Treatment of Urolithiasis in Children: When to Combine Extracorporeal Shock Wave Lithotripsy with Retrograde Intrarenal Surgery?

Öz

Objective: The objective of this study was to evaluate the indications for extracorporeal shock wave lithotripsy (ESWL) in combination with retrograde intrarenal surgery (RIRC) in the treatment of kidney stones in paediatric patients. Material and Methods: A retrospective evaluation was conducted on patients admitted to the clinic with urinary tract stone disease between January 2013 and October 2020. A total of 118 paediatric patients, aged between 0 and 18 years, who underwent ESWL in combination with ESWL and RIRS, and 165 kidneys of patients with stones, were included in the study. The patients were evaluated in terms of demographic data, stone size, side, location, number of ESWL sessions and stone-free status. Results: The mean age of the children who underwent ESWL was 6.51±5.31 years, while the mean age of those who underwent RIRS combined with ESWL was 6.21±3.17 years. The mean stone size was 10.51 (±3.32) mm in the ESWL group and 10.16 (±3.23) mm in the RIRS combined ESWL group. A statistically significant difference was observed between the two groups in terms of the number of stones (p=0.023). The stone-free rate was 83.33% in children who underwent ESWL alone and 86.96% in children who underwent RIRC combined ESWL. Conclusion: It can be concluded that ESWL has a higher success rate in achieving stone-free status in the first session for single stones and stones located in the renal pelvis. The RIRS combined ESWL method has demonstrated efficacy in more challenging stone groups, such as those located in the lower calyx and in multiple stones, although this requires a greater number of sessions. In planning ESWL as a treatment for urinary tract stones in paediatric patients, it is important to consider that it may need to be combined with RIRC, particularly in cases where the location, size and number of stones are significant.

Anahtar Kelimeler

• pediatric
• Urinary Tract Stones
• Extracorporeal Shock Wave Lithotripsy
• Retrograde İntrarenal Surgery
• ; Stone-Free Rate

ÇOCUKLARDA ÜROLİTİAZİS TEDAVİSİ: EKSTRAKORPOREAL ŞOK DALGA LİTOTRİPSİ İLE RETROGRAD İNTRARENAL CERRAHİ NE ZAMAN KOMBİNE EDİLMELİ?

Öz

Amaç: Bu çalışmanın amacı, çocuk hastalarda böbrek taşı tedavisinde yaygın olarak kullanılan ekstrakorporeal şok dalga litotripsi (ESWL) yönteminin, retrograd intrarenal cerrahi (RIRC) ile kombine edilmesinin gerekli olduğu durumları değerlendirmektir. Gereç ve Yöntemler: Ocak 2013 ve Ekim 2020 tarihleri arasında kliniğimize üriner sistem taş hastalığı ile başvuran olgular retrospektif olarak değerlendirildi. ESWL ve RIRC ile kombine ESWL uygulanan 0-18 yaş arası toplam 118 pediatrik hasta ve hastaların taş bulunduran 165 böbreği çalışmaya dahil edildi. Olgular demografik verileri, taş boyutu, tarafı, yerleşimi, ESWL seans sayısı, taşsızlık sağlanması ve hidronefrozun takibi açısından değerlendirildi. Bulgular: ESWL uygulanan çocukların yaş ortalaması 6,51±5,31 yıl, RIRC kombine ESWL uygulanan çocukların yaş ortalaması 6,21±3,17 yıldı. Taş boyutu ESWL grubunda ortalama 10,51(±3,32) mm ve RIRC kombine ESWL grubunda 10,16(±3,23) mm idi. Taş sayısı açısından iki grup arasında istatistiksel fark saptandı (p=0,023). Sadece ESWL uygulanan çocuklarda taşsızlık oranı %83.33, RIRC kombine ESWL uygulanan çocuklarda %86.96 olarak saptandı. Sonuç: ESWL'nin tek ve renal pelvis yerleşimli taşlarda ilk seansta taşsızlık sağlama oranları daha yüksektir. RIRC kombine ESWL yöntemi, alt kaliks ve multipl taşlar gibi daha zorlu taş gruplarında etkinlik göstermiş ancak bu durum hastaya daha fazla seans yapılmasını gerektirmektedir. Çocuk olgularda üriner sistem taş tedavisinde ESWL planlanırken, özellikle taşın yerleşimi, boyutu ve sayısına göre RIRC ile kombine edilmesi gerebileceği unutulmamalıdır.

Anahtar Kelimeler

• Üriner sistem taşları
• Ekstrakorporeal şok dalga litotripsi
• Retrograd intrarenal cerrahi
• Taşsızlık oranı
• Çocuk

Etik Beyan

Bu araştırma noninvaziv, klinik retrospektif bir çalışma olup Eskişehir Osmangazi Üniversitesi Tıp Fakültesi Etik Kurulu tarafından onaylanmış (No 2021-43) ve Helsinki Bildirgesi'ne uygun olarak yürütülmüştür. Tüm veriler Eskişehir Osmangazi Üniversitesi deposundadır. Yazarların açıklayacakları herhangi bir etik çatışma yoktur.

Teşekkür

Biyoistatistik Uzm. Muzaffer Bilgin'e istatistiksel analizdeki uzmanlığı ve yardımı için teşekkür ederiz.

Kaynakça

1. 1. Alfandary H, Haskin O, Davidovits M, Pleniceanu O, Leiba A, Dagan A. Increasing Prevalence of Nephrolithiasis in Association with Increased Body Mass Index in Children: A Population Based Study. J Urol. 2018 Apr;199(4):1044-9.
2. 2. Schlomer BJ. Urologic treatment of nephrolithiasis. Curr Opin Pediatr. 2020 Apr;32(2):288-94.
3. 3. Turney BW, Reynard JM, Noble JG, Keoghane SR. Trends in urological stone disease. BJU Int. 2012 Apr;109(7):1082-7.
4. 4. Mahmud M, Zaidi Z. Percutaneous nephrolithotomy in children before school age: experience of a Pakistani centre. BJU Int. 2004 Dec;94(9):1352-4.
5. 5. Dogan HS, Altan M, Citamak B, Bozaci AC, Karabulut E, Tekgul S. A new nomogram for prediction of outcome of pediatric shock-wave lithotripsy. J Pediatr Urol. 2015 Apr;11(2):84.e1-6.
6. 6. Onal B, Tansu N, Demirkesen O, Yalcin V, Huang L, Nguyen HT, et al. Nomogram and scoring system for predicting stone-free status after extracorporeal shock wave lithotripsy in children with urolithiasis. BJU Int. 2013 Feb;111(2):344-52.
7. 7. EAU Guidelines. In: Presented at the EAU annual congress. Edn. Amsterdam; 2020. 978-94-92671-07-3.
8. 8. Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I. J Urol. 2016 Oct;196(4):1153-60.

9. 9. Muslumanoglu AY, Tefekli A, Sarilar O, Binbay M, Altunrende F, Ozkuvanci U. Extracorporeal shock wave lithotripsy as first line treatment alternative for urinary tract stones in children: a large scale retrospective analysis. J Urol. 2003 Dec;170(6 Pt 1):2405-8.
10. 10. El-Assmy A, El-Nahas AR, Abou-El-Ghar ME, Awad BA, Sheir KZ. Kidney stone size and hounsfield units predict successful shockwave lithotripsy in children. Urology. 2013 Apr;81(4):880-4.
11. 11. Unsal A, Resorlu B, Kara C, Bozkurt OF, Ozyuvali E. Safety and efficacy of percutaneous nephrolithotomy in infants, preschool age, and older children with different sizes of instruments. Urology. 2010 Jul;76(1):247-52.
12. 12. Smaldone MC, Cannon GM Jr, Wu HY, Bassett J, Polsky EG, Bellinger MF, et al. Is ureteroscopy first line treatment for pediatric stone disease? J Urol. 2007 Nov;178(5):2128-31; discussion 2131.
13. 13. Skolarikos A, Straub M, Knoll T, Sarica K, Seitz C, Petřík A ve ark. Metabolic evaluation and recurrence prevention for urinary stone patients: EAU guidelines. Eur Urol. 2015 Apr;67(4):750-63.
14. 14. Raza A, Turna B, Smith G, Moussa S, Tolley DA. Pediatric urolithiasis: 15 years of local experience with minimally invasive endourological management of pediatric calculi. J Urol. 2005 Aug;174(2):682-5.
15. 15. Rizvi SA, Naqvi SA, Hussain Z, Hashmi A, Hussain M, Zafar MN, et al. Pediatric urolithiasis: developing nation perspectives. J Urol. 2002 Oct;168(4 Pt 1):1522-5.
16. 16. Jung H, Nørby B, Osther PJ. Retrograde intrarenal stone surgery for extracorporeal shock-wave lithotripsy-resistant kidney stones. Scand J Urol Nephrol. 2006;40(5):380-4.
17. 17. Wagenius M, Oddason K, Utter M, Popiolek M, Forsvall A, Lundström KJ, et al. Factors influencing stone-free rate of Extracorporeal Shock Wave Lithotripsy (ESWL); a cohort study. Scand J Urol. 2022 Jun;56(3):237-43.
18. 18. NICE Guideline – Renal and ureteric stones: assessment and management: NICE (2019) Renal and ureteric stones: assessment and management. BJU Int. 2019;123(2):220–32.
19. 19. Elsobky E, Sheir KZ, Madbouly K, Mokhtar AA. Extracorporeal shock wave lithotripsy in children: experience using two secondgeneration lithotripters. BJU Int. 2000 Nov;86(7):851-6.
20. 20. Satjakoesoemah AI, Alfarissi F, Wahyudi I, Rodjani A, Rasyid N. Factors related to the success rate of pediatric extracorporeal shock wave lithotripsy (ESWL) in Cipto Mangunkusumo Hospital: an 8-year single-center experience. Afr J Urol. 2021 27:92.
21. 21. Abdel-Khalek M, Sheir KZ, Mokhtar AA, Eraky I, Kenawy M, Bazeed M. Prediction of success rate after extracorporeal shockwave lithotripsy of renal stones--a multivariate analysis model. Scand J Urol Nephrol. 2004;38(2):161-7.
22. 22. Azili MN, Ozcan F, Tiryaki T. Retrograde intrarenal surgery for the treatment of renal stones in children: factors influencing stone clearance and complications. J Pediatr Surg. 2014 Jul;49(7):1161-5.
23. 23. Ceyhan E, Ozer C, Ozturk B, Tekin MI, Aygun YC. Ability of ESWL nomograms to predict stone-free rate in children. J Pediatr Urol. 2021 Aug;17(4):474.e1-474.e6.
24. 24. Lingeman JE, Siegel YI, Steele B, Nyhuis AW, Woods JR. Management of lower pole nephrolithiasis: a critical analysis. J Urol. 1994 Mar;151(3):663-7.
25. 25. Singh BP, Prakash J, Sankhwar SN, Dhakad U, Sankhwar PL, Goel A, et al. Retrograde intrarenal surgery vs extracorporeal shock wave lithotripsy for intermediate size inferior pole calculi: a prospective assessment of objective and subjective outcomes. Urology. 2014 May;83(5):1016-22.
26. 26. Esposito C, Masieri L, Bagnara V, Tokar B, Golebiewski A, Escolino M. Ureteroscopic lithotripsy for ureteral stones in children using holmium: yag laser energy: results of a multicentric survey. J Pediatr Urol. 2019 Aug;15(4):391.e1-391.e7.
27. 27. Farouk A, Tawfick A, Shoeb M, Mahmoud MA, Mostafa DE, Hasan M, et al. Is mini-percutaneous nephrolithotomy a safe alternative to extracorporeal shockwave lithotripsy in pediatric age group in borderline stones? a randomized prospective study. World J Urol. 2018 Jul;36(7):1139-47.
28. 28. Göktaş C, Akça O, Horuz R, Gökhan O, Albayrak S, Sarica K. Does child's age affect interval to stone-free status after SWL? A critical analysis. Urology. 2012 May;79(5):1138-42.
29. 29. Rodrigues Netto N Jr, Longo JA, Ikonomidis JA, Rodrigues Netto M. Extracorporeal shock wave lithotripsy in children. J Urol. 2002 May;167(5):2164-6.