality such as ultrasound. This review examines the use of ultrasound in the diagnosis and treatment of pediatric urolithiasis. Specifically, the role of ultrasound in shockwave lithotripsy, percutaneous nephrolithotomy, and, more recently, ureteroscopy will be examined.

Laparoscopic Pyelolithotomy in Children Less Than Two Years Old with Large Renal Stones: Initial Series.

Treatment of pediatric urolithiasis is still on debate. This study was designed to evaluate the safety and efficacy of laparoscopic pyelolithotomy in five children less than two years old. Five children (less than two years old) with large kidney stones underwent laparoscopic pyelolithotomy. All patients underwent laparoscopic pyelolithotomy via a transperitoneal approach. After medial mobilization of colon and once renal pelvis and ureteropelvic junction were exposed, a longitudinal or circular incision was made on the renal pelvis, depending on the location and shape of the stone. Stones were extracted using an Endobag. Demographic data, size of stones, operation time, duration of hospital stay and stone free rate were assessed. Four boys and a one girl were included in this study. The mean age of patients was 17.6 (range: 13-22) months and the mean duration of operation was 130 (range: 115-145) minutes. The mean size of stone was 24.6 (range: 22-27) mm and the mean duration of hospital stay was 4.4 (range: 4-5) days. Stone free rate was 100%. There was no major complication. Even with a small number of patients, our results seem to show that laparoscopic pyelolithotomy could be a treatment option for selected cases of young pediatric cases with large renal stones. We believe that transperitoneal laparoscopic pyelolithotomy is feasible and it introduces a novel approach for managing kidney stones in pediatric population.&nbsp.

Epidemiology of pediatric urolithiasis

Pediatric urolithiasis is an endemic disease in certain parts of the world, namely Turkey and the Far East. As a recurrent pathology which may reveal functional as well and morphologic changes in the urinary tract, environmental factors together with urogenital abnormalities should be evaluated thoroughly in each patient. The aims of management should be complete clearance of stones, treatment of urinary tract infections, and preservation of renal function and prevention of stone recurrence. In addition to certain minimally invasive stone removal procedures, treatment of pediatric urolithiasis requires a detailed metabolic evaluation in all patients on an individual basis. Obstructive pathologies have to be corrected immediately and children with a positive family history should be followed carefully with respect to a high likelihood of stone re-growth and recurrence. Although specific management of each metabolic abnormality seems to be the key factor in the medical management of stone disease, as general advice each child should be forced to adequate fluid intake which will reveal the urine volume increase in accordance with the body mass index. Moreover, medical therapeutic agents that increase urine citrate levels should be encouraged.

Efficacy and safety of percutaneous nephrolithotomy with adult standard size instruments in children under 3 years of age: a 10 years single-center experience.

Using percutaneous nephrolitotomy (PCNL) with large adult instruments in treatment of pediatricurolithiasis is still in debate. This study was conducted to evaluate the efficacy and safety of PCNL with adult's instrument in treatment of patients less than 3 years old. Data on patient characteristics and outcomes for 261 consecutive children undergoing PCNL at a Labbafinejad University Hospital were collected prospectively from September 2006 to February 2016. Thirty-two children, with 34 renal units, who were treated with PCNL were enrolled in the study. All PCNL procedures were performed via subcostal approach with one access tract in all of them. Postoperative complications were evaluated according to the modified Clavien grading system. The mean age of patients was 19.4 ± 6.2 months. Two patients had bilateral stones; thus, PCNL was performed on 34 kidney units. The mean size of the largest stone diameter was 17.5 ± 7.8 mm. The mean duration of procedures was 121.52 ± 29.05 minutes, ranging from 60 to 180 minutes. The most common complication was fever (n = 9, 26.4%), and hemorrhage that needs transfusion was the second one (n = 4, 11.7%). Seventeen patients with complications were in the first degree of Clavien complication system and five of them were in the second degree. Due to our experience, utilizing PCNL with adult-sized instruments in management of urolithiasis in less than 3 years old children appeared to be effective and relatively safe.

Outcomes following ‘mini’ percutaneous nephrolithotomy for renal calculi in children. A single-centre study

This retrospective review was undertaken to identify the postoperative outcomes of children undergoing 'mini' percutaneous nephrolithotomy (MPCNL) at a single institution. Outcomes measured included: percentage of stone clearance, postoperative analgesia requirements, the need for intraoperative or postoperative blood transfusion, length of stay and morbidity. A total of 46 patients were reviewed over a two-and-a-half-year period; the mean age was 7.3 years (range: 1-16 years). The MPCNL was performed with a radiological-guided peripheral puncture, followed by dilatation of the nephrostomy tract to a maximum Amplatz sheath size of 16-French; an 11-French nephroscope was used. Stone disintegration was achieved either with pneumatic or laser lithotripsy. Complete stone clearance was achieved in 35/46 children (76%). The remaining 11 children had a stone clearance rate of over 80%. No patients required intraoperative/postoperative blood transfusion. A total of 39% of patients were managed on simple/non-opiate based analgesia, with 54% requiring opioid analgesia postoperatively for less than 24 h. There were no procedure-related complications and no mortalities. The mean length of stay was 2.24 days. The management of urolithiasis can be challenging in children. The use of percutaneous nephrolithotomy, is becoming increasingly popular in the treatment of paediatric urolithiasis. The stone clearance rate in children undergoing standard PCNL, has been reported to be 50-98% in the literature [1,2,3,4]. Samad et al. [2] in 2006, reported their experience in 188 consecutive PCNLs, using a 17Fr or 26Fr nephroscope. Their largest sub group included children aged >5-16 yrs. Within this group, 57% were treated with a 17Fr nephroscope and 43% with the 26Fr nephroscope, achieving stone clearance of only 47% with PCNL monotherapy. In this group the transfusion rate was 3% [2]. Badawy et al., reported their experience of 60 children in 1999, using a 26 or 28Fr Amplatz sheath. They reported an 83.3% stone clearance with single session PCNL, with only one procedure being abandoned due to intraoperative bleeding requiring blood transfusion [3]. In 2007, Bilen et al. reported their experience and compared the use of 26Fr, 20Fr and 14Fr (mini) PCNL. Stone size, previous surgery and the mean haemoglobin drop postoperatively did not change between the groups, however the blood transfusion rate was higher in the 26Fr and 20Fr Amplatz sheath groups. The stone clearance was highest in the 'mini PCNL' group at 90%, compared to 69.5% in the 26Fr and 80% in the 20Fr group [4]. MPCNL has become increasingly popular over recent years, with stone clearance reported as 80-85% [5-7] following a single session of MPCNL as monotherapy. In 2012, Yan et al. reported 85.2% stone clearance with mini PCNL monotherapy (tract size 14-16Fr), with no children requiring blood transfusion [6]. Zeng et al. reported their experience of 331 renal units in children, with stone clearance rates reaching 80.4% and a blood transfusion rate of 3.1% [8]. In our centre, we do not perform postoperative haemoglobin levels as a matter of routine and any investigations are performed on an intention to treat principle. Bilen et al. reported no blood transfusions being required in their cohort of patients undergoing MPCNL [4] and this is supported by Yan et al. [6]. Mini PCNL is an effective and safe procedure for the treatment of paediatric renal stones. In the present series, all children achieved greater than 80% stone clearance, none received a blood transfusion (intra/postoperatively) and there were no mortalities. Postoperative pain was managed with simple analgesia in 39%; however, the majority required opiate analgesia for less than 24 hours.

Percutaneous Nephrolithotomy in Children with Cystine Stone: Long-Term Outcomes from a Single Institution

We determined the effectiveness of percutaneous nephrolithotomy in children with cystine stones and present the long-term outcomes. We reviewed the data of 65 renal units in 51 children who underwent percutaneous nephrolithotomy for cystine stones between 2000 and 2012. Of the patients 19 (37%) had undergone ipsilateral renal surgery and 11 (22%) had undergone extracorporeal shock wave lithotripsy. Children were designated as being stone-free or having residual stone (any evidence of persistent stone fragments irrespective of size). Medical treatment with α-mercaptopropionylglycine, potassium citrate or potassium sodium hydrogen citrate was recommended for all patients after stone analysis. Median stone burden was 3.3 cm(2) (range 1 to 13) and median patient age was 6 years (1 to 17). Stone-free status was achieved in 41 renal units (63.1%). Stone-free status was increased to 73.8% with additional endoscopic procedures. The remaining patients with residual stones were followed. Complication rate was 15.4%. A total of 35 children (68.6%) receiving regular medical treatment were followed for a median of 95 months (range 6 to 136). The recurrence rate for children achieving stone-free status was 31.2%, and the regrowth rate for children with residual stones was 29.4%. Percutaneous nephrolithotomy is a safe and effective treatment for children with cystine stones. Our high recurrence and regrowth rates emphasize that our treatment schedule is inadequate to prevent recurrent cystine calculi. Additional investigation is needed to determine the optimal medical therapy for preventing recurrence and regrowth of cystine stones.

Laparoscopic management of pediatric renal and ureteric stones

ObjectiveTo assess the feasibility of laparoscopy in the treatment of pediatric urolithiasis, we report our experience with the transperitoneal laparoscopic removal of stones. MethodRenal pelvic stones of size ≥1 cm on ultrasound were included for laparoscopic pyelolithotomy while smaller stones were managed with shock-wave lithotripsy monotherapy. Intrarenal stones, calyceal stones, complete staghorn stones, multiple stones and kidneys with intrarenal pelvis were excluded. Ureteric stones included for laparoscopic ureterolithotomy were of size ≥1 cm in the upper, mid or lower ureter, and smaller stones not responding to non-operative treatment. ResultsA total of 22 procedures were performed: 12 pyelolithotomies, and 8 lower and 2 upper ureterolithotomies. Complete removal of calculi was accomplished in 21 (95.45%) procedures. Complications associated with laparoscopic lithotomy included urinoma (4.54%), failure (4.54%) and omental prolapse (4.54%). ConclusionLaparoscopic lithotomy is safe and feasible in pediatric urolithiasis with pyelic and ureteric stones, with minimal complications and failure rate.

Pediatric Urolithiasis in Taiwan: A Nationwide Study, 1997-2006

To investigate the prevalence, incidence, associated risk factors, and treatment of pediatric urolithiasis in Taiwan. The present study used a subset of the National Health Insurance Research Database, known as the Longitudinal Health Insurance Database 2005, which contains the data for all paid medical benefit claims from 1997 to 2006 for a subset of 1 million beneficiaries randomly drawn from the population of 22.72 million individuals during any part of the calendar year 2005. Our analysis included the data of all newly diagnosed pediatric patients with an "International Classification of Disease, 9th revision," diagnosis of urolithiasis from 1997 through 2006. A total of 1679 pediatric subjects who had newly diagnosed urolithiasis without a previous attack were identified from 1997 to 2006 as the study sample. Of the 1679 patients, 808 were boys (48.1%) and 871 were girls (51.9%). The incidence rate of urolithiasis in 2005 was 0.047%. The peak age of pediatric stone occurrence in the study sample was 15-18 years (49.6%). The most common associated disease was urinary tract infection (34.1% of all subjects). The occurrence rate of pediatric urolithiasis correlated significantly with the urbanization level of the residence and geographic area. Using a nationwide, population-based study provides important clinical and epidemiologic information regarding pediatric urolithiasis. Additional studies are warranted to determine the effect of geographic area and urbanization level on the occurrence of pediatric stone disease.

Treatment of pediatric urolithiasis: how small is “small enough”?

“Big” scars for stone removal are only needed in unusual circumstances. This is true given the fact that technology is fast evolving and instruments becoming smaller and smaller. The management of urolithiasis in children has undergone a paradigm shift in the past decade. Management of pediatric urolithiasis necessitates a balance between stone clearance and morbidity related to the procedure. A variety of treatment options are available, which include shock wave lithotripsy (SWL), percutaneous Nephrolithotomy (PCNL), and retrograde intra renal surgery (RIRS) and open surgery. Concerns regarding endourologic treatment include eVect on the renal development and function, the side eVects of radiation, and the implications of residual stones. Children with pediatric urolithiasis need to be worked up metabolically to prevent recurrence. The treatment options should be chosen with prudence, as each of the treatment options has its share of problems. SWL has been the treatment of choice for renal calculi less than 15 mm in size. The stone-free rates range from 68 to 84% [1]. In our study, ESWL was found to be safe and eVective in children as was in adults for solitary renal and upper ureteric stones less than 2 cm in size. We found that children required fewer and lower energy shock waves to achieve equivalent results. Considering that long-term data are awaited regarding functional consequences of shock waves on pediatric kidneys, it would be prudent to shock these kidneys as little as possible. In this context, we feel to minimize the “shock loss,” and optimizing the number and energy of shock waves, the patient should be given optimum anaesthesia with the use of ultrasound and Xuoroscopy for localizing and monitoring of stone fragmentation [2]. PCNL remains the most eVective option for treating large stones in this age group. The obvious downside of this approach is the potential for life-threatening complications such as bleeding; hence, surgeon experience is paramount in deciding the number and site of access. Stone-free rates of more than 90% have been shown in pediatric age group [3]. Percutaneous Nephrolithotomy has been described even in children as small as 11 months, having complex calyceal stones and/or staghorn calculi. The method to gain access, ultrasound or Xuoroscopy, is a matter of experience and personal preference. Ultrasound oVers the advantage of visualization of spleen and liver and avoids injury. It also minimizes radiation to these kids. The key to success in PCNL in these small patients is staging the procedure if required, miniaturization of instruments, and using ultrasound as the method of achieving access. PCNL oVers a good clearance rates with acceptable morbidity. Miniaturization of instruments particularly smaller nephroscopes and newer energy sources will decrease the morbidity of PCNL. The question is how small is small enough! In this regard, in our opinion, microperc is the “new kid on the block.” It has a role to play in percutaneous management of these small patients. Essentially, “microperc” involves performing the procedure through the eye of the needle. The microoptics of 0.9 mm diameter are used. The assembly has a integrated light head inserted through the working sheath of the needle, and PCNL can be done through the same needle sheath with a 3-way needle allowing irrigation, passage of Xexible telescope and a laser Wbre [4]. Although investigational, larger multicentre trials that are already underway will prove its utility. M. Desai (&) Nadiad, India e-mail: mrdesai@mpuh.org

Extracorporeal shock wave lithotripsy in the treatment of pediatric urolithiasis: a single institution experience

To compare the efficacy and safety of the electromagnetic lithotripter in the treatment of pediatric lithiasis to that of the earlier electrohydraulic model. Two groups of children with lithiasis aged between 10 and 180 months who underwent extracorporeal shock wave lithotripsy (ESWL). In the first group (26 children), ESWL was performed by using the electrohydraulic MPL 9000X Dornier lithotripter between 1994 and 2003 while in the second group (19 children) the electromagnetic EMSE 220 F--XP Dornier lithotripter was used from April 2003 to May 2006. In the first group, 21/26 children (80.7%) were stone free at first ESWL session. Colic pain resolved by administration of an oral analgesic in 6 (23%), brief hematuria (<24 h) resolved with increased fluid intake in 5 (19.2%), while slightly elevated body temperature (<38°C) occurred in 4 (15.3%). Four children (15.3%) failed to respond to treatment and were treated with ureteroscopy. In the second group 18/19 children were completely stone free at first ESWL session (94.7%). Complications were infrequent and of minor importance: colic pain treated with oral analgesic occurred in 1 (5.26%), brief hematuria (<24 h), resolved with increased fluid intake in 4 (21%) and slightly elevated body temperature (<38° C) monitored for 48 hours occurred in 6 (31.5%). Statistical analysis showed that electromagnetic lithotripter is more efficacious and safer than the earlier electrohydraulic model. Technological development not only has increased efficacy and safety of lithotripter devices in treating pediatric lithiasis, but it also provided less painful lithotripsy by eliminating the need for general anesthesia.

UROLOGIST VERSUS RADIOLOGIST-MADE PCNL TRACTS; THE UK EXPERIENCE

To assess the feasibility of laparoscopy in the treatment of pediatric urolithiasis, we report our experience with the transperitoneal laparoscopic removal of stones.Renal pelvic stones of size ≥1 cm on ultrasound were included for laparoscopic pyelolithotomy while smaller stones were managed with shock-wave lithotripsy monotherapy. Intrarenal stones, calyceal stones, complete staghorn stones, multiple stones and kidneys with intrarenal pelvis were excluded. Ureteric stones included for laparoscopic ureterolithotomy were of size ≥1 cm in the upper, mid or lower ureter, and smaller stones not responding to non-operative treatment.A total of 22 procedures were performed: 12 pyelolithotomies, and 8 lower and 2 upper ureterolithotomies. Complete removal of calculi was accomplished in 21 (95.45%) procedures. Complications associated with laparoscopic lithotomy included urinoma (4.54%), failure (4.54%) and omental prolapse (4.54%).Laparoscopic lithotomy is safe and feasible in pediatric urolithiasis with pyelic and ureteric stones, with minimal complications and failure rate.

Shockwave Lithotripsy and Endourological Management of Urinary Calculi in Children: A Single-Center 10-year Experience

Shock wave lithotripsy (SWL) and endourological techniques revolutionized the management of pediatric urolithiasis. We sought to assess the impact of new technology and local practice in the treatment of pediatric urolithiasis during a 10-year period. Between 1997 and 2006, 125 children (90 boys and 35 girls), aged 18 months to 15 years, were managed in our department for urolithiasis. Stone localization, stone composition, presence of anatomic abnormalities, and treatment modality were evaluated retrospectively. In 102 children, the stone was located in renal pelvis (0.5-45-mm diameter), in eight in the renal pelvis and one in the calyx; three had staghorn calculi; and 12 had ureteral stone (4-12-mm diameter). Ninety-three of 125 children underwent a total of 108 SWL sessions. Stone size ranged from 0.5 to 35 mm. The stone-free rates were 86%, 92%, and 96% after first, second, and third SWL session, respectively. Ureteroscopy was performed in 12/125 children, and 10/12 (83.5%) were rendered stone free. Nine of 125 children underwent percutaneous nephrolithotomy, and four of nine were stone free (44.5%), although five of the nine children (55.5%) required SWL for residual stone fragments. Open surgery was performed as initial procedure in 11 (9%) children. In 9 of 11 children, ureteropelvic junction obstruction was corrected simultaneously. Open surgery was followed by SWL in 3 of 11 patients. Two of three patients with staghorn calculi underwent nephrolithotomy and SWL and one of three with cysteinuria was managed with SWL. SWL and endourological techniques are safe and effective in managing urolithiasis in pediatric patients. These minimally invasive methods reduced dramatically the cases of open surgery, which should be undertaken mainly in coexisting anatomic abnormalities.

Stone size is the sole factor in determining the outcome of eswl in children

Purpose We prospectively evaluated the role of stone location and size in the efficacy of SWL for the treatment of urinary calculi in children. Material and methods Between January 2006 and March 2007, 94 pediatric patients (108 renoureteral units) were treated by Siemens Lithostar under sedo-analgesia. There were 58 boys and 36 girls, with a mean-age of 57.4 (8- 180) months. The stones were localized in the renal pelvis, lower, middle, upper calices and ureteropelvic junction in 24, 30, 17, 7 and 10 renal units. 14 renal units had stones in multiple locations. Four patients had proximal and 2 had distal ureteral calculi. Stone free rates and efficiency quotients were assessed 3 months after SWL. Results The mean stone burden was 74.6mm2 (20-380). Sixtysix (61.1%) renal units were stone-free within 12 weeks after an average of 1.48 (1-4) SWL sessions. Stone-free rates for pelvis, lower, middle, upper pole, ureteropelvic junction, upper and lower ureter were 83.3 %, 43,%, 52.9%, 71.4%, 60%, 100% and 50% respectively. Efficiency quotients for stones <5mm, 6-10 mm, 11-15 mm and 16-20mm were 0.62, 0.42, 0.53, 0.27 respectively with an overall 0.44. Conclusions Our results indicated SWL in the treatment of pediatric urolithiasis has acceptable stone-free rates with lower efficiency quotients, the latter compensated by the minimally invasive nature of this treatment modality. Stone-size seems to be the only factor affecting the efficiency.