Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway. Issue 2 (April 2023)

• Record Type: Journal Article
• Authors: Nelson, Ryan; Stamm, John; Timmons, Zebulon; Grimsby, Gwen M.
• Is Part Of: Journal of pediatric urology. Volume 19:Issue 2(2023)
• Page Start: 177.e1
• Page End: 177.e6
• Publication Date: 2023-04
• Subjects: Ureteral calculus -- Urinary tract stones -- Ureteral colic -- Tamsulosin; Pediatric urology -- Periodicals; Urologic Diseases -- Periodicals; Urogenital Diseases -- Periodicals; Urologic Surgical Procedures -- Periodicals; Child; Infant; Urologie pédiatrique -- Périodiques; Appareil urinaire -- Maladies -- Périodiques; Pédiatrie; Urologie; Pediatric urology; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); Electronic journals; Periodicals; Electronic journals; 618.926
• DOI: 10.1016/j.jpurol.2022.11.015
• Languages: English
• ISSNs: 1477-5131

Abstract

Summary: Introduction/Background: Urolithiasis is an increasingly common condition seen in children with an annual incidence of 2–3% in children under 18, and up to 10% in adolescents. Treatment of stones varies including observation, IV hydration, pain management, medical expulsive therapy (MET), or surgery. Though well-studied and often used in adults, MET (alpha-adrenergic antagonists to facilitate passage of ureteral stones), is not routinely prescribed in pediatric patients. Objective: The goals of this study were to review a quaternary children's hospital's emergency room frequency of MET utilization for ureterolithiasis as well as evaluate the clinical outcomes of children who were prescribed MET compared to those treated with pain control alone. Study design: A retrospective review was performed of children 2 months to 18 years with ureterolithiasis who presented to a quaternary children's hospital ED from 2011 to 2017. The primary outcome was the frequency of MET prescribed. Secondary outcomes included the following comparisons in patients who received MET and analgesics with those who received analgesics alone: hospital admission rate, length of hospitalization, emergency room re-presentation rate, surgical intervention, spontaneous stone passage, urology consultation, how the urology consult affected MET utilization, referral to outpatient urology and nephrology clinics, and CT utilization in the ED. Comparisons were performed utilizing Fischer's exact and t-tests. Results: 139 patients were included with a mean age of 14 years (SD 4.14), 42% male. There was no difference between age, gender, stone size, return to the ED, serum creatinine, or length of hospitalization (if admitted) between patients who were and were not placed on MET. The rate of stone passage was significantly higher for those placed on MET (45%) versus not (20%) (p = 0.0022). Urology was consulted for 93% of the cases where children were prescribed MET, compared with only 52% of cases where MET was not prescribed (p = <0.0001). Discussion: In our experience MET was significantly underutilized in patients where urology was not involved. This is similar to a study by Itano et al. which found urology consultation in the ED significantly increased use of tamsulosin for ureterolithiasis in adults. Children with ureterolithiasis placed on MET had a significantly higher rate of stone passage compared to children managed by pain control alone. Conclusion: Given the benefits of MET to increase the rate of spontaneous stone passage it may be considered first line therapy for treatment of children with ureterolithiasis. Summary Table Comparison of patient treated with MET versus pain control alone. a Summary Table MET (n = 75) No MET (n = 64) P value Age in years ; mean, median, (SD) 14.5, 13.4 (3.53) 13.4, 11.8 (4.73) 0.1362 Male gender ; n (%) 32 (43) 27 (42) 1.0000 Stone size in mm ; mean, median, (SD) 4.6, 4.0 (2.42) 4.6, 4.0 (3.23) 0.9400 Distal ureteral stone ; n (%) 37 (49) 39 (61) 0.1774 Serum creatinine ; mean, median, (SD) 0.75, 0.76 (0.271) 1.03, 0.85 (1.30) 0.1286 Urology contacted in ED ; n (%) 70 (93) 33 (52) <0.0001 Discharged from ED ; n (%) 45 (60) 37 (58) 0.8632 Prescribed opioids ; n (%) 35 (47) 26 (41) 0.4974 Days in hospital if admitted ; mean, median, (SD) 2.0, 2.0 (1.00) 2.7, 2.5 (1.66) 0.0757 Repeat ED visit with renal colic ; n (%) 12 (16) 6 (9) 0.3141 Passed stone ; n (%) 34 (45) 13 (20) 0.0022 Surgery for stone ; n (%) 23 (31) 25 (39) 0.3713 a Comparisons were performed utilizing Fischer's exact and t-tests.