Serdar Tekgül

Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children's Continence Society

PURPOSE We provide updated, clinically useful recommendations for treating children with monosymptomatic nocturnal enuresis. MATERIALS AND METHODS Evidence was gathered from the literature and experience was gathered from the authors with priority given to evidence when present. The draft document was circulated among all members of the International Childrens Continence Society as well as other relevant expert associations before completion. RESULTS Available evidence suggests that children with monosymptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse. The mainstays of primary evaluation are a proper history and a voiding chart. The mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin. Therapy resistant cases should be handled by a specialist doctor. Among the recommended second line therapies are anticholinergics and in select cases imipramine. CONCLUSIONS Enuresis in a child older than 5 years is not a trivial condition, and needs proper evaluation and treatment. This requires time but usually does not demand costly or invasive procedures.

EAU Guidelines on Vesicoureteral Reflux in Children

CONTEXT Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention. OBJECTIVE To present a management approach for VUR based on early risk assessment. EVIDENCE ACQUISITION A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come. EVIDENCE SYNTHESIS There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated. Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques. CONCLUSIONS While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.

Practical consensus guidelines for the management of enuresis

Despite the high prevalence of enuresis, the professional training of doctors in the evaluation and management of this condition is often minimal and/or inconsistent. Therefore, patient care is neither optimal nor efficient, which can have a profound impact on affected children and their families. Once comprehensive history taking and evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic enuresis can be managed efficaciously in the majority of patients. Non-monosymptomatic enuresis is often a more complex condition; these patients may benefit from referral to specialty care centers. We outline two alternative strategies to determine the most appropriate course of care. The first is a basic assessment covering only the essential components of diagnostic investigation which can be carried out in one office visit. The second strategy includes several additional evaluations including completion of a voiding diary, which requires extra time during the initial consultation and two office visits before treatment or specialty referral is provided. This should yield greater success than first-line treatment. Conclusion: This guideline, endorsed by major international pediatric urology and nephrology societies, aims to equip a general pediatric practice in both primary and secondary care with simple yet comprehensive guidelines and practical tools (i.e., checklists, diary templates, and quick-reference flowcharts) for complete evaluation and successful treatment of enuresis.

A study of the etiology of idiopathic calcium urolithiasis in children : Hypocitruria is the most important risk factor

PURPOSE To determine the association of metabolic risk factors with pediatric calcium urolithiasis we compared metabolic evaluation data on children with idiopathic calcium stones and those on healthy children. MATERIALS AND METHODS Metabolic evaluation was done in 78 calcium stone formers 1 to 15 years old (mean age 7.2) who were free of urinary tract infection, anatomical abnormalities, and metabolic, endocrinological and intestinal disorders, and in 24 healthy children. Evaluation included serum biochemistry, and measurement of daily excretion of urinary calcium, oxalate, urate, phosphorus, citrate and magnesium. RESULTS Demographic characteristics, serum parameters, and daily excretion of calcium, urate, phosphorus and magnesium did not differ statistically in the 2 groups. However, urinary oxalate was significantly higher and urinary citrate was significantly lower in stone formers than in controls (p = 0.002 and 0.028, respectively). Hypocitruria and hyperoxaluria were 4.3 and 3-fold more common in stone formers than in controls, respectively. Multivariate analysis using logistic regression showed that hypocitruria was the only significant risk factor for idiopathic calcium stones (p = 0.008). CONCLUSIONS Hypocitruria was the most important risk factor in our patients. Hyperoxaluria was also common and accompanied hypocitruria in many stone formers. In contrast to many previous reports, we failed to show that hypercalciuria is an important metabolic defect for idiopathic calcium stones, possibly because our study evaluated a different population.

Urinary tract infections in children: EAU/ESPU guidelines

CONTEXT In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract. OBJECTIVE To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI. EVIDENCE ACQUISITION The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low. EVIDENCE SYNTHESIS UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded. CONCLUSIONS The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage. PATIENT SUMMARY In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.

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

PURPOSE We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi. MATERIALS AND METHODS We 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. RESULTS A 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. CONCLUSIONS Semirigid 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.

Oral Potassium Citrate Treatment for Idiopathic Hypocitruria in Children With Calcium Urolithiasis

PURPOSE We evaluated the clinical and laboratory outcome of oral potassium citrate treatment in children with idiopathic hypocitruria and calcium stones. MATERIALS AND METHODS The charts of 64 children 1 to 15 years old with hypocitruria and calcium stones (median age 7.2) treated with oral potassium citrate were reviewed. Evaluation parameters were tolerability, adverse reactions, metabolic profile and stone recurrence. RESULTS No serious adverse reaction due to potassium citrate administration was recorded. Normal citrate excretion was restored in all patients. After treatment median urinary citrate daily plus or minus SD increased from 197 +/- 72 to 632 +/- 218 mg./1.73 m.2 (p <0.001) and mean urinary pH increased from 5.3 +/- 0.3 to 6.2 +/- 0.7 (p <0.01). Mean calcium excretion decreased from 3.5 +/- 2.7 to 2.5 +/- 2.7 mg./kg. (p <0.05). At an average followup of 22 months (range 3 to 67) the recurrence rate in the group overall was 0.07 per patient-year. The previous recurrence rate of 0.32 per patient-year in the 20 children with a history of recurrent stone disease decreased to 0.17 per patient-year after treatment. None of the 44 initial stone formers had recurrent stones. CONCLUSIONS Our results show the safety and efficacy of oral potassium citrate treatment for restoring normal urinary citrate and suggest a preventive effect for recurrent calcium stone disease in children with hypocitruria and calcium stones.

Tubeless Mini Percutaneous Nephrolithotomy in Infants and Preschool Children: A Preliminary Report

PURPOSE We retrospectively analyzed the outcomes of tubeless mini percutaneous nephrolithotomy in infants and preschool children, and compared them with age matched controls who underwent nephrostomy drainage. MATERIALS AND METHODS A total of 28 renal units in 26 children were operated on for stone disease using the mini percutaneous nephrolithotomy technique. Holmium laser and pneumatic lithotriptor were used for stone fragmentation. Children who underwent complete stone removal and had a clear nephrostomy tract only had a ureteral catheter placed. Those with residual stones or bleeding from the nephrostomy tract underwent nephrostomy drainage. We compared both groups with regard to patient and stone characteristics, and postoperative findings. RESULTS A total of 12 renal units had only a ureteral catheter for diversion, while 16 had nephrostomy drainage. Mean respective ages of the stentless and nephrostomy groups were 3 (range 0.58 to 6) and 3.3 years (1.5 to 6). Mean respective stone burdens were 192 (range 100 to 400) and 416 (775 to 1,380) mm2. Surgery and fluoroscopy times were shorter in the tubeless group. Complication rates were higher (6 of 14 vs 0 of 12) and duration of hospitalization was longer (4.9 [range 3 to 14] vs 3.1 days [2 to 6]) in the nephrostomy group. Stone-free rates were 91.6% in the tubeless and 78.5% in the nephrostomy groups. CONCLUSIONS Tubeless percutaneous nephrolithotomy was observed to be a safe option for selected children with stone disease. The success and safety of tubeless percutaneous nephrolithotomy depends on patient selection criteria, including low volume and infection-free stones that are removed completely without any bleeding from the access tract.

Percutaneous renal surgery in children with complex stones.

OBJECTIVE We report our experience with percutaneous nephrolithotomy (PNL) therapy for staghorn or complex pediatric renal calculi. PATIENTS AND METHODS We retrospectively analyzed the case records of 105 patients younger than 17 years who underwent PNL. The cases included 53 complex calculi analyzed in 51 patients. We defined complex calculi as either staghorn or those with a stone bulk larger than 300 mm(2), involving more than one calix, the upper ureter or stone in anomalous kidney. RESULTS Mean age of patients with complex calculi was 9.7+/-0.7 years and stone burden was 654+/-92.4mm(2). The median duration of PNL was 90+/-4.7 (30-220) min. Complete clearance was achieved in 39 patients (73.6%). Of these, 32 (60.4%) required a single tract, while 21 (39.6%) required multiple tracts. With subsequent shock wave lithotripsy and PNL, the clearance rate increased to 86.8%. The average hemoglobin drop was 1.6+/-0.16 g/dL. Assessing the factors affecting the hemoglobin drop, the number of tracts (P=0.01) and size of tracts (P=0.002) were found to be significant. The mean change in serum creatinine concentration between preoperative and postoperative measurements was -0.01+/-0.02 mg/dL, for both patients with a single tract and those with multiple tracts. CONCLUSIONS PNL is safe and effective in the management of staghorn and complex renal calculi in children. Tract dilatation and number of tracts are important factors in reducing blood loss.

Use of the holmium:YAG laser for ureterolithotripsy in children

To review our experience with rigid ureteroscopy and holmium:YAG laser for treating ureteric calculi in children.