尿路结石术前应用抗菌药物治疗的指征是什么?

感染是尿路结石常见的并发症之一.感染性尿液可渗入肾实质内,破坏正常的肾组织而引起肾功能受损,甚至导致肾功能丧失.细菌及内毒素进入血液可发生脓毒血症甚至感染性休克,危及患者生命.对于细菌感染或具感染风险的患者,如果术前使用抗生素有效控制尿路感染,并且能够保持手术时血液及肾盂内一定的药物浓度,可以降低碎石时肾盂内的细菌负荷,减少细菌入血机会,预防感染进一步扩散和加重.目前多数指南对于尿路结石术前应用抗菌药物的指征,仅局限于已经存在尿路感染的患者,作者就这一问题进行进一步探讨.     

A study of the etiology of idiopathic calcium urolithiasis in children: hypocitruria is the most important risk factor

PURPOSE: To determine the association of metabolic risk factors with pediatric calcium urolithiasis we compared metabolic evaluation data on children with idiopathic calcium stones and those on healthy children. MATERIALS AND METHODS: Metabolic evaluation was done in 78 calcium stone formers 1 to 15 years old (mean age 7.2) who were free of urinary tract infection, anatomical abnormalities, and metabolic, endocrinological and intestinal disorders, and in 24 healthy children. Evaluation included serum biochemistry, and measurement of daily excretion of urinary calcium, oxalate, urate, phosphorus, citrate and magnesium. RESULTS: Demographic characteristics, serum parameters, and daily excretion of calcium, urate, phosphorus and magnesium did not differ statistically in the 2 groups. However, urinary oxalate was significantly higher and urinary citrate was significantly lower in stone formers than in controls (p = 0.002 and 0.028, respectively). Hypocitruria and hyperoxaluria were 4.3 and 3-fold more common in stone formers than in controls, respectively. Multivariate analysis using logistic regression showed that hypocitruria was the only significant risk factor for idiopathic calcium stones (p = 0.008). CONCLUSIONS: Hypocitruria was the most important risk factor in our patients. Hyperoxaluria was also common and accompanied hypocitruria in many stone formers. In contrast to many previous reports, we failed to show that hypercalciuria is an important metabolic defect for idiopathic calcium stones, possibly because our study evaluated a different population.     

Assessment of risk factors of pediatric urolithiasis in Egypt

Objective

Pediatric urolithiasis is a significant medical problem, which has seen an increasing incidence in developing countries. The main objective of the present study was to investigate the clinical characteristics and the most important risk factors that contribute to stone formation in Egyptian children.

Patients and methods

This prospective study was carried out at the outpatient clinics of Cairo university children’s hospital as well as October 6 University hospitals, between November 2008 and March 2012. One hundred and fifty children (100 males, 50 females; mean age 3.5 years; range, 1-14 years) suffering from urinary stones were included. The mean follow-up duration; 33.1 months. All patients underwent detailed medical and family histories, dietary habits and physical examination, including Growth percentiles. Laboratory investigations were performed including: complete urine analysis and culture and sensitivity tests, urine collection in 24-h to quantity urinary volume, pH, calcium, uric acid, magnesium, creatinine, oxalate and citrate. Blood samples were obtained to measure (serum creatinine, calcium, phosphorus, uric acid level, and alkaline phosphatase and electrolyte levels, in addition to pH and pCO₂ values). Radio-sonographic investigation of the abdomen and pelvis was also performed.

Results

The commonest presentations were abdominal pain in 42 children (28%) and gross hematuria in 35 patients (23%). Urinary tract infection was the most common risk factor, 60 patients (40%) had UTI, 70% of them had recurrent infections. Genito-urinary abnormalities, as a risk factor, were detected in 38 children (25%), with vesico-uretheral refux being the commonest abnormality (18/38). Metabolic risk factors were detected in 34 children (23%) with hypercalciuria and hyperoxaluria being the commonest metabolic abnormalities. Treatments used were, ESWL in 69 patients (46%), endoscopic interventions in 40 children (27%) and open surgery in 15 children (10%). The remaining 26 children (17%) were managed conservatively.

Conclusions

treatment of pediatric urolithiasis requires stone removal besides a thorough metabolic and environmental evaluation of all patients on an individual basis, entailing the treatment of metabolic abnormalities. Children with a positive family history should be followed up cautiously to avoid stone recurrence.     

Characteristics of patients with staghorn calculi in our experience

PURPOSE: To elucidate the factors contributing to staghorn stone formation in patients. MATERIALS AND METHODS: The records of 82 patients (44 men and 38 women) with complete staghorn calculi were reviewed retrospectively for clinical presentation, metabolic disturbances and anatomical abnormalities. RESULTS: There were 79 unilateral and three bilateral cases. The patient performance of the activities of daily life was assessed with the modified Rankin scale (MRS) and it was found that 69 patients were functionally independent (84.1%, MRS 0-1) and 10 patients had a severe disability (12.2%, MRS 4-5). Seven patients had chronic indwelling catheters (8.5%). A positive urine culture was found in 24.4% of patients. Analysis of stone composition revealed magnesium ammonium phosphate and mixed calcium oxalate-phosphate were the most frequently identified types of stone (32.1% and 22.2%, respectively). Urinary pH was low in patients with uric acid stones (mean 5.4). Hyperuricemia, cystinuria and hypercalciuria were found in 14.6%, 2.4% and 37.8%, respectively. Hypercalciuria was found more frequently in calcium-stone cases. Eleven patients (13.4%) showed structural abnormalities of the kidney. CONCLUSIONS: Our data show that the patients with severe disability, urinary tract infection and hypercalciuria could be recognized more frequently in staghorn calculi compared with common urolithiasis. However, in Western countries, the frequency of both urinary tract infection and struvite stones is much higher than in our data. Other Japanese authors have also reported the low frequency of struvite stones in staghorn calculi, suggesting that various factors other than urinary tract infection possibly contribute to the formation of staghorn calculi in Japan.     

Clinical evaluation of urolithiasis in Crohn's disease

Objectives:   To investigate the characteristics of urolithiasis associated with Crohn's disease in a Japanese population.
Methods:   We studied 98 patients with Crohn's disease: 39 with urolithiasis and 59 without urolithiasis. Patients were treated at the Social Insurance Central General Hospital, or at the Toho University Omori, Ohashi, or Sakura Medical Centers.
Results:   Calculi were more frequent in men ( n  = 30) than women ( n  = 9). Mean time from diagnosis of Crohn's disease to diagnosis of calculi was 8.8 years (range 0 to 22 years). Calculi were present on the right side in 19 patients and the left side in 19 patients. Stone were composed of calcium oxalate in nine patients, calcium oxalate and calcium phosphate in two patients, and ammonium urate in five patients. The rate of concurrent calculi was significantly higher in ileostomates. The probability of developing calculi was approximately eight times higher for patients with a urine pH of ≤6.0 than for those with a urine pH of ≥6.5.
Conclusions:   The rate of concurrent urolithiasis was higher in patients with a urine pH of ≤6.0, ileostomy, or two or more bowel resections. To prevent formation of calculi, Crohn's disease patients require regular urological examination including urinalysis, ultrasonography, and kidney ureter bladder X-ray.     

儿童特发性高钙尿症52例临床分析

目的探讨特发性高钙尿症（IH）的临床特点及与泌尿系结石的关系。方法分析52例确诊为IH患儿的临床资料特点,并结合文献讨论其与泌尿系结石发生的关系。结果52例患儿均有不同程度血尿。其中41例患儿行腹部B超和X线平片检查及静脉肾盂造影检查,发现肾结石5例。调查52例患儿家族史发现15例家族中有泌尿系结石患者,6例同胞中有类似血尿患者,较正常对照组家族的尿结石发病率明显增高（P〈0．05）。52例患儿进行钙负荷试验,其中肠道吸收亢进型29例．肾脏漏出型23例。结论除血尿外,泌尿系结石也是IH的常见临床表现,尤其见于高钙尿状态持续时间较长者。IH与家族泌尿系结石的发病有密切关系,有遗传倾向。     

The role of vitamin D receptor gene polymorphisms in Turkish infants with urolithiasis

Polymorphisms in the vitamin D receptor (VDR) gene have recently been reported to be associated with urinary calculi in pediatric and adult cases, but no studies have looked at the youngest period of life. The purpose of this study was to investigate the role of VDR gene polymorphisms in infantile urolithiasis in a Turkish population. We compared a study group of 104 infants (55 girls and 49 boys, mean age 6.94?±?3.81 months) with a control group of 96 infants (51 girls and 45 boys, mean age 7.51?±?3.23) to evaluate their demographics and metabolic risk factors. PCR-based restriction analysis of the polymorphisms on the VDR gene (BsmI and TaqI) showed statistically significant differences between study and control groups (p?=?0.001 and 0.043, respectively). In addition, the prevalence of the BsmI genotype was significantly different between the hypercalciuric and normocalciuric stone formers (p?=?0.007). Allelic frequencies were similar between the urolithiasis and control groups (p?>?0.05). The B allele of BsmI and the A allele of ApaI were more prevalent in the hypercalciuric stone formers than in the normocalciuric stone formers (p?=?0.018 vs.0.036, respectively). These results suggest that the BsmI and TaqI VDR genotypes could be candidate genes leading to infantile urolithiasis.     

Extracorporeal shock wave lithotripsy for cystine urolithiasis in children: Outcome and complications

The Siemens Lithostar Litotriptor was used to treat 6 children withcystine nephrolithiasis, previously treated by open surgery. Fivechildren had renal calculi (3 multiple caliceal, 2 pelvis) and one hadureteral calculus. Stone size ranged from 0.2–2.5 cm in diameter,and stone burden was from 0.24 to 10.81 cm³ per kidney. Fromone to 4 ESWL sessions per unit were applied, with a total of 1,800 to12,000 shock waves. The stone free rate at 3 months was 50%. Acomplete elimination was obtained with cystine stones in renal pelvisand ureter, however, up to 4 ESWL treatments failed in caliceal stones.Rather location of cystine calculi than previous surgery was associatedwith ESWL success rate. Two patients with positive urine cultures weresuccessfully treated with appropriate antibiotics before ESWL wasattempted. Perirenal hematoma was major complication demonstrated byradionuclide scintigraphy in one patient, and resolved spontaneously by3 months. In the combined treatment of cystine urolithiasis in childrenESWL, as auxillary procedure, was safe and effective in pelvis stone butfailed in caliceal stones. Medical dissolution for retained fragmentswas found effective.     

Management of pediatric urolithiasis in Pakistan: experience with 1,440 children

PURPOSE: We evaluated the efficacy and safety of different modalities for pediatric urolithiasis in a developing country in 2 eras, namely before and after the advent of minimally invasive surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of 1,440 children younger than 14 years treated with various modalities during a 14-year period. From 1987 to 1995, 486 and 50 patients were treated with open surgery, and extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) and minimally invasive methods, respectively. Between 1996 and 2000, 518 and 386 children were treated with surgery and minimally invasive methods, respectively. RESULTS: Of the 1,440 children 795 (55.2%) had renal, 198 (13.8%) had ureteral and 447 (31%) had bladder calculi. Of the renal stones 556 (70%), 177 (22%) and 62 (7.8%) were treated with open surgery, ESWL and percutaneous nephrolithotomy, respectively. Of the ureteral calculi 85 (43%), 37 (18.6%) and 76 (38%) were managed by ESWL, ureterorenoscopy and open surgery, respectively. Of the bladder calculi 307 (68%), 77 (17.2%) and 63 (14%) were treated with open vesicolithotomy, transurethral pneumatic cystolithotripsy and ESWL, respectively. The renal stone clearance rate was 98% after open surgery, 84% after ESWL and 68% after percutaneous nephrolithotomy monotherapy at 3 months of followup. Similarly the ureteral stone-free rate was 54% after ESWL and 86.9% after ureterorenoscopy. Of the patients with bladder calculi 48% and 93% become stone-free after ESWL and transurethral pneumatic cystolithotripsy, respectively. CONCLUSIONS: The use of ESWL, percutaneous nephrolithotomy and ureterorenoscopy has resulted in treating a large number of children with a short hospital stay and early return to school. Open surgery is reserved only for complex stones.     

Prevention and treatment of complicated urinary tract infection

A complicated urinary tract infection (UTI) has relapsing and refractory characteristics, and is sometimes life-threatening because of patient predisposing factors as well as the recent worldwide spread of multi-drug resistant bacteria. Patients with complicated UTI should be treated with effective antimicrobial therapy along with appropriate urological intervention to remove predisposing factors when the symptoms are associated. By contrast, routine use of antimicrobial prophylaxis for asymptomatic bacteriuria (ASB) is not recommended, as that would contribute to an increase in even more resistant pathogens. Here, four classifications of complicated UTI, which are considered to be clinically important for general urologists, are reviewed, including UTI in patients with diabetes mellitus (DM) and those with a neurogenic bladder, as well as catheter-associated UTI (CAUTI) and obstructive pyelonephritis secondary to urolithiasis. Appropriate treatment approaches can only be chosen by proper understanding of the etiologies of complicated UTI, as well as correct diagnostic strategies and treatment options.     

Is there need for both intravenous urography and voiding cystography in the evaluation of children with recurrent urinary tract infections?

Summary In a prospective study 33 children (aged 6–14 years) consecutively referred for recurrent urinary tract infections (RUTI), underwent intravenous urography (IVU) as well as voiding cystography (VC). Seven children had unilateral and two children had bilateral renal scarring, while ten children had unilateral and six children had bilateral vesico-ureteral reflux (VUR). Following normal IVU VUR was demonstrated in 22% of the ureters, but in all cases of low grade. In abnormal IVU, i.e. renal scarring or dilatation of the ureters, VC showed high grade VUR in 54% of the ureters. Based on these results and the current theories on the significance of patient age and the grade of VUR, we conclude that in case of a normal IVU in children with RUTI and age of at least 6 years, there is no reason to supplement the pre-treatment evaluation with VC.     

Procalcitonin as a predictor of renal scarring in infants and young children

The aim of this study was to evaluate the usefulness of procalcitonin (PCT) as a marker of renal scars in infants and young children with a first episode of acute pyelonephritis. Children aged 7 days to 36 months admitted for first febrile urinary tract infection (UTI) to a pediatric emergency department were prospectively enrolled. The PCT concentration was determined at admission. Acute ^99mTc-dimercaptosuccinic acid (DMSA) scintigraphy was performed within 7 days of admission and repeated 12 months later when abnormal findings were obtained on the first scan. Of the 72 children enrolled in the study, 52 showed signs of acute pyelonephritis (APN) on the first DMSA scan. A follow-up scintigraphy at the 12-month follow-up performed on 41 patients revealed that 14 (34%) patients had developed renal scars; these patients also presented significantly higher PCT values than those without permanent renal lesions [2.3 (interquartile range 1–11.6) vs. 0.5 (0.2–1.4) ng/mL; p = 0.007]. A comparison of the PCT concentration in patients with febrile UTI without renal involvement, with APN without scar development and with APN with subsequent renal scarring revealed a significant increasing trend (p = 0.006, Kruskal–Wallis test). The area under the ROC curve for scar prediction was 0.74 (95% confidence interval 0.61–0.85), with an optimum statistical cut-off value of 1 ng/mL (sensitivity 78.6%; specificity 63.8%). Based on these results, we suggest that serum PCT concentration at admission is a useful predictive tool of renal scarring in infants and young children with acute pyelonephritis.     

Evaluation of abnormal radiological findings in children aged 2 to 36 months followed by recurrent urinary tract infection: a retrospective study

Our aim is to determine the rational usage of imaging techniques in order to prevent or minimize permanent renal damage in recurrent urinary tract infections (UTIs). This study was enrolled children aged between 2 and 36 months, following-up with the diagnosis of recurrent UTI. All children had ultrasonography (USG) and dimercaptosuccinic acid scanning, 39 of them had underwent on voiding cystourethrography. There were 133 children (87 girls, 46 boys) with the mean age of 32.82?±?38.10 months included into the study. Forty-three kidney units were normal in ultrasonogram of which seven units had reflux whereas among 35 units with hydronephrosis 22 units had reflux. Sensitivity and specificity presence of hydronephrosis in ultrasonogram for prediction of reflux was 75.9% and 73.5%, respectively. There were 19 dilated ureters in ultrasonogram, and among them 14 had reflux. Sensitivity and specificity of presence with ureteral dilatation in ultrasonogram for prediction of reflux was found as 48.3% and 89.8%, respectively. The sensitivity of parenchymal thinning seen in ultrasonogram for the evaluation of renal parenchyma was 15.9%, whereas specificity was 98.2% .Sensitivity and specificity of dimercaptosuccinic acid for prediction of reflux was 51.6% and 72.3%, respectively. The normal ultrasonogram findings cannot rule out neither possibility of reflux presence nor development of renal scarring. Therefore, DMSA scanning has major role both in determination of parenchymal damage and prevention of scarring. Also we get an important result as ureteral dilatation seen in USG, related to presence of reflux.     

小儿上尿路结石286例临床分析

目的:进一步探讨新疆地区小儿泌尿系结石的临床特征.方法:对收治的286例小儿上尿路结石患儿的临床资料进行分析.其有明显的区域、族群分布和结石成分特征;均经影像学确诊;239例行开放手术取石治疗.结果:开放手术取石239例,一次取尽结石率89.0%,术后2～12年复发41(14.3%)例,术中术后未发现严重并发症.结论:影像学检查是诊断小儿泌尿系结石的主要手段,磁共振尿路成像对小儿尿路结石形态诊断,具有较好的实用性和优越性;开放手术适应证广、技术成熟,仍是目前小儿泌尿系结石的主要治疗方法.