Carmin Kalorin

Pediatric Urinary Stone Disease—Does Age Matter?

PURPOSE It has been proposed that younger children are less likely to pass renal calculi spontaneously, and that children younger than 10 years are more likely to have an identifiable metabolic abnormality and subsequently a higher risk of recurrence. We report our clinical outcomes in children with urinary calculi, specifically examining these factors. MATERIALS AND METHODS We performed a retrospective review of all pediatric patients diagnosed with renal or ureteral calculi at our institution between 2000 and 2007. Of 150 patients evaluated and treated during this period 80 (86 stones) had sufficient followup data to be included. Patients were divided into 2 groups according to age, namely 10 years or younger and older than 10 years. There were 39 patients in the younger group and 41 patients in the older group. Stone size and location, successful passage or intervention, recurrence and 24-hour urine metabolic study results were recorded. RESULTS Of the younger cohort stones were ureteral in 43% and renal in 57%. The opposite trend was seen in older patients, with 69% having ureteral and 31% having renal stones (p = 0.02). Mean stone size (greatest dimension) did not differ significantly between the older and younger groups (6.9 mm vs 5.5 mm, p = 0.17). Overall stone passage rate was 34% for younger and 29% for older patients (p = 0.65). No significant mean size differences in passed stones existed between the groups (3.2 mm vs 2.5 mm, p = 0.31). Overall younger vs older ureteral stone passage rate was 37% vs 41% (p = 0.58), and for renal stones it was 32% vs 0%. Stones recurred in 7 younger and 6 older patients. CONCLUSIONS Younger children were more likely to present with renal stones, while older children had more ureteral stones. Overall children 10 years old or younger are as likely to pass stones as older children. Renal stones are more likely to be successfully managed expectantly in younger children. Metabolic abnormalities and stone recurrences are observed at similar rates between younger and older children.

Protein oxidation as a novel biomarker of bladder decompensation

To measure the degree to which partial bladder outlet obstruction (PBOO) results in oxidative bladder damage, which subcellular components of the bladder are affected and whether these changes correlate with bladder function.

Tonsillectomy Does Not Improve Bedwetting: Results of a Prospective Controlled Trial

PURPOSE Sleep disordered breathing caused by tonsillar hypertrophy has been implicated as a cause of primary and secondary nocturnal enuresis in children. We prospectively studied the preoperative and postoperative rates of nocturnal and daytime incontinence in a group of children with tonsillar hypertrophy undergoing tonsillectomy compared to a matched control group undergoing surgery unrelated to the airway or urinary tract. MATERIALS AND METHODS A total of 326 toilet trained children 3 to 15 years old were included, with 257 in the tonsillectomy group and 69 in the control group. Severity of tonsillar hypertrophy was graded preoperatively on a scale of 1 to 4. A voiding questionnaire regarding number of bedwetting and daytime incontinence episodes per week, voids per day, bowel movements per week, secondary or primary enuresis and family history was completed by parents preoperatively, and at 3 and 6 months postoperatively. RESULTS Preoperatively the respective rates of nocturnal enuresis and daytime incontinence were 33% and 17% in the tonsillectomy group (p=0.89), and 35% and 14% in the control group (p=0.3). The respective cure rates for bedwetting at 3 and 6 months postoperatively were 40% and 50% in the tonsillectomy group (p=0.60), and 35% and 48% in the control group (p=0.61). Similarly no difference was seen in improvement or cure of daytime incontinence at 3 and 6 months postoperatively. CONCLUSIONS We found no association between tonsillar hypertrophy and urinary incontinence before or after tonsillectomy.

Splenda® Improves Tolerance of Oral Potassium Citrate Supplementation for Prevention of Stone Formation: Results of a Randomized Double-Blind Trial

BACKGROUND AND PURPOSE Oral citrate supplements have been shown to decrease kidney stone recurrence rates in both laboratory and clinical studies. The taste of the citrate supplements, however, is poor, and long-term compliance is low. Our objective was to determine if Splenda(®) added to potassium citrate (KCit) improves palatability without changing 24-hour urine parameters. PATIENTS AND METHODS 12 subjects were randomly assigned to receive either KCit alone for 3 days or KCit + Splenda in a double-blind trial. The 24-hour urine collections were performed before and after 3 days of therapy. After 1 week, the two groups switched treatments. After each treatment, a visual analog taste scale was completed to gauge the taste and palatability. The 24-hour urine parameters of kidney stone risk factors were compared between groups. The primary end points were to determine whether Splenda improved palatability of citrate supplementation and whether it altered 24-hour urine parameters. RESULTS Taste was judged to be 2.5 ± 0.9 points better in the Splenda + KCit compared with KCit alone (P=0.02). The 24-hour Cit, K, and pH were significantly higher in the KCit and KCit + Splenda groups compared with baseline, but not significantly different from each other. CONCLUSION Splenda significantly improves the palatability of KCit therapy and does not alter the beneficial effects of KCit on 24-hour urine Cit, K, or pH. The addition of Splenda altered the average taste score from one that might prohibit compliance to one that would not.

Complete eversion of the urinary bladder: presentation, review, and algorithm for management.

BACKGROUND: Complete eversion of the urinary bladder is a rare problem that presents a serious management challenge. Currently no standard treatment recommendations exist for management. We describe our experience with bladder eversion and present an algorithm for treatment. CASE: An elderly, multiparous woman presented with complete bladder eversion after partial colpocleisis. Her bladder was reduced by a combined suprapubic and perineal approach with cystopexy to the anterior abdominal wall. CONCLUSION: Multiparous postmenopausal women appear to be at highest risk for complete bladder eversion. External transurethral reduction is sometimes successful, but most cases require laparotomy.

Phenytoin metabolite renal calculus: an index case.

INTRODUCTION Drugs and their metabolites are known factors in 1% to 2% of all kidney stones. Certain antiepileptic drugs are known to cause stone formation. Phenytoin is used as a first line antiepileptic therapy for many seizure disorders. We present what we believe to be the first report of a phenytoin metabolite urinary stone. METHODS A 79-year-old woman with a fever and seizure disorder was found to have a right pelvic kidney with hydronephrosis and multiple large calcifications. She had been taking the antiepileptic medication phenytoin for the past 10 years. Average total serum phenytoin level from the year prior was in the normal range. Free phenytoin levels were not routinely monitored, but the one value available was elevated at 5.1 ng/dL. The patient underwent a percutaneous nephrolitomy, ultimately expiring from medical complications after the procedure. Final stone analysis revealed a composition of 35% phenytoin metabolite (5-(para-hydroxyphenyl)-5-phenylhydantoin) and 65% proteinaceous material. An extensive review of literature including PubMed, MedLine, and various internet search engines was performed, searching for any prior reports of urinary calculi formed from phenytoin or its metabolite. RESULTS No previous reports of phenytoin or phenytoin metabolite urinary stones were found in the medical literature. Phenytoin has many known ill effects on the genitourinary system including acute interstitial nephritis, nephrotic syndrome, acute renal failure, and priapism. Now we can add urinary lithiasis to the list of its potential adverse effects. This article represents the first report of a phenytoin metabolite urinary stone. CONCLUSION A metabolite of the commonly used antiepileptic medication phenytoin can cause clinically relevant urolithiasis leading to significant morbidity and even mortality. Clinicians should have an increased level of suspicion for metabolite stone formation in symptomatic patients taking antiepileptic medications. Further studies on phenytoin metabolism and its potential for inducing urinary lithiasis should be performed.

ANONYMOUS SURVEY TO DETERMINE THE MANAGEMENT OF HEMATURIA BY VA PRIMARY CARE PROVIDERS

INTRODUCTION AND OBJECTIVES: The prompt workup of hematuria can lead to early diagnosis of significant serious conditions of the GU tract. The benefits of early detection of hematuria include not only the early discovery of significant benign and malignant conditions, but also reduced mortality from bladder cancer in screened populations. However, there is often a delay in the evaluation of patients with hematuria. METHODS: An anonymous 9 question online survey was sent to primary care providers within the VA system. We evaluated hematuria practice patterns amongst primary care physicians, nurse practitioners, and physician assistants. We attempted to determine the thresholds for “significant hematuria”, further diagnostic testing and specialist referral. RESULTS: There were 648 responses from physicians (64%), nurse practitioners (30%), and physician assistants (7%). Routine yearly urinalysis in all asymptomatic patients was performed by 343 (53%) providers. 12% never checked a routine yearly urinalysis and 34% checked only in patients with specific conditions such as diabetics and smokers. The most commonly accepted definition of hematuria was >5 RBC/HPF (61%); 18% (117) considered any RBC/HPF as hematuria, 9% (55) considered it a positive dipstick, and 4% (27) considered only gross hematuria to be significant. As the “initial step” for microscopic hematuria, most providers would either repeat the urinalysis or send the urine for culture (67% and 17%, respectively). The most commonly utilized “next steps” for microscopic hematuria were imaging studies (36%), urine culture (19%), urine cytology (17%), and referral to urology (14%). For gross hematuria the most common “initial steps” were imaging studies (45%), urine culture (20%), and urology referral (12%). The most frequent “next steps” for gross hematuria were referral to a urologist (59%) and imaging studies (23%). The initial imaging studies of choice were renal ultrasound (35%), CT scan with and without I.V. contrast (20%), and intravenous pyelogram (18%). CONCLUSIONS: There is a wide range in the definition and evaluation of both microscopic and gross hematuria in the primary care setting. The lack of standardized definitions and protocols for screening and workup may in some cases delay the diagnosis of significant GU pathology resulting in adverse outcomes. The data provides a platform on which to develop educational materials for primary care providers.