Nihat Satar

PERCUTANEOUS NEPHROLITHOTOMY IN THE MANAGEMENT OF PEDIATRIC RENAL CALCULI

BACKGROUND AND PURPOSESnIn the era of extracorporeal shockwave lithotripsy (SWL), there are still some patients who will require percutaneous nephrolithotomy (PCNL). Our experience with this procedure is reviewed and discussed.nnnPATIENTS AND METHODSnFifty five patients with a mean age of 7.9 years (10 months-14 years) underwent 67 PCNL procedures on 62 renal units between September 1997 and April 2001. Of the patients, 13 had previous open renal surgery, 4 had a solitary kidney, 4 were SWL failures, 2 had osteogenesis imperfecta, one had anuria secondary to bilateral calculi, 2 had poorly functioning kidneys, and 1 had cystinuria (complete staghorn calculus). One disabled patient with neurologic disorders who had multiple stones underwent PCNL in order to decrease the stone burden and to improve the kidney function. Operations were performed under the guidance of monoplane fluoroscopy. Pneumatic or ultrasonic lithotripsy and forceps extraction were used with a rigid nephroscope or ureteroscope (as an alternative instrument in small-caliber tracts).nnnRESULTSnExcluding the patient with neurologic disorders, 53 of the renal units (86.9%) were stone free at the time of discharge, and the success rate was 96.7%, with six patients having insignificant residual fragments after the procedure. In one patient, open surgery was required, and the other patient was sent for SWL treatment. There was no contiguous organ injury, but in 16 procedures (23.9%), intraoperative hemorrhage was seen, and blood transfusions were required.nnnCONCLUSIONnPediatric urolithiasis is usually a result of metabolic abnormalities and urinary tract infection, and there is always a risk of recurrence that may necessitate multiple additional intervention. Therefore, PCNL must be considered in selected cases by urologists who are experienced in adult percutaneous procedures.

Factors Affecting Complication Rates of Ureteroscopic Lithotripsy in Children: Results of Multi-Institutional Retrospective Analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society

PURPOSEnWe evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi.nnnMATERIALS AND METHODSnWe retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates.nnnRESULTSnA total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate.nnnCONCLUSIONSnSemirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Pediatric transumbilical laparoendoscopic single-site nephroureterectomy: initial report.

OBJECTIVEnTo present a case of laparoendoscopic single-site surgery (LESS) nephroureterectomy (NUx), a type of embroyonic natural orifice translumenal endoscopic surgery, which is one of the recent innovations in the era of laparoscopy, in a child.nnnMETHODSnA 10-year-old girl underwent left nephroureterectomy by LESS due to end-stage reflux nephropathy on December 25, 2008. The surgery is performed transperitoneally, through a 2-cm semicircular incision in the left inner curve of the umbilicus using three 5-mm trocars. NUx with LESS was performed duplicating standard laparoscopic steps with the help of flexible and straight laparoscopic instruments.nnnRESULTSnOperation time was 140 minutes and the blood loss was minimal. There was no intraoperative or postoperative complication. The patient was discharged at the 24th postoperative hour. The postoperative cosmetic result was excellent as the incision scar was hidden inside the belly button.nnnCONCLUSIONSnNUx with LESS is a feasible technique with the advantages of less pain, shortened convalescence, improved cosmesis, and absence of wound complications in children. However, clear indications of LESS in children remain to be clarified.

Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society

PURPOSEnWe assessed factors affecting complication rates of percutaneous nephrolithotomy in children.nnnMATERIALS AND METHODSnWe retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates.nnnRESULTSnA total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis.nnnCONCLUSIONSnPercutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

The effects of ureteral obstruction on Cajal-like cells in rats.

OBJECTIVEnTo determine the changes in number and morphology of interstitial cells of Cajal (ICC)-like cells (ICC-LC) at the ureteropelvic junction (UPJ) of rats after experimental distal ureteral obstruction.nnnMATERIALS AND METHODSnOf a total of 109 rats, 20 served as controls (C), 20 underwent sham-operations (SH) and 69 were in the study (S) groups. The UPJs were extracted initially in the C and SH groups, and 7, 14, 30, 60 and 90 days after ligation of the distal ureter in the study groups (S1, S2, S3, S4 and S5, respectively). The sections stained by c-kit anticore were studied under a light microscope.nnnRESULTSnThe mean number of ICC-LC was 4.55+/-2.21 in C, 5.15+/-3.51 in SH, 7.40+/-6.88 in S1, 21.16+/-19.03 in S2, 12.63+/-8.16 in S3, 10.40+/-5.09 in S4, and 10.9+/-6.33 in S5. There was a statistically significant increase in ICC-LC in the study groups, except S1, compared to the C and SH groups. No significant difference was detected in Cajal cell morphology and distribution pattern between groups.nnnCONCLUSIONSnBased on the changes in number of ICC-LC at the UPJ after obstruction of the distal ureter compared with the limited data available in the literature, we suggest that ICC-LC have a close relationship with motility of the ureter.

An unusual cause of pleural effusion, urinothorax in a child with urinary stone disease.

The association of obstructive uropathy with ascites has been known since 1863 and with pleural effusion since 1954. Urinothorax is a rare complication of blunt renal trauma, ureteral instrumentation or ureteral surgery. Leakage from the urinary tract may cause urinoma, retroperitoneal collection of fluid, which can lead to urinothorax. This case report describes a child with a massive right-sided pleural effusion that was caused by same-sided renal calculi. The effusion disappeared within a few days after adequate urinary drainage had been established.

Laparoscopy in the Management of Impalpable Testicle

Abstract Purpose : In paediatric urology, one of the main applications of laparoscopy is the evaluation and treatment of impalpable testis. Herein we present our initial experience with laparoscopy in patients with impalpable testis. Material and Methods : Laparoscopy was performed under general anaesthesia on 13 patients. If the internal spermatic vessels and vas deferens made their way into the internal inguinal ring, the inguinal canal was dissected. Laparoscopic orchiopexy or orchiectomy was performed in cases with intra-abdominal testis. If the internal spermatic vessels found terminated intraperitoneally with a blind-end, the case was considered as a vanishing testis. Results : Thirteen boys, aged from 18 months to 25 years (median 9.8 years) were identified with 21 impalpable testes. 14 of the 21 impalpable testes, the vas and the vessels were through the internal ring, and the inguinal region needed dissection. Orchiopexy was performed on 12 testes and orchiectomy was performed on two atrophic testes. Four of 21 testes were intra-abdominally localized. Laparoscopic orchiopexy was performed in two testes and laparoscopic orchiectomy was performed in two testes. Two boys were diagnosed as vanishing testes; the absence was unilateral on the left side in one case and bilateral in the other. Conclusion : Diagnostic laparoscopy is a very helpful, minimally invasive technique in the diagnosis of impalpable testes especially when ultrasonography and/or computed tomography are not informative enough. In addition, orchiectomy and orchiopexy can be done as laparoscopically in the patients with intra-abdominal testes. Therefore, the laparoscopy has an important role in the diagnosis and treatment of impalpable testes.

Renal stone composition does not affect the outcome of percutaneous nephrolithotomy in children

PurposeWe sought to investigate the association between renal stone composition and percutaneous nephrolithotomy outcomes in pediatric patients and define the characterization of the stone composition.MethodsThe data of 1157 children who underwent percutaneous nephrolithotomy between 1991 and 2012 were retrieved from the multicenter database of the Turkish Pediatric Urology Society. The study population comprised 359 children (160 girls, 199 boys) with stone analyses. Patients were divided into five groups according to the stone composition [group 1: calcium oxalate; group 2: calcium phosphate; group 3: infection stones (magnesium ammonium phosphate, ammonium urate); group 4: cystine; group 5: uric acid, xanthine stones].ResultsPatient characteristics, perioperative, postoperative, and stone characteristics were compared considering the stone composition. There were no significant differences between the groups concerning age, sex, side involved, preoperative hematocrit levels, and solitary renal unit. Patients with cystine stones were more likely to have a history of stone treatment. Groups 2 and 5 had mostly solitary stones. However, group 3 had staghorn stone more often, and group 4 frequently had multiple stones. Overall stone-free rate (79.4%) was similar among the groups. Although stone composition was related to blood transfusion and prolonged operative and fluoroscopy screening times on univariate analysis, it was not a significant predictor of them on multivariate analysis.ConclusionsStone composition was not a predictor of outcomes of pediatric percutaneous nephrolithotomy. However, cystine and infection stones, which are larger and filled multiple calyxes due to the nature of stone forming, were more challenging cases that need multiple tracts.

Factors predicting postoperative febrile urinary tract infection following percutaneous nephrolithotomy in prepubertal children

BACKGROUNDnPredictive tables and scoring systems can predict stone clearance. However, there is a paucity of evidence regarding the prediction of complications during percutaneous nephrolithotomy (PCNL), particularly in children, which remains under-researched. To our knowledge, no studies have evaluated the risk factors for febrile urinary tract infection (FUTI) after pediatric PCNL.nnnOBJECTIVESnTo assess the predictive factors of FUTI in prepubertal children after PCNL and determine whether any prophylactic cephalosporins are superior for decreasing the FUTI rate.nnnSTUDY DESIGNnData from 1157 children who underwent PCNL between 1991 and 2012 were retrieved from the multicenter database of the Turkish Pediatric Urology Society. Children >12 years of age were excluded, leaving 830 children (364 girls, 466 boys). Data were analyzed according to the presence of FUTI and compared between the FUTI and non-FUTI groups.nnnRESULTSnMean age was 6.46xa0±xa03.38 years. Twenty-nine (3.5%) children had FUTI which was confirmed by urine culture. FUTI occurred more frequently in young children (5.5%) than school-age children (2.4%). In univariate analysis, there were significant differences between the FUTI and non-FUTI groups regarding age, cephalosporin subgroup (first, second and third generation cephalosporin), side of PCNL, staghorn stones, tract size, operative time, postoperative ureteral catheter usage, perioperative complications (SATAVA), and blood transfusion. Multivariate analysis revealed that age, side of PCNL, staghorn stones, tract size, operative time, and blood transfusion were independent predictors of FUTI.nnnDISCUSSIONnThe smaller tract size could cause FUTI with poor fluid drainage that may lead to elevate renal pelvic pressure and trigger bacteremia-causing pyelovenous backflow. Filling the calyx and renal pelvis by a staghorn stone and the resulting obstruction of fluid drainage may elevate intrarenal pelvis pressure. Longer operative time is likely to increase renal pelvic pressure over longer periods, which may account for FUTI after pediatric PCNL.nnnCONCLUSIONSnYounger age, right-sided PCNL, staghorn stones, mini-PCNL, longer operative time, and blood transfusion are risk factors for FUTI. First-, second-, and third-generation cephalosporins are equally effective for prophylaxis in prepubertal children undergoing PCNL.