Sarica_new_Cardiology_book_temp 16/03/2010 10:23 Page 85
Paediatric Urolithiasis
urinary tract in children, the success rates decrease as the stone Thus, the same techniques are used in this population as in adults and
passes to the more distal parts of the ureter.
9,17,18
Despite definitive age is not considered to be a limitation.
removal of ureteral stones by endoscopic procedures, acceptable
success rates by ESWL had made it a favourable first-line treatment With the clinical introduction of smaller nephroscopes, ‘miniperc‘
modality for the majority of proximal ureteral stones. Currently, larger procedures are feasible where hol:YAG laser, smaller pneumatic
stones (>1cm), impacted stones, Ca-oxalate monohydrate and cystine lithoclast and ultrasound probes can be used with smaller
stones, stones in children with unfavourable anatomy and in whom nephroscopes during PCNL in children. The use of the hol:YAG laser is
localisation difficulties exist are the cases in which SWL is likely to be appealing in children, and various studies have demonstrated the safe
unsuccessful. Although indwelling ureteral stents are seldom required use of this system. Ultrasound-guided puncture is a good alternative
after ESWL for upper-tract stones, ureteral pre-stenting appeared to to fluoroscopy in children and has the advantages of avoiding
decrease the stone-free rate of initial treatment and re-treatment by radiation, providing a straight peripheral calyceal puncture and
12 and 14%, respectively.
19–21
preventing visceral injury.
45–47
Ureteroscopy Indications for PCNL in children are similar to those in adults and
Traditionally, the standard treatment for ureteral stones in children was include a large stone burden, significant renal obstruction with urinary
open surgical removal. However, over the past 10 years, with the infection, failure of SWL and significant volume of residual stones after
advances in endoscopic technology the management of ureteral calculi open surgery.
48–50,52
PCNL has been advocated as a suitable treatment
has changed considerably and the principles of ureteral stone treatment for children with significant stone burdens to avoid numerous SWL
are now similiar to those in adults, where open surgery is needed rarely sessions under anaesthesia and the prospect of repeated open
in such cases.
31–33
Today, ureteroscopy may be applied for diagnostic surgery. With the availability of smaller instruments and with
and/or therapeutic purposes, and with the clinical introduction of fine, ultrasound guidance, the procedure can now be performed safely in
smaller-calibre instruments this modality has become the treatment of experienced hands.
4,8,11,50,52,53
Concerning the efficacy of the technique,
choice in middle and distal ureteric stones in children.
34–36
stone-free rates of about 90% (ranging from 67 to 100%) and no
significant complications have been reported in many series.
2,48,49,51,52
The early concern with larger-calibre instruments included the risk of Several investigators have demonstrated the effectiveness of PCNL,
damage to ureteral mucosa, ureteral meatus and the urethra in male with stone-free rates ranging from 79 to 87.5%.
46,47
children. However, with the use of 4.5 and 6.0Fr semi-rigid
ureteroscopes and 6.9Fr flexible ureterorenoscope and holmium: Cystolithotomy
yttrium–aluminum–garnet (hol:YAG) laser energy source, instrument- The majority of the stones located in the bladder are usually large and
related complications are rare.
37–41
hard, and can be treated by either transurethral or percutaneous
suprapubic lithotripsy or litholopaxy. The major concern with the
Previous studies of paediatric ureteroscopy have shown satisfactory transurethral approach is the posssible damage to the male urethra,
results, particularly for mid- and lower ureteral stones, with the explaining the rare and judicious use of this technique. In recent years
reported success rate in different paediatric series ranging from suprapubic cystolithotomy has evolved as a safe and effective
87.5 to 100%. However, the results obtained in upper ureteral stones alternative technique in such cases. After removing the stone intact,
are less encouraging, with a success rate of 78%, which is worse one option will be closing the bladder primarily, or, in small openings,
than that achieved in lower parts of the ureter. Regarding the the bladder may be drained for several days to let the opening close.
efficacy of ESWL and URS, stone-free rates in patients with calculi of This procedure could be performed on an outpatient basis. Lastly, by
>10mm were 93% with ureteroscopy and 50% with SWL, while for making a small incision in the augment and placing a sheath into the
calculi of <10mm the stone-free rates were 100 and 80% for bladder (‘mini-lap’ approach), the stone particles in the vesical cavity
ureteroscopy and SWL, respectively. Ureteroscopy may provide can be removed in a safe manner and the cavity can be examined.
11,54,55
more efficient stone clearance, and should be preferred for distal
ureteral stones, larger stones and impacted stones.
9,32,35,36,40
The principles of management of bladder calculi are similar to those
Complications may occur after ureteroscopy in 0–7% of the patients, for upper urinary tract calculi. Approaches for bladder stones are the
and include ureteral avulsion, perforation, haematuria, infection and endoscopic, suprapubic percutaneous access and open surgery
ureteral stricture. In case of a short and uncomplicated procedure routes. Subrapubic cystolithotomy is appropriate in cases of large,
for a relatively small stone located in the vicinity of the bladder, no hard vesical calculi.
54,55
stent is necessary.
4,9,40
Laparoscopic Surgery
Percutaneous Nephrolithotomy The role of laparoscopy in the management of paediatric stone
Following the first report of a series in 1985, PCNL has begun to be disease remains to be explored. Despite the limited data reported in
applied first in adult populations with increasing success rates. The the literature, we believe that further studies including larger series of
gradual acceptance of this technique in children was due to concerns children are needed.
56,57
regarding long-term renal damage, small kidney size, relatively large
instruments, radiation exposure and the risk of major complications Retrograde Intra-renal Surgery
such as bleeding. However, as the experience in this field grew, the With increasing experience of retrograde intra-renal surgery (RIRS) in
results of relatively large series demonstrated that there can be only adults, recently a few reports of successful ureterorenoscopic
minimal scarring and insignificant loss of renal function after PCNL. management of inferior calyceal stones in children have been
Radioisotope scans before and after PCNL revealed unchanged published. In future, RIRS may be used more frequently to treat
differential function and no evidence of significant renal scars.
42–44
residual stones after SWL, inferior calyceal stones and cystine stones.
EUROPEAN UROLOGICAL REVIEW 85
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