30th ESPU Congress - Lyon, France - 2019

S21: STONES 1

Moderators: Serdar Tekgül (Turkey), MS Ansari (India)

ESPU Meeting on Saturday 27, April 2019, 10:06 - 10:46


10:06 - 10:11
S21-1 (LO)

★ ESWL IN CHILDREN IN ONE-DAY SURGERY - SAFE AND EFFECTIVE TREATMENT OF UROLITHIASIS IN CHILDREN - A PROSPECTIVE STUDY

Adam Maksymilian HALINSKI and Andrzej HALINSKI
University Hospital in Zielona Góra, Clinical Department od Paediatric Surgery and Urology, Zielona Gora, POLAND

PURPOSE

The development of ESWL equipment over the years has made it safe and effective. Reducing the focus of the ultrasound wave allows avoiding the complications of damage to neighboring organs. The introduction of piezoelectrics also reduced the pain during the procedure and the need to use painkillers. This allowed to perform treatments in almost every age group of patients.

MATERIAL AND METHODS

The full data evaluation assessed 420 children (aged 1 - 18; mean 8,7) treated for urolithiasis with the application of ESWL method. The procedures were done since 2010. The treatment was applied to children with stones in the kidney and in the ureter not promising spontaneous expulsion with urine. All surgeries was performed under anesthesia - analgo-sedation. Stone size range 5-22 mm, mean 10.7. The length of the treatment is from 35 to 60 min. The length of stay is from 5-7 hours, in the children's urology department one day. Energy fractionation during the procedure was used. Pulse frequency = 1 / sec. Treatments were carried out under constant ultrasound control. C-arm was used for localization less than 8,1% of stones. The children were discharged home on the same day. Antibiotic therapy was selected individually.

RESULTS

None of the children required urgent admission to the hospital during the night. Follow-up ultrasound was performed at the clinic the next morning. No hematoma was found.
Overall efficiency was 89%. Only 4% required immediate admission to the hospital to perform URS-L. Stein strasse only in 3 cases. Hematuria in 30%. Cost of treatment can be reduce up to 60%.

CONCLUSIONS

ESWL is the treatment of choice for lithiasis in children. As a one day surgery procedure it can reduce children and parents stress associated with admission to the hospital. It seems, that with good preparation it is effective and safe method of treatment urolithiasis.


10:11 - 10:14
S21-2 (PP)

PREDICTING ESWL SUCCESS ON PELVIC STONES BY DETERMINATION OF HOUNSFIELD UNIT ON NON-CONTRAST CT IS CLINICALLY IRRELEVANT IN CHILDREN.

Perviz HAJIYEV 1, Aykut AKINCI 2, Cagri AKPINAR 2, Muammer BABAYIGIT 2, Utku BAKLACI 2, Murat KARABURUN 2, Tarkan SOYGUR 1 and Berk BURGU 1
1) Ankara University School of Medicine, Pediatric Urology, Ankara, TURKEY - 2) Ankara University School of Medicine, Urology, Ankara, TURKEY

PURPOSE

Adult studies had revealed the relationship between Hounsfield unit (HU) value and ESWL success with diffrent cut-off densities.Generally 1000 HU is accepted as a predictor of unsuccsessfull ESWL.We aimed to investigate whether it is clinically useful to determine the stone density to predict the ESWL success in children parallel to adult studies.

MATERIAL AND METHODS

119 patients aged 2-16years with renal pelvic stone measuring <15mm were selected for treatment with ESWL between 2008and2018. Patients divided into two groups;38 with performed non-contrast helical CT scan pre-ESWL and 81 patient without CT examination.Both the groups were compared for stone size,stone location,stone free rate(SFR) after a singleESWL session. Also maximum stone density in Hounsfield Units (UH)in CT performed group was noted.Mean radiation exposure for CTscan followed by ESWL and direct ESWL groups were compared. Besides spot urine pH were noted in every patient.Known cystinestones were excluded.All patients underwent ESWL a part from the stone density.

RESULTS

Median stone size was 13.5 mm(8 to19mm) in CT performed group and 12.6 mm(6 to17mm) in without CT group.The stone clearance rate in CT and non-CT group at 2 week after ESWL was 78.9%(30/38) and 81.4%(66/81)(p>0.05), respectively.There was not statistical significance between groups in terms of stone compositions,stone size.Only 7(18.4.%) patients had a stone density greater than 1000 HU in total and 3 of these(7.8%) was stone-free after the first ESWL.Most of the pediatric ESWLs were performed with USscan targeting without any radiation exposure.(23.5%).Only 28 out of 119 required a fluoroscopic targeting with a mean exposure of 2.6(1–3.4)mSv.

CONCLUSIONS

NCCT scan theoretically provides information of stone composition and predict the effectiveness ESWL. However, in clinical practice extra radiation exposure and the limited number of stone dansities higher than 1000 HU suggests that this step is unnecessary in the decision making and better be avoided.


10:14 - 10:17
S21-3 (PP)

THE IMPACT OF CALCIUM PHOSPHATE (CAPH) CONTENT ON THE EFFICACY OF EXTRA-CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) IN CHILDREN

Maria ASIMAKIDOU 1, Wesley HAYES 2, William VAN'THOFF 2 and Naima SMEULDERS 1
1) Great Ormond Street hospital, Paediatric Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital, Paediatric Nephrology, London, UNITED KINGDOM

PURPOSE

In children, stone-size, multiplicity, location and cystine stone-composition have been shown to affect ESWL outcomes. We examined the effect of calcium-phosphate (CaPh) content of the stone on stone-clearance after ESWL.

MATERIAL AND METHODS

Data for all children undergoing ESWL between 2007-2017 were prospectively collected, including patient demographics, stone characteristics and outcome. Factors affecting stone clearance were analysed using non-parametric tests (Chi-squared, Mann-Whitney) and multivariate logistic regression. 

RESULTS

167 patients, aged 2months-17.2years(median 7.3years), received a total of 371 ESWL sessions to 297 stones. Stone-composition was available for 160(53.8%) stones. 33 stones had >70%CaPh, 116 <70%CaPh and 11 were cystine stones. Clearance (stone-free or fragment <2mm) was achieved for 74.3% patients and 79.1% stones. Excluding the 11 cystine stones, 19/33(57.6%) stones with >70%CaPh cleared compared to 92/116(79.3%) stones with <70%CaPh content, 17/19 (vs 70/92) doing so after the first ESWL session. CaPh composition was the only factor affecting clearance in univariate and multivariate analysis.

Individual stone-clearance (excluding cysteine-stones)

Chi-squared

Mann-Whitney 

Multivariate 

Confidence interval

Age 

_

p=0.291

0.670

0.995-1.008

Stone-size 

_

p=0.852

0.450

0.520-4.364

Location(Lower pole/other)

0.278

_

0.416

0.322-1.599

CaPh-composition(%)

0.021*

_

0.007*

0.140-0.726

Shocks applied 

_

 

0.105

0.999-1.000

 

Finally, clearance was similar for stones with >70%CaPh (19/33;58%) and cystine stones (6/11;54%) (Fisher-exact, p=0.566). 

CONCLUSIONS

This prospective study shows ESWL to be less efficacious for stones with high (>70%)-CaPh content. Expected clearance for these stones is 58%, similar to cystine stones, although most that clear do so following a single session of ESWL.


10:17 - 10:20
S21-4 (PP)

★ ENDOSCOPIC MANAGEMENT OF PAEDIATRIC URETERIC STONES: COMPARISION OF THE DISINTEGRATION MODALITIES

Bashir AHMED, Sadaf ABA UMER KODWAVWALA, Sajid SULTAN, Philip G. RANSLEY and Adeeb-Ul-Hassan RIZVI
SINDH INSTITUTE OF UROLOGY AND TRANSPLANTATION, Philip G. Ransley Department of Paediatric Urology, Karachi, PAKISTAN

PURPOSE

To compare the safety, efficacy and outcome (stone clearance and complications ) between Pneumatic lithoclast VS Low power 30Watt Ho:YAG lasertripsy VS High power 80 Watt Ho:YAG  lasertripsy for lower ureteric calculi in children

MATERIAL AND METHODS

Records of 554 children with lower ureteric stone managed endoscopically using Pneumatic lithoclast (PL), low power 30 Watt Ho:YAG lasertripsy and high power 80 Watt Ho:YAG lasertripsy performed between 2009 and 2016 were reviewed. Clinical records were reviewed for age, gender, stone laterality, location, size, need for ureteric stenting, duration of the procedure, stone clearance, complications and cost. ANOVA and chi- square tests were used for statistical analysis.

RESULTS

Of the 554 children, 191 were managed by pneumatic lithoclast (PL), 279 by Ho:YAG (low power 30 W) LPH and 99 by high power 80 Watt (HP) Ho:YAG lasertripsy. Mean age and gender ratio in the three groups were comparable 6.4+3.6 VS 6.4+3.8 VS 5.6+3.8 (p=0.90) and 1.4:1 VS 1.5:1 VS 1.8:1 (P= 0.59). Stone laterality was also comparable as well (p=0.59). The mean stone volume (cm2) and mean number of session were also comparable, 0.7+0.50 VS 0.73+0.56 VS 0.74+0.45 cm2 (p=0.65) and 1.2+0.5 VS 1.3+0.7 VS 1.2+0.44 (P=0.24). The operating time was slightly higher in the (HP) Ho: YAG 68.1+72.4 VS 59.2+41.6 VS 83+37. The stone clearance rate was 91% VS 89% VS 95% (P=0.5). Complication (Clavier grade l and lll) 37% VS 25% VS 27%. Cost of equipment $20,000 VS $36,000 $80,000. Laser fiber cost was 10-20 dollars per procedure.

CONCLUSIONS

This study showed excellent stone clearance by all three modalities with acceptable complication rates. Pneumatic lithoclast is the cheapest and HP laser is the most expensive technology among the three. 


10:20 - 10:32
Discussion
 

10:32 - 10:35
S21-5 (PP)

URINARY CYSTATIN C AND NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN: NOVEL BIOMARKERS FOR DETECTION OF EARLY KIDNEY DYSFUNCTION IN CHILDREN WITH UROLITHIASIS

Larisa KOVACEVIC 1, Hong LU 1, Natalija KOVACEVIC 1, Ronald THOMAS 2, Ahmad FAROOQI 2 and Yegappan LAKSHMANAN 1
1) Children's Hospital of Michigan, Pediatric Urology, Detroit, USA - 2) Children's Hospital of Michigan, Statistics, Detroit, USA

PURPOSE

We aimed (1) to screen for the presence of biomarkers involved in tubular injury and kidney damage in children with urolithiasis (RS), and (2) to validate these proteins by ELISA.

MATERIAL AND METHODS

Initial screening test was done by quantitative proteomic comparison of pooled urine from RS versus age- and gender-matched healthy controls (HC), using liquid chromatography-mass spectrometry. Proteins of interest were selected using the following criteria: 1) ≥5 spectral counts; 2) ≥2-fold difference in spectral counts; and 3) ≤0.05 p-value for the Fisher’s Exact Test. Validation was performed by ELISA testing.

RESULTS

Proteomic analysis identified five proteins of interest (Cystatin C, neutrophil gelatinase-associated lipocalin-NGAL, kidney injury marker 1, beta2-microglobulin, liver-type fatty acid binding protein ) that were significantly over-represented in RS group versus HC. ELISA analysis revealed significantly increased urinary levels of Cystatin C and NGAL in RS group compared to controls (Table).

 

 

Stone group (n=26)

Control group (n=13)

Age(years)

 

12.2 ± 4.9

 

12.4 ± 3.16

 

Gender (Male/Female)

12/14

5/8

Serum Creatinine

(mg/dl)

0.55 ± 0.15

 

0.64 ± 0.13

 

Urinary Cystatin C

(ng/mg creatinine)

 

55.3 ± 37.5**

 

20 ± 32.3

 

Urinary NGAL

(ng/mg creatinine)

 

2.37 ± 2.7*

 

1.0  ± 0.86

 

Results presented as Mean ± SD; *P<0.05, ** P<0.01

CONCLUSIONS

Children with kidney stone showed significant increase in urinary Cystatin C and NGAL irrespective of their normal serum creatinine. These biomarkers indicate tubular injury and early kidney damage and represent novel tools for early screening when traditional tests are normal. Their presence suggests the need for more aggressive management.


10:35 - 10:40
S21-6 (VP)

AN INNOVATION SYSTEM FOR KIDNEY STONE

Alfredo BERRETTINI 1, Stefano ZANETTI 2, Dario Guido MINOLI 1, Michele GNECH 1, Erika Adalgisa DE MARCO 1, Elisa DE LORENZIS 2, Gianantonio MANZONI 1 and Emanuele MONTANARI 2
1) Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Pediatric Urology Unit, Milan, ITALY - 2) Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Urology, Milan, ITALY

PURPOSE

Surgical treatment of pediatric kidney stones are changing over the years with the tendency to miniaturiazion of instrument. This however led to make difficult the extraction of the fragments and longer surgical time. PCNL remains first surgical option for renal stone >2 cm, staghorn or multiple stone, but it presents high rate of major complications as blood transfusion and longer fluoroscopy time. The use of minimally invasive percutaneous nephrolithotomy could reduce the complication rate but lengthen the operating time. This video shows the working principles of this system and a procedure performed using a Clear Petra nephrostomy sheath.

MATERIAL AND METHODS

A 9 years old girl (22 Kg) presented to our department in complete anuria and acute renal failure due to two bilateral staghorn stone. The girl had never complained of any other symptoms before. Initially the girl was underwent to bilateral JJ stent placement and then to PCNL procedure.

RESULTS

This video shows the use of a Clear Petra nephrostomy sheath A 12 Fr nephroscope was employed and Holmium YAG Laser used for lithotripsy. Lapaxy was performed through the aspiration linked to the lateral arm of the sheath. No baskets or forceps were used.

CONCLUSIONS

PCNL using CPS is an effective and safe procedure for treating complex kidney stones allowing to treat large stone in not long time. It ensure excellent visibility and low intrarenal pressure thereafter reducing the need to use extraction baskets of fragments.


10:40 - 10:46
Discussion