Pediatric kidney transplantation in Egypt: Results of 10-year single-center experience.

Pediatric kidney transplantation is a multidisciplinary therapy that needs special consideration and experience. In this study, we aimed to present CUCH experience; over a 10-year period, as a specialized center of kidney transplantation in children. We studied 148 transplantations performed at a single center from 2009 to 2018. Pretransplant and follow-up data were collected and graft/patient survival rates were evaluated. A total of 48 patients developed at least one rejection episode during 688 patient-years of follow-up. Infections, recurrence of original disease, and malignancy were the most important encountered medical complications (20%, 2%, and 1.4%, respectively). One-year patient survival was 94.1%, while graft and patient survival was 91.9%. Graft/patient survival at 5, 7, and 9 years was 90%, 77%, and 58%, respectively. Infections were the main cause (69%) of mortality. Death with a functioning graft and CR were the main causes of graft loss (48% and 33%, respectively). Pediatric kidney transplantation in Egypt is still a challenging yet successful experience. Rejections and infections are the most frequent complications. Short-term outcomes surpass long-term ones and graft survival rates are similar to the international standard.

Risk factors for urological complications following living donor renal transplantation in children.

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy-three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow-up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study.

OBJECTIVES: To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes. PATIENTS AND METHODS: A database of children (<18 years old) who underwent RTx between May 2008 and April 2012 was reviewed. Patients were divided into those with LUTD (group A, n = 29) and those with other causes of ESRD (group B, n = 74). RTx was performed after achieving low intravesical pressure (<30 cmH2 O) with adequate bladder capacity and drainage. The groups were compared using Student's t-test, Mann-Whitney, chi-squared or exact tests. Graft survival rates (GSRs) were evaluated using Kaplan-Meier curves and the log-rank test. RESULTS: The mean ± sd (range) age of the study cohort was 5.05 ± 12.4 (2.2-18) years. Causes of LUTD were posterior urethral valve (PUV; 41.4%), vesico-ureteric reflux (VUR; 37.9%), neurogenic bladder (10.3%), prune belly syndrome (3.4%), obstructive megaureter (3.4%) and urethral stricture disease (3.4%). There was no significant difference in age, dialysis duration or donor type. In group A, 25 of the 29 patients (86.2%) underwent ≥1 surgery to optimize the urinary tract for allograft. Pretransplant nephrectomy was performed in 15 of the 29 patients (51.7%), PUV ablation in nine patients (31%) and ileocystoplasty in four patients (13.7%). The mean ± sd follow-up was 4.52 ± 1.55 and 4.07 ± 1.27 years in groups A and B, respectively. There was no significant difference in creatinine and eGFR between the groups at different points of follow-up. The GSRs at the end of the study were 93.1 and 91.1% in groups A and B, respectively (P = 1.00). According to Kaplan-Meier survival curves, there was no significant difference in the GSR between the groups using the log-rank test (P = 0.503). No graft was lost as a result of urological complications. In group B, one child died from septicaemia. The rate of urinary tract infections was 24 and 12% in groups A and B, respectively, but was not significant. No significant difference was found between the groups with regard to the incidence of post-transplantation hydronephrosis. Of the 22 patients who had hydronephrosis after transplantation, three were complicated by UTI. Injection of bulking agents was required in two patients for treatment of grade 3 VUR. In the third patient, augmentation cystoplasty was needed. CONCLUSION: Acceptable graft function, survival and UTI rates can be achieved in children with ESRD attributable to LUTD. Thorough assessment and optimization of LUT, together with close follow-up, are key for successful RTx.

Lower calyceal and renal pelvic stones in preschool children: A comparative study of mini-percutaneous nephrolithotomy versus extracorporeal shockwave lithotripsy.

OBJECTIVES: To compare outcomes of the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy for lower calyceal and renal pelvic stones in preschool children. METHODS: From January 2010 to December 2014, single renal pelvic or lower calyceal calculi 10-25 mm in size in children (age ≤6 years) treated by either extracorporeal shockwave lithotripsy (64 patients) or the mini-percutaneous nephrolithotripsy technique (54 patients) were included. Extracorporeal shockwave lithotripsy was carried out by using a Dornier electromagnetic lithotripter. The mini-percutaneous nephrolithotripsy technique was through 14-Fr renal access using a 9.5-Fr semirigid ureteroscope with holmium:yttrium aluminium garnet lithotripsy. The two study groups were compared using Mann-Whitney, χ(2) -test or Fisher's exact test. RESULTS: Stone parameters were similar in the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy groups in all patients, and in the pelvic (39 Miniperc, 52 extracorporeal shockwave lithotripsy) and lower calyceal (15 Miniperc, 12 extracorporeal shockwave lithotripsy) subgroups. Stone-free rates in the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy groups were 88.9% versus 43.8% (P < 0.001) and 94.4% versus 81.2% (P = 0.032) after first and last sessions, respectively. In the renal pelvis, they were 87.2% versus 50% (P < 0.001) and 94.9% versus 84.6% (P = 0.179), whereas in the lower calyx, they were 93.3% versus 16.7% (P < 0.001) and 93.3% versus 66.7% (P = 0.139) after first and last sessions, respectively. Retreatment rates in the mini-percutaneous nephrolithotripsy technique versus extracorporeal shockwave lithotripsy were 7.4% versus 50% (P < 0.001), 7.7% versus 46.2% (P < 0.001), and 6.7% versus 66.7% (P = 0.003) in all patients, renal pelvic and lower calyceal stones, respectively. No significant difference was found in complications (P = 0.521). Auxiliary procedures were required in 9.4% and 1.9% of children in the extracorporeal shockwave lithotripsy and mini-percutaneous nephrolithotripsy technique groups, respectively. CONCLUSIONS: The mini-percutaneous nephrolithotripsy technique has significantly higher stone-free rates than extracorporeal shockwave lithotripsy for renal pelvic and lower calyceal stones (10-25 mm), with a lower retreatment rate and without a significant increase in complications.

Caudal extradural catheterization in pediatric renal transplant and its effect on perioperative hemodynamics and pain scoring: a prospective randomized study.

PURPOSE: 'Hockey stick incision' used in renal transplant is large enough to cause severe postoperative morbidity especially in pediatric recipients. Although epidural analgesia is known to be effective in pain control, the resulting sympathectomy might affect hemodynamics interfering with the transplant process. In our study, we evaluated the feasibility and safety of inserting an epidural catheter to the thoracic level via the caudal route, and the effect of using epidural local anesthetics at low concentrations on hemodynamics. METHODS: After approval from the ethical committee at Kasr Al Ainy University Hospital and consent from parents/legal guardians, sixty patients aged 3-12 years who were scheduled for renal transplant were randomly divided into two equal groups. Group I (epidural group) received continuous caudal epidural bupivacaine 0.125 % with fentanyl together with intravenous (IV) fentanyl and paracetamol. Group II (control group) received only IV fentanyl and paracetamol. Intraoperative data included heart rate (HR), mean arterial blood pressure (MAP) and central venous pressure (CVP). Postoperative variables included HR, MAP, CVP, pain score and complications. RESULTS: Threading failure via the caudal route occurred in 6.67 % of cases. Intraoperative differences in hemodynamics and CVP were not clinically significant between groups. Postoperative HR, MAP, and CVP were generally higher in the control group. Pain control was more satisfactory and postoperative complications were less in the epidural group. CONCLUSION: Caudal epidural anesthesia in pediatric renal transplant is a valuable addition to general anesthesia as it provides stable perioperative hemodynamics, excellent postoperative analgesia and is associated with fewer complications than narcotic-dependent analgesia. CLINICAL TRIAL REGISTRATION NUMBER: NCT02037802.

Ureteric stents vs percutaneous nephrostomy for initial urinary drainage in children with obstructive anuria and acute renal failure due to ureteric calculi: a prospective, randomised study.

OBJECTIVES: To compare percutaneous nephrostomy (PCN) tube vs JJ ureteric stenting as the initial urinary drainage method in children with obstructive calcular anuria (OCA) and post-renal acute renal failure (ARF) due to bilateral ureteric calculi, to identify the selection criteria for the initial urinary drainage method that will improve urinary drainage, decrease complications and facilitate the subsequent definitive clearance of stones, as this comparison is lacking in the literature. PATIENTS AND METHODS: A series of 90 children aged ≤12 years presenting with OCA and ARF due to bilateral ureteric calculi were included from March 2011 to September 2013 at Cairo University Pediatric Hospital in this randomised comparative study. Patients with grade 0-1 hydronephrosis, fever or pyonephrosis were excluded. No patient had any contraindication for either method of drainage. Stable patients (or patients stabilised by dialysis) were randomised (non-blinded, block randomisation, sealed envelope method) into PCN-tube or bilateral JJ-stent groups (45 patients for each group). Initial urinary drainage was performed under general anaesthesia and fluoroscopic guidance. We used 4.8-6 F JJ stents or 6-8 F PCN tubes. The primary outcomes were the safety and efficacy of both groups for the recovery of renal functions. Both groups were compared for operative and imaging times, complications, and the period required for a return to normal serum creatinine levels. The secondary outcomes included the number of subsequent interventions needed for clearance of stones. Additional analysis was done for factors affecting outcome within each group. RESULTS: All presented patients completed the study with intention-to-treat analysis. There was no significant difference between the PCN-tube and JJ-stent groups for the operative and imaging times, period for return to a normal creatinine level and failure of insertion. There were significantly more complications in the PCN-tube group. The stone size (>2 cm) was the only factor affecting the rates of mucosal complications, operative time and failure of insertion in the JJ-stent group. The degree of hydronephrosis significantly affected the operative time for PCN-tube insertion. Grade 2 hydronephrosis was associated with all cases of insertion failure in the PCN-tube group. The total number of subsequent interventions needed to clear stones was significantly higher in the PCN-tube group, especially in patients with bilateral stones destined for chemolytic dissolution (alkalinisation) or extracorporeal shockwave lithotripsy (ESWL). CONCLUSION: We recommend the use of JJ stents for initial urinary drainage for stones that will be subsequently treated with chemolytic dissolution or ESWL, as this will lower the total number of subsequent interventions needed to clear the stones. This is also true for stones destined for ureteroscopy (URS), as JJ-stent insertion will facilitate subsequent URS due to previous ureteric stenting. Mild hydronephrosis will prolong the operative time for PCN-tube insertion and may increase the incidence of insertion failure. We recommend the use of PCN tube if the stone size is >2 cm, as there was a greater risk of possible iatrogenic ureteric injury during stenting with these larger ureteric stones in addition to prolongation of operative time with an increased incidence of failure.

Holmium:YAG laser ureteroscopic lithotripsy for ureteric calculi in children: predictive factors for complications and success.

OBJECTIVES: To evaluate the impact of age, stone size, location, radiolucency, extraction of stone fragments, size of ureteroscope and presence and degree of hydronephrosis on the efficacy and safety of holmium:YAG (Ho:YAG) laser lithotripsy in the ureteroscopic treatment of ureteral stones in children. METHODS: Between October 2011 and May 2013, a total of 104 patients were managed using semirigid Ho:YAG ureterolithotripsy. Patient age, stone size and site, radiolucency, use of extraction devices, degree of hydronephrosis and size of ureteroscope were compared for operative time, success and complications. RESULTS: In all, 128 URS were done with a mean age of 4.7 years. The mean stones size was 11 mm. Success rate was 81.25 %. Causes of failure were 12.5 % access failure, 1.5 % extravasation and 4.7 % stone migration. Overall complications were 23.4 %. Failure of dilatation and extravasation were detected only in children <2 years old. Extravasation was significantly higher in smaller ureters and cases with stone size >15 mm. Stone migration was significantly higher in upper ureteric stones. CONCLUSIONS: Failure and complications rates in Ho:YAG ureterolithotripsy were significantly affected by younger age (<2 years), upper ureteric stones and smaller ureters but were not related to stone radiolucency or degree of hydronephrosis. Larger stones (>15 mm) were associated with increased complications. After multivariate analysis, the age of the patients remained significant predictor for failure of dilatation and stone migration, while size of the ureter was the only significant predicting factor for failure.

Visual internal urethrotomy for management of urethral strictures in boys: a comparison of short-term outcome of holmium laser versus cold knife.

PURPOSE: To compare efficacy and safety of visual internal urethrotomy (VIU) using holmium laser (Ho:YAG) (group A) versus cold knife (group B) in children with urethral strictures. It may be the first comparative study on this issue in children. METHODS: This study compared Ho:YAG group, which was evaluated prospectively from January 2014 till January 2016, versus cold knife group, which was a historical control performed from March 2008 till February 2010. Children ≤ 13 years old with urethral strictures ≤ 1.5 cm were included successively. Recurrent cases, congenital obstructions and cases with complete arrest of dye in voiding cystourethrography were excluded. Scar tissue was incised at twelve o'clock. Outcome was compared using Student's t, Mann-Whitney, Chi-square or Fisher exact tests as appropriate. RESULTS: Each group included 21 patients. Mean age was 6.27 ± 3.23 (2-13) years old. Mean stricture length was 1.02 versus 1 cm in group A versus B, respectively (p = 0.862). Ten cases of penile/bulbous strictures and another 11 cases of membranous strictures were found in each group. There was no significant difference between both groups in preoperative data. Success rate for initial VIU was 66.7% in group A versus 38% in group B (p = 0.064). This was associated with significantly higher Qmax in group A (mean 16.52 vs 12.09 ml/s; p = 0.03). Success rate after two trials of VIU was 76.2% for group A and 47.61% for group B (p = 0.057). No complications were reported in both groups. CONCLUSION: Laser VIU has a higher success rate than cold knife VIU for urethral strictures ≤ 1.5 cm in children with significantly higher Qmax. Both are easy to perform, low invasive and safe.

The role of voiding cystourethrography in asymptomatic unilateral isolated ureteropelvic junction obstruction: A retrospective study.

INTRODUCTION: The presence of concomitant vesicoureteric reflux (VUR) and ureteropelvic junction obstruction (UPJO) is uncommon. Nevertheless, the reported VUR coexisting with asymptomatic unilateral isolated hydronephrosis (AUIH) requiring pyeloplasty for correction of UPJO was of low grade and mostly resolved during conservative follow-up. Therefore, VCUG may be not indicated in these children except if voiding symptoms, urinary tract infection (UTI), dilated ureters, or bladder and ureteric abnormalities are suspected. OBJECTIVES: The aim was to evaluate the need for VCUG in infants <1 year old with AUIH for whom a dismembered pyeloplasty was indicated for correction of UPJO. METHODS: Ninety-six children <1 year old with pyeloplasty carried out from January 2012 to March 2014 were retrospectively included. Children with voiding symptoms or dilated ureter, duplex system, fused kidneys, bilateral dilatation, or any bladder abnormality on ultrasound were excluded. Anderson-Hynes pyeloplasty was performed through a flank incision. Preoperative VCUG was analyzed in relation to outcome and any UTI during follow-up. The Student t test, Mann-Whitney U test, or Fisher exact test were used to compare variables. RESULTS: Five children had concomitant VUR with UPJO. Most of the children were circumcised during the first postnatal week. The remaining few children were circumcised at the time of pyeloplasty. Side, grade of detected VUR, and complications (18.75%) (postoperative or during follow-up) are presented in the Table. Outcomes in children with and without VUR were not different. Dismembered pyeloplasty was successful in children with VUR and with no complications except for non-febrile UTI in one child only. Ureters were still not dilated at the last follow-up. DISCUSSION: The required imaging in infants with AUIH is still a subject of debate. As we expected, there was a low incidence of associated VUR in the present study. They were of low grade without any complications during follow-up and without affecting the outcome. The present study has its limitations, including the retrospective nature and short follow-up. However, as at least 2 years of follow-up were documented without any harm or ureteric dilation, VUR will mostly resolve. The present study is strengthened by inclusion of infants only. CONCLUSIONS: Our data suggest that VCUG is not indicated in infants with AUIH requiring pyeloplasty for correction of UPJO. VCUG will not affect the treatment decision, operative outcome, or postoperative complications. VCUG may be indicated in case of suspected voiding symptoms, UTI, dilated ureters, or bladder and ureteric abnormalities.

Outcome of Mini-percutaneous Nephrolithotomy for Renal Stones in Infants and Preschool Children: A Prospective Study.

OBJECTIVE: To assess the safety and efficacy of Miniperc for renal stones in preschool-age patients. To the best of our knowledge, this may be the first prospective study on this subject. Reports on Miniperc are still few and mostly retrospective using a sheath size of ≥ 18Fr, which is still relatively large for young children. PATIENTS AND METHODS: From January 2012 to May 2013, Miniperc was performed for 26 children (≤ 6 years old) with renal calculi <5 cm through 14Fr sheath using a 9.5Fr semirigid ureteroscope with Holmium:yttrium-aluminum-garnet laser lithotripsy. Effects of different factors on operative time, complications, and stone-free rate (SFR) were compared using chi-square, Fischer exact, or Mann-Whitney tests as appropriate using SPSS v15.0. RESULTS: Primary SFR, SFR after retreatment, and SFR after auxiliary extracorporeal shock wave lithotripsy (ESWL) were 77%, 85%, and 92%, respectively. Retreatment rate was 8%. Auxiliary ESWL was done in 11%. Complications were bleeding (8%), hematuria and blood transfusion (4%), renal pelvis perforation (4%), leakage (8%), and fever (15%). Operative time was significantly prolonged in multiple (>2) stones (P = .006), calyceal stones (P = .002), or stone size ≥ 30 mm (P = .022). SFR was significantly lower in children with >2 stones (P = .028) and increased stone size ≥ 30 mm (P = .014). CONCLUSION: Miniperc is a safe and effective minimally invasive procedure for pediatric renal stones using 14Fr access sheath. SFR was significantly lower in children with >2 stones or increased stone size ≥ 30 mm. This was overcome by retreatment and auxiliary ESWL.

Transurethral Holmium Laser Cystolithotripsy in Children: Single Center Experience.

PURPOSE: To evaluate prospectively safety and efficacy of transurethral cystolithotripsy (CL) in children using holmium:yttrium-aluminum-garnet (Ho:YAG) laser. This is important in developing countries, because the risk of bladder stones in children is high. Open cystolithotomy (OC) was the main line of treatment. A gradual shift has occurred toward endourologic treatment after improvement of pediatric endoscopes. PATIENTS AND METHODS: Between January 2010 and May 2011, 33 children <12 years old with vesical calculi were treated. Children with orthopedic deformities, urethral stricture, history of urethral operations or bladder reconstruction, or stones >4 cm were excluded. Cystoscopies were performed under general anesthesia using 9 to 11F cystoscopes. Stones were completely fragmented under video guidance. Ho:YAG was applied at a power of 30 W. RESULTS: Median age was 3 years (0.5-11). Mean stone size was 2.02±0.82 cm (1-4 cm). Mean operative duration was 31.21 minutes (20-50). All children were discharged within 24 hours. A single operative session was performed for each patient. No complications were detected. After a mean follow-up of 16.87±4.08 months, all children were stone free, without development of any urethral stricture or recurrence of stones. Operative duration was significantly longer in stones >20 mm (P<0.001). CONCLUSION: Ho:YAG laser CL is a safe and successful minimally invasive treatment option for bladder stones in children. Success rate was 100% without development of any complications or recurrence.

Management of obstructive calcular anuria with acute renal failure in children less than 4 years in age: a protocol for initial urinary drainage in relation to planned definitive stone management.

OBJECTIVES: To describe and evaluate our protocol for management of children≤4years old with obstructive calcular anuria (OCA) and acute renal failure (ARF) to improve selection of initial urinary drainage (ID) method and to facilitate subsequent definitive stone management (DSM) as studies discussing this special group of patients are still few. PATIENTS AND METHODS: Patients with a contraindication to any method of ID were excluded. Decision (percutaneous nephrostomy (PCN) or double J (JJ) stent) was based on degree of hydronephrosis and planned DSM. We used 4.8-5Fr JJ or 6-8Fr PCN under general anesthesia and fluoroscopic guidance. According to our protocol, JJ is inserted for hydronephrosis≤grade 1. When the hydronephrosis is >grade 1, patients with radiolucent stones were treated by JJ whatever the site of the stone. When the stones were radiopaque, PCN was reserved for stones in a solitary functioning kidney and bilateral ureteric stones prepared for subsequent bilateral ureterolithotomy (or stone prepared for ureterolithotomy in a solitary kidney). After normalization of renal functions, DSM was staged attacking only one side before discharge. Both sides were cleared at the same session in cases with bilateral ureterolithotomy. Renal or ureteric stones suitable for SWL in a solitary kidney were treated with percutaneous nephrolithotripsy (PNL) or ureteroscopy. This was followed also in patients with bilateral stones suitable for SWL by clearing one side using ureteroscopy or PNL before discharge. Open surgery (OS) was reserved for cases with failed ureteroscopy or PNL, for ureteric stones>2.5 cm in size or very large volume complex renal stones. Stone free rate (SFR) was evaluated by CT. Our protocol was evaluated as regard recovery of renal functions, complications, and number of interventions to clear stones. RESULTS: This study included 62 boys and 22 girls presented with anuria for 1-4 days. JJ and PCN were inserted in 105 and 30 ureterorenal units (URU), respectively. Creatinine returns normal within 72 h. JJ insertion formed a part of DSM in 78/159 (49%) URU (stones prepared for extracorporeal shockwave lithotripsy or oral chemolytic dissolution therapy). PCN was the ideal tract for subsequent PNL in 11/159 (6.9%) URU. Accordingly, ID participated by 55.97% in DSM. Both operative and imaging times were slightly longer with PCN than JJ. There was no statistically significant difference in the insertion success or mean period to return to normal chemistry. Complications of both methods were mild and without any significant difference. Endourologic procedures constituted the majority of our interventions. Open surgical and endoscopic interventions for clearance of stones (including ID, treatment conversion and 2ry procedures) were done once for 25 patients, twice for 43 patients while it was needed three times for 16 patients. Total number of interventions was 149 procedures. SFR was 94%. CONCLUSION: Our protocol ensures adequate ID with minimal complications when using our selection criteria in children≤4 years in age with OCA and ARF. It also minimizes number of subsequent procedures to clear stones. Complications and success in insertion and drainage were equivalent in PCN and JJ groups.

Surgical complications and graft function following live-donor extraperitoneal renal transplantation in children 20 kg or less.

OBJECTIVES: To evaluate the effect of patient, surgical, and medical factors on surgical complications and graft function following renal transplantation (Tx) in children weighing ≤ 20 kg, because the number of this challenging group of children is increasing. PATIENTS AND METHODS: Between June 2009 and October 2013, 26 patients received living donor renal allotransplant using the extraperitoneal approach (EPA). The immunosuppression regimen was composed of prednisolone, mycophenolate mofetil, and ciclosporin or tacrolimus. RESULTS: The mean weight was 16.46 ± 2.61 kg. Mean cold ischemia time was 53.85 ± 12.35 min. The graft survival rate (GSR) and patient survival rate (PSR) were 96% at 3 years. Acute rejection episodes (AREs) occurred in eight patients (30%). Postoperative surgical complications were ureteral leakage (3), vesicoureteric reflux (2), and renal vein thrombosis (2) (with one graft nephrectomy). Mean follow-up was 37.5 ± 7.4 months. CONCLUSION: Excellent PSR and GSR can be achieved in low weight (<20 kg) recipients. Even in very low weight patients, the EPA was used. No cases were reported with primary graft non-function due to use of living donors, increasing pre-Tx body weight to at least 10 kg and maintaining adequate filling pressure before graft reperfusion. The presence of related donors and use of induction therapy and tacrolimus decreased the rate of ARE while the presence of pre-Tx lower urinary tract surgical interventions increased the rate of ureteric complications, but this was statistically insignificant.

Effect of size and site on the outcome of extracorporeal shock wave lithotripsy of proximal urinary stones in children.

OBJECTIVE: To determine the effect of location and size of stones on the outcome of extracorporeal shock wave lithotripsy (ESWL) in children. PATIENTS AND METHODS: In 2008-2010, 150 children (median age 6.6 years) with radio-opaque ureteric and renal stones measuring ≤4 cm were treated. Exclusion criteria were coagulation disorders, pyelonephritis, distal obstruction, non-functioning kidney and hypertension. ESWL was performed under general anesthesia. Follow up period was 5-22 months. RESULTS: 186 stones were treated: 76 calyceal, 92 pelvic and 18 proximal ureteral. Mean stone size was 1.3 cm. A total of 312 sessions were performed (mean per stone = 1.67 sessions). The mean number of shock waves per session was 2423.68. Overall stone-free rate was 89.24%. Having a calyceal location did not significantly affect the stone-free rate (p = 0.133). The failure rate was significantly higher (66.7%) in stones >3 cm in size (p < 0.001). Complications were encountered in 18 patients; 2 underwent auxillary ureteroscopy and 4 uretrolithotomy for treatment of steinstrasse. CONCLUSION: ESWL is a safe and effective method for treatment of stones up to 2 cm in children. Rate of auxillary procedures increases in stones >2 cm in size. About 80% of failures were associated with stone size >1.35 cm while 52.3% of completely cleared stones were associated with size <1.35 cm.

Renal recoverability in infants with obstructive calcular anuria: is it better than in older children?

OBJECTIVE: Urolithiasis in infants can cause considerable morbidity. The literature regarding calcular anuria in this age group is very defective. Our aim was to evaluate impact of intervention on renal recoverability in these infants. PATIENTS AND METHODS: A series of 24 patients presenting with obstructive calcular anuria were included in this study. Mean age was 16.5 ± 6.2 months. They were treated either by initial urinary diversion or definitive endoscopic (ureteroscopy or JJ stenting with medical alkalinization) or open surgical (ureterolithotomy or pyelolithotomy) treatment. RESULTS: Mean serum creatinine was 5.8 ± 2.6 mg/dl. Initial peritoneal dialysis and/or urinary diversion was needed in 11 patients (45.8%). Open surgical treatment was applied in 5 (20.8%), endoscopic treatment was applied in 15 (62.5%), while combined treatment was applied in 4 (16.6%) patients. All patients had normal serum creatinine on discharge. Three (12.5%) had residual stones which were cleared by 2ry ureteroscopic intervention at 6 months. The overall complication rate in this study was 12.5% in the form of postoperative leakage (1) and postoperative fever (2). No mortality or development of chronic renal failure was reported at 6 months follow up. In comparison with these results, a previous study carried out in our centre on an older age group had a higher complication rate (28%) with higher mortalities and lower renal function recoverability rate (94%). CONCLUSIONS: Appropriate and timely medical and surgical management of calcular anuria will mostly lead to full recovery of renal functions. In comparison with older children, renal prognosis in those less than 2 years seems more favorable.

Renal pelvis reduction during dismembered pyeloplasty: is it necessary?

OBJECTIVE: To compare treatment results in patients who underwent pyeloplasty with and without pelvic reduction for ureteropelvic junction obstruction (UPJO). METHODS: This randomized prospective study involved 40 patients, all diagnosed with unilateral UPJO; 20 each were randomly selected to undergo open dismembered pyeloplasty with pelvic reduction (group A) or pelvis-sparing pyeloplasty (group B). Patients were evaluated with ultrasound and DPTA renography scans 6 months postoperatively. Mean follow-up was 9 months. RESULTS: The mean age in group B was 5.71 ± 6.36 years; in group A it was 4.81 ± 6.78 years. There was a decrease in mean anteroposterior renal pelvic diameter (from 49.9 to 26.35 ± 0.949 mm in A and 50.9 to 30.8 ± 1.556 mm in B) with improvement of split renal function (from 39 ± 22.47% to 42.4 ± 22.13% in A and 34.92 ± 16.79% to 38.8 ± 19.66% in B), glomerular filtration rate (from 37.25 ± 15.33 to 41.7 ± 19.34 ml/min in A and 31.3 ± 18.50 to 38.1 ± 23.23 ml/min in B) and draining curves on the 6-month scans, but without any significant difference between groups (p > 0.05). Two cases in group A and three in group B needed redo pyeloplasty, but without any significant difference in failure rate. CONCLUSION: Excision of the pelvis is not necessary in dismembered pyeloplasty procedures. We had similar surgical outcomes for patients with or without pelvis reduction.

Semi-rigid ureteroscopy for ureteric and renal pelvic calculi: Predictive factors for complications and success.

OBJECTIVE: To analyse and compare the effect of stone site and size, method of lithotripsy, and level of experience on the results and complications of semi-rigid ureteroscopy for ureteric and renal pelvic stones. PATIENTS AND METHODS: Between April 2010 and May 2011, 90 patients underwent 95 ureteroscopies, using 7.5- and 9-F semi-rigid ureteroscopes, with or without pneumatic or laser lithotripsy. The peri-operative findings were analysed and compared. RESULTS: The mean (SD) longest diameter of the stones was 11.8 (4.5) mm. Laser lithotripsy was used in 32 cases and pneumatic lithotripsy in 26. There were complications in 35 procedures in the form of colicky pain (2%), haematuria (1%), stone migration (7%), equipment failure (5%), access failure (8%), mucosal injury (7%), fever (2%) and extravasation (3%).The calculi were successfully retrieved in 75 patients (83%). The success rate was 95%, 77%, 85%, and 53% in the lower, middle, upper ureter and renal pelvis, respectively. CONCLUSIONS: Upper ureteric stones can be managed safely with the semi-rigid ureteroscope. Renal pelvic stones are associated with a lower success rate, and thus they were not a primary indication for ureteroscopic intervention. The secondary ureteroscopic management of renal pelvic stones improved the results of subsequent alkalinisation or shock-wave lithotripsy if they could not be eradicated completely. The failure rate was significantly small in lower ureteric stones and stones of <10 mm. Less experience, a stone size of >15 mm and patients ⩽2 years old were associated with more complications or a lower success rate. There was no significant difference in the success or complication rate between laser and pneumatic lithotripsy.

Assessment of recoverability of kidney function in children with obstructive calcular anuria: multicenter study.

OBJECTIVE: Urolithiasis in children can cause considerable morbidity. Our aim was to evaluate the impact of intervention on the recoverability of kidney functions. MATERIALS AND METHODS: This prospective study included 93 children (66 boys and 27 girls) with median age of 3 years (range 0-14). Inclusion criteria were presence of anuria, oliguria, serum creatinine >2 mg% and/or hyperkalemia ≥ 6 mmol/L. The mean duration of anuria or oliguria was (mean ± SE) 5.3 ± 0.4 days. On presentation, mean plasma creatinine was 6.5 ± 0.29 mg/dl with a mean estimated glomerular filtration rate (eGFR) of 14 ml/min and creatinine clearance (CC) of 8.24 ml/min. Dialysis was performed in 21 (22.6%) patients. When condition allowed, emergency surgery was performed. RESULTS: Mean follow up was 1.5 years with compliance of 82%. At the end of treatment, 83% of patients had complete clearance of calculi. Mean plasma creatinine after treatment was 3.3 ± 0.35 mg/dl with an average GFR of 24.5 ml/min. After treatment renal function returned to normal in 57%, improved in 27% and deteriorated in 16% of children. Renal function recoverability rate was 94.6%. Chronic renal failure developed in 3 (3.2%) patients and 2 (2.2%) patients died. When absolute plasma creatinine concentration [P(cr)] improved 20-50% the eGFR and CC were doubled, and when improved 50-70% eGFR and CC tripled. Beyond 70% improvement in [P(cr)], eGFR and CC improved 7-8 times. Using Spearman's correlation, the mode of presentation and the type of management had a significant correlation with renal function outcome (P = 0.019 and 0.013 respectively). CONCLUSION: Urgent management of calcular anuria both medically and surgically is the cornerstone for favorable outcome. The mode of presentation and the type of management are significant factors affecting final renal function outcome.