Pediatric Urolithiasis
The Case for a Multi-disciplinary
Pediatric Stone Center
Eugene Minevich, MD
Professor, Division of Pediatric Urology
Director, Stone Center
Cincinnati Children’s Hospital , Cincinnati, USA
FOIU, 2018
Financial and Other Disclosures
Off-label use of drugs, devices, or other agents: None or
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Pediatric Nephrolithiasis
Rapid increase in incidence over the past several
decades in the United States
4% increase in incidence, per year, between 1984-2008
Increasing prevalence of ED visits, inpatient admissions,
referrals, and outpatients surgeries
Recurrence rate is up to 50%
Metabolic disorders not uncommon
Annual health care costs (USA) $375 million - data from inpatient and ED sources in 2009
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From a relatively rare
occurrence to see a stone
patient in clinic in 2003
to now seeing new
patients on an almost
daily basis
• Surgical procedures
increasing significantly
over the years 0
10
20
30
40
50
60
70
2003 2008 2013 2016
Surgical Cases
Ureteroscopy at Cincinnati
Children’s
Cincinnati Children’s Experience
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Renal Ultrasound - first line
imaging modality in Children
Renal stone Distal ureteral stone with hydroureter
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Spiral Non-contrast CT Scan
Gold standard in imaging of urolithiasis
- commonly performed in community Emergency Departments
Unique considerations for radiation exposure in
children
- children are considerably more sensitive to radiation than
adults
- children have a longer life expectancy than adults, resulting
in a larger window of opportunity for expressing radiation
damage
- children may receive a higher radiation dose than necessary if
CT settings are not adjusted for their smaller body size
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Image Gently
Image Gently is an educational and awareness
campaign created by the Alliance for Radiation
Safety in Pediatric Imaging
- protocols to “child-size” radiation dose for children (2008)
- updated protocols are now available to address
technology improvements to CT scanners
- www.imagegently.org
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Surgical Treatment of
Urinary Stones in Children
Stone size and location
Number of stones
Stone composition
Urinary tract anatomy
Surgeon’s experience and availability of
technology
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Pediatric ESWL Monotherapy
Pts/renal
utits
Stone
location (%)
Stone free/retreatment
rate (%)
Tejwani (4 years; 5
states data base), 2016
1087 66R/34U /18
Raza, 2005 122/140 n/a 69
DeFoor, 2005 88 100R 74
Demirkesen, 2006 126/151 67R/33U 71/40
Nelson, 2008 111 87R/13U 58/22
Landau, 2009 216 73R/27U 80R-78U/20
Badawy, 2012 500 90R/10U 84R-56U/32
Habib, 2013 150/185 90R/10U 89 (1.67 sessions)
Complications: 0 - 14.7%
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ESWL at CCHMC
Mobile system
- allows pediatric urologists to perform procedure at own institution with dedicated pediatric anesthesia/OR staff
Universal urological table
- additional endoscopic procedures can be performed concurrently
2011-2015 – 144 ESWL (SPU AUA, 2018)
30-day ED visits – 6.9%, readmissions 3.5%, complications –
2.1%
Pain: ED visits - 30%, readmission - 20%
No independent predictors of ED visits, readmissions, or
complications after ESWL on multivariate analysis
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Pediatric Ureteroscopy
Primary treatment option for ureteral stones
Widespread availability of endoscopes in
pediatric institutions
- effective miniaturization
- superior durability
- excellent video-imaging capability
- large working channels
Sophisticated intracorporeal lithotripsy devices
and ancillary instruments
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Initial experience (Minevich et al, J Urology, 2005)
85 pts/92 procedures - 98% stone free
2011-2015 - 162 URS (SPU AUA, 2018)
30-day ED visits - 9.9%, readmissions 6.2%, complications -
4.3%
Pain: ED visits - 43.8%, readmission - 40.0%
Multivariate analysis
complication and family history of urolithiasis were independently
predictive of ED visits
complication was the only independent predictor of readmissions
positive intraoperative urine culture was independently predictive of
complications
Ureteroscopy at CCHMC
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Pediatric PCNL
Difficult positioning (spinal anomalies, spinal
hardware, limb contracture)
proper padding of pressure point
Previously reconstructed patients complex anatomy
Significant comorbidity - anesthesia concerns
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CCHMC Hybrid OR
Maquet surgical table
Surgical light
4 integrated cameras for
Augmented Reality navigation
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CCHMC Hybrid OR Imaging
Capabilities State-of-the-art IR fixed C-arm (Philips monoplane FlexMove Azurion)
Live fluoroscopy
Digital Subtraction Angiography (DSA)
Up to 95% X-ray dose reduction with pediatric specific settings
C-arm Cone beam CT (CBCT)
3D reconstruction
3D Rotational Angiography (3DRA)
Fluoro co-registration (onto prior CBCT, CT, MR, PET) integrated
navigation
Video Augmented Reality navigation (pending FDA approval)
State-of-the-art Ultrasound system (Philips EPIQ Affinitty)
Fusion with CT, MR, PET navigation
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C-arm Cone Beam CT
X-Ray Beam
Digital X-Ray Detector
Rotation
= CT Scanner !
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Our practice for many years has
been to evaluate for urinary
metabolic abnormalities after the
first stone episode
For many years we have
collaborated with our local
Nephrologists as well as John
Asplin and Fred Coe in Chicago
(Litholink lab)
Our major goal has been to identify
risk factors for stone recurrence
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Metabolic Evaluation
2002
2005
2006
2008
2012
2017
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Litholink
• No formal guidelines were followed in the management of
stone patients after the stone episode
• Practice variation was common in regards to initial
evaluation and medical management
• Indications for Nephrology consultation were not
standardized
• Genetic abnormalities were not typically evaluated
• No collaboration between Urology, Radiology and the
Emergency Department was established regarding clinical
management and imaging recommendations
• Nutrition evaluation was non-existent
CCHMC Experience
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2012 • Urology and Nephrology identified unmet need for
comprehensive care for children with kidney stone disease
2013
• Obtained program funding from hospital leadership
• Hired nurse coordinator (0.5) and outcomes manager (0.35)
• Steering Committee* began quarterly meetings
2014
• Stone Center clinic began seeing patients
• Clinic patients discussed at clinical care conference to determine consensus on management
*Steering Committee consisted of members
from Nephrology, Urology, Genetics, Dietary,
Emergency Department, and Radiology
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CCHMC Experience
The Stone Center Multi-Disciplinary Treatment of Urinary Tract Stones
Established 2014
Our Team
Urology
Nephrology
Genetics
Interventional
Radiology
Emergency
Medicine
Nutrition Therapy
Condition Treated
Urolithiasis
Cystinuria
Dent disease
Hypercalciuria
Hyperoxaluria
Hypocitraturia
• Surgeries offered
Ureteroscopy
Laser Lithotripsy
PCNL
ESWL
Robotic Surgery
STONE CENTER
__________________________________________________________________________________________ Patient Name: CCHMC MR: Date of Birth: Age: 8y Height: Weight: Diagnosis: urolithiasis, nephrolithiasis HDN, crystalluria, hypercalciuria, hypocitraturia, CKD stage 1, extrinsic asthma Chief Complaint: new visit Allergies: molds Medications: hydrochlorothiazide 12.5mg cap daily, cytra-k 15ml BID, singulair 4mg chewable 1 tab daily __________________________________________________________________________________________ Current Management: fluids, medications __________________________________________________________________________________________ History: 6/10/14: stone center, siblings with calcium oxalate crystals 10/26/13: presented thru the ED, left obstructing 5mm distal ureteral stone, presented with back pain Current issues: currently doing well, has been working with the adherence center to learn how to swallow pills Surgery history: 1/29/14: R ESWL, right ureteral stent removal 1/17/14: cysto, R retrograde pyelogram with stent placement 11/14/13: R ESWL, L ureteral stent removal, L retrograde pyelogram 10/26/13: cystourethroscopy, L retrograde pyelogram, L ureteral stent placement Test results: 12/9/14: KUB 7/28/14: Dexa Scan-normal 6/27/14: RUS- bilateral mid pole nonobstructing 3mm renal stone 5/12/14: KUB- no stones 1/16/14: RUS- 7mm obstructing stone at the Right UPJ Labs:
The Stone Center
7/10/14: RP-B/C ratio 30(H), otherwise normal 1/16/14: RP- Na 141 K 3.6 Cr 0.42 Ca 8.8 PH 4.3 Litholink results: 6/20/14: volume is better at 1.21L, citrate is now normal at 689, Ca 161 12/6/13: inadequate urine volume, significant hypercalciuria, mild hypocitraturia, mild hypernatiruira, mild hypokaluiria Plan: Nephrology: (Devarajan) Urology: (Defoor) Genetics: father has kidney stones, 2 siblings with crystalluria, cousin with kidney stones 6/10/14: pt seen but no formal recommendations made regarding any testing Dietician: 6/10/14: discussed H2O goals, lower Na diet, increase fruits and veggies, 1100mg Calcium Pain: asymptomatic at this time
The Stone Center
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The Stone Center
Dedicated phone
line established:
803-ROCK
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CCHMC experience since 6/2014 (AUA/SPU, 2018)
208 pts
90 (49%) had metabolic abnormalities (26 hypercalcuria, 25
hypocitraturia)
73 pts underwent surgical procedures (prior to visit to Stone
Center)
ED visits per year - decreased from 1.5 to 0.5% before and
after the first Stone Center visit (p<0.0001)
Surgeries – number of patients decreased from 40% to 18%
during the one year before and at any time after the first
Stone Center visit (p<0.0001)
CT scan usage trended to decrease from 32% to 25% (p=0.3)
Clinical Outcomes of the
Pediatric Stone Center
FOIU, 2018
Given the rising prevalence and impact of stone
disease in children, a multi-disciplinary Stone Center
can be a feasible option to coordinate care and
improve clinical outcomes.
The number of patients requiring surgical procedures
and ED visits appeared to significantly decrease after
enrolling patients in the Stone Center
Further analysis is necessary to determine if
aggressive medical management will improve urinary
metabolic indices and decrease kidney stone
recurrence rates
Pediatric Stone Center
FOIU, 2018
