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Mokhless IA et al, 2014: Retrograde Intrarenal Surgery Monotherapy Versus Shock Wave Lithotripsy for Stones 10 to 20 mm in Preschool Children: A Prospective, Randomized Study

Mokhless IA, Abdeldaeim HM, Saad A, Zahran AR
Urology Department, Alexandria University, Alexandria, Egypt


Abstract

PURPOSE: We compared the outcome of retrograde intrarenal surgery monotherapy vs shock wave lithotripsy for stones 10 to 20 mm in preschool children.

MATERIALS AND METHODS: This prospective study included 60 children with a mean ± SD age of 2.4 ± 1.3 years. Patients were randomly divided into 2 groups. Group 1 underwent shock wave lithotripsy and group 2 underwent retrograde intrarenal surgery as monotherapy. Retrograde intrarenal surgery was started using a 7.5Fr semirigid ureteroscope (Storz®) and the holmium laser, and completed by the Flex X™2 flexible ureterorenoscope. A ureteral access sheath was not used and only hydrodilatation was performed. Patients were evaluated preoperatively by ultrasound and plain abdominopelvic x-ray. Followup was 3 months.

RESULTS: The stone-free rate after a single session treatment was 70% and 86.6% in groups 1 and 2, respectively. Mean operative time was 27.9 ± 3.5 and 40 ± 7.8 minutes, mean fluoroscopy exposure time was 60 ± 42 and 50 ± 35 seconds, and mean hospital stay was 6 ± 2 and 12 ± 8 hours, respectively. No major complication occurred in either group and no child in either group received blood transfusion. Nine group 1 patients needed a second shock wave lithotripsy session, of whom 2 required a third session. At 3 months the overall stone-free rate was 93.3% and 96.6% in groups 1 and 2, respectively.

J Urol. 2014 May;191(5 Suppl):1496-500. doi: 10.1016/j.juro.2013.08.079. Epub 2014 Mar 26
PMID:24679882[PubMed - in process]

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Comments 1

Hans-Göran Tiselius on Thursday, 23 January 2014 13:36

How stones best should be removed from the urinary tract in young children remains a matter of debate. The authors of this report were able to recruit 60 children, a number that probably is much larger than that in most other centres. Although no stone analyses were reported it also can be assumed that most stones were dominated by COM. Despite a numerically lower stone-free rate in SWL-treated children, the difference was not statistically different.

Interestingly stone-free rates after 3 months were as good as 93% and 97% in SWL and RIRS groups, respectively. That result was, however, obtained following repeated SWL in 9 children. The need of repeated SWL cannot be judged, but experience has shown that children have a remarkable capacity to get rid of also quite large fragments because of a much more powerful ureter than we see in adults.

The benefit of a high stone-free rate in the RIRS group is to some extent offset by the need of a second anaesthesia-requiring procedure for stent removal. From data in the article it can be concluded that the number of anaesthesia-requiring sessions were 41 in the SWL group and 61 in the RIRS-group.

It can also be assumed that the good results with RIRS to some extent can be explained by a substantial ureteroscopic expertise. Nevertheless some concern can be raised on how the small children's ureters are affected in a long term perspective by 40 minutes operative manipulation.

Hans-Göran Tiselius

How stones best should be removed from the urinary tract in young children remains a matter of debate. The authors of this report were able to recruit 60 children, a number that probably is much larger than that in most other centres. Although no stone analyses were reported it also can be assumed that most stones were dominated by COM. Despite a numerically lower stone-free rate in SWL-treated children, the difference was not statistically different. Interestingly stone-free rates after 3 months were as good as 93% and 97% in SWL and RIRS groups, respectively. That result was, however, obtained following repeated SWL in 9 children. The need of repeated SWL cannot be judged, but experience has shown that children have a remarkable capacity to get rid of also quite large fragments because of a much more powerful ureter than we see in adults. The benefit of a high stone-free rate in the RIRS group is to some extent offset by the need of a second anaesthesia-requiring procedure for stent removal. From data in the article it can be concluded that the number of anaesthesia-requiring sessions were 41 in the SWL group and 61 in the RIRS-group. It can also be assumed that the good results with RIRS to some extent can be explained by a substantial ureteroscopic expertise. Nevertheless some concern can be raised on how the small children's ureters are affected in a long term perspective by 40 minutes operative manipulation. Hans-Göran Tiselius
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