Burak Çıtamak

A new nomogram for prediction of outcome of pediatric shock-wave lithotripsy

INTRODUCTION Despite the fact that shock-wave lithotripsy (SWL) remains a very good treatment option for smaller stones, it is being challenged by endourologic treatment modalities, which offer similar or even higher success rates in a shorter time, with minimal morbidity and invasiveness. The present study aimed to bring a new and practical insight in order to predict the outcomes of pediatric SWL and to provide objective information about pediatric SWL outcomes. OBJECTIVE To design a nomogram for predicting the outcomes of pediatric shock-wave lithotripsy. STUDY DESIGN The study was conducted with a retrospective design and included 402 renal units who underwent SWL between January 2009 and August 2013. Patients with known cystine stone disease and cystinuria, with internal or external urinary diversion, were excluded. Analysis was performed on 383 renal units. Postoperative imaging was performed by plain abdominal graphy and ultrasonography with 3-month intervals. Patients who were completely free of stones were considered to be a success and statistical analysis was done regardingly Multivariate analysis was conducted by logistic regression analysis and a nomogram was developed. RESULTS The male/female distribution was 216/167, with a mean age of 48 ± 40 months and a mean stone size of 9 ± 3.5 mm. The overall stone-free rate was 70% (270/383) and efficacy quotient was 0.57. Mean follow-up was 11 ± 11 months (3-54 months). The number of shock waves and amplitude of energy were higher in failed cases. Multivariate analysis showed that gender, stone size, number of stones, age, location of the stone, and history of previous intervention were found to be the independent prognostic factors for assessing the stone clearance rates. A nomogram was developed using these parameters. In this nomogram, the points achieved from each parameter are summed and total points correspond to the risk of failure in percent. DISCUSSION A previous nomogram study by Onal et al. showed that younger age (<5 years), smaller stone burden (<1 cm), absence of previous stone treatment history, single stone, pelvis or upper ureter location (in girls) were favorable prognostic factors for successful outcome. As being the first pediatric study, it had some shortcomings. The study included 381 patients within a time period of 16 years. The present study included a similar number of cases within a 4-year period, which may reflect more homogeneity of data collection. Another issue is concern about the practical use of that nomogram. It constitutes two pages, which is a limiting factor for daily use. From a statistical point of view, they performed 200 bootstrapings with the aim of internal validation, which is less than the ideal number of 1000 bootstrapings, which was performed in the present nomogram. The presented nomogram is more practical, in that the pre-operative factors can be placed on the nomogram, the points can be added up and the parents can be given the approximate percentage of predicted stone-free rate after a single session. The expected treatment modality shown to the parents and patients ought to be the least minimally invasive, have the highest success rate, the least complication rate, and show the efficacy in one procedure at a time within the shortest period. However, SWL does not completely meet these criteria. The results gained from the present critical analysis of SWL in children, which was based on a strict definition of success, showed that outcome after a single session is not that good. Therefore, defining the patients who will benefit the most became one of the main issues. A more objective and skeptical look at SWL data enabled a nomogram to be developed that brings a new and practical insight in order to predict the outcomes of pediatric SWL. CONCLUSION In most of the pediatric stone cases, SWL is the first-line treatment option. However, it is wise to define the patients who will benefit the most. Therefore, nomograms can be useful for this purpose. The nomogram in the present study revealed that gender, stone size, number of stones, age, location of the stone, and history of previous intervention were found to be the independent prognostic factors for assessing the stone clearance rates. This nomogram can practically be used to inform the parents, and for proper patient selection for SWL.

Factors affecting the success of endoscopic treatment of vesicoureteral reflux and comparison of two dextranomer based bulking agents: Does bulking substance matter?

INTRODUCTION Among the interventional treatment modalities for vesicoureteral reflux (VUR), endoscopic subureteric injection seems to be the least invasive method with acceptable outcomes when applied in appropriate patients. OBJECTIVE The aim of the presented study is to investigate the parameters which may affect the outcomes of endoscopic injection and to compare the efficacy of two different bulking agents both composed of dextranomer-hyaluronic acid copolymer. STUDY DESIGN The data of patients who underwent endoscopic VUR treatment between 2003 and 2012 were retrospectively reviewed. Patients with history of previous open antireflux surgery, more than one failed endoscopic treatment for reflux, VUR caused by posterior urethral valve, duplex system and overt spinal dysraphism were excluded. Surgical technique was the classical STING method. One of the two dextranomer-hyaluronic acid copolymer agents was used (Deflux in 109 and Dexell in 131 patients). Both agents were composed of similar amounts of hyaluronic acid gel (15 mg in Deflux versus 17 mg in Dexell) but different sized dextranomer microspheres (80-250 μm in Deflux and 80-120 μm in Dexell). During the follow-up, ultrasonography was performed with 3-month interval, antibiotic prophylaxis was continued until the control voiding cystourethrography (VCUG) was taken. Patient based success was defined as the disappearance of reflux on control VCUG performed 3-6 months after the operation. RESULTS Data were available for 240 patients. Mean age and mean postoperative follow-up were 78 ± 41 months and 19 ± 18 months. The overall success rate was 73.2%. Gender, laterality, grade of VUR, presence of voiding dysfunction, renal scar and preoperative breakthrough infection (BTI) were not found to affect the outcome, whereas age younger than 54 months and previous history of failed endoscopic injection were found to negatively affect the outcome both in univariate and multivariate analysis. The postoperative UTI (5 febrile and 43 nonfebrile) rate was 20%. Both univariate and multivariate analysis showed that postoperative UTI was more common in patients with persisting reflux, with preoperative breakthrough infections and in girls. Patient characteristics, treatment outcome and postoperative UTI rate were similar regarding the used bulking agent. No ureteral obstruction was experienced within the follow-up period. DISCUSSION Our success rate for second injection is about 60%, which is significantly lower than for the patients who underwent first injection. We could not find any affecting factor for this difference. Contrary to the literature, our success rates were similar in different reflux grades. We can explain this finding that we value the intraoperative orifice configuration more than the grade which can be accepted as a patient selection bias. The lower success rate in children younger than 54 months can be explained by unstabilized bladder dynamics and higher voiding pressures in this age group, who are still in the toilet-training phase. Despite successful endoscopic treatment, UTI might occur. Postoperative UTI was more common in patients with persisting reflux, preoperative BTI and girls. The similar success rates of both bulking agents proved that dextranomer size does not affect the clinical outcome. Limitations of our study can be counted as follows: 1. the data do not include the number of patients in whom conversion to open surgery was decided intraoperatively because of the unfavorable orifice configuration, 2. our data do not include the injected volume records. CONCLUSION Endoscopic treatment of VUR has satisfying outcomes in properly selected cases. Younger age (<54 months) and previous history of failed injection history were found to be related to unfavorable results. Postoperative UTI occurs more frequently in patients with persisting reflux, preoperative breakthrough infection history and girls. The choice of one of the dextranomer-based substances does not affect the surgical outcome and postoperative UTI development.

Percutaneous Nephrolithotomy in Solitary Kidneys: 17 Years of Experience

OBJECTIVE To compare the demographics and the results of patients who underwent percutaneous nephrolithotomy (PCNL) with solitary and bilateral kidneys. MATERIALS AND METHODS Between January 1998 and August 2014, 2268 patients underwent PCNL at Hacettepe University Hospital. We retrospectively analyzed the data of 91 patients with a solitary kidney and 2177 patients with bilateral kidneys treated by PCNL. We compared the success and complication rates between patients with solitary and bilateral kidneys. Additionally, we determined the factors affecting success and serious complications for patients with a solitary kidney. All statistical analyses were performed using SPSS 17.0 for Windows. The threshold for statistical significance was set at P <.05. RESULTS The median age was 48 years and 61 patients (67%) were male. The median stone burden was 400 mm2. The stones were located in the renal pelvis in 27 patients (30%), in calices in 50 patients (55%), and in the staghorn in 14 patients (15%). A total of 57 patients (62%) underwent a left-side surgery. The comparison between solitary and nonsolitary patients showed that stone free, transfusion, and postoperative urinary tissue infection rates were similar. Complication rates, postoperative JJ stent requirements, and length of hospital stay were statistically higher in patients with a solitary kidney. The presence of a staghorn stone, the stone number (single-multiple), and male gender were found to have a negative impact on success. The existence of upper-pole stones was found to be the only factor that led to serious complications (Clavien 3-4). CONCLUSION PCNL is an effective but more complicated option in patients with a solitary kidney, with stone-free rates similar to patients with bilateral kidneys.

Invasive Squamous Carcinoma and Adenocarcinoma of an Unreconstructed Exstrophic Bladder with HPV Infection.

Bladder exstrophy is a complex abnormality and is traditionally treated within the early years of life. It is associated with an increased risk of bladder cancer, with 95% of the arising tumors being adenocarcinomas and 3 to 5% being squamous cell carcinomas. HPV infections are also associated with an increased risk of bladder cancer. This case represents a patient with bladder exstrophy that gave rise to coinciding squamous cell carcinoma and adenocarcinoma. Final pathology results showed an infection with HPV. We presented the management of the case and discussed the diagnosis and treatment methods for this patient.

Surgical Outcome of Patients With Vesicoureteral Reflux from a Single Institution in Reference to the Espu Guidelines: A Retrospective Analysis

INTRODUCTION Vesicoureteral reflux (VUR) is an anatomic or functional disorder, and it is a condition associated with renal scarring, hypertension, and end-stage renal disease. Renal damage can be prevented by appropriate medical and surgical intervention for selected patients. OBJECTIVES The objective of this study was to retrospectively analyze the surgically treated patient group of this study in reference to the risk analysis criteria used in European Association of Urology (EAU), European Society for Paediatric Urology (ESPU) guidelines to see the outcome of the study management protocol within the last 15 years in respect to this risk analysis. STUDY DESIGN A total of 686 patients who were operated upon in a single institution for VUR between 1997 and 2016 were retrospectively analyzed. According to the criteria in EAU/ESPU guidelines, the patients were classified into three groups: low, medium, and high risk. Risk factors were compared between the groups. RESULTS The patient numbers for low, medium, and high risk were 92 (13.4%), 485 (70.7%), and 109 (15.9%), respectively. In the high-risk group, surgeons tended to do more ureteroneocystostomy (UNC) (82.6%), whereas in the low-risk group, surgeons tended to do more subureteric injection (STING) (76.1%). The success rates for STING and UNC were found to be 75% and 93%, respectively. Although there was a difference in success rates among patients treated with STING or UNC, this difference was not statistically significant in success rates regarding risk groups for patients treated with STING or UNC. DISCUSSION The most recent guideline was that which was published by the EAU/ESPU organization in 2012. This guideline is established based on the risk analysis. The analysis revealed that patients in the low-risk group tended to undergo endoscopic surgery treatment method, whereas patients in the high-risk group tended to undergo open surgery. Therefore, the study management over the last 10 years has been mainly in line with the current recommendations. CONCLUSION The analysis shows that when the patients are classified according to the EAU/ESPU risk classification, surgeons tended to perform more endoscopic and more open surgery for the low- and high-risk groups, respectively. Although each surgical modality had similar success rates in each group, open surgical results were overall much higher than those of endoscopic surgery in each group. This was a specifically important finding in high-risk group where the endoscopically treated group of patients was small in number, and the need for a definitive correction is essential in this group because of increased risk of renal injury.

Semi-Rigid Ureteroscopy Should Not Be the First Option for Proximal Ureteral Stones in Children

PURPOSE To investigate the factors that predict the success and complication rates of semi-rigid ureteroscopy (URS) in pediatric population. MATERIALS AND METHODS This is a retrospective analysis of the database including 182 patients who underwent URS between 2001 and 2016. The possible factors that might affect the outcome were age, gender, stone laterality, largest stone size, number of stones, stone location, orifice dilatation status, and caliber of ureteroscope. RESULTS The mean age was 68.1 (7-204) months, and male-to-female ratio was 94:88. Operative side was left for 97, right for 82, and bilateral for 3 patients. One hundred and forty-four patients had a single stone, and 38 patients had multiple stones. The median largest stone size was 7 (2-20) mm. Postoperative ureteral stenting was performed in 150 (86.2%) patients. The overall success rate was 84.6%, while 81.6% and 85.4% in 8F URS and 4.5F URS groups, respectively (p = 0.560). Stone-free rate was higher among patients who were older than 36 months, distal ureteral stones and single stones (p = 0.012, 0.002, and 0.009, respectively). Complication rate was higher for proximally located stones (p = 0.029). The mean follow-up was 23.9 ± 32.5 months. CONCLUSION URS is a safe procedure with acceptable success rates in the pediatric population. Younger age, multiple stones, and proximal location are the predisposing factors for failure, whereas proximal location was the only factor for complication occurrence. Therefore, semi-rigid ureteroscopy should not be the first choice in the treatment of proximal ureteral stones, and alternative methods should be preferred, if available.

Positioning the Instillation of Contrast Cystography: Does It Provide Any Clinical Benefit?

OBJECTIVE To outline positioning the instillation of contrast cystography (PICC)s benefits in clinical practice. MATERIALS AND METHODS A total of 198 patients underwent PICC with the following indications: patients with positive preoperative conventional voiding cystourethrography (VCUG) for a single ureteric side, patients with urinary tract infection (UTI), and negative VCUG for both ureteric sides. Patients with positive VCUG served as the control group. Preoperative, intraoperative, and postoperative features of all patients were compared. RESULTS The reflux rate for the contralateral vesicoureteric reflux (VUR) investigation group was 39.1%. Only the cystoscopic view of the anatomically deficient ureteric orifice was found to be a significant predictor of contralateral reflux (P = .002). For patients who presented with UTI, the reflux rate was 58.3%. Resolution of infection was assessed for patients who presented with UTI, and 54.1% of these patients had a complete response in the follow-up period. When the patients were classified as PICC positive and negative, infection-free rates were 58.3% and 48%, respectively (P = .296). CONCLUSION PICC is an effective diagnostic method for revealing occult reflux. However, the clinical significance of this finding is vague. In patients with UTI, PICC was useful for diagnosing occult VUR and clearing the symptoms in more than half of the patients. Further, the symptom-free state in the follow up period was slightly higher but not more significant than it was in those with no VUR diagnosed.