IRFAN WAHYUDI DEPARTMENT OF UROLOGY RSCM/ FKUI JAKARTA

CONTENTS  Introduction  Outcome and Complication: Literature Review  Effect on kidney function  Our Series

Introduction  Pediatric urolithiasis is rare, with a global incidence of pediatric urolithiasis is 2–3 %  Increasing in pediatric patients per capita and is an inevitable urological condition  More frequent in developing countries - 17% of urolithiasis patient in Turkey < 14 years old Lu P et al. Urolithiasis (2015) 43: Tellaloglu S et al. Turk J. Pediatr 26(1984): 1-4

Introduction  ESWL has been used for pediatric urolithiasis treatment since 1986 (Newman)  Become one of the principle treatments for urolithiasis: - minimally invasive - economical - a shorter hospital duration - lower complication rate  EAU/AUA Nephrolithiasis Guideline Panel’s 2007: ESWL remains a first-line treatment option for most pediatric upper tract urinary calculi Granberg CF et al. Pediatr Clin N Am 59 (2012)

 Studies published in  14 studies, 1842 patients  Majority from developing countries  Retrospective from database

 Size and location of the stone VariablesRelative RiskComment Stone Free Rate 10 mm 1.14 (95% CI 1.07, 1.21)Significant Stone Free Rate in renal pole calyx (PC) vs renal pelvis 0.95 (95% CI 0.893, 1.009) Not significant Stone Free Rate in upper/middle PC vs lower PC 1.07 (95% CI 0.997,1.156) Not significant Stone Free Rate in proximal ureter vs middle/distal ureter (95% CI 1.005,1.154) Significant

ESWL Outcomes in Children  Children have a greater propensity vs adult for passing stone fragments after ESWL (95% vs 79%) - Shorter length of ureter - Greater elasticity of ureter  Slower delivery rates of shockwave (80/ minutes) have better results regarding stone clearance than fast delivery (120 shockwaves/ minutes) 90%: 73% Salem HK et al. J. Urol 191( 2014):

ESWL Outcomes in Children  Body mass index (BMI) does not seem to negatively correlate with stone free status in children - In adult skin-to stone distance (SSD) as measured on noncontrast CT scan < 10 cm more likely to fail treatment  Knowledge of stone composition based on preoperative CT hounsfield unit (HU) may contribute to decision making of treatment - Stone attenuation < 1000 HU is a significant predictor of success (77% vs 33%) McAdams S et al. J Urol 184 (2010): El-Assmy A et al. Urology 81(2013): 880-4

ESWL Outcomes in Children  α -blocker (Doxazosin 0.03 mg/ kg BW) shorten the stone expulsion time for mm renal pelvis stones in pediatric population (21.8 vs 31.3 days) but not superior to watchful waiting after ESWL in term of stone free rate Telli O et al. dx.doi.org/10.106/ J. Ped Surg

ESWL Complications  Steinstrasse (6%)  Pain (6.29%)  Others (<5%): Subcapsular hematoma, skin bruishing, retention, sepsis, stricture, ureteral obstruction, UTI Granberg CF et al. Pediatr Clin N Am 59 (2012)

ESWL Effect in Pediatric Kidney Function  Serum cystatin C, urine albumin to creatinine ratio and new early of tubular injury (interleukin-18, NGAL) confirmed the safety of ESWL and the procedure does not cause any episode of acute renal injury Jobs K et al. Centr Eur J Immunol 39 (2014):384-91

ESWL Effect in Pediatric Kidney Function  Prospective study using DMSA scan and GFR measurement with DTPA comparing with pre- and 6 months after ESWL showed no patient developed renal scarring or statistically significant decrease in renal function  Reisiger et al showed that treatment with ESWL did not impact renal growth in children Griffin SJ et al. J. Urol 183 (2010):2332-6

ESWL URSPCNL Typical useSimple renal/ ureter stone <1- 2 cm Staghorn/ multiple larger stone AnesthesiaGeneral ServiceOutpatient Inpatient (2-6 days) Site of entry into bodyNonetransurethraThrough flank skin (percutaneous) Stone removal rate44%-95%50%-100%70%-90% Need for second surgeryLow-moderateLowModerate-high Success depends on spontaneous stone fragment passage TotallyPartiallyNone Need for nephrostomy tube postopNone High Need for ureteral stent postopVery lowHigh Complications0%-18%0%-8%0%-30% Possibility of adjacent organ injuryVery lowNoneLow Need for blood transfusionNone <5% Days off from school/workUp to 7Up to 14Up to 20 Granberg CF et al. Pediatr Clin N Am 59 (2012)

A REPORT FROM

PEDIATRIC UROLITHIASIS TREATMENT MODALITIES IN RSCM No. of cases : 65

PEDIATRIC ESWL IN RSCM  Wolf Piezolith 3000  Total ESWL cases from = cases  Pediatric* population only 39 cases (0.6 %) * ≤ 18 years old  Number of patients: 34 patients

DEMOGRAPHIC DATA VariablesDescription GenderMale: Female = 16:23 AgeMean: ± 0.67 (Range: 3 – 18) y.o. HeightMean: ± 2.56 (Range: 104 – 168) cm WeightMean: ± 1.97 (Range: 16 – 70) kg BMIMean: ± 0.48 (Range: ) kg/m2 Nutritional StatusNormal: 31, Obese: 3, Overweight: 3, Underweight: 2 Type of CaseNew Case: 34, Retreatment: 5 LocationKidney: 25 Ureter: 14

DEMOGRAPHIC DATA VariabelsDescription Anatomical Location Kidney: Inferior Calyx: 8 Medial Calyx: 4 Superior Calyx: 3 Pyelum: 10 Ureter: Distal: 8, Proximal : 6 LateralityRight: 21, Left: 18 Stone Max. LengthMean: ± 1.01 (Range: 5 – 28) mm Stone Perpendicular Length (Width) Mean: 8.67 ± 0.74 (Range: 4 – 21) mm Stone Burden Mean: ± (Range: 20 – 500) mm2 Stone Radiological Type Radio-opaque: 28 Radio-lucent: 11

DEMOGRAPHIC DATA VariablesDescription Power ESWLMean: ± 0.38 (Range: 9 – 20) kV ESWL ShocksMean: ± (Range: 2000 – 6500) Type of Anestesia No: 29 General: 10

OUTCOME OF PEDIATRIC ESWL IN RSCM  Overall success rate/immediate stone-free rate for all cases: (32 success cases / 39 overall cases) = % Retreatment: - 7/39 cases = 17.95%  Success rate/immediate stone-free rate for kidney stone: (18 success case / 25 cases) = 72 %  Success rate/immediate stone-free rate for ureteral stone: (14 success case / 14 cases) = 100 %

Conclusions  ESWL remains a first-line treatment option for most pediatric upper tract urinary calculi  Size, delivery rate, location in ureter, stone attenuation on non CT scan are important predicting factors for stone free rate  There is no evidence that ESWL significantly decreased kidney function in acute phase and 6 months evaluation