The management of paediatric urolithiasis

Objective To evaluate the efficacy and safety of the management of paediatr ic urolithiasis by extracorporeal shock wave lithotripsy (ESWL), endoscopic ureterolithotomy, percutaneous nephrolithotomy (PCNL) and open nephrolitho tomy. Patients and methods In a 3-year period (1997-1999), 59 children were treat ed for urolithiasis and underwent a total of 79 procedures. Thirty-two ESWL sessions were performed in 23 children (mean age 7.4 years, median 6.0). P CNL was undertaken in 30 renal units in 25 children (mean age 6.4 years, me dian 4.0). Eight patients (mean age 7.8 years, median 5) underwent 17 urete roscopic procedures, six of which involved the use of a holmium laser. Thre e children with staghorn calculi underwent open nephrolithotomy under condi tions of renal ischaemia and hypothermia. Results Of the 23 children treated using ESWL, 21 (91%) became stone-free; 17 underwent one ESWL session (74%), three had two sessions and three (13%) had three sessions. All eight patients who underwent ureteroscopy became s tone-free. Four patients in whom the stone could not be reached by ureteros copy initially had a JJ stent inserted, and the stone and stent subsequentl y removed. Stones were cleared using PCNL in 27 of 30 renal units (90%); th ree patients who had residual stone fragments were rendered stone-free by E SWL. Two of three children undergoing open nephrolithotomy were stone-free after surgery and the remaining one rendered stone-free with ESWL. Metaboli c evaluation showed that 25 of 45 children (55%) had a urinary infection, e ight (18%) had hyperoxaluria, three (7%) had hypercalciuria, two (4%) had c ystinuria, and no identifiable cause was found in seven (16%). Treatment by a single modality rendered 52 of the 59 children (88%) stone-free; when th e different modalities were combined, 57 of 59 patients (97%) were cleared of their stones. Conclusions Technological advances in ESWL, ureteroscopy and PCNL have had a significant effect on the management of urolithiasis in children, allowin g a safe and successful outcome. The comprehensive care of children with ur olithiasis should include a full metabolic evaluation. Anatomical anomalies contribute to the complexity of many cases, necessitating a close liaison between adult and paediatric urologists, nephrologists and radiologists to optimize stone management in children.