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469 Stone disease in children: An endourological challenge
469
Stone disease in children: An endourological challenge Eur Urol Suppl 2016;15(3);e469
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Beltrami P., Bettin L., Zattoni F., Iannetti A., Guttilla A., Castagnetti M., Dal Moro F., Zattoni F. University of Padua, Dept. of Surgical, Oncological and Gastroenterological Sciences - Urology Clinic, Padua, Italy INTRODUCTION & OBJECTIVES: Children constitute only a small number of the total patients with urolithiasis. Nevertheless pediatric stone disease is relevant for high recurrence risk during lifetime and a very slight urinary structure. The first aim of the study was to evaluate the feasibility, safety and the stone free rate (SFR) of endourological treatment in pediatric patients with urinary stone. As a second aim we evaluated independent predictors of SFR in this population. MATERIAL & METHODS: From January 2010 to June 2015 we retrospectively collected a single surgeon experience in pediatric endourological treatment of urinary stones. The procedures performed were ureterorenoscopy (URS), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL) and bladder PCNL (PCNL-B). SFR was defined as the absence of any visible or radiological stone after the procedure. A Dindo-Clavien classification was used to evaluate intra and postoperative complications (< 30 days after the procedure). Predictors of SFR were assessed with uni and multivariate logistic regression. RESULTS: Median age of the entire populations was 9 (IQR 4.4-14.2). A total of 91 procedures were performed in 55 patients (28 male, 27 female). Stone location was: kidney in 31 cases (34%), ureter in 18 (19.8%), multiple or staghorn in 32 (35.2%) and bladder in 10 (11%). Bilateral stones were present in 3 children (0.5%). URS, RIRS, PCNL and PCNL-B, were performed respectively in 15 (16.5%), 45 (49.5%), 21 (23.1%), 10 (10.9%). Due to poor ureter compliance only 1 URS and 1 RIRS were unsuccessful. Male were treated with a higher number of PCNL compared to female (p<0.02) in order to avoid complications to the urethra. No significant differences between stone size were observed between sex. For those patients with good ureter compliance performing URS (14/15 procedures), SFR was obtained in all the procedures with only one treatment. SFR with RIRS (44/45) was obtained in 31/44 cases (70.5%) with a single procedure while 13/44 (29.5%) with a second treatment. The SFR was 100% with a single RIRS procedure for stone burden less than 20 mm. For stones > 20 mm SFR was achieved with a single treatment in 22/36 (61%) while 14/36 (39%) needed a second RIRS. Intraoperative complications were respectively 4 (4.3%) Clavien I and 1 (1%) Clavien IIIb (thorax drainage for pneumothorax), while postoperative complications were observed in 3 (3.2%) Clavien I, and 1 (1%) Clavien IIIb (DJ position for urinary spreading after PCNL). At univariate analysis predictors of SFR were surgery time (OR 33.0 95% IC 4.5-308.4 p<0.001), stone burden (OR 1.04 95%CI 1.02-1.6, p<0.001 ) and the presence of multiple stone (OR 22, 95%CI 6.4-103.3, p<0.001). At multivariate analysis only stone burden (OR 1.2, 95%CI 1.1-28.3, p0.05) and multiple stone (OR 11.2, 95%CI 2.8-58.8, p 0.001) were independent predictors of SFR. CONCLUSIONS: Evolution of technique and miniaturization of instruments have changed the management of pediatric stone disease. The endourological indication should consider not only stone burden and stone position but also patients’ sex and age. Endourological treatment, and in particular the retrograde approach, is safe and effective in the pediatric population. Only high volume centers, however, which have acquired experience in adults, should offer this mininvasive treatment.
Stone disease in children: An endourological challenge Eur Urol Suppl 2016;15(3);e469
Print! Print!
Beltrami P., Bettin L., Zattoni F., Iannetti A., Guttilla A., Castagnetti M., Dal Moro F., Zattoni F. University of Padua, Dept. of Surgical, Oncological and Gastroenterological Sciences - Urology Clinic, Padua, Italy INTRODUCTION & OBJECTIVES: Children constitute only a small number of the total patients with urolithiasis. Nevertheless pediatric stone disease is relevant for high recurrence risk during lifetime and a very slight urinary structure. The first aim of the study was to evaluate the feasibility, safety and the stone free rate (SFR) of endourological treatment in pediatric patients with urinary stone. As a second aim we evaluated independent predictors of SFR in this population. MATERIAL & METHODS: From January 2010 to June 2015 we retrospectively collected a single surgeon experience in pediatric endourological treatment of urinary stones. The procedures performed were ureterorenoscopy (URS), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL) and bladder PCNL (PCNL-B). SFR was defined as the absence of any visible or radiological stone after the procedure. A Dindo-Clavien classification was used to evaluate intra and postoperative complications (< 30 days after the procedure). Predictors of SFR were assessed with uni and multivariate logistic regression. RESULTS: Median age of the entire populations was 9 (IQR 4.4-14.2). A total of 91 procedures were performed in 55 patients (28 male, 27 female). Stone location was: kidney in 31 cases (34%), ureter in 18 (19.8%), multiple or staghorn in 32 (35.2%) and bladder in 10 (11%). Bilateral stones were present in 3 children (0.5%). URS, RIRS, PCNL and PCNL-B, were performed respectively in 15 (16.5%), 45 (49.5%), 21 (23.1%), 10 (10.9%). Due to poor ureter compliance only 1 URS and 1 RIRS were unsuccessful. Male were treated with a higher number of PCNL compared to female (p<0.02) in order to avoid complications to the urethra. No significant differences between stone size were observed between sex. For those patients with good ureter compliance performing URS (14/15 procedures), SFR was obtained in all the procedures with only one treatment. SFR with RIRS (44/45) was obtained in 31/44 cases (70.5%) with a single procedure while 13/44 (29.5%) with a second treatment. The SFR was 100% with a single RIRS procedure for stone burden less than 20 mm. For stones > 20 mm SFR was achieved with a single treatment in 22/36 (61%) while 14/36 (39%) needed a second RIRS. Intraoperative complications were respectively 4 (4.3%) Clavien I and 1 (1%) Clavien IIIb (thorax drainage for pneumothorax), while postoperative complications were observed in 3 (3.2%) Clavien I, and 1 (1%) Clavien IIIb (DJ position for urinary spreading after PCNL). At univariate analysis predictors of SFR were surgery time (OR 33.0 95% IC 4.5-308.4 p<0.001), stone burden (OR 1.04 95%CI 1.02-1.6, p<0.001 ) and the presence of multiple stone (OR 22, 95%CI 6.4-103.3, p<0.001). At multivariate analysis only stone burden (OR 1.2, 95%CI 1.1-28.3, p0.05) and multiple stone (OR 11.2, 95%CI 2.8-58.8, p 0.001) were independent predictors of SFR. CONCLUSIONS: Evolution of technique and miniaturization of instruments have changed the management of pediatric stone disease. The endourological indication should consider not only stone burden and stone position but also patients’ sex and age. Endourological treatment, and in particular the retrograde approach, is safe and effective in the pediatric population. Only high volume centers, however, which have acquired experience in adults, should offer this mininvasive treatment.