Pediatric stone disease.
ABSTRACT Urinary stone disease is less common in children than adults. Although many aspects of pediatric stone disease are similar to that of adults, there are unique concerns regarding the presentation, diagnosis, and management of stone disease in children. We present a review of the increasing prevalence of pediatric stone disease, the diagnostic concerns specific to children, recent results from pediatric series regarding the expectant management and surgical treatment of stones, metabolic evaluation, and current research on the genetics of nephrolithiasis.
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ABSTRACT: The clearance rather than stone disintegration of lower pole stones after shock wave lithotripsy (SWL) is significantly inferior according to the other localizations of the kidney. We retrospectively evaluated the impact of caliceal pelvic anatomy on stone clearance after SWL for pediatric lower pole stones. We treated 163 renal units (RUs) in children 16 years old or younger with SWL between March 1992 and February 2002. In 36 RUs stones were localized in the lower calices. All patients were treated with sedoanalgesia except 3 (8%) who were treated under general anesthesia. Patients were evaluated by excretory urography and ultrasonography 12 weeks after the last session, and were designated as stone-free or with residual stone. The lower infundibular length, width, length-to-width ratio, pelvic caliceal height and lower infundibulopelvic angle were determined on standard excretory urography before SWL. All measurements were done by 1 urologist who was unaware of the results. Statistical analysis was performed with chi-square, Fisher's exact and Mann-Whitney U tests. ROC analysis was done to determine the cutoff points of caliceal anatomy measurements for stone clearance. We treated 36 RUs in 23 males and 10 females with isolated lower caliceal stones. Median patient age was 10.5 years (range 2 to 16). Median stone burden was 0.7 cm (range 0.2 to 4), and median number of shock waves and energy used for the entire patient population was 1,500 and 17.2 kV, respectively. Overall stone-free rates for the 36 RUs were 61% after a median treatment session of 1 (range 1 to 7) and retreatment rates were 39%. Of the patients rendered free of stones 13 (59%) were treated in a single SWL session and 9 (41%) underwent 2 or more sessions. Median lower infundibular length, width, length-to-width ratio and pelvic caliceal height in the stone-free and residual stone group were 25.5, 28.0 mm, 4.5, 5.0 mm, 6.4, 5.5 mm and 21.5, 21.5 mm, respectively (p = 0.810, 0.327, 0.511 and 0.511). Median lower infundibulopelvic angle in the stone-free and residual stone groups was 92.50 and 92.50 degrees, and 60.0 and 54.50 degrees, respectively (p = 0.860 and 0.089). On ROC analysis no parameter predicting stone-free rate and cutoff points of caliceal anatomy measurements for stone clearance was found. Our results suggest that caliceal pelvic anatomy in pediatric lower pole stones has no significant impact on stone clearance after SWL. There was a highly significant relation between retreatment rates and stone burden, which should be considered for determining the treatment modality.The Journal of Urology 10/2004; 172(3):1082-6. · 3.70 Impact Factor
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ABSTRACT: The prognosis for patients with primary hyperoxaluria has been ominous, with the expectation of renal failure, poor results with transplantation, and early death. We studied the long-term effects of orthophosphate and pyridoxine therapy in 25 patients with primary hyperoxaluria who were treated for an average of 10 years (range, 0.3 to 26). Their mean age at the start of treatment was 12 years (median, 6; range, 0.5 to 32). We also studied the effect of orthophosphate and pyridoxine on urinary supersaturation with calcium oxalate, crystal inhibition using a seeded growth system, and crystal formation using scanning electron microscopy in 12 patients during three-day stays in the clinical research center. The mean (+/- SD) glomerular filtration rate at the start of treatment was 91 +/- 26 ml per minute per 1.73 m2. The median decline in glomerular filtration rates was 1.4 ml per minute per 1.73 m2 of body-surface area per year. The actuarial survival free of end-stage renal disease was 96, 89, 74, and 74 percent of 5, 10, 15, and 20 years, respectively. Treatment with orthophosphate and pyridoxine reduced urinary supersaturation with calcium oxalate from 8.3 +/- 3.0 to 2.1 +/- 1.7 kJ per mole at 38 degrees C (P < 0.001), increased the inhibition of calcium oxalate formation from 63 +/- 11 to 108 +/- 10 inhibitor units per 24 hours (P < 0.001), and improved the crystalluria score from 2.6 +/- 0.3 to 0.6 +/- 0.1 (P < 0.001). Treatment of patients with primary hyperoxaluria with orthophosphate and pyridoxine decreases urinary calcium oxalate crystallization and appears to preserve renal function.New England Journal of Medicine 12/1994; 331(23):1553-8. · 51.66 Impact Factor
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ABSTRACT: We compared the results of percutaneous nephrolithotomy and shock wave lithotripsy for the treatment of 1 to 2 cm renal stones in children. The study included 166 children with renal stones 1 to 2 cm. A total of 75 patients (82 kidneys) were treated with percutaneous nephrolithotomy and 91 (93 kidneys) were treated with shock wave lithotripsy. Mean followup was 31 +/- 10 months (range 6 to 84). Both groups were compared regarding stone-free rate, re-treatment rate, complications and incidence of stone recurrence. Both groups were comparable regarding preoperative characteristics. Of the units treated with percutaneous nephrolithotomy 4 (4.9%) were associated with minor complications. Stone-free rate after a single session of percutaneous nephrolithotomy was 86.6% (71 units), and the remaining 11 kidneys with residual stones were successfully treated with repeat percutaneous nephrolithotomy in 7 and shock wave lithotripsy in 4. Therefore, a total of 78 units (95%) were stone-free after percutaneous nephrolithotomy monotherapy, and the overall stone-free rate at 3 months was 100%. Of the patients undergoing shock wave lithotripsy 1 (1.1%) had development of steinstrasse and was successfully treated with ureteroscopy. The overall re-treatment rate after shock wave lithotripsy was 55%. A total of 79 units (84.9%) were stone-free after shock wave lithotripsy monotherapy, whereas 7 (7.5%) with no gross response to treatment were treated with percutaneous nephrolithotomy and 7 with insignificant stones less than 4 mm were followed. Therefore, the overall stone-free rate at 3 months was 92.5%. The differences in stone-free rates and re-treatment rates significantly favored percutaneous nephrolithotomy, while the incidence of complications and stone recurrence at last followup were not significantly different between the groups. For treatment of 1 to 2 cm renal stones in children percutaneous nephrolithotomy is better than shock wave lithotripsy, yielding higher stone-free and lower re-treatment rates.The Journal of Urology 09/2006; 176(2):706-10. · 3.70 Impact Factor