El-Assmy A et al, 2015: Clinically Insignificant Residual Fragments: Is It an Appropriate Term in Children?
El-Assmy A, El-Nahas AR, Harraz AM, El Demerdash Y, Elsaadany MM, El-Halwagy S, Sheir KZ.
Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
OBJECTIVE: To assess the outcome of clinically insignificant residual fragments (CIRFs) after shock wave lithotripsy (SWL) and percutaneous nephrolithotomy (PNL) in children.
METHODS: Sixty-one children with CIRFs diagnosed by noncontrast computed tomography (NCCT) 3 months after SWL and 1 month after PNL with documented follow-up ≥6 months were included in the study. Children were evaluated by urinalysis, urine culture, plain abdominal radiography, and urinary ultrasonography or noncontrast computed tomography. Outcomes measured were fragment regrowth, spontaneous fragment passage, and secondary interventions. A clinically significant outcome was defined as the need for secondary intervention for development of complications or regrowth of the residual fragment (RF).
RESULTS: The study included 42 boys and 19 girls with mean age of 6.2 years (range 1-14). After a median follow-up of 18 months, 16 children (26.2%) passed RF spontaneously. Regrowth of the RF was observed in 15 children (24.6%), and in 4 children (6.6%) the RF (of the same original size) slipped to the ureter and was treated by ureteroscopy. Therefore, a clinically significant outcome occurred in 31.2% of children with RF. Children with history of stone disease were more likely to develop clinical significance with time (HR, 4.38; 95% CI, 1.37-14; P = .013)
CONCLUSION: The term CIRF is not appropriate for all children with post-SWL and -PNL fragments, as one-third of patients have had fragments that became clinically significant. History of stone disease was the only predictor of clinical significance.
Urology. 2015 Sep;86(3):593-8. doi: 10.1016/j.urology.2015.06.017. Epub 2015 Jun 28.
The Urology and Nephrology Center at Mansoura University has a very good reputation. But this is not a paper I like.
Today a study that would submit children to non-contrast -CT after stone removal and KUB every three months during the first year and every 6 months during the following years would not be accepted because of the radiation exposure. But this intensive follow up should at least provide solid data concerning the problem addressed.
No stone analysis, no metabolic work up and no details about how recurrence-preventive measures were followed. Nearly half of the kidneys were hydronephrotic at follow up? Only 8 of 61 (13%) children had previous stone events. But based on these few children statistics are supposed to prove that this is a special risk to develop problems during the follow up.
The conclusion “This result highlights the importance of a thorough metabolic evaluation of children with recurrent stone disease to find out the underlying disorder for adoption of specific rather than general metaphylaxis” is not substantiated by any finding in the study reported.