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Limitations of extracorporeal shock wave lithotripsy for urinary tract calculi in young children
Limitations of Extracorporeal Shock Wave Lithotripsy for Urinary Tract Calculi in Young Children By P. Losty, R. Surana, and B. O’Donnell Dublin, 0 Despite success rates with a variety of urinary tract calculi, there is growing concern that extracorporeal shock wave lithotripsy (ESWL) has limitations and that its role needs to be redefined. We report the outcome of 28 consecutive children (age range, 8.5 months to 7 years; mean, 3.6 years} with urinary calculus disease, treated over a 5-year period. Thirteen patients had ESWL monotherapy. and 8 achieved stone clearance. The other 5 children in the ESWL monotherapy group, all with multiple calculi, required surgery to render them stone free. A further 14 patients (6 staghorn calculi, 6 multiple calculi, 1 solitary renal, and 1 child with multiple bladder calculi) were considered unsuitable for ESWL and had primary surgery. Twelve of those 14 were cleared by open surgery, one had residual fragments successfully treated by ESWL, and one still awaits adjuvant ESWL. One child had a solitary renal calculus (5 mm) which passed spontaneously. This study demonstrates that ESWL monotherapy cleared stones in only 8 of 28 patients and clearance in a further 6 was achieved with surgery. Surgery will continue to play an important role in the management of paediatric urolithiasis for large staghorn, multiple urinary tract calculi and lithotripsy failures. Copyright o 1993 by W.B. Saunders Company IhlDEX WORDS: Urinary shock wave lithotripsy.
calculi,
children;
extracorporeal
T
HE INTRODUCTION of extracorporeal shock wave Iithotripsy (ESWL) into clinical practice by Chaussy et al initiated such changes in the treatment of urinary tract calculi that open operation has become uncommon.’ Its success was measured by its widespread application in adult and, more recently, paediatric urological practice.‘+r Concern has been expressed recently not only about possible long-term effects on renal function but also a limited ability to treat staghorn, multiple renal, and ureteric calculi.4-x The aim of this study was to examine the impact that ESWL had on our practice and attempt to formulate a selection policy for future management. MATERIALS
AND METHODS
Between 1986 and 1990 inclusive, 28 children attended our unit with urinary tract calculi. Their ages ranged from 6.5 months to 7 years (mean, 3.6 years). Twenty-six children presented with urinary tract infection. one with haematuria, and one was asymptomatic. Seven patients (25%) had associated renal tract anomalies-four vesicoureteric reflux. one pelviureteric junction obstruction, one duplex system, and one horshoe kidney. One child had previously undergone a pyeloureterolithotomy for calculus disease. All patients had renal blood chemistry profile estimation (urea and creatinine), metabolic evaluation, urinalysis, urine culture, plain film radiology. micturating cystourethrography, and intravenous urograms prior to treatment. The relevant data were analysed and
JournalofPedialric
Surgery, Vol28, No 8 (August).
1993: pp 1037.1039
Ireland patient suitability paediatric surgeon
for ESWL was determined by the attending and adult urologists who conducted and super-
vised the lithotripsy sessions. ESWL was performed using the Siemens
Lithostar
Lithotriptor
under general anesthesia. Stones were targeted by fluoroscopy and shock waves generated using an electromagnetic shock head. The success of treatment was assessed by the appearance of fragmentation during ESWL and by observing stone clearance, ie, the complete absence of stone fragments on a follow-up plain radiographs. Patients deemed unsuitable for ESWL and the lithotripsy failures had conventional open stone surgery. Surgical success was assessed
by the same methods.
RESULTS
Thirteen of 28 patients had ESWL monotherapy (Fig 1). Eight of 13 achieved complete stone clearance; five had calculi all 125 mm and three had staghorn calculi (mean size, 33 mm). One patient with a 45mm staghorn calculus developed a pyonephrosis secondary to acute ureteric obstruction (‘Steinstrasse’) following treatment and required percutaneous nephrostomy and antibiotic therapy. The other five in whom ESWL failed (4 multiple renal tract calculi, 1 bilateral staghorn calculi) required surgery to render them stone free. Two of these patients (one duplex system) required pyeloureterolithotomy, one cystolithotomy for multiple bladder calculi and one ESWL in combination with percutaneous nephrolithotomies for bilateral staghorn stones (mean size, 53 mm). A nephrectomy was performed in a child who developed a renal abscess following ESWL for recurrent multiple calculus disease originating in a chronically inflamed kidney. Fourteen patients were considered unsuitable for ESWL because of associated anomalies of the urinary tract, large staghorn calculi, multiple calculi, and age of the patient. One patient had pyelolithotomy and pyeloplasty for associated pelviureteric obstruction. Another patient underwent nephrectomy for an associated nonfunctioning kidney. Four patients with large staghorn calculi (mean size, 47 mm) and two From the Department of Paediatric Surgery and C’hildren’s Reseurch Center, Our Lady’s Hospital for Sick Children, Dublin, Ireland. Presented at the 39th Annual International Congress of the British Association of Paediatric Surgeons, Leeds, England. July 15-1X, 1992. Address reprint requests to Professor Bany O’Donnell, Children’s Research Centre, Our Lady’s Hospital for Sick Children, Crumlin. Dublin 12, Ireland. Copvright o I993 by W.B. Saunders Company 0023-3-mRl93/2808-001~$03.0010 1037
1038
LOSTY, SURANA, AND O’DONNELL
Fig 1. Flow diagram tient management.
patients with multiple renal calculi were treated with conventional surgery. Extensive surgery via pyeloureterolithotomy (2 patients), pyelocystolithotomy (1 patient), and pyeloureterocystolithotomy (1 patient) was required for multiple renal tract involvement. A cystohthotomy was carried out in a child with multiple bladder calculi. We had reservations in the early part of the study about referring a 6.5-month-old infant for ESWL who successfully underwent pyelolithotomy. Overall, 12 of 14 patients became stone free after surgery--one patient (multiple renal tract calculi) had residual fragments successfully treated by ESWL and another (bilateral staghom disease) awaits adjuvant ESWL. One patient passed a 5-mm solitary renal calculus and required no treatment. DISCUSSION
ESWL has made a signiftcant impact in the management of urolithiasis. The initial success rates reported for unselected series of urinary calculi have been challenged by studies advocating better case selection.3,5-8 In this study we achieved a 61% stone clearance rate in a selected cohort of patients treated by lithotripsy. The majority of these patients had small calculi all 125 mm. Although three patients with staghorn calculi (mean size, 33 mm) became stone-free, one developed an acute pyonephrosis secondary to a Steinstrasse requiring nephrostomy and aggressive antibiotic support. Five lithotripsy “failures” (all multiple calculi) required surgery and three children warrant further discussion. One patient with a duplex system underwent pyeloureterolithotomy. In retrospect such a patient would probably have been served better by primary surgery as recommended by Assimos et al.9 A further child (aged 2 years) with bilateral staghorn calculi (mean size, 53 mm) had had ESWL in combination with percutane-
of pa-
nephrolithotomies (PCNLs) at another centre. This approach is justifiable when dealing with large staghorn calculi, in adults. PCNL was required on more than one occasion (the first attempt was unsuccessful). We have reservations advocating PCNL in young patients ( <5 years) because of its inherent risks to renal reserve and technical difficulties.rO Nephrectomy proved necessary in one child who developed a renal abscess following ESWL for recurrent calculus disease which originated in a chronically inflamed kidney. Similar reports have been recorded in adult series7 The results of primary surgery were satisfactory, with 86% of selected patients achieving stone clearance. Lessons derived from patients early in the study who did not do well following lithotripsy influenced subsequent case selection. Surgical results proved particularly rewarding in patients with large staghorn calculi. Therefore, like others, we now believe ESWL to be inappropriate primary treatment for the larger Multiple calculi have similarly staghorn calculi. 5,7~11 been shown to adversely affect stone clearance by ESWL.6 In our series all ESWL “failures” had multiple calculi and those selected for surgery primarily required more extensive procedures. ESWL did demonstrate a useful adjuvant role in patients with residual disease following surgery. One patient (multiple renal tract calculi) had residual stone fragments cleared by lithotripsy whilst another child awaits treatment. ous
ACKNOWLEDGMENT The authors wish to thank Professor E. Guiney, Mr R. Fitzgerald, and Mr P. Puri for permission to include their patients in this study. We also thank Professor J.M. Fitzpatrick’s Unit at the Mater Misericordiae Hospital, Dublin, for their cooperation in patient assessment and provision of lithotripsy services. Thanks also go to Ann Brennan for preparation of the manuscript.
LIMITATIONS
OF LITHOTRIPSY
1039
IN YOUNG CHILDREN
REFERENCES 1. Chaussy C. Brendell W, Schmiedt E: Extracorporeally induced destruction of kidney stones by shock waves. Lancet 2:12651268, 1980 2. Thornhill JA, Moran K, Mooney EE, et al: Extracorporeal shock wave lithotripsy monotherapy for paediatric urinary tract calculi. Br J Urol65:638-640,199O 3. Mishriki SF, Wills MI, Mukherjee A. et al: Extracorporeal shockwave lithotripsy for renal calculi in children. Br J Urol 69:303-305, 1992 4. Corbally MT, Ryan J, Fitzpatrick J, et al: Renal function following extracorporeal lithotripsy in children. J Pediatr Surg 26:539-540,199l 5. Gleeson MJ. Griffith DP: Extracorporeal shock wave lithotripsy monotherapy for large renal calculi. Br J Urol 64:329-332. 1989 6. Gleeson MJ. Shabsigh R. Griffith DP: Outcome of ESWL in
patients with multiple renal calculi based on stone burden and location. J Endourol2:145-149, 1988 7. Neerhut GJ, Ritchie A, Tolley D: Extracorporeal piezoelectric lithotripsy for all renal stones: Effectiveness and limitations. Br J Urol64:5-9, 1989 8. Parr NJ, Ritchie A, Moussa S, et al: The impact of extracorporeal piezoelectric lithotripsy on the management of ureteric calculi: An audit. Br J Urol67:18-23,199l 9. Assimos DG, Boyce WH, Harrison LH, et al: The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol 142:263-267.1989 10. Webb DR, Fitzpatrick JM: Percutaneous nephrolithotripsy: A functional and morphological study. J Ural 134578-591, 1985 11. Wilbert D. Schafer 0, Reidmiller H: Longterm results of extracorporeal shock wave lithotripsy in children. J Urol 142:579581.1988
calculi,
children;
extracorporeal
T
HE INTRODUCTION of extracorporeal shock wave Iithotripsy (ESWL) into clinical practice by Chaussy et al initiated such changes in the treatment of urinary tract calculi that open operation has become uncommon.’ Its success was measured by its widespread application in adult and, more recently, paediatric urological practice.‘+r Concern has been expressed recently not only about possible long-term effects on renal function but also a limited ability to treat staghorn, multiple renal, and ureteric calculi.4-x The aim of this study was to examine the impact that ESWL had on our practice and attempt to formulate a selection policy for future management. MATERIALS
AND METHODS
Between 1986 and 1990 inclusive, 28 children attended our unit with urinary tract calculi. Their ages ranged from 6.5 months to 7 years (mean, 3.6 years). Twenty-six children presented with urinary tract infection. one with haematuria, and one was asymptomatic. Seven patients (25%) had associated renal tract anomalies-four vesicoureteric reflux. one pelviureteric junction obstruction, one duplex system, and one horshoe kidney. One child had previously undergone a pyeloureterolithotomy for calculus disease. All patients had renal blood chemistry profile estimation (urea and creatinine), metabolic evaluation, urinalysis, urine culture, plain film radiology. micturating cystourethrography, and intravenous urograms prior to treatment. The relevant data were analysed and
JournalofPedialric
Surgery, Vol28, No 8 (August).
1993: pp 1037.1039
Ireland patient suitability paediatric surgeon
for ESWL was determined by the attending and adult urologists who conducted and super-
vised the lithotripsy sessions. ESWL was performed using the Siemens
Lithostar
Lithotriptor
under general anesthesia. Stones were targeted by fluoroscopy and shock waves generated using an electromagnetic shock head. The success of treatment was assessed by the appearance of fragmentation during ESWL and by observing stone clearance, ie, the complete absence of stone fragments on a follow-up plain radiographs. Patients deemed unsuitable for ESWL and the lithotripsy failures had conventional open stone surgery. Surgical success was assessed
by the same methods.
RESULTS
Thirteen of 28 patients had ESWL monotherapy (Fig 1). Eight of 13 achieved complete stone clearance; five had calculi all 125 mm and three had staghorn calculi (mean size, 33 mm). One patient with a 45mm staghorn calculus developed a pyonephrosis secondary to acute ureteric obstruction (‘Steinstrasse’) following treatment and required percutaneous nephrostomy and antibiotic therapy. The other five in whom ESWL failed (4 multiple renal tract calculi, 1 bilateral staghorn calculi) required surgery to render them stone free. Two of these patients (one duplex system) required pyeloureterolithotomy, one cystolithotomy for multiple bladder calculi and one ESWL in combination with percutaneous nephrolithotomies for bilateral staghorn stones (mean size, 53 mm). A nephrectomy was performed in a child who developed a renal abscess following ESWL for recurrent multiple calculus disease originating in a chronically inflamed kidney. Fourteen patients were considered unsuitable for ESWL because of associated anomalies of the urinary tract, large staghorn calculi, multiple calculi, and age of the patient. One patient had pyelolithotomy and pyeloplasty for associated pelviureteric obstruction. Another patient underwent nephrectomy for an associated nonfunctioning kidney. Four patients with large staghorn calculi (mean size, 47 mm) and two From the Department of Paediatric Surgery and C’hildren’s Reseurch Center, Our Lady’s Hospital for Sick Children, Dublin, Ireland. Presented at the 39th Annual International Congress of the British Association of Paediatric Surgeons, Leeds, England. July 15-1X, 1992. Address reprint requests to Professor Bany O’Donnell, Children’s Research Centre, Our Lady’s Hospital for Sick Children, Crumlin. Dublin 12, Ireland. Copvright o I993 by W.B. Saunders Company 0023-3-mRl93/2808-001~$03.0010 1037
1038
LOSTY, SURANA, AND O’DONNELL
Fig 1. Flow diagram tient management.
patients with multiple renal calculi were treated with conventional surgery. Extensive surgery via pyeloureterolithotomy (2 patients), pyelocystolithotomy (1 patient), and pyeloureterocystolithotomy (1 patient) was required for multiple renal tract involvement. A cystohthotomy was carried out in a child with multiple bladder calculi. We had reservations in the early part of the study about referring a 6.5-month-old infant for ESWL who successfully underwent pyelolithotomy. Overall, 12 of 14 patients became stone free after surgery--one patient (multiple renal tract calculi) had residual fragments successfully treated by ESWL and another (bilateral staghom disease) awaits adjuvant ESWL. One patient passed a 5-mm solitary renal calculus and required no treatment. DISCUSSION
ESWL has made a signiftcant impact in the management of urolithiasis. The initial success rates reported for unselected series of urinary calculi have been challenged by studies advocating better case selection.3,5-8 In this study we achieved a 61% stone clearance rate in a selected cohort of patients treated by lithotripsy. The majority of these patients had small calculi all 125 mm. Although three patients with staghorn calculi (mean size, 33 mm) became stone-free, one developed an acute pyonephrosis secondary to a Steinstrasse requiring nephrostomy and aggressive antibiotic support. Five lithotripsy “failures” (all multiple calculi) required surgery and three children warrant further discussion. One patient with a duplex system underwent pyeloureterolithotomy. In retrospect such a patient would probably have been served better by primary surgery as recommended by Assimos et al.9 A further child (aged 2 years) with bilateral staghorn calculi (mean size, 53 mm) had had ESWL in combination with percutane-
of pa-
nephrolithotomies (PCNLs) at another centre. This approach is justifiable when dealing with large staghorn calculi, in adults. PCNL was required on more than one occasion (the first attempt was unsuccessful). We have reservations advocating PCNL in young patients ( <5 years) because of its inherent risks to renal reserve and technical difficulties.rO Nephrectomy proved necessary in one child who developed a renal abscess following ESWL for recurrent calculus disease which originated in a chronically inflamed kidney. Similar reports have been recorded in adult series7 The results of primary surgery were satisfactory, with 86% of selected patients achieving stone clearance. Lessons derived from patients early in the study who did not do well following lithotripsy influenced subsequent case selection. Surgical results proved particularly rewarding in patients with large staghorn calculi. Therefore, like others, we now believe ESWL to be inappropriate primary treatment for the larger Multiple calculi have similarly staghorn calculi. 5,7~11 been shown to adversely affect stone clearance by ESWL.6 In our series all ESWL “failures” had multiple calculi and those selected for surgery primarily required more extensive procedures. ESWL did demonstrate a useful adjuvant role in patients with residual disease following surgery. One patient (multiple renal tract calculi) had residual stone fragments cleared by lithotripsy whilst another child awaits treatment. ous
ACKNOWLEDGMENT The authors wish to thank Professor E. Guiney, Mr R. Fitzgerald, and Mr P. Puri for permission to include their patients in this study. We also thank Professor J.M. Fitzpatrick’s Unit at the Mater Misericordiae Hospital, Dublin, for their cooperation in patient assessment and provision of lithotripsy services. Thanks also go to Ann Brennan for preparation of the manuscript.
LIMITATIONS
OF LITHOTRIPSY
1039
IN YOUNG CHILDREN
REFERENCES 1. Chaussy C. Brendell W, Schmiedt E: Extracorporeally induced destruction of kidney stones by shock waves. Lancet 2:12651268, 1980 2. Thornhill JA, Moran K, Mooney EE, et al: Extracorporeal shock wave lithotripsy monotherapy for paediatric urinary tract calculi. Br J Urol65:638-640,199O 3. Mishriki SF, Wills MI, Mukherjee A. et al: Extracorporeal shockwave lithotripsy for renal calculi in children. Br J Urol 69:303-305, 1992 4. Corbally MT, Ryan J, Fitzpatrick J, et al: Renal function following extracorporeal lithotripsy in children. J Pediatr Surg 26:539-540,199l 5. Gleeson MJ. Griffith DP: Extracorporeal shock wave lithotripsy monotherapy for large renal calculi. Br J Urol 64:329-332. 1989 6. Gleeson MJ. Shabsigh R. Griffith DP: Outcome of ESWL in
patients with multiple renal calculi based on stone burden and location. J Endourol2:145-149, 1988 7. Neerhut GJ, Ritchie A, Tolley D: Extracorporeal piezoelectric lithotripsy for all renal stones: Effectiveness and limitations. Br J Urol64:5-9, 1989 8. Parr NJ, Ritchie A, Moussa S, et al: The impact of extracorporeal piezoelectric lithotripsy on the management of ureteric calculi: An audit. Br J Urol67:18-23,199l 9. Assimos DG, Boyce WH, Harrison LH, et al: The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol 142:263-267.1989 10. Webb DR, Fitzpatrick JM: Percutaneous nephrolithotripsy: A functional and morphological study. J Ural 134578-591, 1985 11. Wilbert D. Schafer 0, Reidmiller H: Longterm results of extracorporeal shock wave lithotripsy in children. J Urol 142:579581.1988