Preoperative stone attenuation value predicts success after shock wave lithotripsy in children.

PURPOSE: We determined whether stone attenuation can predict stone fragmentation after shock wave lithotripsy in the pediatric population. Previous studies show that preoperative attenuation in HU on noncontrast computerized tomography predicts shock wave lithotripsy success. To our knowledge study of this parameter in the pediatric population has been lacking to date. MATERIALS AND METHODS: We performed a multi-institutional review of the records of 53 pediatric patients 1 to 18 years old who underwent shock wave lithotripsy for 3.8 to 36.0 mm renal calculi. Stone size, average skin-to-stone distance and attenuation value were determined by bone windows on preoperative noncontrast computerized tomography. Success was defined as radiographically stone-free status at 2 to 12-week followup after a single lithotripsy session without the need for further sessions or ancillary procedures. RESULTS: After lithotripsy 33 patients (62%) were stone-free and 20 had incomplete fragmentation or required additional procedures. Mean ± SD stone attenuation in successfully treated patients vs those with incomplete fragmentation was 710 ± 294 vs 994 ± 379 HU (p = 0.007). Logistical regression analysis revealed that only attenuation in HU was a significant predictor of success. When patients were stratified into 2 groups (less than 1,000 and 1,000 HU or greater), the shock wave lithotripsy success rate was 77% and 33%, respectively (p <0.003). CONCLUSIONS: Stone attenuation less than 1,000 HU is a significant predictor of shock wave lithotripsy success in the pediatric population. This finding suggests that attenuation values have a similar predictive value in the pediatric population as that previously reported in the adult population.

Stone size is only independent predictor of shock wave lithotripsy success in children: a community experience.

PURPOSE: We determined whether age, gender, body mass index, number of stones, stone location or total stone diameter could independently predict stone-free rates after extracorporeal shock wave lithotripsy in children. MATERIALS AND METHODS: We reviewed 149 patients 3 to 17 years old undergoing shock wave lithotripsy between 2001 and 2008. Cases were retrieved from a regional shock wave lithotripsy database. Variables analyzed included age, gender, body mass index, number of shocks delivered, stone location, number of stones and total stone diameter. Stone-free status on followup imaging at 2 weeks to 3 months was considered a successful outcome. RESULTS: Of 149 patients 32 had multiple stones. After shock wave lithotripsy 106 patients (71%) were stone-free, 12 (8%) required a repeat procedure and 31 (21%) had residual fragments. Number of stones per patient ranged from 1 to 18 (mean +/- SD 2.14 +/- 2.60). Mean +/- SD number of stones was 1.87 +/- 2.42 in successfully treated patients and 2.81 +/- 2.92 in those with treatment failure (p = 0.065). Total stone diameter ranged from 2 to 90 mm (mean +/- SD 14.03 +/- 16.68). Mean total stone diameter was 11.1 +/- 13.4 mm in successfully treated patients and 21.3 +/- 21.4 mm in those with treatment failure (p <0.005). CONCLUSIONS: To our knowledge we present the first multi-institutional cohort study in children demonstrating no significant relationship between successful outcome and patient age, gender, body mass index, stone location or number of stones. Only total stone diameter independently predicted shock wave lithotripsy success.

Complex cloacal anomaly in discordant monozygotic twins.

Urorectal septum malformation sequences are rare congenital malformations. We report a case of persistent cloaca prenatally diagnosed at 26 weeks of gestation in 1 of a set of discordant monozygotic twins. The affected fetus at birth had a phallus-like structure, bladder outlet obstruction, an imperforate anus, and uterine distension. Diverting colostomy, vesicostomy, and percutaneous colpostomy tube were initially placed before definitive posterior sagittal anorectovaginoplasty was completed. A cloacal anomaly occurring in only 1 of a set of monozygotic twins is an exceedingly rare event.

Cystoscopy-assisted laparoscopic partial cystectomy.

BACKGROUND AND PURPOSE: Laparoscopic partial cystectomy is performed in selected patients with isolated diseases, such as bladder endometriosis, pheochromocytoma, leiomyoma, and malignant bladder tumors. Laparoscopic partial cystectomy is indicated for a solitary bladder tumor that is distant from the bladder neck, the ureteral orifices, and the trigone, to allow a resection margin of 1 to 2 cm. We report our experience with cystoscopy-assisted laparoscopic partial cystectomy. MATERIALS AND METHODS: The bladder was mobilized adequately by laparoscopy. Intraoperative cystoscopy was performed Cystoscopic guidance was used for the initial cystotomy. Further excision of the bladder tumor with a safety margin of 1.5 to 2 cm was performed under laparoscopic vision. RESULTS: Three patients underwent cystoscopy-assisted laparoscopic partial cystectomy. Cystoscopy aided in planning a proper and adequate safety margin around the tumor as well as helped in marking the initial cystotomy. CONCLUSIONS: Cystoscopic assistance during laparoscopic partial cystectomy helps to properly place the initial cystotomy as well aids in planning the safety margin around the tumor. It is safe, easy, and does not add to increased operative time or morbidity.

Genital self-mutilation in nonpsychotic heterosexual males: Case report of two cases.

Genital self-mutilation is a rare event that is commonly associated with psychotic disorders. However such injuries have also been reported from nonpsychotic patients as a result either from bizarre autoerotic acts, attempts at crude sex change operation by transsexuals or secondary to complex religious beliefs and delusions regarding sexual guilt. We report two cases of genital self-mutilation in nonpsychotic married heterosexual males as a result of conflict and frustration.

Ureteroscopic stone management in prepubertal children.

Ureteroscopy for treating ureteric stones in prepubertal children has become more common with the advent of smaller endoscopes. We retrospectively reviewed our experience with ureteroscopy for ureteric stone in this cohort of patients. During the period Jan 2001 and June 2005, we performed 22 ureteroscopic procedures in 20 children. Ureteroscopy was done in a manner similar to that in adults. Ureteral dilatation was done in all cases. A stent was placed postoperatively if there was significant stone burden, ureteral trauma, impaction and edema of ureteric orifice. Of the 20 children, 18 were male and 2 were females. Average age was 5.2 years (range 3-9). Stones were 4-14 mm in size (average 6 mm). Overall 90% of the children were rendered stone free after one procedure and 100% after two procedures. Ureteroscopy for ureteric stones in prepubertal children is safe and effective first line treatment in whom conservative therapy fails. Routine ureteral stent placement postoperatively is not always necessary.