Pediatric urololithiasis in coastal Tunisia

Pediatric urolithiasis is a globally growing problem. The composition and frequency of urinary tract stones vary not only among different countries, but across various regions in a country. Hence, we aimed to identify the types and frequencies of urinary tract stones in children from our region (Inner Western Anatolian part of Turkey), and to compare our findings with the results from other regions in our country. In this retrospective analysis of 53 pediatric urolithiasis cases that were treated in our hospital between 2009 and 2019, the demographic data, clinical course, radiological and metabolic findings, the recurrence rate, and the composition of the stones were evaluated. The mean age of the patients was 5.9±4.6 (0.5-18) years, and there were 30 (56.6%) girls and 23 (43.4%) boys. An analysis of the composition of the stones revealed that the majority (85%) consisted of calcium oxalate. The highest risk of recurrence and the need for multiple shockwave lithotripsy (SWL) sessions or surgical intervention appeared to be related with the presence of whewellite stones, which are the most challenging stones in childhood. According the study results, the urinary stone types vary across different regions in our country, and the frequency of uric acid stones decreased going westward, while the frequency of oxalate stones increased. We conclude that this difference in the frequency of the type of urinary stones might reflect the regional dietary habits. Regional frequency and etiology studies for the types of urolithiasis may facilitate the approach to the treatment of urolithiasis.

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Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Urolithiasis in Pediatric Patients: A Single Center Study of Incidence, Clinical Presentation and Outcome

ObjectiveSince 1980s, the clinical and biological characteristics of urolithiasis in Tunisian children have continuously evolved. This retrospective study defines the current status of urolithiasis among children and adolescents in Tunisia.MethodsWe retrospectively reviewed the records of 310 children and adolescents (age: 3 months - 19 years) between 2003 and 2010, holding urolithiasis. A first-line metabolic, urine and plasma work-up was performed in all patients. Physical and chemical analysis of the stones was performed respectively by stereomicroscopy and infrared spectroscopy. Statistical analysis of the results was performed with SPSS 11.0 software. The Chi-square test was used for comparison of percentages.FindingsOur study shows a male predominance of urolithiasis with a sex ratio of 1.5. Stones were located in the upper urinary tract in 70.7% of cases. Calcium oxalate was the predominant constituent in 52.6% of stones. There was an increasing prevalence of calcium oxalate stones according to age in both genders (48.6% in infants vs 68.5% in teenagers (P<0.01)). Struvite was more frequent in patients aged 2-9 years (P<0.02) and significantly more prevalent in boys than in girls (P<0.001). Ammonium urate stones were observed in 14.2% and were more frequent in infants.ConclusionOur results emphasize a high percentage of calcium oxalate stones and a low percentage of struvite stones. The persistence of urate stones reflects the particular eating habits and the infectious risk factors. The patient's age is an important factor that must be taken into account during etiopathogenic work-up.

BACKGROUND AND OBJECTIVES:Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.METHODS:We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.RESULTS:Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.CONCLUSION:Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

A Simple Method for Selecting Urine Samples that Need Culturing

Objective To discuss clinical characteristics of children with urosepsis. Methods Between January 2017 and June 2018, a total of 51 children were admitted as study group with the diagnosis of urosepsis. And another 102 children with non-urosepsis were selected into control group through random extraction function of Microsoft Excel 2016. The medical records of demographic data, laboratory tests, and prognosis were collected. Independent-samples t test was performed on platelet count (PLT), fibrinogen (Fib), and erythrocyte sedimentation rate (ESR). White blood cell (WBC), hemoglobin (Hb), alanine transferase (ALT), aspartate aminotransferase (AST), albumin, total bilirubin (TB), lactate dehydrogenase (LDH), creatinine, blood urea nitrogen (BUN), serum Na+ , serum K+ , serum Ca2+ , serum Cl-, glucose, D-dimer (DDI), fibrinogen degradation (FDP), N-terminal pro-brain natriuretic peptide (NTBNP), troponin I (cTnI), pH value, and lactic acid were compared by Mann-Whitney U rank sum test. The chi-square test or continuity correction were used to perform statistical analysis on the ratios of gender ratio, pediatric intensive care unit (PICU) occupancy rate, and mortality. This study was in line with the World Medical Association Declaration of Helsinki revised in 2013. There was no significant difference in gender composition ratio between two groups (χ2=1.593, P=0.207). Results ①The median age of study group was 6-month old (4-12 months old), which was younger than that of control group [10-month old (5-24 months old)] (Z=-2.660, P=0.008). ② The levels of WBC and CRP in study group were 17.4×109/L [(11.8-26.6)×109/L] and 120 mg/L (87-160 mg/L), which were higher than 12.0×109/L [(5.0-17.6)×109/L] and 48 mg/L (20-135 mg/L) in control group. The differences between two groups were statistically significant (Z=-4.145, -4.465; P all 15×109/L and CRP>40 mg/L in study group were 62.7% (32/51) and 90.2%(46/51), which were higher than those of control group 38.2%(39/102) and 55.9%(57/102), and the differences between two groups were statistically significant (χ2=8.212, 18.197; P=0.004, 10 s, PLT 100 U/L, neurological symptoms, Ca2+ <2.1 mmol/L in study group were 11.8% (6/51), 3.9% (2/51), 8.0% (2/25), 7.8% (4/51), 3.7% (1/27), 6.0% (3/50), 29.4% (15/51), 6.1% (3/49), lower than 47.1%(48/102), 27.5%(28/102), 35.3% (24/68), 20.6% (21/102), 34.4% (22/64), 25.5% (26/102), 61.8% (63/102) and 27.6%(27/98) of control group, and the differences were statistically significant (χ2=18.545, 11.941, 6.761, 4.040, 9.458, 8.255, 14.241, 9.235; P all<0.05). ⑤ Among 51 children in study group, 49 children (96.1%, 49/51) showed increased levels of leucocytes and pus cells according to urine routine examination results, another 2 children showed normalities in urine and urine culture but abdominal CT examination results showed renal abscess. ⑥ The PICU transfer rate and mortality of study group were significantly lower than those of control group, and the differences between two groups were statistically significant (χ2=17.480, 6.142; P all<0.05). Conclusions Children with urosepsis is more likely to have higher WBC and CRP level, lower organ function rate and better prognosis. For children with sepsis accompanied by high level of inflammatory maker and lower organ dysfunction rate, it is of great significance to carry out early urinalysis, urine culture and have ultrasound or CT of urinary system. Key words: Sepsis; Urinary tract infections; Inflammasomes; Bacterial infections; Procalcitonin; Diagnosis; Prognosis; Child

Infection stones in children: A twenty-seven-year review

The continued evolution of stone treatment modalities, such as endourologic procedures, open surgery and shock wave lithotripsy, makes the assessment of continuous outcomes are essential. Pediatric urolithiasis are an important health problem allover the world, especially in Middle East region. We evaluate the safety, efficacy and factors affecting success rate and clearance of stones in children treated with shock wave lithotripsy. Between 2005 and 2010, a total of 500 children with stones in the upper urinary tract at different locations were treated by Extracorporeal shock wave lithotripsy (ESWL) in our department, Sohag University, Egypt. We have used the Siemn's Lithostar Modularis machine, Germany. A total of 371 boys and 129 girls with the average age of 8.63 ± 5 years, and a range from 9 months to 17 years were included in this study. Diagnosis of their urinary calculi was established either by the use of abdominal ultrasound, plain X-ray, intravenous urography, or CT scan. The stones were located in the kidney in 450 (90%) patients; 298 (66%) pelvic, 26 (5.7%) upper calices, 57 (12.6%) mid calices, and lower calices in 69 (15.3%) patients. The average of their stone sizes was 12.5 ± 7.2 mm. The other 50 children their stone were located in the proximal ureteral stones in 35 patients (70%); middle third in 5 (10%) patients and in the distal ureter in 10 (20%) patients. The average ureteral stone size was 7.5 ± 3.2 mm. All children were treated under general anesthesia with adequate lung and testes shielding using air foam. We treated the distal ureteral stones of young children in the supine position through greater sciatic foramen and lesser sciatic foramen as the path of shockwave instead of prone position, which is not a comfortable or natural position and could adversely affect cardiopulmonary function especially under general anesthesia. Localization was mainly done by ultrasound, and X-ray was only used to localize ureteral calculi. For follow-up, we have used abdominal ultrasound, plain X-ray, and CT scan if needed to confirm stone disintegration and clearance. The overall success rate for renal and ureteral calculi was 83.4 and 58.46%, respectively. The re-treatment rate was 4% in renal group and 28% for the ureteral group. No serious complications were recorded in our patients. Minor complications occurred in 15% of our patients; renal colic was reported in 10% of our treated patients, and repeated vomiting was reported in 5% that respond to antiemetics. In the renal group; children with history of pervious urologic surgical procedures had low success rate of stone clearance after ESWL. In the ureteral group stone burden, stone location, had a significant impact on stone clearance outcome. This study showed that SWL in pediatric age group for both renal and ureteral stone is cost effective, safe with an acceptable re-treatment rate; however children with large stone burden or previous urologic surgery have low success rate.

Background: Urinary tract infection (UTI) is a frequent cause of morbidity in children, particularly in malnourished populations where immune compromise increases susceptibility and complications. Early diagnosis is essential to prevent renal damage; however, urine culture—the gold standard—is time-consuming and resource intensive. Urine analysis offers a rapid and economical alternative, but its diagnostic reliability in malnourished children in Peshawar remains insufficiently explored. Objective: To determine the diagnostic accuracy of urine analysis for detecting UTIs in malnourished children, using urine culture as the reference standard. Methods: The current cross-sectional validation study was carried out at the Department of Pediatrics, Lady reading Hospital, Peshawar, during the period between July 2024 and January 2025. The malnourished children who were aged 1-5 years and had suspected UTI were enrolled consecutively (290 in total). A urine sample was collected either in a clean-catch or suprapubic aspiration and placed under urine analysis and culture. Definitions of Pyuria were 10 or more WBC/mm 3 or 5 or more WBC/HPF. Sensitivity, specificity, predictive values, and accuracy were determined in terms of diagnostic indices. Results: UTI was established in 61 (21.0%) children by urine culture. Urine examination was affirmative in 86 (29.7) cases. The sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy of urine measure stood at 80.3, 83.8, 57.0, 94.1, and 83.1 respectively. Conclusion: The sensitivity of urine analysis is high and the negative predictive is good, thus, it is a sensitive screening tool to rule out UTI in the malnourished child. Nevertheless, a urine culture must confirm positive results in order to proceed with the series of antimicrobial therapy.

Background: Urinary tract infections (UTI) are one of common clinical condition encountered in various clinical settings. This the most common infection, typically diagnosed on the basis history and clinical examination endorsed by urine analysis and culture sensitivity. Timely diagnosis and treatment are crucial in management. For diagnosis of UTI, Urine culture is standard, as it provide detail information for urinary pathogens, but it has certain disadvantages e.g. urine culture is costly, takes longer time, and up to 60-80% of the results are negative. Objective: To determine the diagnostic accuracy of urinalysis (Urine DR) in detection of urinary tract infection (UTI) among suspected cases of UTI by taking urine culture as gold standard. Materials And Methods: This cross sectional study was conducted at study was conducted at Department of Urology, Jinnah Postgraduate Medical Centre (JPMC) Karachi, from march 2021 to September 2021. All patients who visited to JPMC Karachi and fulfilled the inclusion criteria and were included in the study after getting Informed consent. All patients were evaluated by urinalysis and urine culture. The results of urinalyses were recorded and compared with the results obtained on subsequent urine cultures. All of the specimens were obtained by the “clean-catch” method. All data and results were recorded on proforma and used electronically for research purpose. Results: Mean ± SD of age was 52.6±8.5 years. In distribution of gender, 60 (53.1%) patients were male while 53 (46.9%) were female patients. Diagnostic accuracy of urinalysis was 73.45% in diagnosis of urinary tract infection with sensitivity 76.47%, specificity 72.15% PPV 54.17% and NPV was found to be 87.69% by using urine culture findings as gold standard. Conclusion: It is to be concluded that evaluating of urinary tract infection (UTI) with urinalysis (Urine DR) did not prove helpful and comparable to urine culture. Urine culture should be done in each and every suspected case of UTI. Keywords: Bacteriuria, Diagnostic Accuracy, Sensitivity, Specificity, Urinalysis

The association between foreign objects in the urinary system and urinary tract infections (UTI) is well established. The incidence of bacteriuria in patient with urinary catheters increases as dwelling time lengthens. The presence of ureteral stents and kidney stones is also associated with increased risk for bacteriuria and urinary tract infection. The aim of this study was to assess the bacterial characteristics of urine culture (UC) and foreign body culture (FBC), the concordance between them, and to identify risk factors for postoperative infections, in order to improve the treatment in these patients, using a prospectively collected database of patients who underwent ureteroscopy or percutaneous nephrolithotomy (PCNL) for the treatment of urinary stones between 2005 and 2016 at our institute. Preoperative UC was obtained from voided mid-stream urine for all patients. FBCs were obtained from ureteral stents removed and stones collected during the surgery. The cohort included 1011 patients. Mean age was 53 (SD 15.8), and 679 (67.2%) patients were male. Two hundred eighteen (21.6%) had a UTI in the year prior to the surgery. Among 795 patients who had sterile UC, 98 (12.3%) patients had positive FBC. Positive FBC was found in 53.7% of the patients with positive UC; however, FBC pathogens were similar to those identified in UC in 31% patients. The sensitivity of UC to detect FBC pathogens was 31.3%, and the PPV was 0.31. Urine cultures do not recognize all cases of pathogens colonizing foreign bodies in the urinary system. The colonization may be associated with an increased risk for SIRS. In more than one-quarter of the patients, the causative pathogen of sepsis is identified by FBC, but not by UC.

ObjectivePrevious studies on diagnostic accuracy of dipstick testing for leukocyte esterase (LE) and nitrite to diagnose urinary tract infection (UTI) had used urine culture, which is an imperfect gold standard. Estimates of diagnostic accuracy obtained using the classical gold standard framework might not reflect the true diagnostic accuracy of dipstick tests.MethodsWe used the dataset from a prospective, observational study conducted in the emergency department of a teaching hospital in southern India. Patients with a clinical suspicion of UTI underwent dipstick testing for LE and nitrite, urine microscopy, and urine culture. Based on the results of urine microscopy and culture, UTI was classified into definite, probable, and possible. Patients with microscopic pyuria and a positive urine culture were adjudicated as definite UTI. Unequivocal imaging evidence of emphysematous pyelonephritis or perinephric collections was also considered definite UTI. We estimated the diagnostic accuracy of LE and nitrite tests using the classical analysis (assuming definite UTI as gold standard) and two different Bayesian latent class models (LCMs; 3-tests in 1-population and 2-tests in 2-populations models).ResultsWe studied 149 patients. Overall, 64 (43%) patients had definite, 76 (51%) had probable, and 2 (1.3%) had possible UTI; 7 (4.6%) had alternate diagnoses. In classical analysis, LE was more sensitive than nitrite (87.5% versus 70.5%), while nitrite was more specific (24% versus 58%). The 3-tests in 1-population Bayesian LCM indicated a substantially better sensitivity and specificity for LE (98.1% and 47.6%) and nitrite (88.2% and 97.7%). True sensitivity and specificity of urine culture as estimated by the model was 48.7% and 73.0%. Estimates of the 2-tests in 2-populations model were in agreement with the 3-tests in 1-population model.ConclusionsBayesian LCMs indicate a clinically important improvement in the true diagnostic accuracy of urine dipstick testing for LE and nitrite. Given this, a negative dipstick LE would rule-out UTI, while a positive dipstick nitrite would rule-in UTI in our study setting. True diagnostic accuracy of urine dipstick testing for UTI in various practice settings needs reevaluation using Bayesian LCMs.

Kidney stones has been known since the time of ancient Babylonians and Egyptians, a urinary tract stones (urolithiasis) are found in the urinary tract, ranging from kidney calix system, pielum, ureters, bladder and urethra. The cause of the formation of urinary tract stones allegedly associated with urinary tract disorders, metabolic disorders, urinary tract infections, dehydration and other circumstances that remain unclear (idiopathic). Urinary tract stones in general contain elements: calcium oxalate, calcium phosphate, uric acid, magnesium-ammonium-phosphate (MAP), xanthyn and cystine. Understanding the composition of rock found important in the prevention of the possibility of recurrent stone. Presence or absence of a definitive diagnosis of kidney stones can be known through the analysis of urine routine examination (urinalis) and the X-ray examination stomach and abdomen area. Prevention can be done by reducing the types of foods that contain purine like sardines, organ meats, liver, brain, shellfish and other food. Treatment can be done by taking certain drugs for the stones are still small, whereas for large-sized stones that already can be done by way of ESWL (Extra-corporeal Shock Wave Lithotripsy), or by performing surgery.Kata kunci : Urollithiasis, Batu Ginjal, Saluran Kemih, Kalsium Oksalat, KalsiumFosfat, Asam Urat