Pediatric Urolithiasis - The Case for a Multi-disciplinary Pediatric Stone Center - Med

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

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  Off-label use of drugs, devices, or other agents: None or
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  Data from IRB-approved human research is presented [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

                                                       FOIU, 2018

Cincinnati Children’s Experience
 From a relatively rare             Ureteroscopy at Cincinnati
                                             Children’s
    occurrence to see a stone   70
    patient in clinic in 2003   60

    to now seeing new           50

    patients on an almost       40

    daily basis                 30

•   Surgical procedures
                                20

                                10

    increasing significantly     0
                                     2003    2008         2013        2016
    over the years                             Surgical Cases

                                                                FOIU, 2018

Renal Ultrasound - first line
  imaging modality in Children

Renal stone     Distal ureteral stone with hydroureter

                                         FOIU, 2018

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

                                                         FOIU, 2018

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

                                                      FOIU, 2018

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

                                             FOIU, 2018

Pediatric ESWL Monotherapy
                          Pts/renal      Stone     Stone free/retreatment
                            utits     location (%)        rate (%)
Tejwani (4 years; 5         1087       66R/34U               /18
states data base), 2016
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%
                                                                    FOIU, 2018

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 FOIU, 2018

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

                                                 FOIU, 2018

Ureteroscopy at CCHMC
 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

                                                                     FOIU, 2018

Pediatric PCNL
 Difficult positioning (spinal anomalies, spinal
  hardware, limb contracture)
    proper padding of pressure point
 Previously reconstructed patients
    complex anatomy
 Significant comorbidity - anesthesia concerns

                                                  FOIU, 2018

CCHMC Hybrid OR
                               Surgical light

4 integrated cameras for
Augmented Reality navigation                    Maquet surgical table

                                                         FOIU, 2018

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
                                                                  FOIU, 2018

C-arm Cone Beam CT
                       = CT Scanner !

Digital X-Ray
Detector
                                    Rotation

                X-Ray Beam

                                               FOIU, 2018

Metabolic Evaluation
 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

                                          FOIU, 2018

2002

2005

2006

2008

2012

2017

       FOIU, 2018

Litholink

CCHMC Experience
•   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

                                                  FOIU, 2018

CCHMC Experience
       • Urology and Nephrology identified unmet need for
         comprehensive care for children with kidney stone disease
2012
       • Obtained program funding from hospital leadership
       • Hired nurse coordinator (0.5) and outcomes manager
         (0.35)
2013   • Steering Committee* began quarterly meetings

       • Stone Center clinic began seeing patients
       • Clinic patients discussed at clinical care conference to
2014     determine consensus on management

       *Steering Committee consisted of members
       from Nephrology, Urology, Genetics, Dietary,
       Emergency Department, and Radiology                          FOIU, 2018

The Stone Center
     Multi-Disciplinary Treatment of Urinary Tract Stones
                       Established 2014

 Our Team           Condition Treated   • Surgeries offered
    Urology            Urolithiasis         Ureteroscopy
    Nephrology         Cystinuria           Laser Lithotripsy
    Genetics           Dent disease         PCNL
    Interventional     Hypercalciuria       ESWL
     Radiology          Hyperoxaluria        Robotic Surgery
    Emergency          Hypocitraturia
     Medicine
    Nutrition Therapy

The Stone Center
                                                        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

                                                                                     FOIU, 2018

The Stone Center
            Dedicated phone
            line established:
            803-ROCK

                   FOIU, 2018

Clinical Outcomes of the
             Pediatric Stone Center
 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

Pediatric Stone Center
 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                                FOIU, 2018