Case Presentation - Pediatric Endourology

Transcription

1 Case Presentation - Pediatric Endourology PA N E L : E U G ENE M I N EV I C H, U S A J O NAT H A N G L A S S, UK R OY M O R AG, I S R A E L YO R A M M O R, I S R A E L P I N C H AS L I V N E, I S R A E L M O D E R ATO R : I L A N K A F KA, I S R A E L

2 Financial and Other Disclosures I have the following financial interests or relationships to disclose: No financial relationships Disclosure code N 2

3 Case #1 10 y.o. male VACTERL Association Imperforated anus/ Megasigma Sacral Agenesis Lt. Renal Agenesis End Colostomy + Partial Sigmoidectomy after birth Age 3 Vesicostomy Non contractile Bladder by FUDS Age 7 Bladder Augmentation (Gastro ileal) w/ Mitrofanoff- CIC by caregiver ACE (Malone procedure)

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5 CIC- 12 Fr Fr ---- Trouble performing CIC Age 9- Underwent Revision of Mitrofanoff Age 10 -Recurrent UTI s Presents to ED with Rt. Flank Pain Finished Last course of oral Abx. one day prior US- Rt. Mild Hydroureteronephrosis, susp. 8 mm Stone distal ureter + 1 cm Bladder stone. Creat No Fever, Normal Signs

6 Plan? Ureteroscopy Access through Mitrofanoff Unable to ID Ureteral Orifice Sub-Febrile, Normal white count, Cr. Still 1.2 Urine Culture- Pseudomonas Aeruginosa What Now?

7 IV Abx by sensitivities Nephro-ureteral stent Placed by IR UVJ narrowing with distended ureter- trouble working wire to bladder Distal Ureteral Stone still ID by Fluoroscopy during placement

8 Plan? Percutaneous Cistolithalopaxy 30 Fr Access Sheath Flexible URS + Laser Lithotripsy, basket extraction No Stricture seen UVJ, wide ureter

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10 Creatinine normalizes Stone Analysis- Struvite 100% Plan?

11 Case #2 4y.o Female Born Term 38 weeks Recurrent UTI s from age 1-3 VCUG No Reflux / Normal repeat US

12 Chronic Abdominal Pain Lately - Recurrent Nausea + Vomiting Urine Leu+ Ery +++ Nit+ Urine Culture- Proteus Mirabilis Normal Blood Work

13 5 days on Abx according to sensitivities No clinical improvement US- Rt. Mild hydronephrosis, susp. 1.5 cm LP calculus Plan?

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16 Plan? Prone Mini PCNL UP access 18Fr AS, Laser lithotripsy Active Basket stone Retrieval

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18 Stone Analysis CaOxM 30% Struvite 40% CaPh. 30% 24hr. Collection Volume 1500 ml/24 hrs Normal Electrolytes Normal UA Normal Ox + Citr Neg. Cystein profile ph 7.8

19 4 yo male Case 3 Born Term, 38 weeks, C-Section d/t placenta previa Parents- 1 st degree cousins Dx. Age 12 days- Microvillus inclusion disease - Home TPN through central line. Recurrent line sepsis Recurrent UTI s- Proteus Mirabilis/ Klebsiella Pneumoniae

20 24 months - Macroscopic Hematuria -Renal US- LT kidney Small Calcifications of lower pole, no Hydronephrosis -Urine Culture- Klebsiella Pneumoniae -Abx. treatment with resolution of symptoms -No urology Consult

21 Age 27 months- Abdominal Pain Urine Culture - Proteus Mirabilis Renal US- LT KIDNEY unchanged from previous exam RT KIDNEY- Mild Hydronephrosis, multiple Calcifications, 6mm stone in UPJ No Urology Consult IV Abx. And D/C

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24 Age 29 months- Vomiting, Fever, Abdominal Pain Severe Hyponatremia and Hypokalemia, Cr 0.77, HB 7.9 Hemodynamically Stable Abdominal US LT KIDNEY Several larger Stones than in previous exam RT KIDNEY- Severe Hydronephrosis, multiple Calcifications, 6mm stone in UPJ

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27 PLAN?

28 PLAN? Bilateral Ureteral Drainage by DJS Stabilized, Labs Normalize

29 Recurrent line Sepsis + Recurrent Line Leaks Anemia requiring Blood transfusions Metabolic Imbalances Recurrent UTI s Patient unfit for definitive stone clearance PLAN?

30 DJS exchange every 2 months Age 36 months- Lt. encrusted stent- incomplete LT DJS Retrieval PLAN?

31 Percutaneous antegrade stent insertion by IR- Uneventful

32 Patient is D/C 3 weeks later- Massive hematuria Anemia- requiring transfusions Negative Urine cultures Abdominal US- Dense material in LT collecting system, Mild Hydronephrosis, Proximal Coils of DJS s in place PLAN?

33 Angiography- Small Pseudo Aneurysm-Coil

34 Stabilizes Hemodinamically- D/C Cleared for definitive Stone Surgery after a few weeks Negative Urine Cultures Normal Labs PLAN?

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36 What s next?

37 Bilateral Prone PCNL 18 Fr Access- Laser Lithotripsy + Active basket stone retreival LT. Remnant proximal stent removal Bilateral antegrade ureteroscopies Bilateral 8 Fr Coop Nephrostomy Removal POD 2 No post-op fever, Stable Hb/ Cr. D/C POD 3

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39 Two Weeks later Gross Hematuria- HB drop 1.5 grams since d/c Rt. Flank Pain Negative Culture PLAN?

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41 Stone Analysis- Struvite 100% Follow up- US 6 months- No evidence of nephrolithiasis

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43 Case 4 8 y.o male 12 hrs. before arrival - abdominal pain and difficulty urinating Urine Dipstick- Blood ++ Leu+ Normal Labs. KUB- Susp. Urethral calcification Foley inserted at local hospital and D/C Arrived to ED with 8Fr Foley catheter Normal Signs

44 PLAN? PLAN?

45 Abdominal US Both Renal units normal, Catheter in bladder, no other findings Negative Urine culture Cystoscopy with Basket retrieval of stone D/C Home Nephrology FU- Idiopatic Hypercalciuria Thiazides + K- Citrate Stone Analysis- CaOx Monohydrate 100%

46 3 years later Lt. Intermitent Flank Pain US- LT. no hydro 0.7 mm stone LP No fever, normal labs Next Step?

47 Failed LT ESWL LT. Flexible ureteroscopy- laser lithotripsy and basket extraction

48 Nephrology FU- No Change Stone- CaOx Monohydrate 100% 3 years later Asymptomatic Urine General- Ery + Leu + ph 7 Normal Labs US- Multiple calcifications in Lt. Kidney up to 7 mm size

49 PLAN?

50 Thank You!