Management of KidneyStones inChildren

USFAdvances inUrology 2017

Hubert SSwanaMD

KeyWest Florida

Disclosures

• No disclosures to report

• MET: Tamsulosin: not FDA approved children

Case

• 12 year old girl (186lbs)

• Presented abdominal pain,

• Treated empirically for constipation

• Returned 3 weeks later

Return

• Persistent pain

• Fevers 102

• Hypotensive

• U/A:

– Bld +++

– Leuk est +++1.8 cm

18 mm stone Fluids:AbxStent placed emergentlyDeferveced

Overview• Epidemiology

• Pediatric Presentation

• AUAGuidelines:Children

– MET

– Surgical Modalities

• URS

• SWL

• PCNL

• Open/Laparoscopic/Robotic

Increase

A Rise in Kidney Stones Is Seen inU.S.Children:October 27, 2008

KidneyStones and Kids:A PainfulComboNov. 14, 2008

More KidsGetting KidneyStonesSept. 19, 2013

Epidemiology: 2000‐present

• Single Institution andState Studies

• Sas

• Kairam

2011

2013

• Larger Surveys: PHIS

• Bush

• Routh

2010

2010

Incidence of Pediatric Nephrolithiasis in South Carolina

Sas D J CJASN 2011;6:2062-2068

©2011 by American Society of Nephrology

Incidence of Pediatric Nephrolithiasis in South Carolina

Sas D J CJASN 2011;6:2062-2068

©2011 by American Society of Nephrology

G 7.7

B 8.0

G 21.9

B 15.3

• 1,312,487 pediatric visits.

1005 (0.077%) were for renal colic. 

The median age 16 years

• The percentage of ED pediatric visits

61% female.

0.048% in 1999

0.089% in 2008

• Increase of 86%– (95% confidence interval, 36%‐154%; P < 0.001)

Rise in Emergency Department Visits of Pediatric Patientsfor Renal Colic From 1999 to 2008

Neeraja Kairam, MD, .John R. Allegra, MD, PhD, and B a nzet Eskin, i\1D, PhD

0.10% -r--- --- ---------- -

0.08%

- •R;z= 0.69

ccu:= 0.07%cu

0 .06%

0.05% ---------------

0 .04% - + - -------. - - - - - r - - - - - r - - - - - . - - - - - - .------- - - - -.- - - ---r-- --.-----------,

1999 2000 2001 2002 2003 2004 2005 2006 2007 200B

YearFIGURE2. Pediatric EDrenalcolicvisits increasefrom 1999to 2008.

Pediatric Emergency Care • Volume 29, Number 4, April 2013

• 7,921 children with urolithiasis

• Mean number of stone cases per hospital per year increased from

13.9 to 32.6• Compared to total hospital patients/ pediatric

• urolithiasis

– 18.4per 100,000 in 1999 to

– 57.0 per 100,000 in 2008,

– adjusted annual increase of 10.6% (p 0.0001).

Limitations

• StatewideStudies / Regional Differences

• PHIS: 42 hospitals

– Tertiary, free standing hospitals

– Hospital based, not population based

• ICD9 diagnoses

• Incidentally found ?

Epidemiology Summary• Increasing emergency room visits

• Greater numbers of children that go to ER

are being diagnosed with kidney stones

• PHIS hospitals greater incidence of patients 

and admissions

Case

• 12 year old girl (186lbs)

• Presented abdominal pain,

• Treated empirically for constipation

• Returned 3 weeks later

Acute presentation

Abdominal Pain: 53‐75%

Gross Hematuria: 14‐33%

UTI: 8‐20%

‐Infants up to 75%

Unilateral renal colic: 7%

Kokoroski et al Ind JUrol. 2010Oct‐Dec; 26(4): 531–535

Case

18mm stone Fluids:AbxStent placed emergentlyDeferveced

MET• Statement 46: In pediatric patients with 

uncomplicated ureteral stones ≤10 mm, 

clinicians should offer observation with or 

without MET using α‐blockers.

• Moderate Recommendation; Evidence Level

Grade B

Velazquez et al. J PediatrUrol. 2015 Dec; 11(6): 321‐327

• 5 studies: 3 RCT and 2 retrospective cohorts

• Significantly increased the odds spontaneous

stone passage (OR 2.21, 95%CI 1.40–3.49).

• Very few side effects: somnolence

Velazquez et al. J PediatrUrol. 2015 Dec; 11(6): 321‐327

GuidelineStatement 47:

• Clinicians should offerURS orSWL for pediatric 

patients with ureteral stones who are unlikely to pass 

the stones or who failed observation and/or MET,

based on patient‐specific anatomy and body habitus.

• Strong Recommendation; Evidence LevelGrade B

First Line < 20mmStatement 50:

• In pediatric patients with a total renal stone 

burden ≤20mm, clinicians may offer SWL or 

URS as first‐line therapy. (Index Patient 14) 

Moderate Recommendation; Evidence Level 

Grade C

ESWL Results

First Reported in 1986

Success rates 68‐84%

Often times requires several treatments 36‐68% stone‐free after one sx

Rhee K, Palmer JS: Ungated extracorporeal shockwave lithotripsy in children: an initial series.Urology 2006, 67:392–393.

ESWLComplications/Concerns

• Complications: 20%

– Nausea/Vomiting, Hematuria

– Steinstrasse

– Renal hematoma, liver or splenic hematoma

• Concerns:– Renal vessel vasoconstriction,

– RenalTubular Injury

– Subcapsular  Hematomas

Ureteroscopy

Stone free rates

• 88‐100% distal ureteral stones

• 58‐82% Intrarenal

Ureteroscopy

• Complications

• Overall 5.4%

Uti/ Pyelonephritis 

Ureteral perforation

VUR

Ureteral stricture

Reddy, P, DeFoor,WR.Ureteroscopy:The standard of care in themanagement of upper tract urolithiasis in children. Indi JUrol. 2010Oct‐Dec; 26(4): 555–563.

Routine Stenting/ URS

• Statement 49: In pediatric patients with 

ureteral stones, clinicians should not routinely 

place a stent prior toURS. (Index Patient 13) 

ExpertOpinion

Percutaneous Nephrolithotomy

• Stone free rate approx 85% after one procedure

• Complication/ Rates 25‐50 %

– Urosepsis 5 %

– Bleeding/ transfusion 10‐15%

– Urine leak/ stent

– Adjacent organ injury

4‐6 %

rare

CT scan• Statement 48:

• Clinicians should obtain a low‐doseCT scan 

on pediatric patients prior to performing

PCNL. (Index Patient 13)

Strong Recommendation; Evidence LevelGrade C

Stent

• Statement 51: In pediatric patients with a 

total renal stone burden >20mm, both PCNL 

andSWL are acceptable treatment options. If 

SWL is utilized, clinicians should place an 

internalized ureteral stent or nephrostomy 

tube. (Index Patient 14) ExpertOpinion

Increased risk of:

Complete ureteral obstruction 

Sepsis

Open Surgery/Laparoscopy??

Open Surgery/Laparoscopy??• Statement 52: In pediatric patients, except in 

cases of coexisting anatomic abnormalities, 

clinicians should not routinely perform 

open/laparoscopic/robotic surgery for upper 

tract stones. (Index Patients 13, 14) Expert 

Opinion

Observation?

• Statement 53: In pediatric patients with 

asymptomatic and non‐obstructing renal 

stones, cliniciansmay utilize active 

surveillance with periodic ultrasonography. 

(Index Patient 14) ExpertOpinion

Treatment

‐URS‐Stone‐free‐Stent removed in office ( string)‐Ca‐oxalate

Summary‐Stone disease increasing: ER visits, admissions

‐Presentation:Abdominal pain

‐MET <10mm

‐URS/SWL <20mm

‐Stents only if > 20 mmSWL

References

1.Hernandez JD, Ellison JS, LendvayTS.CurrentTrends,

Evaluation, andManagement of Pediatric Nephrolithiasis. JAMA 

Pediatr. 2015;169(10):964‐970.

2.TasianGE,Copelovitch L. Evaluation andMedical 

Management of Kidney Stones inChildren. JUrol. 2014 

Nov;192(5):1329‐36