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Summary Background The incidence of urolithiasis in children has risen worldwide over the last decades with geographical varieties. As pediatric patients begin forming stones earlier in life, they have high risk of recurrence. Extracorporeal shockwave lithotripsy (SWL) is a non-invasive treatment modality that is preferred in the management of pediatric stones. Reports about the safety and efficacy of SWL in patients younger than 24 months are scarce in the literature. Objective The aim of the study was to evaluate the effectiveness and safety of SWL in patients younger than 24 months. The authors also aimed to assess the validity of the Dogan nomogram in predicting stone-free rates. Study design Between January 2009 and March 2019, data of 247 patients younger than 24 months at the time of SWL were retrospectively collected. Analysis was performed on 260 renal units. Success was considered in patients who were completely free of stones after the first session. Results and Discussion The female/male ratio was 103/157, with a median age of 15 (5–24) months, a median stone size of 8 (3–30) mm and a median follow-up period of 7 (3–20) months. Multiple stones and lower calyx stones were observed in 19.6% (51/260) and 23.4% (61/260) of patients, respectively. Complications were detected in 5.8% (15/260) of patients (9 with steinstrasse, 3 with UTI, 2 with vomiting, 1 with hematuria). After the first session, 56.9% (148/260) of patients were stone-free. Forty-six of the failed 112 first sessions underwent second session. A total of 5 patients had a third session. The efficacy quotient was 57%. On univariate analysis, younger age (≤16 months), single stone, small stone size ( Conclusion Shockwave lithotripsy is a safe and effective treatment modality in patients younger than 24 months and could be the first option in this particular age-group in whom the other endourological modalities are not always applicable. The Dogan nomogram is reliable in predicting the stone-free rate in this age-group. Table . Comparative analysis of the factors affecting the stone-free rates after a single session. Parameter Stone-free (SF) rate (%) P Gender Male 61.1% 0.090 Female 50.5% Metabolic abnormality None 64.5% 0.198 Hypocitraturia 58.8% Hyperoxaluria 42.1% Hypocitraturia + hyperoxaluria 73.1%% Degree of hydronephrosis None, mild 56.5% 0.750 Moderate, severe 59.1% Age (months) ≤16 64.3% 0.003 >16 45.6% Side Right 52.4% 0.152 Left 61.2% Stone number Single 64.6% Multiple 25.5% Size ≤10 mm 61.3% 0.007 >10 mm 41.1% Location Lower pole calyx 47.2% 0.051 Non–lower pole 60.6% Previous intervention Yes 58.0% 0.864 No 56.7% Dogan nomogram score ≤150 64.9% >150 27.3%

Extended Summary Introduction Vesicoureteral reflux (VUR) is an anatomic or functional disorder, and it is a condition associated with renal scarring, hypertension, and end-stage renal disease. Renal damage can be prevented by appropriate medical and surgical intervention for selected patients. Objectives The objective of this study was to retrospectively analyze the surgically treated patient group of this study in reference to the risk analysis criteria used in European Association of Urology (EAU), European Society for Paediatric Urology (ESPU) guidelines to see the outcome of the study management protocol within the last 15 years in respect to this risk analysis. Study design A total of 686 patients who were operated upon in a single institution for VUR between 1997 and 2016 were retrospectively analyzed. According to the criteria in EAU/ESPU guidelines, the patients were classified into three groups: low, medium, and high risk. Risk factors were compared between the groups. Results The patient numbers for low, medium, and high risk were 92 (13.4%), 485 (70.7%), and 109 (15.9%), respectively. In the high-risk group, surgeons tended to do more ureteroneocystostomy (UNC) (82.6%), whereas in the low-risk group, surgeons tended to do more subureteric injection (STING) (76.1%). The success rates for STING and UNC were found to be 75% and 93%, respectively. Although there was a difference in success rates among patients treated with STING or UNC, this difference was not statistically significant in success rates regarding risk groups for patients treated with STING or UNC. Discussion The most recent guideline was that which was published by the EAU/ESPU organization in 2012. This guideline is established based on the risk analysis. The analysis revealed that patients in the low-risk group tended to undergo endoscopic surgery treatment method, whereas patients in the high-risk group tended to undergo open surgery. Therefore, the study management over the last 10 years has been mainly in line with the current recommendations. Conclusion The analysis shows that when the patients are classified according to the EAU/ESPU risk classification, surgeons tended to perform more endoscopic and more open surgery for the low- and high-risk groups, respectively. Although each surgical modality had similar success rates in each group, open surgical results were overall much higher than those of endoscopic surgery in each group. This was a specifically important finding in high-risk group where the endoscopically treated group of patients was small in number, and the need for a definitive correction is essential in this group because of increased risk of renal injury. Table . Comparison of surgical procedures according to risk groups. Parameters Low risk Medium risk High risk p Operation STING 70 (76.1%) 203 (41.9%) 19 (17.4%) UNC 22 (23.9%) 282 (58.1%) 90 (82.6%) All patients Successful 71 (77.2%) 417 (86%) 97 (89%) 0.045 Unsuccessful 21 (22.8%) 68 (14%) 12 (11%) STING Successful 52 (74.3%) 153 (75.4%) 14 (73.7%) 0.975 Unsuccessful 18 (25.7%) 50 (24.6%) 5 (26.3%) UNC Successful 19 (86.4%) 264 (93.6%) 83 (92.2%) 0.426 Unsuccessful 3 (13.6%) 18 (6.4%) 7 (7.8%) STING, subureteric injection; UNC, ureteroneocystostomy. Bold values are statistically significant.

Introduction Many studies have been performed on adult patients to reveal the relationship between Hounsfield unit (HU) value and composition of stone, but none have focused on childhood. Objective We aimed to predict stone composition by HU properties in pre-intervention non-contrast computed tomography (NCCT) in children. This could help to orient patients towards more successful interventions. Materials and methods Data of 94 children, whose pre-intervention NCCT and post-interventional stone analysis were available were included. Stones were grouped into three groups: calcium oxalate (CaOx), cystine, and struvite. Besides spot urine PH value, core HU, periphery HU, and Hounsfield density (HUD) values were measured and groups were compared statistically. Results The mean age of patients was 7 ± 4 (2–17) years and the female/male ratio was 51/43. The mean stone size was 11.7 ± 5 (4–24) mm. There were 50, 38, and 6 patients in the CaOx, cystine, and struvite groups, respectively. The median values for core HU, periphery HU, and mean HU in the CaOx group were significantly higher than the corresponding median values in the cystine and struvite groups. Significant median HUD difference was seen only between the CaOx and cystine groups. No difference was seen between the cystine and struvite groups in terms of HU parameters. To distinguish these groups, mean spot urine PH values were compared and were found to be higher in the struvite group than the cystine group (Table). Table. Comparison of stone types according to HU parameters, spot urine PH, and p values. Parameters Core HU Periphery HU Mean HU Spot urine PH CaOx vs Cyst

Despite the fact that shock-wave lithotripsy (SWL) remains a very good treatment option for smaller stones, it is being challenged by endourologic treatment modalities, which offer similar or even higher success rates in a shorter time, with minimal morbidity and invasiveness. The present study aimed to bring a new and practical insight in order to predict the outcomes of pediatric SWL and to provide objective information about pediatric SWL outcomes.To design a nomogram for predicting the outcomes of pediatric shock-wave lithotripsy.The study was conducted with a retrospective design and included 402 renal units who underwent SWL between January 2009 and August 2013. Patients with known cystine stone disease and cystinuria, with internal or external urinary diversion, were excluded. Analysis was performed on 383 renal units. Postoperative imaging was performed by plain abdominal graphy and ultrasonography with 3-month intervals. Patients who were completely free of stones were considered to be a success and statistical analysis was done regardingly Multivariate analysis was conducted by logistic regression analysis and a nomogram was developed.The male/female distribution was 216/167, with a mean age of 48 ± 40 months and a mean stone size of 9 ± 3.5 mm. The overall stone-free rate was 70% (270/383) and efficacy quotient was 0.57. Mean follow-up was 11 ± 11 months (3-54 months). The number of shock waves and amplitude of energy were higher in failed cases. Multivariate analysis showed that gender, stone size, number of stones, age, location of the stone, and history of previous intervention were found to be the independent prognostic factors for assessing the stone clearance rates. A nomogram was developed using these parameters. In this nomogram, the points achieved from each parameter are summed and total points correspond to the risk of failure in percent.A previous nomogram study by Onal et al. showed that younger age (5 years), smaller stone burden (1 cm), absence of previous stone treatment history, single stone, pelvis or upper ureter location (in girls) were favorable prognostic factors for successful outcome. As being the first pediatric study, it had some shortcomings. The study included 381 patients within a time period of 16 years. The present study included a similar number of cases within a 4-year period, which may reflect more homogeneity of data collection. Another issue is concern about the practical use of that nomogram. It constitutes two pages, which is a limiting factor for daily use. From a statistical point of view, they performed 200 bootstrapings with the aim of internal validation, which is less than the ideal number of 1000 bootstrapings, which was performed in the present nomogram. The presented nomogram is more practical, in that the pre-operative factors can be placed on the nomogram, the points can be added up and the parents can be given the approximate percentage of predicted stone-free rate after a single session. The expected treatment modality shown to the parents and patients ought to be the least minimally invasive, have the highest success rate, the least complication rate, and show the efficacy in one procedure at a time within the shortest period. However, SWL does not completely meet these criteria. The results gained from the present critical analysis of SWL in children, which was based on a strict definition of success, showed that outcome after a single session is not that good. Therefore, defining the patients who will benefit the most became one of the main issues. A more objective and skeptical look at SWL data enabled a nomogram to be developed that brings a new and practical insight in order to predict the outcomes of pediatric SWL.In most of the pediatric stone cases, SWL is the first-line treatment option. However, it is wise to define the patients who will benefit the most. Therefore, nomograms can be useful for this purpose. The nomogram in the present study revealed that gender, stone size, number of stones, age, location of the stone, and history of previous intervention were found to be the independent prognostic factors for assessing the stone clearance rates. This nomogram can practically be used to inform the parents, and for proper patient selection for SWL.

Summary Introduction Among the interventional treatment modalities for vesicoureteral reflux (VUR), endoscopic subureteric injection seems to be the least invasive method with acceptable outcomes when applied in appropriate patients. Objective The aim of the presented study is to investigate the parameters which may affect the outcomes of endoscopic injection and to compare the efficacy of two different bulking agents both composed of dextranomer-hyaluronic acid copolymer. Study design The data of patients who underwent endoscopic VUR treatment between 2003 and 2012 were retrospectively reviewed. Patients with history of previous open antireflux surgery, more than one failed endoscopic treatment for reflux, VUR caused by posterior urethral valve, duplex system and overt spinal dysraphism were excluded. Surgical technique was the classical STING method. One of the two dextranomer-hyaluronic acid copolymer agents was used (Deflux in 109 and Dexell in 131 patients). Both agents were composed of similar amounts of hyaluronic acid gel (15 mg in Deflux versus 17 mg in Dexell) but different sized dextranomer microspheres (80–250 μm in Deflux and 80–120 μm in Dexell). During the follow-up, ultrasonography was performed with 3-month interval, antibiotic prophylaxis was continued until the control voiding cystourethrography (VCUG) was taken. Patient based success was defined as the disappearance of reflux on control VCUG performed 3–6 months after the operation. Results Data were available for 240 patients. Mean age and mean postoperative follow-up were 78 ± 41 months and 19 ± 18 months. The overall success rate was 73.2%. Gender, laterality, grade of VUR, presence of voiding dysfunction, renal scar and preoperative breakthrough infection (BTI) were not found to affect the outcome, whereas age younger than 54 months and previous history of failed endoscopic injection were found to negatively affect the outcome both in univariate and multivariate analysis. The postoperative UTI (5 febrile and 43 nonfebrile) rate was 20%. Both univariate and multivariate analysis showed that postoperative UTI was more common in patients with persisting reflux, with preoperative breakthrough infections and in girls. Patient characteristics, treatment outcome and postoperative UTI rate were similar regarding the used bulking agent. No ureteral obstruction was experienced within the follow-up period. Discussion Our success rate for second injection is about 60%, which is significantly lower than for the patients who underwent first injection. We could not find any affecting factor for this difference. Contrary to the literature, our success rates were similar in different reflux grades. We can explain this finding that we value the intraoperative orifice configuration more than the grade which can be accepted as a patient selection bias. The lower success rate in children younger than 54 months can be explained by unstabilized bladder dynamics and higher voiding pressures in this age group, who are still in the toilet-training phase. Despite successful endoscopic treatment, UTI might occur. Postoperative UTI was more common in patients with persisting reflux, preoperative BTI and girls. The similar success rates of both bulking agents proved that dextranomer size does not affect the clinical outcome. Limitations of our study can be counted as follows: 1. the data do not include the number of patients in whom conversion to open surgery was decided intraoperatively because of the unfavorable orifice configuration, 2. our data do not include the injected volume records. Conclusion Endoscopic treatment of VUR has satisfying outcomes in properly selected cases. Younger age ( Table . Comparison of treatment success regarding several factors (chi-square test). Male vs female %66 vs 75.4 p = 0.174 Age 54 m. %65.7 vs 78.5 p = 0.043** Unilateral vs bilateral %77.5 vs 67.6 p = 0.087 Grade 1–2 vs 3 vs 4–5 %77.9 vs 73 vs 67.4 p = 0.455 Grade 1–2–3 vs 4–5 %74.7 vs 67.4 p = 0.311 VD, no vs yes %80 vs 78.1 p = 0.774 Scar, no vs yes %72 vs 72.4 p = 0.941 BTI, no vs yes %73 vs 74.5 p = 0.806 Deflux vs Dexell %75.2 vs 71.8 p = 0.545 Previous failed STING, no vs yes %75.9 vs 59.5 p = 0.038** BTI = breakthrough infection; VD = voiding dysfunction. *p is lower than 0.05 by chi-square test.