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The Future of Stone Management
alternative to SWL for renal calculi with a size of 1–2cm located in lower-pole stones after SWL is significantly inferior according to
the renal pelvis and calices. A short treatment time, the high stone- the other localisations of the kidney. This is commonly related
free rate and the accessibility of lower-pole stones, which are less to caliceal anatomy. Onal et al.
30
showed that caliceal pelvic
amenable to SWL, are of particular importance. However, due to anatomy in paediatric lower-pole stones has no significant impact
the limited sheath diameter this technique represents an extension on stone clearance after SWL, but was strongly related to the
of the indication for conventional PCNL. overall stone burden, which should be considered for determining
the treatment modality.
Due to technical enhancement of endourological methods, surgical
therapy of renal and ureteral stones has become a very uncommon This is quite contradictory to findings in adults, where we
intervention in developed countries. This experience is nicely commonly believe that caliceal anatomy such as infundibulopelvic
supported by a review by Hruza et al.
27
that clearly demonstrates that angle or a narrow caliceal neck may significantly prevent stone
in Europe and North America the surgical therapy of urolithiasis only clearance following SWL. This underlines that anatomy in children
plays a role in cases of abnormal renal anatomy, in cases of very large must be interpreted in a different way and stones in children
or hard stones and after failure of SWL or endourological procedures. should be handled at dedicated paediatric stone centres.
There is even a trend towards laparoscopic procedures in these rare
cases in daily urological practice. However, in developing countries Conclusions
where endourology is not readily available, these techniques still There is a renaissance in the field of endourological procedures
have a higher importance. Similar findings were presented by due to technical refinements and high success rates, and because
Nambirajan et al.,
28
who demonstrated laparoscopic surgery to be an immediate stone removal is preferred by both patients and
effective tool for complex renal stones, rendering open-stone surgery urologists. Since little has changed in stone metaphylaxis,
a rare indication in the future. This is supported by Simforoosh et al.,
29
urological surgery will be mandatory for stone treatment in the
since they even performed complex laparoscopic anatrophic foreseeable future. n
nephrolithotomy for the treatment of large staghorn calculi. While
offering a minimally invasive approach with an acceptable stone-free
rate, it can minimise the need for secondary invasive interventions
H Christoph Klingler is Vice Chairman of the
Department of Urology at the Medical University of
and will be the preferred method in selected patients in the future.
Vienna. His main clinical topics are neuro-urology and
However, it must be noted that all of these interventions are rare
urinary incontinence and minimally invasive
indications and that performing laparoscopy in these cases is
laparoscopic and robotic techniques. He has published
over 55 peer-reviewed or review articles on these
challenging. Consequently, these indications will remain in the hands
topics and given over 350 national and international
of laparoscopic experts and centres.
presentations. He has been an invited Visiting Professor
at national and international urological centres. Dr
Klingler has received six international awards, including a grant from the European
Stone Treatment in Children
Urological Scholarship Foundation. He is member of nine scientific societies and was
There is little doubt that the primary treatment option for children
on the Editorial Board of European Urology.
is SWL. However, the clearance of stone fragments and debris of
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EUROPEAN UROLOGICAL REVIEW 81
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