Aktuelle Aspekte zur Steintherapie im Kindesalter

Surgical treatment of pediatric urolithiasis

Introduction: Surgical treatment of urolithiasis in children is quite complex and specific due to certain anatomical and functional features of childhood. Methods of surgical treatment at this age are: extracorporeal lithotripsy (ESWL), intracorporeal (endoscopic) lithotripsy - pneumatic and laser, percutaneous nephrolithotripsy (PCNL) and open surgery. Aim: The aim of this study was evaluation of the effects of ureterorenoscopy and endoscopic lithotripsy in children, as methods of minimally invasive surgical treatment. Material and methods: The retrospective study was conducted at the Institute for Mother and Child Health Care of Serbia "Dr Vukan Cupic" in Belgrade from 2010 to 2020. The study included 112 patients (50 boys and 62 girls) aged 1-18 years with urolithiasis, treated by endoscopic (laser or pneumatic) lithotripsy. The retrospective study was conducted at the Institute for Mother and Child Health Care of Serbia "Dr Vukan Cupic" in Belgrade from 2010 to 2020. The study included 112 patients (50 boys and 62 girls) aged 1-18 years with urolithiasis, treated by endoscopic (laser or pneumatic) lithotripsy. Results: After one ureterorenoscopy, the calculus was successfully disintegrated in 87 (78%) patients: in the renal pelvis in 22 (79%), in the upper pole calices of the kidney in 14 (100%), in the lower pole calices in 10 (50%), in the proximal segment of the ureter in 10 (83%), in the distal segment of the ureter in 27 (79%), in the bladder in 4 (100%) cases. In 19 (17%) patients the second intervention was necessary: in the renal pelvis in 28 (100%), in the upper pole calices in 14 (100%), in the lower pole calices in 14 (70%), in the proximal segment of the ureter in 12 (100%), in the distal segment of the ureter in 34 (100%) and in the bladder in 4 (100%) patients. Conclusion: The primary treatment of pediatric urolithiasis is ureterorenoscopy in combination with pneumatic or laser lithotripsy. It is successfully used in all segments of the urinary tract. The procedure is partially limited in the lower pole calices of the kidney, due to anatomical circumstances and mechanical limitations of the instruments.

Ability of ESWL nomograms to predict stone-free rate in children

INTRODUCTION

We aimed to evaluate whether the pediatric extracorporeal shock wave lithotripsy (ESWL) nomograms can predict stone-free status in children effectively and whether they are applicable to our series. We hypothesize that two current nomograms predicting successful treatment with ESWL in pediatric patients are valid.

STUDY DESIGN

We evaluated 415 renal units (children <18 years) with eligible data who received ESWL treatment for upper urinary tract stones. Children's age, gender, stone size, stone surface area, stone location and history of previous intervention were recorded. Children with no residual fragments after ESWL treatment were designated as stone-free. The nomograms described by Dogan and Onal were implemented to our series for the prediction of stone-free status.

RESULTS

Mean age of children was 64.7 ± 57.2 months. Male to female ratio was 219:196.78.8% (327) of children had single stone. Mean stone size was 10.0 ± 3.7 mm and mean stone surface area was 380.0 ± 72.2 mm². Our stone-free rate after single ESWL session was 52.5% (218/415). Mean residual stone size and stone surface area after single session was 6.4 ± 3.3 mm and 36.0 ± 44.2 mm² respectively. There were no significant difference between stone-free children and children with residual fragments regarding gender, age and history of previous intervention. Mean stone size and stone surface area in stone-free children were lower and lower pole stones had the lowest stone-free rate (p < 0.05). Area under curve for Dogan and Onal nomogram were 0.628 and 0.580 respectively in ROC analysis (0.05). The agreement between Dogan and Onal score was moderate in our series. In multivariate analysis only stone surface area and Dogan score found to be independent predictors of stone-free status (p < 0.05).

DISCUSSION

Only one study has assessed both nomograms in the literature. Both nomograms are reported to be independent predictors of stone free status. ROC analysis in our study revealed fair accuracy for both nomograms with higher area under curve for Dogan nomogram. Higher accuracy for both nomograms were reported by other authors. These nomograms offer practical data but more effective tools are needed to be developed for the prediction of stone-free status in pediatric ESWL.

CONCLUSIONS

Stone size and stone surface area are associated with stone clearance. Dogan and Onal nomograms can be useful in prediction of stone-free status in children. Dogan nomogram is superior to Onal nomogram.

Role of Mini-Percutaneous Nephrolithotomy in the Management of Pediatric Stone Disease: A Systematic Review of Literature

Introduction: Kidney stone disease in the pediatric setting is rare, but the incidence is rising. Mini-percutaneous nephrolithotomy (mPCNL) is one of the newer surgical interventions to have been developed in recent decades. The aim of this study was to carry out a systematic review (SR) to formally evaluate the safety and efficacy of pediatric mPCNL, which was defined as PCNLs using tract size between 15F and 20F. Methods: An SR was carried out in accordance with Cochrane guidelines and A MeaSurement Tool to Assess systematic Reviews (AMSTAR) checklist. Original studies reporting on outcomes of mPCNL with 20 or more patients (aged ≤18 years) were included. Results: Eight studies were finally identified, which satisfied our predefined criteria. This included two randomized trials and six cohort studies. A total of 384 patients with a weighted mean age of 7.5 years (range: 0.5-18 years) and a male:female ratio of 3:2 underwent mPCNL. The weighted mean stone size was 1.2 cm (range: 0.8-3.5 cm). The weighted mean operative time and length of hospital stay were 76.8 minutes (range: 20-120 minutes) and 4.6 days (range: 1-33 days), respectively. The most common location(s) of stones were lower pole (57%) and renal pelvis (24.3%). The weighted mean initial and overall stone-free rates were 87.9% (range: 76%-97.5%) and 97% (range: 91.3%-100%), respectively. None of the cases required intraoperative conversion to standard PCNL. Complications occurred in 19% (n = 73) of patients. The weighted mean transfusion rate reported across studies was 3.3% (range: 0%-10.3%). Conclusions: mPCNL is safe and effective in the pediatric population. Further randomized studies will help determine its formal role in pediatric endourology and help guideline recommendations accordingly.