A population-based retrospective cohort study of surgical trends and outcomes of pediatric urolithiasis in Ontario, Canada (2002-2019).

INTRODUCTION: The worldwide incidence of pediatric urinary stone disease (PUSD) is increasing. However, there is no commensurate data on whether this translates to an increasing need for surgical intervention for PUSD, given the role of conservative management. OBJECTIVE: We aimed to evaluate the trends and outcomes of clinically significant PUSD, using administrative databases to identify patients surgically treated for PUSD. STUDY DESIGN: This retrospective population-based cohort study assessed the incidence and trends of surgically treated PUSD and outcomes in Ontario, Canada in patients <18 years of age who underwent their first PUSD procedure between 2002 and 2019 utilizing administrative databases held at the Institute of Clinical Evaluative Sciences (ICES). We assessed the incidence of surgically treated PUSD, demographics, initial surgical treatment and imaging modality, and risk factors for repeat intervention within 5 years. Statistical analyses summarized demographics, surgical trends, and logistic regression was used to identify risk factors for repeat surgical intervention. RESULTS: We identified 1149 patients (mean age 11.3 years), with 59.6% older than 12 years. There was a decrease in the number of PUSD procedures performed per year that was close to statistical significance (p = 0.059) and a trend towards increased utilization of ureteroscopy (URS) compared with Shockwave Lithotripsy (SWL). In addition, there was a significant increase in the proportion of females surgically treated with PUSD (p = 0.001). In the 706 patients followed for 5 years, 17.7% underwent a repeat procedure within 6 months, while 20.4% underwent a repeat procedure from 6-months to 5 years. Renal stone location (OR 2.79, 95% confidence interval (CI) 1.62-4.80, p = 0.0002) and index SWL (OR 1.66, 95% CI 1.20-2.31, p = 0.0025) were risk factors for repeat surgical intervention within the first 6-months. There was an increasing utilization of ultrasound (US) compared to computerized tomography (CT) (p = 0.0008). DISCUSSION: Despite the literature reporting increasing PUSD incidence, we observed a non-significant decrease in the number of surgical PUSD procedures performed. Exclusion of those treated conservatively may explain our results. The increase in the proportion of females treated reflects the narrowing gender gap in stone disease. A trend towards increased URS utilization was observed and re-intervention rates were similar to previous studies. CONCLUSION: The overall rate of surgically treated PUSD did not show an increasing trend in Ontario, Canada from 2002 to 2019. URS was the most common surgical treatment modality, with a corresponding decline in SWL rates. PUSD was associated with a high surgical re-intervention rate within 6 months.

Thulium fiber laser lithotripsy: Is it living up to the hype?

Objective: The holmium:yttrium-aluminium-garnet laser (Ho:YAG) has been the gold standard for laser lithotripsy over the last three decades. After demonstrating good in vitro efficacy, the thulium fiber laser (TFL) has been recently released in the market and the initial clinical results are encouraging. This article aims to review the main technology differences between the Ho:YAG laser and the TFL, discuss the initial clinical results with the TFL as well as the optimal settings for TFL lithotripsy. Methods: We reviewed the literature focusing on the technological aspects of the Ho:YAG laser and TFL as well as the results of in vitro and in vivo studies comparing both technologies. Results: In vitro studies show a technical superiority of TFL compared to the Ho:YAG laser and encouraging results have been demonstrated in clinical practice. However, as TFL is a new technology, limited studies are currently available, and the optimal settings for lithotripsy are not yet established. Conclusion: TFL has the potential to be an alternative to the Ho:YAG laser, but more reports are still needed to determine the optimal laser for lithotripsy of urinary tract stones when considering all parameters including effectiveness, safety, and costs.