[Extracorporeal lithotripsy in children. Study of its efficacy and evaluation of renal parenchymal damage by DMSA-Tc 99m scintigraphy: a series of 39 children]

Impact of repeated extracorporeal shock wave lithotripsy on prepubertal rat kidney

This study aimed to investigate the effects of repeated extracorporeal shock wave lithotripsy (ESWL) on the kidneys of prepubertal and adult rats. Thirty rats were used: 15 were prepubertal (3 weeks of age) with an average body weight of 72.3 ± 3.3 g, and 15 were adults with of 265 ± 11.3 g. The prepubertal and adult rats were separately and randomly allocated to three groups, each consisting of five rats. Following anesthetization, the left kidney of each rat in each group received shock waves in one, two, or three sessions separated by 72 h. The rats in each group were killed 72 h after the last ESWL session, and both kidneys were harvested; the right kidney was used as the control. Renal injury was examined with histological analysis, immunohistochemistry, and Western blot to detecting the expression of heat-shock protein-70, tumor necrosis factor-alpha-α, intercellular adhesion molecule-1, and monocyte chemoattractant protein-1 as markers of renal damage. All of these markers were similarly increased with increased ESWL sessions in both age groups. Histological analysis revealed more serious fibrosis and inflammation in the ESWL-treated kidneys in both groups than in the controls, with the damage increasing with increasing numbers of sessions. ESWL on the kidney increased renal damage according to the number of sessions in both age groups of rats, and the effects of ESWL on renal injury were similar in the two groups. However, there were generally no significant differences in the effects of ESWL on molecular indicators of renal injury between prepubertal and adult rats.

Comparative risk of chronic kidney diseases in patients with urolithiasis and urological interventions: a longitudinal population-based study

Large cohort studies on whether any association existed between urological interventions for urolithiasis and the development of CKD are lacking. From claims data of the National Health Insurance (NHI) program of Taiwan, we identified 54,433 patients newly diagnosed with urolithiasis during 1998-2010. For each case, four individuals without urolithiasis were randomly selected and frequency matched by age, sex, and diagnosis year. Both groups were followed up until the end of 2010. Incident CKD events were identified by the International Classification of Diseases, Ninth Revision (ICD-9) code in the NHI registration database. The overall incidence of periodontal diseases was 1.85-fold greater in the urolithiasis group than in the comparison group (33.9 vs 18.3 per 10,000 person-years; 95 % confidence interval [CI] 1.81-1.90). Compared with the adjusted hazard ratios (aHRs) of nonurolithiasis patients, those of patients with urolithiasis increased with the number of medical visits (from 0.91 [95 % CI 0.83-1.00] to 10.6 [95 % CI 9.48-11.8]) and urological interventions (from 1.22 [95 % CI 1.10-1.35] to 86.4 [95 % CI 67.6-110.6]). The aHR was similar in different urological intervention methods, extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrostolithotomy, and open stone surgery. The urological intervention for urolithiasis is associated with an increased risk of CKD. We should be aware of the risk for CKD, especially in patients who have received multiple urological interventions and those elderly.

Extracorporeal shockwave lithotripsy under sedoanalgesia for treatment of kidney stones in infants: a single-center experience with 102 cases

OBJECT

We present the efficacy of shockwave lithotripsy (SWL) therapy administered with sedoanalgesia in infants with kidney stones.

MATERIALS AND METHODS

We enrolled 102 patients aged 5-24 months who had kidney stones and received SWL therapy under sedoanalgesia using a Siemens Lithostar Modularis device. Patient and stone characteristics, therapy parameters, pain score, complications, discharge time, and follow-ups were registered and evaluated. Pain score was assessed using a Neonatal Infant Pain Score (NIPS). Postanesthetic discharge scoring system (PADSS) was used for the assessments of postprocedural discharge procedure.

RESULTS

Mean age of the patients was 17.2 ± 6.3 months (5-24 months). Mean stone size was 7.9 ± 3.3 mm (5-23 mm). The most common concomitant metabolic disorders were hypercalciuria and hypocitraturia. The stone-free rates of the infants were 70.6, 87.3, and 99.1 % after the first, second, and third sessions of SWL therapy, respectively. The mean NIPS scores procedure during, and at 1 h after SWL procedure were determined as 0.24 ± 0.45 and 0.34 ± 0.47, respectively. There was no statistically significant difference between two pain score values (P = 0.114). The mean discharge time of patients after the SWL procedure were 108.6 ± 27.9 min. Forty-two patients (41.1 %) were followed up. The follow-up period varied between 8 and 48 months (mean 19.5 months); none of those patients showed evidence of diabetes mellitus, hypertension, or renal function impairment.

CONCLUSIONS

SWL therapy under sedoanalgesia is a safe and efficient treatment modality that can be administered with low complication rates and high stone-free rates in the treatment of renal stones in infants.

Pediatric urolithiasis: experience from a tertiary referral center

OBJECTIVE

Pediatric urolithiasis can cause significant morbidity and damage to the kidney, or even renal failure. We review our experience of the management of urolithiasis in pediatric patients at a tertiary referral center.

PATIENTS AND METHODS

We reviewed medical records of all children with urolithiasis who were diagnosed and managed at our center from August 2003 to October 2011. Management was planned according to stone burden and location. We noted and statistically analysed data about age, sex, stone burden, clinical features, management, metabolic abnormalities and recurrence.

RESULTS

There were 325 children with 378 stone sites. Age range was 3-17 (mean 8) years. The male to female ratio was 3:1. Most common presentation was abdominal pain in 257 children (79%), and the most common stone site was kidney in 215 (57%). Twenty-four (7%) children (stone burden ≤3 mm) were managed conservatively, while the rest received some form of intervention. Metabolic workup could be done in 154 (47%) children. A metabolic abnormality was seen in 67 (43%) children, normocalcemic hypercalciuria being the most common. Recurrence of urolithiasis was seen in 78 (24%) children after a mean follow-up of 3.2 (1-6) years, and was more common in those who had a metabolic abnormality or in whom small residual fragments were left in situ.

CONCLUSIONS

Availability of smaller instruments has led to safer use of percutaneous endoscopy and ureteroscopy in children, with results comparable to those in adults and an acceptable complication rate. The presence of a metabolic abnormality is quite common and is a cause of recurrence.

Pediatric extracorporeal shock wave lithotripsy: Predicting successful outcomes

Extracorporeal shock wave lithotripsy (ESWL) is currently a first-line procedure of most upper urinary tract stones <2 cm of size because of established success rates, its minimal invasiveness and long-term safety with minimal complications. Given that alternative surgical and endourological options exist for the management of stone disease and that ESWL failure often results in the need for repeat ESWL or secondary procedures, it is highly desirable to identify variables predicting successful outcomes of ESWL in the pediatric population. Despite numerous reports and growing experience, few prospective studies and guidelines for pediatric ESWL have been completed. Variation in the methods by which study parameters are measured and reported can make it difficult to compare individual studies or make definitive recommendations. There is ongoing work and a need for continuing improvement of imaging protocols in children with renal colic, with a current focus on minimizing exposure to ionizing radiation, perhaps utilizing advancements in ultrasound and magnetic resonance imaging. This report provides a review of the current literature evaluating the patient attributes and stone factors that may be predictive of successful ESWL outcomes along with reviewing the role of pre-operative imaging and considerations for patient safety.

[Cystinuria in children: A report of 4 cases]

Cystinuria is an inherited autosomal-recessive disorder of renal reabsorption of the dibasic amino acids. It is the cause of about 6% of all kidney stones observed in children. Cystine is relatively insoluble at the physiological pH of urine. Cystine stones are characteristic and frequent recurrences are observed. We report on 4 cases and describe the initial presentation (obstructive renal failure, urinary sepsis, familial screening) and the medical and surgical management. Medical management is mainly based on hyperhydration and urine alkalinization. Long-term therapy with sulfhydryl agents to prevent formation of renal stones seems to be effective but adverse side effects are frequent, requiring the withdrawal of treatment. Urological management has evolved from surgical stone removal to minimally invasive procedures (extracorporeal shock wave lithotripsy, ureteroscopy).

Evaluation of renal function in children undergoing extracorporeal shock wave lithotripsy

PURPOSE

The effect of extracorporeal shock wave lithotripsy on the growing kidneys of young children has always been a concern. We determined whether shock wave lithotripsy causes renal parenchymal scarring or affects glomerular filtration rate in children.

MATERIALS AND METHODS

This prospective study included 100 children with renal stones who presented to the shock wave lithotripsy unit at our institution between March 2005 and March 2008. A total of 28 children had multiple stones in the same kidney. All children with bilateral renal stones had 1 kidney cleared of stones by percutaneous nephrolithotomy before undergoing shock wave lithotripsy. A total of 138 stones were subjected to shock wave lithotripsy. All children underwent radionuclide scan of the renal parenchyma using dimercapto-succinic acid, and glomerular filtration rate was estimated using diethylenetriamine pentaacetic acid before extracorporeal shock wave lithotripsy and 6 months afterward. Children with renal scarring due to previous surgery or vesicoureteral reflux were excluded from the study. The number of shock wave lithotripsy sessions to achieve stone-free status and the dose of shock waves used were recorded for each patient.

RESULTS

No patient demonstrated renal parenchymal scarring on dimercapto-succinic acid scan or any statistically significant change in glomerular filtration rate on diethylenetriamine pentaacetic acid scan up to 6 months after shock wave lithotripsy.

CONCLUSIONS

Shock wave lithotripsy is a safe modality for treating renal calculous disease in children up to 16 years old, with no impact on long-term kidney function.

[Extracorporeal lithotripsy in children - the efficacy and long-term evaluation of renal parenchyma damage by DMSA-99mTc scintigraphy]

PURPOSE

To determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) and possible deleterious effects on renal parenchyma of children subjected to treatment of renal lithiasis, using renal scintigraphy with 99mTc dimercapto-succunic acid (DMSA).

PATIENTS AND METHODS

From January 2004 to November 2007, 18 children (age 3-10 years) underwent ESWL (Philips-Dornier) for kidney urolithiasis. All patients underwent preoperative evaluation, including physical examination, urine culture, image exams and renal scintigraphy with Tc99-DMSA. Evaluation after treatment consisted of a clinical examination, blood pressure measurement, urine culture, renal ultrasound and Tc99-DMSA, repeated at 3, 6 and 12 months, which were compared to the scans obtained before ESWL to determine possible morphological or functional changes.

RESULTS

Success in the stones fragmentation was achieved in all cases - in 9 patients (50%) with one session of ESWL, in 6 (33%) with two sessions and in 3 patients (17%) with 3 sessions of ESWL. Only one patient (5%), after three sessions of ESWL and 6 months of follow-up showed change in size of right kidney with a decrease in tubular function, without hypertension or other major changes. In the other cases, there was absence of hypertension up to 12 months of follow-up, absence of renal hematomas detected by ultrasound or significant renal scars in scintigraphic examinations.

CONCLUSION

ESWL is effective and safe for treating renal lithiasis in children. Renal parenchyma lesions may occur early after treatment, but these lesions are transients and resolve spontaneously in virtually all cases; generally, there are no irreversible renal lesions associated with ESWL, even after the follow-up period with clinical examination, ultrasound examination and 99mTc-DMSA scintigraphy.

Is extracorporeal shock wave lithotripsy in pediatrics a safe procedure?

Removal of urinary calculi is an essential element in the successful treatment of patients with urinary stone disease. The new generation of lithotriptors allows the treatment without the need for general anesthesia. The patients, often outpatients, have a faster discharge from the hospital with a reduction of hospitalization time and operating costs. Shock wave lithotripsy (SWL) is currently considered a safe technique for treatment of pediatric urinary lithiasias, with a low percentage of complications and subsequent surgical retreatments. But can we define SWL as a safe procedure in pediatrics? Herein, we will review the literature to justify SWL safety in children, focusing on important parameters as the insertion of preoperative stenting, side effects, and complications after the procedure.

Urolithiasis in infants

There are few publications about urolithiasis of the new born baby and infant (UNI). The UNI represents 20% of the pediatric urolithiasis. The etiologies in this age group are chiefly dominated by the urinary-tract infections and metabolic abnormalities. The purpose of this paper was to investigate the epidemiological and clinical characteristics of infant urolithiasis and to define the various treatment modalities adapted to this age group.

Extracorporeal shock wave lithotripsy 25 years later: complications and their prevention

OBJECTIVE

We review the pathophysiology and possible prevention measures of complications after extracorporeal shock wave lithotripsy (ESWL).

METHODS

A literature search was performed with the Medline database on ESWL between 1980 and 2004.

RESULTS

ESWL application has been intuitively connected to complications. These are related mostly to residual stone fragments, infections, and effects on tissues such as urinary, gastrointestinal, cardiovascular, genital, and reproductive systems. Recognition of ESWL limitations, use of alternative therapies, correction of pre-existing renal or systemic disease, treatment of urinary tract infection, use of prophylactic antibiotics, and improvement of ESWL efficacy are the most important measures of prevention. Decrease of shock wave number, rate and energy, use of two shock-wave tubes simultaneously, and delivery of two shock waves at carefully timed close intervals improve ESWL efficacy and safety.

CONCLUSION

ESWL is a safe method to treat stones when proper indications are followed. The need for well-designed prospective randomised trials on aetiology and prevention of its complications arises through the literature review.

Extracorporeal shock wave lithotripsy as first line treatment alternative for urinary tract stones in children: a large scale retrospective analysis

PURPOSE

Management of urinary tract stones in children represents a challenging problem. In this study we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (SWL) in children.

MATERIALS AND METHODS

During a 12-year period 408 urinary tract calculi in 344 children (mean age 8.7 +/- 3.9 years, range 6 months to 14 years) were managed with the Lithostar Plus lithotriptor (Siemens Medical Systems, Iselin, New Jersey). There were 57 caliceal stones, 167 in the renal pelvis, 31 in the proximal ureter, 16 in the mid ureter and 121 in the distal ureter, and 16 bladder stones.

RESULTS

All patients were treated on an outpatient basis, with intravenous sedation being used in 138 (40.1%), general anesthesia in 132 (38.4%) and no anesthesia in 74 (21.5%). A maximum of 3,500 shocks and 18 kV per session was given. A total of 780 SWL sessions were applied (mean 1.9 sessions per stone). Overall, a stone-free rate of 79.9% and clinically insignificant residual fragments in 13.2% of cases were observed at 3-month followup with a re-treatment rate of 53.9%. Overall efficacy quotient was 50.9%. Significantly more favorable results were achieved in ureteral calculi and stones 2 cm or smaller (p <0.05). Complications were observed in 33 patients (9.6%).

CONCLUSIONS

Our results indicate that SWL, with satisfactory stone-free rates and efficacy quotients in stones 2 cm or smaller can be offered as a first line treatment in children.

[Pediatric vesical lithiasis. 70 case reports]

The study focuses on 70 vesicals lithiasis, with a sample consisting of 60 boys (86%) and ten girls (14%). The age varies from one year to 14 years. The revealing signs are dominated by mictional troubles in 47 cases (67%), macroscopic hematurie in 26 cases (37%), the pyurie in 12 cases (17%) and acute retention of urine in 7 cases (10%). The most frequent germs are the staphylococcus aureus with 28% of cases, the protéus mirabilis with 24% of cases and the Echerichia coli with 24% of the cases. Associated malformations were observed in 9% of the cases. The treatment was essentially surgical (99%). The evolution was simple in 97% of the cases.