Yadav P. et al., 2019: Technique, complications, and outcomes of pediatric urolithiasis management at a tertiary care hospital: evolving paradigms over the last 15 years

Friday, 27 March 2020

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Yadav P, Madhavan K, Syal S, Farooq A, Srivastava A, Ansari MS.
Division of Pediatric Urology, Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, U.P., 226014, India.
Division of Pediatric Urology, Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, U.P., 226014, India.

Abstract

BACKGROUND:
Despite technological advancements, there is lack of consensus for the standard treatment modalities for pediatric urolithiasis.

OBJECTIVE:
The primary objective was to review the management of pediatric urolithiasis over the last 15 years in terms of technical modifications, surgical outcomes, and complications. The secondary objective was to compare the efficacy and outcomes of standard percutaneous nephrolithotomy (PCNL) and mini-PCNL for renal and upper ureteric calculi.

STUDY DESIGN:
Medical records of all patients aged <18 years who presented to the authors' tertiary care hospital in northern India between August 2003 and December 2018 were reviewed retrospectively. Before 2010, all PCNLs performed were standard PCNL, whereas after 2010, most PCNLs performed were mini-PCNL. Thus, the patients were divided into two groups: group A (patients up to 2010) and group B (patients after 2010). These were compared for the type of treatment, success rate, and complications. The outcomes of surgical management of lower ureteric and vesical calculi were also reviewed.

RESULTS:
During this period, there were 580 children with urolithiasis (677 stone sites). There were 265 patients (321 stone sites) in group A and 315 patients (356 stone sites) in group B. The median age was seven years (range: 3-18 years). The most common location of calculus was the collecting system of the kidney (n = 398, 58.8%). A total of 175 stone sites (25.8%) were located in the ureter. Urinary bladder calculi were seen in 43 (6.4%) patients. Multiple stones were seen in 61 sites (9.0%). A total of 115 patients in group A underwent standard PCNL, whereas in group B, nine patients underwent standard PCNL and 129 underwent mini-PCNL. Group B had a significantly higher stone clearance rate for mini-PCNL (P < 0.001). Minor complications (grades 1 and 2) accounted for a majority of overall complications in both groups (87.5% in group A and 94.9% in group B).

DISCUSSION:
Mini-PCNL is an excellent option for renal calculi in children as it offers dual advantages of improved stone clearance and reduced major complications such as bleeding. Ureteroscopic lithotripsy has been established as the standard for small lower ureteric calculi.

CONCLUSION:
For renal and upper ureteric calculi, mini-PCNL has evolved as standard technique with a high stone-free rate and minimum complications compared with standard PCNL. Extracorporeal shockwave lithotripsy and ureteroscopic lithotripsy (URSL)/retrograde intrarenal surgery are acceptable alternatives for smaller stone burden. For lower ureteric and vesical calculi, retrograde approaches such as cystolithotripsy and URSL have now become the standard of care.

J Pediatr Urol. 2019 Dec;15(6):665.e1-665.e7. doi:10.1016/j.jpurol.2019.09.011. Epub 2019 Sep 17.

Comments 1

Peter Alken on Friday, 27 March 2020 09:25

This is a well done extensive metaanalysis on pediatric urolithiasis management.

It is also an example of the typical puzzling way the consequences of EWSL are frequently discussed in the literature:
“Furthermore, the biological effects of SWL may induce acute injury of the renal parenchyma and adjacent tissues due to the acute effects of SWL, such as focal hemorrhage, rupture of small veins, extravasation and pooling of blood, necrosis in vasculature, disintegration in podocytes and mesangial cells, blood within Bowman’s space and renal tubules, ischaemic changes, and infiltration by inflammatory cells [29]. Shock wave-induced transient tubular functional damage has been observed by Villanyi KK and colleagues [30].Therefore, these authors recommended that consecutive treatments for pediatric renal stones should be spaced by at least 2 weeks. Although there is no clinical evidence about the long-term effect of SWL on pediatric kidneys [29], this effect should be kept in mind when SWL is chosen for pediatric renal stones due to the kidney still being in the growth and development stage.”

A similar detailed description of renal trauma caused by PNL is usually lacking. But it is pretty clear that a look at the classification of renal trauma as e.g. given in the current EAU guidelines on renal trauma (https://uroweb.org/guideline/urological-trauma/) shows that ESWL is a grade 1 and PNL a grade 4 trauma

Grade of renal injury
1 Contusion or non-expanding sub-capsular haematoma.No laceration
2 Non-expanding peri-renal haematoma. Cortical laceration 1 cm without urinary extravasation
4 Parenchymal laceration: through corticomedullary junction into collecting system
or
Vascular: segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel thrombosis
5 Parenchymal: shattered kidney or Vascular: renal pedicle or avulsion

The long term consequences of both iatrogenic injuries are negligible - as a rule with differing exceptions according to the initial trauma principally inflicted with the procedure. That is always higher with PNL.

This is a well done extensive metaanalysis on pediatric urolithiasis management.

It is also an example of the typical puzzling way the consequences of EWSL are frequently discussed in the literature: 
“Furthermore, the biological effects of SWL may induce acute injury of the renal parenchyma and adjacent tissues due to the acute effects of SWL, such as focal hemorrhage, rupture of small veins, extravasation and pooling of blood, necrosis in vasculature, disintegration in podocytes and mesangial cells, blood within Bowman’s space and renal tubules, ischaemic changes, and infiltration by inflammatory cells [29]. Shock wave-induced transient tubular functional damage has been observed by Villanyi KK and colleagues [30].Therefore, these authors recommended that consecutive treatments for pediatric renal stones should be spaced by at least 2 weeks. Although there is no clinical evidence about the long-term effect of SWL on pediatric kidneys [29], this effect should be kept in mind when SWL is chosen for pediatric renal stones due to the kidney still being in the growth and development stage.”

A similar detailed description of renal trauma caused by PNL is usually lacking. But it is pretty clear that a look at the classification of renal trauma as e.g. given in the current EAU guidelines on renal trauma  (https://uroweb.org/guideline/urological-trauma/)  shows that ESWL is a grade 1 and PNL a grade 4 trauma

Grade of renal injury
1 Contusion or non-expanding sub-capsular haematoma.No laceration
2 Non-expanding peri-renal haematoma. Cortical laceration  1 cm without urinary extravasation	
4 Parenchymal laceration: through corticomedullary junction into collecting system
or
Vascular: segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel thrombosis
5 Parenchymal: shattered kidney or Vascular: renal pedicle or avulsion

The long term consequences of both iatrogenic injuries are negligible - as a rule with differing exceptions according to the initial trauma principally inflicted with the procedure. That is always higher with PNL.

This is a well done extensive metaanalysis on pediatric urolithiasis management. It is also an example of the typical puzzling way the consequences of EWSL are frequently discussed in the literature: “Furthermore, the biological effects of SWL may induce acute injury of the renal parenchyma and adjacent tissues due to the acute effects of SWL, such as focal hemorrhage, rupture of small veins, extravasation and pooling of blood, necrosis in vasculature, disintegration in podocytes and mesangial cells, blood within Bowman’s space and renal tubules, ischaemic changes, and infiltration by inflammatory cells [29]. Shock wave-induced transient tubular functional damage has been observed by Villanyi KK and colleagues [30].Therefore, these authors recommended that consecutive treatments for pediatric renal stones should be spaced by at least 2 weeks. Although there is no clinical evidence about the long-term effect of SWL on pediatric kidneys [29], this effect should be kept in mind when SWL is chosen for pediatric renal stones due to the kidney still being in the growth and development stage.” A similar detailed description of renal trauma caused by PNL is usually lacking. But it is pretty clear that a look at the classification of renal trauma as e.g. given in the current EAU guidelines on renal trauma (https://uroweb.org/guideline/urological-trauma/) shows that ESWL is a grade 1 and PNL a grade 4 trauma Grade of renal injury 1 Contusion or non-expanding sub-capsular haematoma.No laceration 2 Non-expanding peri-renal haematoma. Cortical laceration 1 cm without urinary extravasation 4 Parenchymal laceration: through corticomedullary junction into collecting system or Vascular: segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel thrombosis 5 Parenchymal: shattered kidney or Vascular: renal pedicle or avulsion The long term consequences of both iatrogenic injuries are negligible - as a rule with differing exceptions according to the initial trauma principally inflicted with the procedure. That is always higher with PNL.

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