Does percutaneous nephrolithotomy in children cause significant renal scarring?

ObjectiveTo determine the frequency of renal parenchymal damage following percutaneous nephrolithotomy (PCNL) in children.Patients and methodsFifty-six children undergoing PCNL in 60 renal units between January 2000 and December 2004 were included in this prospective study, and were subjected to postoperative technetium-99m dimercaptosuccinic acid (^99mTc-DMSA). Using a standard questionnaire, demographics, number, size and location of stones, procedure details, outcome as indicated by clearance with PCNL alone or additional procedures, and follow up were documented. Presence of focal renal damage and its association with the PCNL tract were examined.ResultsOut of 60 renal units, cortical defects on ^99mTc-DMSA scan were seen in 10 renal units (17%). In three of these kidneys, the site of focal defect corresponded to the access site for tract formation during PCNL. Two additional kidneys had scarring at multiple sites, one of which corresponded to the access site during PCNL. In the remaining five kidneys no association between focal renal damage and nephrostomy tract site could be ascertained. No association was seen between renal damage and the size of nephroscope used during PCNL.ConclusionThere exists a risk of focal damage to renal parenchyma from the formation of the nephrostomy tract. In our series, focal damage was seen in 5% of patients; this may be an overestimate since preoperative ^99mTc-DMSA scans were not available for our patients. Meticulous technique is important combined with a smaller nephroscope to minimize renal damage. Long-term follow up of such children is required to assess how many are left with permanent renal scars.     

Impact of epilepsy surgery on quality of life: Systematic review and meta-analysis

Improved quality of life (QoL) is an important outcome goal following epilepsy surgery. This study aims to quantify change in QoL for adults with drug-resistant epilepsy (DRE) who undergo epilepsy surgery, and to explore clinicodemographic factors associated with these changes. We conducted a systematic review and meta-analysis using Medline, Embase, and Cochrane Central Register of Controlled Trials. All studies reporting pre- and post-epilepsy surgery QoL scores in adults with DRE via validated instruments were included. Meta-analysis assessed the postsurgery change in QoL. Meta-regression assessed the effect of postoperative seizure outcomes on postoperative QoL as well as change in pre- and postoperative QoL scores. A total of 3774 titles and abstracts were reviewed, and ultimately 16 studies, comprising 1182 unique patients, were included. Quality of Life in Epilepsy Inventory–31 item (QOLIE-31) meta-analysis included six studies, and QOLIE-89 meta-analysis included four studies. Postoperative change in raw score was 20.5 for QOLIE-31 (95% confidence interval [CI] = 10.9–30.1, I² = 95.5) and 12.1 for QOLIE-89 (95% CI = 8.0–16.1, I² = 55.0%). This corresponds to clinically meaningful QOL improvements. Meta-regression demonstrated a higher postoperative QOLIE-31 score as well as change in pre- and postoperative QOLIE-31 score among studies of cohorts with higher proportions of patients with favorable seizure outcomes. At an individual study level, preoperative absence of mood disorders, better preoperative cognition, fewer trials of antiseizure medications before surgery, high levels of conscientiousness and openness to experience at the baseline, engagement in paid employment before and after surgery, and not being on antidepressants following surgery were associated with improved postoperative QoL. This study demonstrates the potential for epilepsy surgery to provide clinically meaningful improvements in QoL, as well as identifies clinicodemographic factors associated with this outcome. Limitations include substantial heterogeneity between individual studies and high risk of bias.     

“Per protocol” practice patterns for Children's Oncology Group trials within the radiation oncology community

Little is known about the prevalence of pediatric radiation oncologists treating patients off study according to Children's Oncology Group (COG) trials before data are available regarding toxicity and efficacy of novel radiotherapy regimens. We conducted a 12-question survey of 358 pediatric radiation oncologists to characterize practice patterns regarding ongoing and completed COG protocols off study. With 130 responses (40.3%), the prevalence of providing treatment per protocol, but off study, before data are available in abstract or peer-reviewed form varied from 9.1% (for ACNS1422) to 88.1% (for AHOD1331). Future studies are needed to understand the effects of these practice patterns on outcomes.