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Stone Management
childhood originates from this type of hyperoxaluria. However, Surgical Management
children with PH2 usually do not present until their second or third Technological advances and the miniaturisation of endourological
decade of life.
5,6
instruments along with the increasing experience of the surgeons
have significantly altered the management principles in paediatric
The natural history of paediatric stone disease is not as well defined stone disease. Currently, the majority of stones in children can be
as it is in adult stone disease. The pathology is associated with managed with shock-wave lithotripsy (SWL), percutaneous nephro-
considerable morbidity, with recurrence rates of 6.5–44%. Without lithotomy (PCNL) or ureterorenoscopy (URS), or a combination of
follow-up and medical intervention, stone recurrence rates have these modalities while open surgery is currently needed in a limited
been reported to be as high as 50% within five or six years. In number of cases.
3–5,8–10
In order to select the most appropriate
children, stone recurrence rates range widely (from 3.6 to 67%), and treatment modality, in addition to the stone-related factors (location,
appear to be highest in children with metabolic abnormalities. The composition and size) and anatomy of the collecting system, the
rate of stone recurrence in our previous report was 4% during a five- presence of obstruction and/or infection are important factors.
year follow-up period.
1–3
Extracorporeal Shock-wave Lithotripsy
Given the high risk of subsequent calculus formation, it could be With increasing experience, extracorporeal shock-wave lithotripsy
argued that all children should undergo some form of evaluation to (ESWL) has become the preferred treatment alternative in the
determine the cause of their kidney stone and to help plan proper minimally invasive management of stones in children, with satisfactory
management strategies. It is well known that certain groups of stone-free rates. Despite the common use of PCNL development of
children should undergo a full metabolic work-up due to the high risk smaller-diameter flexible ureteroscopes and ancillary instruments,
of recurrence. Through these efforts, future stone formation and/or SWL still remains the least invasive and most simple, safe and effective
growth may be controlled in paediatric populations, limiting the treatment alternative in the paediatric population.
9–13
However, it
morbidity of this disease. should be kept in mind that the higher incidence of metabolic and
anatomical abnormalities affects the ultimate effectiveness of
The principles of stone management in children should consider treatment, which aims to render the child stone-free over a short
complete stone clearance, prevention of stone recurrence and period of time with a reasonable number of SWs and limited auxiliary
regrowth, preservation of renal functions, control of urinary tract procedures. Following treatment, residual fragments after SWL should
infections and correction of anatomical abnormalities and the be followed closely with regular visits in the light of the higher
underlying metabolic disorders. Long-term post-operative follow-up is incidence of metabolic and anatomical abnormalities in this specific
mandatory, especially after using newer technical innovations for age group.
14–16
urinary calculus management during childhood based on metabolic
evaluation, stone analysis data and the frequency of stone events. Renal pelvic stones or calyceal stones up to 2cm in diameter are
ideal indications for SWL and success rates tend to decrease as the
Medical Management size of the stone(s) increases. Currently, depending on the size,
As a result of the multifactorial causes of stones in children number, location and chemical composition of the stones, more than
(metabolic, anatomical and/or recurrent urinary tract infection), 90% of all urinary stones in adults and nearly 80% of all stones in
treatment can be successful only when combined with additional children are successfully treated with ESWL. Following SWL, stone-
appropriate prophylactic measures. Despite continuous efforts for the free rates ranging from 57 to 97% during short-term follow-up and
successful prevention of recurrent calcium oxalate stones, 57 to 92% during long-term follow-up have been reported in the
no medication has proved itself in terms of adequate recurrence literature.
8,11,12
Re-treatment rates range from 13.9 to 53.9% in
prophylaxis. Like in the adult population, pediatric patients can be different series,
13–15
while ancillary procedures and/or additional
treated conservatively with an increased fluid intake with or without interventions range from 7 to 33%.
16,17
Although general anaesthesia
dietary manipulations or by administering pharmacological agents.
1,6
is generally performed, especially with first-generation lithotriptors,
Among the medical theraputic options, as a pharmacological agent sedation is needed to relieve possible discomfort in younger children
potassium citrate has been used with acceptable success rates. during SWL.
18–21
However, depending on the size as well as the
However, it is really very troublesome to keep the child under a number of stones, stone-free rates after SWL may decrease with an
certain preventative measure for a long period of time. Co-operative increasing need for ancillary procedures.
22–24
Despite its effective and
parents with older children more often demonstrate acceptable minimally invasive profile, theoretical concerns have been raised
successful outcome following these measures.
7
regarding the safety and the bioeffects of SWL on the immature and
growing kidney and the surrounding organs, but no irreversible
To summarise, in addition to stone removal procedures, the serious side effects of high-energy shock waves have been seen
treatment of paediatric urolithiasis requires a thorough metabolic during short- or long-term follow-up. Finally, taking the potential
and environmental evaluation of all patients on an individual basis. deterioration of renal function into account (although it is transient),
Obstructive pathologies, along with the established metabolic restriction of the number of SWs and the energy used in each session
abnormalities, should be treated on time. Children with a positive will be helpful in protecting the kidneys.
25–30
family history are candidates for a close and careful follow-up with
respect to stone recurrence. Urine volume should be increased, Regarding the management of ureteral stones, in contrast to the
with adequate fluid intake evenly distributed over the course of the effective results of SWL in renal stones, as many as 98% of stones with
day, and medical therapeutic agents, which increase urine citrate a diameter of <5 mm are likely to pass spontaneously; intervention will
levels, may be considered in the medical management of be required in larger and impacted stones. Although ESWL is the first
hypocitraturia in children. treatment modality in the majority of stones located in the upper
84 EUROPEAN UROLOGICAL REVIEW
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