45

TREATMENT OF PAEDIATRIC UROLITHIASIS BETWEEN 1990 AND 2002

Onal B., Demirkesen O., Yalcin V., Tansu N., Kalkan M., Altintas R., Solok V.

Cerrahpasa School of Medicine, Istanbul University, Department of Urology, Istanbul, Turkey

INTRODUCTION & OBJECTIVES: We present our experience with the treatment of paediatric urolithiasis during a 12-year period. In this study, the impact of new technology in the management of paediatric urolithiasis was evaluated.

MATERIAL & METHODS: We retrospectively reviewed the records of 292 patients under the age of 16 years in whom urolithiasis was surgically treated at our department from 1990 to 2002. Age, stone location and changing patterns of treatment with time were reviewed.

RESULTS: The mean age was 9.3 years (9 months-16 years). 292 paediatric patients were treated with endourologic procedures (ESWL, PNL, URS) or open surgery for urolithiasis. There were 195 cases of renal, 64 ureteral, 28 bladder and 5 urethral stones. Endourologic procedures included ESWL in 163 cases, PNL in 20, ureterorenoscopy in 11 and cyst lithotripsy and/or transurethral basket extraction in 20. Seventy nine cases were treated by open surgery (table). The changing patterns of treatment with time was showed in graphic.

Table: The distribution of endourologic and open surgery’s cases

277

THE EFFICACY OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN PAEDIATRIC LOWER POLE STONES

Onal B., Demirkesen O., Tansu N., Kalkan M., Yalcin V., Oner A.

Cerrahpasa School of Medicine, Istanbul University, Department of Urology, Istanbul, Turkey

INTRODUCTION & OBJECTIVES: To evaluate the efficacy of extracorporeal shock wave lithotripsy (SWL) monotherapy for isolated lower pole nephrolithiasis in paediatric population and compare it to those of isolated middle/upper caliceal and renal pelvis stone.

MATERIAL & METHODS: We treated 125 renal units (RU) with isolated caliceal and renal pelvis stones using a Siemens Litho star lithotriptor. Stone load was recorded in square centimetres (cm2). Patients were stratified into 3 groups based on stone localization; lower calyx, middle/upper calices and pelvis renalis stones as group 1, 2 and 3 respectively. The stones were localized in the lower, middle/upper calices and renal pelvis in 40, 24 and 61 RU's, respectively. Patients were evaluated by intravenous urogram and ultrasonography 12 weeks after the last session. They were designated as stone-free or CIRF (nonobstructive and non-infectious insignificant fragments ≤4 mm). SWL was regarded as failure if no fragmentation was noted after the 3rd session. The results were compared with respect to renal localization.

RESULTS: The median patient age was 9 years (range 21 months to 16 years). The median stone burden was 0.9cm2 (0.2-7). The median number of shock waves and energy used for the entire patient population was 1500 and 17.2kV, respectively. Auxiliary procedures were used in 12.8 % before treatment. General anaesthesia was given to 9 (7.2 %). The stone and treatment characteristics and results of 125 renal units were shown in the table. Complication occurred in 9 patients. Only one patient required hospitalization due to fever. Steinstrasse developed in 8 patients. All of these patients were successfully managed by repeat SWL monotherapy without using auxiliary procedures.

CONCLUSIONS: There is no significant difference for success rates between the lower, middle/upper calices and pelvis stones treated with ESWL in paediatric population.

278

EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY IN PEDIATRIC URETERAL STONES: RETROSPECTIVE ANALYSIS OF 168 CASES

Altunrende F., Karadag M., Tefekli A., Erkan E., Sarilar O., Muslumanoglu A.

Haseki Teaching And Research Hospital, Urology, Istanbul, Turkey

INTRODUCTION & OBJECTIVES: Management of ureteral stones in children represents a challenging problem. Extracorporeal shockwave lithotripsy (SWL) can be considered as first line treatment alternative for pediatric ureteral stones. In this study, we retrospectively analyzed our experience with SWL in 168 children with ureteral stones.

MATERIAL & METHODS: Between 1990-2001, 168 cases in pediatric age group (<14 years old) were treated with Siemens Lithostar Plus for ureteral stones. All cases were evaluated with urine analysis, urine culture, coagulation profile, serum creatinine level, plain radiography of the urinary tract, intravenous urography and/or ultrasonography before SWL application. There were 31 stones in proximal ureter, 16 in mid ureter and 121 in distal ureter. Stone free and clinically insignificant residual fragments (CIRF) were defined successful and SWL was regarded as failed if no fragmentation was seen after 3 sessions.

RESULTS: Mean patient age was 8.7±3.9 years (6 months-14 years). There were 108 boys (64.2%) and 60 girls (35.8%). All patients were treated as outpatients with intravenous sedation in 64 cases (38.1%), general anesthesia in 60 cases (35.7%) and no anesthesia in 44 (26.2%). A maximum of 3500 shocks and 18kV per session were applied in all cases. A primary double-j ureteral stent was placed before SWL in 4 children (2.3%) with obstructing distal ureteral stones. A 100% success rate was achieved in all proximal (n: 31) and mid ureteral stones (n: 16). Besides this, stone free and CIRF rates for distal ureter cases (n: 121) were 90.6% and 3.1% in stones less than 1 cm in diameter (n: 91), 91.7% and 8.3% in stones between 1-2 cm (n: 24). In 1 case having distal ureter stone bigger than 2 cm, no success was achieved and open surgery was applied. Overall retreatment and efficacy quotient rates for proximal ureteral stones were 45.1% and 68.9%, 62.5% and 61.5% for mid, 49.6% and 60.0% for distal ureteral stones.

CONCLUSIONS: SWL can be considered as first line treatment alternative for ureteral stones in pediatric age group regarding stone location and size. Especially, proximal and mid ureter stones are having higher success rates than distal ureter stones.

655

IS URODYNAMIC STUDY UNDER SEDATION BETTER TOLERATED BY CHILDREN?

Keskin M.S.¹, Gozacan A.², Oruc O.¹, Ozgen S.², Tekgül S.¹

¹Hacettepe University - Faculty of Medicine, Department of Urology, Ankara, Turkey, ²Hacettepe University - Faculty of Medicine, Department of Anaesthesiology, Ankara, Turkey

INTRODUCTION & OBJECTIVES: The urodynamic study has an invasive and uncomfortable nature. As well as the known risk factors, this experience may be traumatic to the child and the anxiety may interfere with results of the study. Ideal sedative should be: Applied non-invasively, safe, tolerable, cheap and easily available. This study investigates the effects of sedation in children during urodynamic studies.

MATERIAL & METHODS: 57 children (21m/36f) with a mean age of 6.6(4-10) were included into study. Fifteen minutes prior to catheterization for urodynamic study patients were given midazolam intranasally (26) or sublingually (14) at a dose of 0.2 mg/kg, and 17 who were in the control group didn’t receive any medication. The indications for the study were voiding dysfunction (25), vesico-ureteric reflux (12), neurogenic bladder (9), recurrent urinary tract infection (6), posterior urethral valves (2), enuresis nocturna (2), female epispadias (1). The patients were monitored by pulse oximeter for oxygen saturation and heart rate by an anaesthesiologist The degree of sedation was assessed with OASS (Observer’s Assessment of Alertness/Sedation Scale) 1: being alert 5: deep sedation, and the pain/discomfort was measured with CHEOPS (Children Hospital Eastern Ontario Pain Scale) where the minimum score is 4 and 13 is the maximum. Prior to catheterization the rate of sedation was recorded. The CHEOPS and OASS were measured just before the study, on the urodynamics table, during catheterisation and at each 5 minute intervals during the study. The parents of the patients on the sedation group were later interviewed by telephone for retrograde amnesia.

RESULTS: There were neither complications nor pulse/saturation changes. All patients were well-cooperated and reported first sensation, first desire and strong desire. The sedation scores at the beginning of the study were 2 and 2.47 for the sublingual group and intranasal group respectively. The pain scores during the catheterisation were 8.1, 8.8, 9.25 for the sublingual group, intranasal group and control group respectively. The average pain scores after the catheterization are 6.17, 5.7, 7.12 for the sublingual group, intranasal group and control group respectively. The pain scores during catheterization with or without previous history of urethral catheterisation for urodynamic study or VCUG were 9 and 8.4 respectively. Thirty eight of 40 families reported that their children didn’t remember the procedure. They remembered the route of the drug was given but they failed to define what happened afterwards.

CONCLUSIONS: Both routes for midazolam administration are effective. Midazolam produces mild and safe sedation at a dose of 0.2mg/kg intranasally or sublingually. Previous history of urethral catheterisation for diagnostic study is significant. The sedation affects the amount of pain mildly and it produces effective retrograde amnesia thus, it causes less anxiety for the repeating studies.

658

CONTINENT VESICOSTOMY (MITROFANOFF PRINCIPLE) USING THE APPENDIX OR THE ILEUM: COMPARING THE RESULTS

Catti M., Capizzi A., Zin M., Sciobica F., Passerini Glazel G., Rigamonti W.

Istituto di Urologia, Dipartimento di Scienze Oncologiche e Chirurgiche, Padova, Italy

INTRODUCTION & OBJECTIVES: To evaluate the results of continent vesicostomy according to the Mitrofanoff principle using the appendix compared to the retubularised ileum (Yang-Monti).

MATERIAL & METHODS: From January 1997 to December 2002, 55 Patients (age 4-77 years, mean 28 years) underwent continent vesicostomy according to the Mitrofanoff principle at Our Institution: the appendix was used in 39 cases, ileum in 15, and sigma in 1 case. The underlying indications were: bladder exstrophy (12 cases), neuropathic bladder (11), urinary incontinence following previous surgery (11), pelvic cancer (9), posterior urethral valve or congenital urethral hypoplasia (4), reconstruction of an orthotopic neo-bladder after previous eterothopic urinary diversion (4) and miscellaneous (4). An augmentation cystoplasty was simultaneously performed in 29 cases and an ileal neo-bladder in 14: in these cases an original anti-reflux mechanism was routinely created by hitching the anterior wall of the reconstructed bladder to the anterior abdominal wall, so as to enroll the vesicostomic channel. Cutaneous stomas were located at the umbelicus in 52 cases and at the right lower abdominal quadrant in 3. Mean follow-up (range) was 46 months (7 – 71). The Patients were divided into 2 groups: group A (39 cases) with appendicovesicostomy and group B (15 cases) with ileovesicostomy.

RESULTS: Group A: we complained significant trans-Mitrofanoff incontinence in 2/39 (5.1%) patients and problematic catheterization in 4/39 (10.5%). The patients suffering incontinence refused intervention and remain incontinent. Of the patients with difficult catheterization 1 had stomal stenosis resolved with dilatation, 2 had bladder-level stenosis successfully treated respectively with endoscopic incision and surgical revision and 1 had angulated conduit resolved surgically. Group B: we found significant incontinence in 4/15 (26.6%) and problematic catheterization in 4/15 (26.6%). The incontinence required 5 surgical revisions, after which 1 patients gained perfect continence and the rest significant improvements. Difficult catheterization was due to stomal stenosis in 2 cases (treated with 3 surgical revision), to bladder level stenosis (associated to angulation of the double flap of ileum) in 2 cases which were resolved with 1 endoscopic incision and 2 surgical revisions. The complication rate was significantly higher in group B respect to group A (csquare < 0.5)

CONCLUSIONS: The appendix is the conduit of choice for a continent vesicostomy according to Mitrofanoff‘s principle, with a significantly smaller incidence of complications if compared to retubularised ileum according to Yang-Monti technique.

720

DEMOGRAPHIC AND CLINICAL FEATURES OF PAEDIATRIC STONE DISEASE

Akdogan B., Guliyev F., Gunay M., Inci K., Sahin A., Tekgül S.

Hacettepe University - Faculty of Medicine, Department of Urology, Ankara, Turkey

INTRODUCTION & OBJECTIVES: This study has been put forward in order to get objective and concrete data by multi-parametric evaluation of paediatric stone disease, which is frequent in Turkish population. Several parameters, such as sex, age and primary complaint at admission, localisation of stones, treatment modalities and success rates have been evaluated.

MATERIAL & METHODS: The entire data of 332 paediatric urinary stone patients treated in our clinic have been revised.

RESULTS: 332 patients, 203 (61.1%) male and 129 (38.9%) female, have been followed up for a mean of 14.1 months (range: 3 - 151 months). Twenty-five (7.7%) patients were younger than 1 year old, 122 (37.4%) patients were between 1 to 5 years old and 182 (54.9%) patients were older than 5 years of age. The most frequent complaints at admission were pain (50.3%), urinary tract infection (21.7%) and haematuria (17.3%). In spite of similar rates in all age groups, infection was more common in infants; haematuria was more frequent in patients older than one year of age. Stones were localised in the kidney (81.2%), ureter (15.3%), and bladder (3%). Twenty-six percent of all were localised in the renal pelvis, 11.1% in calyces and 5.7% were staghorn. Of the unicalyceal stones 54 % were in the lower pole. Shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS) rates for right and left renal and ureteral stones were 50.7%, 18.7%, 6.0%, 15% and 49.1%, 19.2%, 4.8%, 15.5% respectively. Mean stone burden in ESWL was 123.2 mm2 (range: 9 - 400 mm2), 257.6 mm2 (range: 30 - 1500 mm2) in open surgery and PNL, 64 mm2 (range: 16 - 225) in URS. The stone free rate plus clinically insignificant residual fragments rates for ESWL was 79.3±10.7%, 70.2±21.3% for PNL, 82.0±15.5% for URS, 73.0±16.2% for open surgery. For infants these rates were 84.3±5.4%, 81.2±10.6% for 1-5 years age group, and 74.6±14.9% for the older group. According stone size these rates were 80.9±9.3% for stones <10 mm and 78.5±13.5 for the larger ones. In the ESWL group stone free rates were 84.7±7.0% for < 10 mm stones and 76.3±10.5% for the larger ones; in the PNL group these rates were 88.9±11.1% and 71.4±22.9 respectively.

CONCLUSIONS: Admission rate in infant age is 7.7%. Male/female ratio is decreased in comparison to adults. Pain is the primary complaint. Eighty percent of the stones were renal and 26.2% of all stones were localised in the renal pelvis. ESWL was the treatment of choice in 50% and resulted with approximately 90% success rate. Although the increasing stone burden decreases the success rates, ESWL can be applied with success in all age groups including infants. Open surgery rate is 15%. PNL is the treatment of choice for the patients with higher stone volumes.

725

ONLAY ISLAND FLAP - A REVIEW OF ONE HUNDRED CASES - THE LIVERPOOL EXPERIENCE

Nair M., Tooth D., Rickwood A.

Royal Liverpool Children’s Hospital, Urology, Birmingham, United Kingdom

INTRODUCTION & OBJECTIVES: The Onlay Island Flap urethral reconstruction is an accepted hypospadias repair with the theoretical advantage of avoiding circumferential anastomoses and hence risk of stricture proximally or meatal stenosis distally. Our objective is to report its results in one hundred consecutive cases.

MATERIAL & METHODS: One hundred patients with hypospadias consecutively underwent repair between 1990 to 2002, the repair was performed as described by its originators (Duckett et al, 1987). Ages of patients range from 14 to 144 months (mean 29), meatal site varied from 1 to 20 mm subcoronally and length of flap from 15 to 40 mms. Particular reference was made to severity and correction of chordee.

RESULTS: The functional and cosmetic results were excellent and satisfying in all hundred cases. Mobilisation of urethral plate was performed on 12 occasions and ten had plication sutures for correction of chordee. Nineteen patients developed urethral fistulae postoperatively typically subcoronally. There were no examples of stricture, meatal stenosis, or breakdown of glans wrap. Excision of excess penile skin was undertaken in 12 cases, 6 simultaneously with fistula repair.

CONCLUSIONS: Onlay Island Flap is a simple and versatile technique producing good cosmetic and functional appearance of the glans and offers more predictable viability and neat ventral skin cover. On this basis we recommend it, and in our experience have extended to include patients with more severe degrees of chordee and more proximal hypospadias with success. The complications were little below those encountered with tubed flaps and we currently prefer and recommend onlay island flaps repairs in finding urethral fistula less troublesome than stricture from a patient's point of view and one more readily amenable to surgical correction.

LB12

KIDNEY TRANSPLANTATION IN CHILDREN. LONG TERM SINGLE CENTRE EXPERIENCE

Hamdi M., Mohan P., Little D.M., Hickey D.P.

Royal College of Surgeons, Urology and Transplantation Department, Beaumont Hospital, Dublin, Ireland

INTRODUCTION & OBJECTIVES: Kidney transplantation in children represents both technical and immunological challenge to the transplantation team. We report our long term experience in the field.

MATERIAL & METHODS: From January 1986 till the end of December 2001, 158 kidney transplants were performed in 130 recipients. (70 males and 60 females). Mean Age at transplantation was 12.73 years (range 2-18 years). Causes of ESRD were pyelonephritis in 57 (36%) patients, glomerulonephritis in 46 (29%), congenital malformation and hereditary disorders each in 16 (10%) and unknown aetiology in 23 (15%). Standard surgical techniques were adopted with intraperitoneal placement of the graft in children less than 20 kg in weight. Postoperative immunosuppression protocols can be classified into 3 eras. Era1 (1986-1990), Cyclosporine, Immuran, and Steroids. Era 2 (1991-1996) Antithymocyte- globulin (ATG), Neoral, Immuran and Steroids. Era 3 (1997-2001), Tacrolimus, Mycophenolate mophetil (MMF), and Steroids.

RESULTS: The overall patient survival is 94%. Causes of death were hyperkalaemia in 3, cardiac arrest in 2, sepsis in 2, subarachnoid haemorrhage in 1, cerebrovascular accident in 1 and post bone marrow transplantation in 1. Median graft survival is 7.37 years. Causes of graft failure were rejection in 44 patients, renal vein thrombosis in 8, recurrence of the original disease in 8, death with a functioning graft in 5 and haemolytic uraemic syndrome in 1. Changing our immunosuppression protocols dramatically affected our results. The 1, 3 and 5 years graft survival were for era1, 56%, 46%, 42%, era2, 79%,72%,64%, era3, 88% 77% 73% respectively.

CONCLUSIONS: For successful kidney transplantation in a child, meticulous surgical as well medical care is needed. Aggressive immunotherapy is a key element of success but should be balanced against the potential harmful impact of these drugs on growth and development.

LB17

SAFETY OF TOLTERODINE PR IN CHILDREN WITH DETRUSOR OVERACTIVITY: POOLED DATA FROM TWO LARGE PLACEBOCONTROLLED TRIALS

Nijman R.¹, Borgstein N.², Ellsworth P.³

¹Groningen University Hospital, Groningen, The Netherlands, ²Pfizer Ltd, Department of Clinical Development, Gi/gu, New London, United States, ³University of Massachusetts Medical Centre, Worcester, United States

INTRODUCTION & OBJECTIVES: Two placebo-controlled trials of similar design were conducted in children with urge incontinence suggestive of detrusor overactivity. Data from the 2 trials were combined to compare the safety profiles of tolterodine and placebo treatments.

MATERIAL & METHODS: Two randomized, double-blind, placebo-controlled, multicentre trials were conducted to evaluate the efficacy and safety of prolonged release (PR) tolterodine in 5- to 10-year-old children with urge urinary incontinence suggestive of detrusor overactivity. After a 1-week run-in, patients were randomized in a 2:1 ratio to receive tolterodine PR 2 mg or placebo once daily for 12 weeks. Assessments occurred at the end of the run-in period and at weeks 4, 8, and 12. A total of 271 patients (57% males, 43% females) continued from 1 of the studies into an open-label extension study.

RESULTS: 710 patients participated in these 2 studies; 486 received tolterodine and 224 placebo. The treatment groups were well balanced with respect to demographic and baseline characteristics. Similar proportions of patients discontinued the studies (8% tolterodine, 11% placebo) and in each group 3% of patients discontinued due to adverse events. The most common event leading to discontinuation was difficulty in micturition (either symptomatic or defined as postvoid residual urine volume ≥20% of theoretical bladder capacity): 5 tolterodine patients and 1 placebo patient. No occurrences of urinary retention were reported. Three adverse events frequently associated with anticholinergic treatment occurred at low rates: diarrhea (3.3 % tolterodine vs. 0.8 % placebo); constipation (2.1 % vs. 0.8 %); and abnormal behaviour (1.6 % vs. 0.4 %). In addition, 2 common childhood ailments occurred more frequently in the tolterodine PR group compared with the placebo group: rhinitis (1.6 % vs. 0.4 %) and ear infection (1.0 % vs. 0.4 %). Dry mouth, nausea, and fatigue occurred slightly less frequently in the patients taking tolterodine. Serious adverse events occurred in 1% of patients in each group. More than 80% remained in the extension study for 6 months or more, and slightly over 50% completed the 12-month study. The most frequent reasons for discontinuation were lack of efficacy (17%) and improvement in baseline symptoms (12%). Difficulty with micturition occurred in 1.8 %, and there were no episodes of urinary retention.

CONCLUSIONS: Tolterodine PR was well tolerated in children 5 to 10 years of age. The incidence of adverse events associated with anticholinergic treatment was generally low. Some adverse events (eg, constipation) occurred slightly more frequently in tolterodine patients than placebo patients yet remained low; others (eg, dry mouth) occurred less frequently with tolterodine PR. Prolonged treatment was not associated with any new or unexpected adverse events.

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