Case Presentation - Pediatric Endourology

PA N E L :

E U G ENE M I N EV I C H , U S A | J O NAT H A N G L A S S , U K | R OY M O R AG , I S R A E L

YO R A M M O R , I S R A E L | P I N C H AS L I V N E , I S R A E L

M O D E R ATO R :

I L A N K A F KA , I S R A E L

Financial and Other Disclosures

2

I have the following financial

interests or relationships to disclose: Disclosure code

No financial relationships N

Case #1 10 y.o. male

VACTERL Association— ◦ Imperforated anus/ Megasigma

◦ Sacral Agenesis

◦ Lt. Renal Agenesis

End Colostomy + Partial Sigmoidectomy after birth

Age 3 ◦ Vesicostomy– Non contractile Bladder by FUDS

Age 7 ◦ Bladder Augmentation (Gastro–ileal) w/ Mitrofanoff- CIC by caregiver

◦ ACE (Malone procedure)

CIC- 12 Fr----- 8Fr ----Trouble performing CIC ◦ Age 9- Underwent Revision of Mitrofanoff

Age 10 -Recurrent UTI’s ◦ Presents to ED with Rt. Flank Pain

◦ Finished Last course of oral Abx. one day prior

◦ US- Rt. Mild Hydroureteronephrosis , susp. 8 mm Stone distal ureter + 1 cm Bladder stone.

◦ Creat 0.7-1.2

◦ No Fever, Normal Signs

Plan?

Ureteroscopy ◦ Access through Mitrofanoff

◦ Unable to ID Ureteral Orifice

Sub-Febrile, Normal white count, Cr. Still 1.2

Urine Culture- Pseudomonas Aeruginosa

What Now?

IV Abx by sensitivities

Nephro-ureteral stent Placed by IR

UVJ narrowing with distended ureter- trouble working wire to bladder

Distal Ureteral Stone still ID by Fluoroscopy during placement

Plan? ◦ Percutaneous Cistolithalopaxy

◦ 30 Fr Access Sheath

◦ Flexible URS + Laser Lithotripsy , basket extraction

◦ No Stricture seen UVJ, wide ureter

Creatinine normalizes

Stone Analysis- Struvite 100%

Plan?

Case #2 • 4 y.o Female

• Born Term 38 weeks

• Recurrent UTI’s from age 1-3

• VCUG –No Reflux / Normal repeat US

Chronic Abdominal Pain

Lately - Recurrent Nausea + Vomiting

Urine – Leu+ Ery +++ Nit+

Urine Culture- Proteus Mirabilis

Normal Blood Work

5 days on Abx according to sensitivities

No clinical improvement

US- Rt. Mild hydronephrosis, susp. 1.5 cm LP calculus

Plan?

Plan?

Prone Mini PCNL

UP access

18Fr AS, Laser lithotripsy

Active Basket stone Retrieval

Stone Analysis ◦ CaOxM 30%

◦ Struvite 40%

◦ CaPh. 30%

24hr. Collection ◦ Volume 1500 ml/24 hrs

◦ Normal Electrolytes

◦ Normal UA

◦ Normal Ox + Citr

◦ Neg. Cystein profile

◦ pH 7.8

Case 3 4 yo male

Born Term, 38 weeks, C-Section d/t placenta previa

Parents- 1st degree cousins

Dx. Age 12 days- Microvillus inclusion disease - Home TPN through central line.

Recurrent line sepsis

Recurrent UTI’s- Proteus Mirabilis/ Klebsiella Pneumoniae

24 months - Macroscopic Hematuria -Renal US- LT kidney – Small Calcifications of lower pole, no Hydronephrosis

-Urine Culture-

Klebsiella Pneumoniae

-Abx. treatment with

resolution of symptoms

-No urology Consult

Age 27 months- Abdominal Pain ◦ Urine Culture - Proteus Mirabilis

◦ Renal US- ◦ LT KIDNEY unchanged from previous exam

◦ RT KIDNEY- Mild Hydronephrosis, multiple Calcifications, 6mm stone in UPJ

◦ No Urology Consult

◦ IV Abx. And D/C

Age 29 months- Vomiting, Fever , Abdominal Pain

Severe Hyponatremia and Hypokalemia, Cr 0.77, HB 7.9

Hemodynamically Stable

Abdominal US – ◦ LT KIDNEY –Several larger Stones than in previous exam

◦ RT KIDNEY- Severe Hydronephrosis, multiple Calcifications, 6mm stone in UPJ

PLAN?

Bilateral Ureteral Drainage by DJS

Stabilized, Labs Normalize

PLAN?

Recurrent line Sepsis + Recurrent Line Leaks

Anemia requiring Blood transfusions

Metabolic Imbalances

Recurrent UTI’s

Patient unfit for definitive stone clearance

PLAN?

DJS exchange every 2 months

Age 36 months- Lt. encrusted stent- incomplete LT DJS Retrieval

PLAN?

Percutaneous antegrade stent insertion by IR- Uneventful

• Patient is D/C

• 3 weeks later- Massive hematuria

• Anemia- requiring transfusions

• Negative Urine cultures

• Abdominal US- Dense material in LT collecting system , Mild Hydronephrosis, Proximal Coils of DJS’s in place

• PLAN?

• Angiography- Small Pseudo Aneurysm-Coil

• Stabilizes Hemodinamically- D/C

• Cleared for definitive Stone Surgery after a few weeks

• Negative Urine Cultures

• Normal Labs

• PLAN?

What’s next?

• Bilateral Prone PCNL • 18 Fr Access- Laser Lithotripsy + Active basket stone retreival

• LT. Remnant proximal stent removal

• Bilateral antegrade ureteroscopies

• Bilateral 8 Fr Coop Nephrostomy ◦ Removal POD 2

◦ No post-op fever, Stable Hb/ Cr.

◦ D/C POD 3

• Two Weeks later… • Gross Hematuria- HB drop 1.5 grams since d/c

• Rt. Flank Pain

• Negative Culture PLAN?

Stone Analysis- Struvite 100%

Follow up- ◦ US 6 months- No evidence of nephrolithiasis

Case 4 8 y.o male

12 hrs. before arrival - abdominal pain and difficulty urinating ◦ Urine Dipstick- Blood ++ Leu+

◦ Normal Labs.

◦ KUB- Susp. Urethral calcification

◦ Foley inserted at local hospital and D/C

Arrived to ED with 8Fr Foley catheter ◦ Normal Signs

PLAN?

PLAN?

Abdominal US ◦ Both Renal units normal, Catheter in bladder, no other findings

Negative Urine culture

Cystoscopy with Basket retrieval of stone

D/C Home

Nephrology FU- Idiopatic Hypercalciuria ◦ Thiazides + K- Citrate

Stone Analysis- CaOx Monohydrate 100%

3 years later

Lt . Intermitent Flank Pain

US- LT. no hydro– 0.7 mm stone LP

No fever, normal labs Next Step?

Failed LT ESWL

LT. Flexible ureteroscopy- laser lithotripsy and basket extraction

Nephrology FU- No Change

Stone- CaOx Monohydrate 100%

3 years later ◦ Asymptomatic

◦ Urine General- Ery + Leu + pH 7

◦ Normal Labs

◦ US- Multiple calcifications in Lt. Kidney up to 7 mm size

PLAN?

Thank You!