1. IRFAN WAHYUDI DEPARTMENT OF UROLOGY RSCM/ FKUI JAKARTA

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

3. 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) 43:199-206 Tellaloglu S et al. Turk J. Pediatr 26(1984): 1-4

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) 897-908

5.  Studies published in 1998-2013  14 studies, 1842 patients  Majority from developing countries  Retrospective from database

6.  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 1.077 (95% CI 1.005,1.154) Significant

7. 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): 1370-4

8. 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): 1804-9 El-Assmy A et al. Urology 81(2013): 880-4

9. ESWL Outcomes in Children  α -blocker (Doxazosin 0.03 mg/ kg BW) shorten the stone expulsion time for 10- 20 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 2014.11.045

10. 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) 897-908

11. 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

12. 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

13. 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) 897-908

14. A REPORT FROM 2008-2014

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

16. PEDIATRIC ESWL IN RSCM  Wolf Piezolith 3000  Total ESWL cases from 2008-2014 = 5.955 cases  Pediatric* population only 39 cases (0.6 %) * ≤ 18 years old  Number of patients: 34 patients

17. DEMOGRAPHIC DATA VariablesDescription GenderMale: Female = 16:23 AgeMean: 14.10 ± 0.67 (Range: 3 – 18) y.o. HeightMean: 148.38 ± 2.56 (Range: 104 – 168) cm WeightMean: 44.51 ± 1.97 (Range: 16 – 70) kg BMIMean: 19.90 ± 0.48 (Range: 12.8 - 27.1) kg/m2 Nutritional StatusNormal: 31, Obese: 3, Overweight: 3, Underweight: 2 Type of CaseNew Case: 34, Retreatment: 5 LocationKidney: 25 Ureter: 14

18. 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: 11.33 ± 1.01 (Range: 5 – 28) mm Stone Perpendicular Length (Width) Mean: 8.67 ± 0.74 (Range: 4 – 21) mm Stone Burden Mean: 121.41 ± 21.43 (Range: 20 – 500) mm2 Stone Radiological Type Radio-opaque: 28 Radio-lucent: 11

19. DEMOGRAPHIC DATA VariablesDescription Power ESWLMean: 16.35 ± 0.38 (Range: 9 – 20) kV ESWL ShocksMean: 4325.64 ± 174.55 (Range: 2000 – 6500) Type of Anestesia No: 29 General: 10

20. OUTCOME OF PEDIATRIC ESWL IN RSCM  Overall success rate/immediate stone-free rate for all cases: (32 success cases / 39 overall cases) = 82.05 % 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 %

21. 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