Poste Italiane S.p.A. - Spedizione in abbonamento postale - D.L. 353/2003 (conv. in L. 27/02/2004 n. 46) Art. 1, comma 1 DCB Milano
Vol. 80; n. 2, June 2008
Medical aspect and minimal invasive treatment of urinary stones in children. Kemal Sarica
Paediatric renal stone disease in Tunisia: A 12 years experience. Akram Alaya, Abdellaatif Nouri, Mohamed Fadhel Najjar
Percutaneous nephrolithotomy for pediatric renal calculus disease: 5 years of local experience. Igor Romanowsky, Leonard Lismer, Murad Asali, Eran Rosenberg, Jackob Kaneti
Prostate cancer metastases to bone: Observational study for the evaluation of clinical presentation, course and treatment patterns. Presentation of the METAURO protocol and of patient baseline features. Giario Conti, Giuseppe La Torre, Virgilio Cicalese, Gennaro Micheletti, Maria Giuseppe Ludovico, Giovanni Donato Vestita, Giuseppe Cottonaro, Carlo Introini, Massimo Cecchi
Activity of Serenoa repens, Lycopene and Selenium on Prostatic Disease: Evidences and Hypotheses. Vittorio Magri, Alberto Trinchieri, Gianpaolo Perletti, Emanuela Marras
Laparoscopic nephrectomy for complete renal infarction due to post traumatic renal artery thrombosis. Stefano Gidaro, Luigi Schips, Luca Cindolo, Richard Ziguener
Laparoscopic transperitoneal adrenalectomy for adrenocortical oncocytoma. Samir Eldahshan, Antonio Celia, Guglielmo Zeccolini, Antonello Guerini, Guglielmo Breda
Chieti-Pescara - 26-29 Novembre 2008 Montesilvano-Palacongressi d’Abruzzo
Main Topic: “Il tumore del rene” Presidente SIUrO e Presidente del Congresso: Prof. Raffaele Tenaglia
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[email protected] www.siuro.it
REMIND Ricordiamo a tutti i Soci SIUrO di rinnovare la loro Quota Associativa per l’anno 2008. Il Socio in regola con la Quota Associativa ha diritto al voto nel corso della Assemblea Amministrativa; ha diritto ad uno sconto sulla Quota di Iscrizione al Congresso Nazionale SIUrO. Riceve gratuitamente copia della rivista “Archivio Italiano di Urologia e Andrologia”. La segreteria SIUrO è a disposizione di chiunque desiderasse verificare la propria posizione associativa. Chi intende iscriversi alla SIUrO trova le istruzioni ed i moduli necessari sul sito internet www.siuro.it È possibile pagare la quota associativa annuale tramite bonifico bancario sul c/c n. 737405, intestato alla Società Italiana di Urologia Oncologica, presso Unicredit Banca Fil 3357 (Via Massarenti) ABI 2008 CAB 02474 o tramite bollettino postale sul c/c n. 28212405 intestato a Società Italiana Urologia Oncologica S.I.Ur.O indicando nella causale “quota associativa anno 2008” Per ottenere ulteriori informazioni è possibile contattare la segreteria c/o Clinica Urologica, Alma Mater Studiorum Università di Bologna – Policlinico S. Orsola Malpighi, Padiglione Palagi Via P. Palagi, 9 - 40138 Bologna Tel +39 051 6362421 Fax +39 051 308037 e-mail
[email protected] www.siuro.it
Congresso
Time table XVIII Congresso Nazionale SIUrO
Official Journal of the SIEUN - Official Journal of the SIUrO EDITORS M. Maffezzini (Genova), G. Perletti (Busto A.), A. Trinchieri (Lecco)
EDITORIAL BOARD P. F. Bassi (Roma), A. Bossi (Villejuif - France), P. Caione (Roma), F. Campodonico (Genova), L. Carmignani (Milano), L. Cheng (Indianapolis - USA), L. Cindolo (Avellino), G. Colpi (Milano), G. Corona (Firenze), A. Giannantoni (Perugia), P. Gontero (Torino), S. Joniau (Leuven - Belgio), F. Keeley (Bristol - UK), L. Klotz (Toronto - Canada), M. Lazzeri (Firenze), B. Ljungberg (Umeå - Svezia), A. Minervini (Firenze), N. Mondaini (Firenze), G. Muir (London - UK), G. Muto (Torino), R. Naspro (Bergamo), A. Patel (London - UK), G. Preminger (Durham - USA), D. Ralph (London - UK), A. Rodgers (Cape Town - South Africa), F. Sampaio (Rio de Janeiro - Brazil), K. Sarica (Istanbul - Turkey), L. Schips (Vasto), H. Schwaibold (Bristol - UK), A. Simonato (Genova), S. Siracusano (Trieste), C. Terrone (Novara), A. Timoney (Bristol - UK), A. Tubaro (Roma), R. Zigeuner (Graz - Austria)
SIUrO EDITOR G. Martorana (Bologna)
SIUrO ASSISTANT EDITOR A. Bertaccini (Bologna)
SIUrO EDITORIAL BOARD G. Arcangeli (Roma), M. Battaglia (Bari), O. Bertetto (Torino), F. Boccardo (Genova), E. Bollito (Torino), S. Bracarda (Perugia), G. Conti (Como), J.G. Delinassios (Athens - Greece), D. Prezioso (Napoli), G. Sica (Roma)
SIEUN EDITOR G. Virgili (Roma)
SIEUN EDITORIAL BOARD E. Belgrano (Trieste), P. Martino (Bari), F. Micali (Roma), M. Porena (Perugia), F.P. Selvaggi (Bari), C. Trombetta (Trieste), G. Vespasiani (Roma)
ASSOCIAZIONE UROLOGI LOMBARDI EDITOR F. Rocco (Milano)
HONORARY EDITOR E. Pisani (Milano)
Indexed in: Medline/Index Medicus - EMBASE/Excerpta Medica - Medbase/Current Opinion - SIIC Data Base www.architurol.it
Contents Medical aspect and minimal invasive treatment of urinary stones in children.
Pag. 0
Kemal Sarica
Paediatric renal stone disease in Tunisia: A 12 years experience.
Pag. 0
Akram Alaya, Abdellaatif Nouri, Mohamed Fadhel Najjar
Percutaneous nephrolithotomy for pediatric renal calculus disease: 5 years of local experience.
Pag. 00
Igor Romanowsky, Leonard Lismer, Murad Asali, Eran Rosenberg, Jackob Kaneti
Prostate cancer metastases to bone: Observational study for the evaluation of clinical presentation, course and treatment patterns. Presentation of the METAURO protocol and of patient baseline features.
Pag. 00
Giario Conti, Giuseppe La Torre, Virgilio Cicalese, Gennaro Micheletti, Maria Giuseppe Ludovico, Giovanni Donato Vestita, Giuseppe Cottonaro, Carlo Introini, Massimo Cecchi
Activity of Serenoa repens, Lycopene and Selenium on Prostatic Disease: Evidences and Hypotheses.
Pag. 00
Vittorio Magri, Alberto Trinchieri, Gianpaolo Perletti, Emanuela Marras
Laparoscopic nephrectomy for complete renal infarction due to post traumatic renal artery thrombosis.
Pag. 00
Stefano Gidaro, Luigi Schips, Luca Cindolo, Richard Ziguener
Laparoscopic transperitoneal adrenalectomy for adrenocortical oncocytoma.
Pag. 00
Samir Eldahshan, Antonio Celia, Guglielmo Zeccolini, Antonello Guerini, Guglielmo Breda
Archivio Italiano di Urologia e Andrologia 2008, 80, 2
III
ORIGINAL PAPER
Medical aspect and minimal invasive treatment of urinary stones in children. Kemal Sarica Department of Urology, Yeditepe University Medical School, Istanbul, Turkey.
Summary
Despite its relatively uncommon incidence, management of the urinary stones in children poses a specific technical challenge to the urologist. Aims of the management should be complete clearance of stones, preservation of renal function and prevention of stone recurrence. In pediatric patients with urinary stones metabolic conditions have been demonstrated in up to 50 % of cases whereas a variety of anatomic anomalies have been found in about 30 % of children with urolithiasis. For this reason in addition to stone removal procedures, treatment of pediatric urolithiasis requires a thorough metabolic and urological evaluation on an individual basis. Obstructive pathologies along with the established metabolic abnormalities should be treated on time. Urine volume should be increased encouraging adequate fluid intake evenly distributed to the whole day and medical therapeutic agents which increase urine citrate levels may be considered in the medical management of hypocitraturia. In order to select the most appropriate surgical treatment, location, composition, and size of the stone(s), the anatomy of the collecting system, and the presence of obstruction along with the presence of infection of the urinary tract should be considered. Improvements in technology and growing experience have resulted in greater acceptance of minimally invasive techniques for the management of pediatric stones and currently urologists can benefit from the whole spectrum of stone management alternatives also in children. SWL is the first choice tteatment for upper tract calculi while other minimally invasive methods have more specific indications. Although SWL is safe and efficient in the treatment of both renal and ureteral stones, ureteroscopy and PCNL in expert hands, can be successfully applied in appropriate cases. In fact gue to the technically demanding nature of these procedures prior experience in the adult population is mandatory. With judicious application of these treatment modalities, excellent stone free rates with minimal morbidity could be obtained in this specific patient population. In patients with anatomical abnormalities open surgery will continue to be the preferred treatment alternative. KEY WORDS: Urinary Calculi; Shock Wave Lithotripsy; Percutaneous Nephrolithotomy; Ureteroscopy. Submitted 15 December 2007; Revised 9 February 2008; Accepted 20 February 2008
INTRODUCTION From 5 to 10% of the human population suffer from stone disease during their lifetime and of these cases only 1-3 % are children. Renal stone disease is frequently considered in the evaluation of kidney disesases in children although its diagnosis is rarely confirmed. Several studies have clearly demonstrated that the pattern of the disease shows marked variation in developed and developing countries. While the disease has been reported to be rather rare in some countries, like Scandinavia, it is still an endemic problem in developing ones such as Turkey, Iran, Pakistan and the Far East.
Stones occur in children of all ages and do not disproportionately affect any age group (1, 2). With respect to the chemical composition and the possible etiology of the stone disease; in United Kingdom and other European countries, 75% of calculi in children are composed of organic matrix and struvite. The majority of these calculi have been found coincident with Proteus infection and urinary tract anomalies. In developing areas however, bladder stones with a chemical composition of ammonium acid urate and uric acid are common stone types for which dietary factors, Archivio Italiano di Urologia e Andrologia 2008; 80, 2
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particularly the dependence on cereal and rice, play a certain role. However, being detected in more than 75% of all children evaluated; calcium oxalate or calcium phosphate calculi account for the majority of the stones in this specific population. Infection stones, which represent 15% to 25% of the total, are the second most common form of calculosis (2, 5, 6). Among the possible underlying causative factors, some well evaluated factors namely metabolic abnormalities, urinary tract infections, anatomical abnormalities and endemic factors have been found to be responsible in the etiology of the disease. Studies evaluating the causative factors in pediatric series including both sexes did show that metabolic conditions may be demonstrated in up to 50% of cases. After the metabolic abnormalities, urinary tract anomalies should be considered. In fact a variety of anatomic anomalies have been found in about 30% of children with urolithiasis, (1, 2, 6). Hypercalciuria is the most common metabolic abnormality in this specific population, accounting for up to 34% of all pediatric stones with 8% showing hyperuricosuria. On the other hand infection-related stones have a general incidence of 2% to 24% and, as quoted above, as many as 75% of stones in European children have been found to be associated with urinary tract infections. Being usually detected before the age of 6 years infection related stones are more common in boys and more than 50% of all children with such stones have associated genitourinary anomalies (5, 6). Cystinuria accounts for 2% to 7% of children with metabolic urolithiasis in industrialized countries. Last, but not least, calcium oxalate calculi or nephrocalcinosis are commonly diagnosed in children suffering from primary hyperoxaluria (type 1 and 2). Massive hyperoxaluria in such cases may cause progressive renal functional deterioration in some cases due to the deposition of calcium oxalate in the renal interstitium without any stone formation. Approximately 50% of children with primary hyperoxaluria have symptoms by age of 5 years. Oxalosis is more common in childern with type 1 primary hyperoxaluria (PH1) and approximately 1% of chronic renal failure in childhood originates from this type of hyperoxaluria. Children with type 2 primary hyperoxaluria (PH2) however usually do not present until their second or third decade of life (5, 6). The natural history of pediatric stone disease is not as well defined as it is in adulthood. The pathology is associated with considerable morbidity, with recurrence rates of 6.5-44%. Without follow-up and medical intervention, stone recurrence rates have been reported to be as high as 50% within 5 or 6 years. In children,stone recurrence rates range widely from 3.6% to 67 % and appears to be highest in children with metabolic abnormalities. The rate of stone recurrence in our previous report was 4% during a 5-year follow-up period (1-3). Given the high risk of recurrent stone formation, it should be kept in mind that all children suffering from stone disease should be evaluated in detail to determine the possible underlying causes and to help planning the proper management strategies. Through these efforts future stone formation and/or growth may be controlled
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Archivio Italiano di Urologia e Andrologia 2008; 80, 2
in an attempt to limit the morbidity of the disease in this specific population. The principles of stone management in children should include complete stone clearance, prevention of stone recurrence and regrowth, preservation of renal function, control of UTI, correction of anatomic abnormalities as well as the underlying metabolic disorders. Long-term post-operative follow-up is needed, especially after using recently developed and established technical innovations for the management of urinary stones in children. Regarding the medical as well as the surgical management of stone forming children, clinicians have to choose the appropriate treatment on the basis of the results of metabolic evaluation and stone analysis as well as the frequency of stone events.
MEDICAL
MANAGEMENT
Because of the multifactorial etiology of stones in children ( metabolic abnormalities, anatomic anomalies and/or recurrent UTI ) treatment can only be successful onlong-term follow-up only if combined with additional appropriate prophylactic measures. Despite continous efforts to find an efficacous treatment regimen in the prevention of recurrent formation of calcium stones, no medication has proven itself in terms of adequate prevention of the recurrences. However, similar to the adult population, these cases can be treated conservatively by an increased fluid intake with or without dietary manipulations or by administering pharmacological agents (1, 6). As a pharmacological agent, potassium citrate has been used with acceptable success rates in adult population, but this medication has not been fully established in children and it is really very troublesome to keep the child under a certain preventive measure for a long period of time. Children at older ages with cooperative parents are the cases which may demonstrate acceptable successful outcome following these measures (7). In summary, it is clear that, in addition to stone removal procedures, treatment of pediatric urolithiasis requires a thorough metabolic and environmental evaluation on an individual basis. Obstructive pathologies along with the established metabolic abnormalities should be treated on time. Children with a positive family anamnesis are the candidates for a close and careful follow-up with respect to stone recurrence. Urine volume should be increased encouraging adequate fluid intake evenly distributed to the whole day and medical therapeutic agents which increase urine citrate levels may be considered in the medical management of hypocitraturia in children.
SURGICAL
MANAGEMENT
Technological advancements, miniaturization of endourologic instruments along with the increasing experience of the surgeons have significantly altered the surgical management of pediatric stone disease. Currently, the majority of stones in children can be managed either with shock-wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL) or ureterorenoscopy (URS), or a combination of these modalities where open surgery is currently needed in a limited per cent of all cases (3-5, 8-
Medical aspect and minimal invasive treatment of urinary stones in children
10). In order to select the most appropriate treatment modality, one should consider the location, composition, and size of the stone(s), the anatomy of the collecting system, and the presence of obstruction along with the presence of infection of the urinary tract. Different approaches in the minimal invasive management of stones in pediatric population are here discussed.
EXTRACORPOREAL
SHOCK WAVE LITHOTRIPSY
(SWL)
Following its clinical introduction in early 1980’s, SWL has first proven its efficacy and safety in adults. With the increasing experience in this field, this modality has become the preferred treatment alternative in the minimal invasive management of the stones in children in consideration of its minimal invasive nature and of satisfactory stone-free rates. Despite the increasing application of percutaneous nephrolithotomy, development of smaller-diameter flexible ureteroscopes and ancillary instruments, SWL still remains as the least invasive, simple, safe and effective treatment alternative in pediatric population(9, 11-13). However, it should be kept in mind that the higher incidence of metabolic and anatomic abnormalities ( when compared with adult population) is a major concern in stone formation and may influence the choice of the management option and the ultimate effectiveness of treatment. It should render the children stonefree over a short period of time with reasonable number of SW and limited auxiliary procedures. Following the management, residual fragments after SWL should be followed closely with regular visits in consideration of the fact that it has been clearly shown that they may predispose to recurrent urolithiasis, especially given the higher incidence of metabolic and anatomic abnormalities in this specific age group (14-16). Renal pelvic stones or calyceal stones up to 2 cm. in diameter are ideal indications for SWL whereas success rates tend to decrease as the size of the stone(s) increase.Currently, depending on the size,number, location and the chemical composition of the stones more than 90% of all urinary stones in adults and nearly 80 % of all stones in children are being treated successfully with SWL. Following SWL, stone free rates ranging from 57 to 97% on short-term and 57 to 92% on long-term follow-up have been reported in the literature (8, 11, 12). Stones located in calyces as well as in abnormal kidneys and larger stones have been found to be harder to be disintegrated and also cleared. Re-treatment rates range from 13.9 to 53.9% in different series (13-15); ancillary procedures and/or additional interventions range from 7 to 33%. (16, 17). Following the management of relatively larger stones the likelihood of urinary obstruction is higher and children should be followed closely for the prolonged risk of urinary obstruction. Although general anesthesia is generally performed, especially with first generation lithotriptors ( due to the more energy to a larger focal zone); a sedation is needed to relieve the possible discomfort in younger children during SWL (18-21). The published data in the literature has well demonstrated that SWL is highly effective in the disintegration of renal calculi and the reported success rates range from
60 to 100%. In addition to the successful treatment, it has also been shown that children pass the disintegrated stone fragments in a quick and easy fashion. However depending on the size as well as the number of stones along with the presence of certain risk factors such as metabolic derangements and anatomical abnormalities, stone free rate after SWL decreases and the need for ancillary procedures increases (22-24). On the other hand again,despite its effective and minimal invasive profile, theoretical concerns have been raised regarding safety and the bioeffects of SWL on the immature, growing kidney and surrounding organs, but no irreversible serious side effect of high energy shock wave could also be demonstrated during short as well as long-term follow-up. Although renal functional deterioration and new-onset of hypertension have been discussed seriously, long-term evaluation of the treated children in various series did not show any significant morphologic as well as functional changes. Finally, taking the potential risk of deterioration of renal function into account ( although it is transient ), restriction of the number of SW and the energy used in each session could be helpful in protecting the kidneys (25-30). About the management of ureteral stones, as much as the 98 % of the stones with a diameter of < 5 mm are likely to pass spontaneously, while intervention could be required in large sized as well as impacted stones. Although SWL is the first treatment modality in the majority of stones located in upper urinary tract in children, the success rates decrease as the stone passes to the more distal parts of the ureter (9, 17, 18). Despite the definitive removal of ureteral stones by endoscopic procedures, acceptable success rates by SWL had made it a favourable first-line treatment modality also for the majority of proximal ureteral stones. Currently, larger stones (> 1 cm), impacted stones, calcium oxalate monohydrate and cystine stones, stones in children with unfavourable anatomy and in whom localization difficulties exist are the ones in which the ESWL may likely to be unsuccessful. When compared with adults, children pass stone fragments well, and the need for a stent for stone passage is rare. If the stone burden is large enough that requires the placement of a ureteral stent, alternative procedures such as percutaneous nephrolithotomy should be discussed. Although indwelling ureteral stents are seldom required after ESWL for upper tract stones, ureteral prestenting appeared to have decreased the stone free rate of initial treatment and re-treatment by 12 to 14% respectively (19-21). In summary, the experience that have been obtained so far has clearly shown that. when combined with judicious use of the auxiliary procedures, SWL is a safe and highly effective management alternative in the management of pediatric stones.
URETEROSCOPY Unlike renal stones, the management of children with ureteral calculi has usually been a challenge for the urologist. Traditionally, the standard treatment for ureteral stones in children was open surgical removal. Over the past 10 years however, with the advances in endoscopic Archivio Italiano di Urologia e Andrologia 2008; 80, 2
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technology, the surgical management of ureteral calculi in children has considerably changed and the principles of ureteral stone treatment is now similiar to that in adults where open surgery is needed rarely in such cases (31-33). Although these newer modalities have been rapidly accepted for the management of ureteral stones in adults, their application to pediatric patients has been gradual. This is because pediatric urolithiasis is relatively uncommon, and there are concerns about the longterm safety of these methods in children. Moreover, until recently, appropriate size ureteroscopes have not been available. Today,ureteroscopy may be applied for diagnostic and/or therapeutic purposes and with the clinical introduction of fine, smaller calibre instruments this modality has become the treatment of choice in middle and distal ureteric stones in children. Reported data in the literature again has clearly shown that ureteroscopic lithotripsy is an acceptable treatment modality with successful outcomes in terms of the therapeutic efficacy and complication rates which are similar if not better than those reported in the adult literature (34-36). As mentioned earlier, ureteroscopic removal of ureteral calculi in prepuberal children has become more common with the advent of smaller instruments and that of laser lithotripsy. The early concern with larger calibre instruments included risk of damage to ureteral mucosa, ureteral meatus and the urethra in male children. Following the use of relatively larger (11.5 and 8.5 F) ureteroscopes in the beginning,with the availability of 4.5 and 6.0 Fr semirigid ureteroscopes and a 6.9 Fr flexible ureterorenoscope and holmium:YAG laser energy source, instrument-related complications are now uncommon (37-41). Previous studies of pediatric ureteroscopy have shown satisfactory results, particularly for mid and lower ureteral stones with the reported success rate in different pediatric series ranging from 87.5% to 100%. However, the results obtained in upper ureteral stones are less encouraging, with a success rate of 78 %, which is lower than that achieved in lower parts of the ureter. Removal of upper ureteral stones requires a high level of endoscopic skill, and the risk of trauma to the ureter may be great, particularly when the stone is impacted.Regarding the comparison with the efficacy of SWL, stone-free rates in patients with calculi of > 10 mm were 93% with ureteroscopy and 50% with SWL, while for calculi
