Faure A et al, 2016: Postural therapy for renal stones in children: A Rolling Stones procedure.
Faure A, Dicrocco E, Hery G, Boissier R, Bienvenu L, Thirakul S, Maffei P, Panait N, Karsenty G, Merrot T, Alessandrini P, Guys JM, Lechevallier E.
Urology Department, Aix-Marseille Université, APHM, CHU Hopital La Conception, Marseille, France.
Paediatric Surgery Department, Aix-Marseille Université, APHM, CHU Hopital La Timone, Marseille, France.
Physical Therapy and Rehabilitation Department, Aix-Marseille Université, APHM, CHU Hopital La Conception, Marseille, France.
INTRODUCTION: Despite many advances, the management of renal stones - especially lower caliceal stones (LCS) - remains a challenge. The gravity-dependent location of the lower calices hinders the spontaneous clearance of fragments, which can be a nidus for future growth and symptomatic recurrence. Currently, there is no standard adjunctive therapy to facilitate fragment passage.
OBJECTIVES: To report the safety and effectiveness of mechanical percussion diuresis and inversion (PDI) therapy for eliminating renal stones in children.
PATIENTS AND METHODS: Since November 2013, children with residual fragments (after shock wave lithotripsy or flexible ureteroscopy) or native symptomatic renal stones were prospectively included in a protocol of four PDI sessions. After giving written consent, the children drank 10 ml/kg of water 30 min before therapy. They then laid in a prone Trendelenburg position on a couch angled at 45° and received continuous 10-min mechanical percussion applied over the affected flank by a physiotherapist (Figure summary). Tolerance stone burden reduction and stone clearance were documented with ultrasound 4 weeks after the last session.
RESULTS: Seventeen participants, with a median age of 10.8 years (range 18 months to 18 years), received 82 PDI sessions performed over 22 months. The median stone diameter was 5 mm (range 3-9). All children tolerated the PDI therapy well. Over a median follow-up of 11 months (range 3-18), no significant adverse effects were noted. The overall stone-free rate was 65%. Four of the six patients with residual fragment passed their fragments. The patients who did not become stone free by PDI experienced a decrease in fragment size of 57% (range 34-71). The observance rate was 100%.
DISCUSSION: Many studies have demonstrated that the gravity-dependent position of the lower calyces appears to be an important factor limiting the clearance of LCS. Positioning patients with a degree of inversion in order to put the collecting system beyond the horizontal plane affected the LCS through gravitational force. Complications were rare. PDI appeared to save costs and have similar success rates as shock wave lithotripsy for native small renal stones in children.
CONCLUSION: PDI is safe and effective for facilitating gravity-dependent drainage of renal stones and provides an opportunity to treat children in a quick, non-invasive, economic, painless, non-radiative and diverting fashion. This therapy is a valuable alternative in the pattern of stone management. In case of persistent fragments, it is recommend that the number of sessions be increased to six.
J Pediatr Urol. 2016 Apr 16. pii: S1477-5131(16)30018-3. doi: 10.1016/j.jpurol.2016.02.019. [Epub ahead of print]
The problem of fragments and stones residing in the lower calyces after low-invasive stone removal remains a matter of continuous concern. Most residuals are found in the lower calyces and although most commonly encountered in patients treated with SWL, residual stone material is also a consequence of URS, RIRS and PNL. The accumulation of stones and stone material in the lower calyces is explained by gravitation.
Although the future course of residuals is difficult to predict, a stone/fragment-free kidney is an excellent prerequisite for lowering the risk of recurrent stone formation.
In this regard the results reported in this article are highly interesting and important. It is of note that only 6 of the 17 children in this series were given percussion-diuresis-inversion (PDI) treatment because of residuals after SWL (n=5) and URS (n=1), whereas as many as 11 children were primarily treated with PDI for symptomatic lower calyx stones. The powerful ureters in children most certainly contributed to the high success rate with elimination of stones as large as 9 mm! With an overall stone-free rate of 65% and reduced stone burden up to 71% the results are impressive.
Application of PDI, carried out in a standardized, consequent and purposeful way, makes it possible to maintain a non-invasive or least invasive treatment concept. Taken seriously this therapeutic approach is definitely worthwhile to incorporate in the complete care of patients with primary or residual stones/fragments in the lower calyces, not only for children but probably for all patients presenting with this problem.
The economic savings and the reduced need of operative procedures makes the principles of PDI highly interesting to generously apply and also to further develop with the aim of improving elimination of stone material. It is thus with great interest I look forward to the randomized study planned by the authors.