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Management of KidneyStones inChildren
USFAdvances inUrology 2017
Hubert SSwanaMD
KeyWest Florida
Disclosures
• No disclosures to report
• MET: Tamsulosin: not FDA approved children
Case
• 12 year old girl (186lbs)
• Presented abdominal pain,
• Treated empirically for constipation
• Returned 3 weeks later
Return
• Persistent pain
• Fevers 102
• Hypotensive
• U/A:
– Bld +++
– Leuk est +++1.8 cm
18 mm stone Fluids:AbxStent placed emergentlyDeferveced
Overview• Epidemiology
• Pediatric Presentation
• AUAGuidelines:Children
– MET
– Surgical Modalities
• URS
• SWL
• PCNL
• Open/Laparoscopic/Robotic
Increase
A Rise in Kidney Stones Is Seen inU.S.Children:October 27, 2008
KidneyStones and Kids:A PainfulComboNov. 14, 2008
More KidsGetting KidneyStonesSept. 19, 2013
Epidemiology: 2000‐present
• Single Institution andState Studies
• Sas
• Kairam
2011
2013
• Larger Surveys: PHIS
• Bush
• Routh
2010
2010
Incidence of Pediatric Nephrolithiasis in South Carolina
Sas D J CJASN 2011;6:2062-2068
©2011 by American Society of Nephrology
Incidence of Pediatric Nephrolithiasis in South Carolina
Sas D J CJASN 2011;6:2062-2068
©2011 by American Society of Nephrology
G 7.7
B 8.0
G 21.9
B 15.3
• 1,312,487 pediatric visits.
1005 (0.077%) were for renal colic.
The median age 16 years
• The percentage of ED pediatric visits
61% female.
0.048% in 1999
0.089% in 2008
• Increase of 86%– (95% confidence interval, 36%‐154%; P < 0.001)
Rise in Emergency Department Visits of Pediatric Patientsfor Renal Colic From 1999 to 2008
Neeraja Kairam, MD, .John R. Allegra, MD, PhD, and B a nzet Eskin, i\1D, PhD
0.10% -r--- --- ---------- -
0.08%
- •R;z= 0.69
ccu:= 0.07%cu
0 .06%
0.05% ---------------
0 .04% - + - -------. - - - - - r - - - - - r - - - - - . - - - - - - .------- - - - -.- - - ---r-- --.-----------,
1999 2000 2001 2002 2003 2004 2005 2006 2007 200B
YearFIGURE2. Pediatric EDrenalcolicvisits increasefrom 1999to 2008.
Pediatric Emergency Care • Volume 29, Number 4, April 2013
• 7,921 children with urolithiasis
• Mean number of stone cases per hospital per year increased from
13.9 to 32.6• Compared to total hospital patients/ pediatric
• urolithiasis
– 18.4per 100,000 in 1999 to
– 57.0 per 100,000 in 2008,
– adjusted annual increase of 10.6% (p 0.0001).
Limitations
• StatewideStudies / Regional Differences
• PHIS: 42 hospitals
– Tertiary, free standing hospitals
– Hospital based, not population based
• ICD9 diagnoses
• Incidentally found ?
Epidemiology Summary• Increasing emergency room visits
• Greater numbers of children that go to ER
are being diagnosed with kidney stones
• PHIS hospitals greater incidence of patients
and admissions
Case
• 12 year old girl (186lbs)
• Presented abdominal pain,
• Treated empirically for constipation
• Returned 3 weeks later
Acute presentation
Abdominal Pain: 53‐75%
Gross Hematuria: 14‐33%
UTI: 8‐20%
‐Infants up to 75%
Unilateral renal colic: 7%
Kokoroski et al Ind JUrol. 2010Oct‐Dec; 26(4): 531–535
Case
18mm stone Fluids:AbxStent placed emergentlyDeferveced
MET• Statement 46: In pediatric patients with
uncomplicated ureteral stones ≤10 mm,
clinicians should offer observation with or
without MET using α‐blockers.
• Moderate Recommendation; Evidence Level
Grade B
Velazquez et al. J PediatrUrol. 2015 Dec; 11(6): 321‐327
• 5 studies: 3 RCT and 2 retrospective cohorts
• Significantly increased the odds spontaneous
stone passage (OR 2.21, 95%CI 1.40–3.49).
• Very few side effects: somnolence
Velazquez et al. J PediatrUrol. 2015 Dec; 11(6): 321‐327
GuidelineStatement 47:
• Clinicians should offerURS orSWL for pediatric
patients with ureteral stones who are unlikely to pass
the stones or who failed observation and/or MET,
based on patient‐specific anatomy and body habitus.
• Strong Recommendation; Evidence LevelGrade B
First Line < 20mmStatement 50:
• In pediatric patients with a total renal stone
burden ≤20mm, clinicians may offer SWL or
URS as first‐line therapy. (Index Patient 14)
Moderate Recommendation; Evidence Level
Grade C
ESWL Results
First Reported in 1986
Success rates 68‐84%
Often times requires several treatments 36‐68% stone‐free after one sx
Rhee K, Palmer JS: Ungated extracorporeal shockwave lithotripsy in children: an initial series.Urology 2006, 67:392–393.
ESWLComplications/Concerns
• Complications: 20%
– Nausea/Vomiting, Hematuria
– Steinstrasse
– Renal hematoma, liver or splenic hematoma
• Concerns:– Renal vessel vasoconstriction,
– RenalTubular Injury
– Subcapsular Hematomas
Ureteroscopy
Stone free rates
• 88‐100% distal ureteral stones
• 58‐82% Intrarenal
Ureteroscopy
• Complications
• Overall 5.4%
Uti/ Pyelonephritis
Ureteral perforation
VUR
Ureteral stricture
Reddy, P, DeFoor,WR.Ureteroscopy:The standard of care in themanagement of upper tract urolithiasis in children. Indi JUrol. 2010Oct‐Dec; 26(4): 555–563.
Routine Stenting/ URS
• Statement 49: In pediatric patients with
ureteral stones, clinicians should not routinely
place a stent prior toURS. (Index Patient 13)
ExpertOpinion
Percutaneous Nephrolithotomy
• Stone free rate approx 85% after one procedure
• Complication/ Rates 25‐50 %
– Urosepsis 5 %
– Bleeding/ transfusion 10‐15%
– Urine leak/ stent
– Adjacent organ injury
4‐6 %
rare
CT scan• Statement 48:
• Clinicians should obtain a low‐doseCT scan
on pediatric patients prior to performing
PCNL. (Index Patient 13)
Strong Recommendation; Evidence LevelGrade C
Stent
• Statement 51: In pediatric patients with a
total renal stone burden >20mm, both PCNL
andSWL are acceptable treatment options. If
SWL is utilized, clinicians should place an
internalized ureteral stent or nephrostomy
tube. (Index Patient 14) ExpertOpinion
Increased risk of:
Complete ureteral obstruction
Sepsis
Open Surgery/Laparoscopy??
Open Surgery/Laparoscopy??• Statement 52: In pediatric patients, except in
cases of coexisting anatomic abnormalities,
clinicians should not routinely perform
open/laparoscopic/robotic surgery for upper
tract stones. (Index Patients 13, 14) Expert
Opinion
Observation?
• Statement 53: In pediatric patients with
asymptomatic and non‐obstructing renal
stones, cliniciansmay utilize active
surveillance with periodic ultrasonography.
(Index Patient 14) ExpertOpinion
Treatment
‐URS‐Stone‐free‐Stent removed in office ( string)‐Ca‐oxalate
Summary‐Stone disease increasing: ER visits, admissions
‐Presentation:Abdominal pain
‐MET <10mm
‐URS/SWL <20mm
‐Stents only if > 20 mmSWL
References
1.Hernandez JD, Ellison JS, LendvayTS.CurrentTrends,
Evaluation, andManagement of Pediatric Nephrolithiasis. JAMA
Pediatr. 2015;169(10):964‐970.
2.TasianGE,Copelovitch L. Evaluation andMedical
Management of Kidney Stones inChildren. JUrol. 2014
Nov;192(5):1329‐36