Risk factors for formation of steinstrasse after extracorporeal shock wave lithotripsy for pediatric renal calculi: a multivariate analysis model

A Rare Case of Spontaneous Steinstrasse

Spontaneous steinstrasse ("stone street") is a collection of stones within the ureter and is a rare and understudied event. Factors such as infection, altered kidney function, and degree of obstruction are used to define the most adequate therapeutic option. Treatment can be either conservative or surgical. The decision of which depends on the clinical presentation. This paper reports a rare case of a 59-year-old patient with spontaneous steinstrasse examined at a urology clinic. Surgical intervention was required because of altered kidney function. The patient is currently undergoing follow-up for the metabolic investigation.

Using vacuum-assisted ureteral access sheath in the treatment of complex steinstrasse

Steinstrasse is an iatrogenic condition resulting from upper urinary tract lithotripsy. Uncomplicated steinstrasse can be managed expectantly. Complex steinstrasse can pose a therapeutic challenge. The vacuum-assisted ureteral access sheath (vaUAS) is similar to a conventional ureteral access sheath but has a side branch that can be connected to vacuum apparatus. This device seemed to be useful in the management of complex steinstrasse. 35 patients with complex steinstrasse, defined as steinstrasse containing ≥ 4 stones or with an aggregate length of ≥ 1.5 cm, were treated in four tertiary medical centers using the vaUAS in this prospective and non-randomized study. The vaUAS was inserted into the ureter over a guidewire until the tip of the vaUAS was in contact with the lowermost stone fragment. A 7 Fr./8.4 Fr. semirigid ureteroscope and a holmium laser were used to pulverize the obstructing stone. All the stone fragments were aspirated either in the space between the scope and the sheath, or through the channel of the sheath by withdrawing the scope to the proximal of the aspiration port. All patients were steinstrasse-free at end of the procedure, as assessed visually and by KUB. At the 3-month follow-up, 94.3% of patients were stone-free with or without a supplementary procedure. There were no perioperative complications. Five patients experienced postoperative fever and/or significant hematuria, and one patient had transient sepsis, a grade I and IV Clavien complication, respectively. vaUAS can be an effective adjunctive device in the management of complex steinstrasse.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

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-percutaneous nephrolithotomy for pediatric complex renal calculus disease: one-stage or two-stage?

OBJECTIVES

To compare two different treatment strategies, one-stage and two-stage multi-tract mini-percutaneous nephrolithotomy (mt-mPCNL), for pediatric complex renal calculus disease.

METHODS

Between the period of July 2016 and July 2018, a total of 36 children aged 15 years and younger, with complex renal calculi disease, who underwent total ultrasound-guided mt-mPCNL by a single experienced urologist were enrolled in our study. All patients were assigned either to Group 1 (n = 18) who received one-stage mt-mPCNL or Group 2 (n = 18) who received planned two-stage mt-mPCNL.

RESULTS

The demographic data were comparable between the two groups. There were no serious complications (Modified Clavien Grade ≥ III) observed in either group. The stone -free rate (SFR), operation time, postoperative creatinine increase, and perioperative complication rates were similar in both groups (P = 0.603, 0.818, 0.161, and 0.402, respectively). The postoperative hospital stay (5.8 days vs. 7.4 days) and cost (17373.3 CNY vs. 23717.1 CNY) were statistically less in Group 1. Group 2 had significantly less total estimated blood loss (70.6 ml vs. 130.0 ml, P < 0.001). The operation time of two cases in Group 1 with perioperative sepsis or systemic inflammatory response syndrome (SIRS) was more than two hours.

CONCLUSIONS

Our preliminary results indicated that both one-stage and two-stage mt-mPCNL were safe and effective for pediatric complex renal calculi. Two-stage mt-mPCNL could significantly reduce blood loss; while one-stage mt-mPCNL could significantly decrease the length and costs of hospitalization. We also suggest that the planned two-stage mt-mPCNL should be applied in children with estimated operation time more than two hours.

Is mini-percutaneous nephrolithotomy a safe alternative to extracorporeal shockwave lithotripsy in pediatric age group in borderline stones? a randomized prospective study

PURPOSE

The extracorporeal shockwave lithotripsy (ESWL) remains the most common first line of treatment for renal stones in the pediatric population. The purpose of this study is to evaluate and compare the outcomes of the ESWL and mini-percutaneous nephrolithotomy (mini-PCNL).

PATIENTS AND METHODS

A total of 108 patients younger than 12 years of age with 1-2 cm single renal stone (pelvic or calyceal) were randomized into two groups, each containing 54 patients. Patients in group A were subjected to mini-PCNL using 16.5 Fr percutaneous sheath while those in group B underwent ESWL using Dornier Compact Sigma.

RESULTS

The stone-free rate (SFR) after first session was 88.9% (48 cases) and 55.6% (30 cases) for groups A and B, respectively. The difference is highly statistically significant P = 0.006. Two patients (3.7%) in group A needed 2nd session of PCNL, while 18 patients (33.3%)in group B needed a 2nd session, of theses 18 patients six patients needed a 3rd session of ESWL. After the third session of ESWL and second look PCNL the stone-free rates were 92.59% (50 cases) and 88.89% (48 cases) for groups A and B, respectively, (P = 0.639), which is statistically insignificant. The mean hospital stay and fluoroscopy exposure were significantly longer in the mini-PCNL group. The complication rate in groups A and group B were (22.2%) and (14.8%), respectively, which is statistically insignificant (P = 0.484).

CONCLUSIONS

According to Clavien grade of complications mini-PCNL is a safe procedure, and after three session of ESWL, mini-PCNL has a similar stone-free rate with a lower retreatment rate. However, the mini-PCNL has more radiation exposure, and requires a longer hospital stay.