Treatment of pediatric urolithiasis: how small is “small enough”?

Abstract

"Big" scars for stone removal are only needed in unusual circumstances. This is true given the fact that technology is fast evolving and instruments becoming smaller and smaller. The management of urolithiasis in children has undergone a paradigm shift in the past decade. Management of pediatric urolithiasis necessitates a balance between stone clearance and morbidity related to the procedure. A variety of treatment options are available, which include shock wave lithotripsy (SWL), percutaneous Nephrolithotomy (PCNL), and retrograde intra renal surgery (RIRS) and open surgery. Concerns regarding endourologic treatment include eVect on the renal development and function, the side eVects of radiation, and the implications of residual stones. Children with pediatric urolithiasis need to be worked up metabolically to prevent recurrence.The treatment options should be chosen with prudence, as each of the treatment options has its share of problems. SWL has been the treatment of choice for renal calculi less than 15 mm in size. The stone-free rates range from 68 to 84% [1]. In our study, ESWL was found to be safe and eVective in children as was in adults for solitary renal and upper ureteric stones less than 2 cm in size. We found that children required fewer and lower energy shock waves to achieve equivalent results. Considering that long-term data are awaited regarding functional consequences of shock waves on pediatric kidneys, it would be prudent to shock these kidneys as little as possible. In this context, we feel to minimize the "shock loss," and optimizing the number and energy of shock waves, the patient should be given optimum anaesthesia with the use of ultrasound and Xuoroscopy for localizing and monitoring of stone fragmentation [2].PCNL remains the most eVective option for treating large stones in this age group. The obvious downside of this approach is the potential for life-threatening complications such as bleeding; hence, surgeon experience is paramount in deciding the number and site of access. Stone-free rates of more than 90% have been shown in pediatric age group [3]. Percutaneous Nephrolithotomy has been described even in children as small as 11 months, having complex calyceal stones and/or staghorn calculi. The method to gain access, ultrasound or Xuoroscopy, is a matter of experience and personal preference. Ultrasound oVers the advantage of visualization of spleen and liver and avoids injury. It also minimizes radiation to these kids. The key to success in PCNL in these small patients is staging the procedure if required, miniaturization of instruments, and using ultrasound as the method of achieving access. PCNL oVers a good clearance rates with acceptable morbidity. Miniaturization of instruments particularly smaller nephroscopes and newer energy sources will decrease the morbidity of PCNL. The question is how small is small enough! In this regard, in our opinion, microperc is the "new kid on the block." It has a role to play in percutaneous management of these small patients. Essentially, ...

Renal Vascular Doppler Resistance after Extracorporeal Shock Wave Lithotripsy

“…Desai et al indicated the revocable variations in the form of proteinuria following lithotripsy using lithoclast with electrohydraulic generator. 7 Similarly, revocable variations of urinary level of materials such as N-β-acetylglucosaminidase, β-galactosidase, δ-glutamyl transferase, creatine phosphokinase, lactate dehydrogenase, and α2-macroglobulin have been demonstrated in human and animal models. These materials may be used as indicators that are helpful in determining the least possible damage following extracorporeal shock wave lithotripsy (ESWL).…”

Beyond ESWL: new concepts for definitive stone removal

“…In contrast, for large renal stones, PNL can safely be applied as demonstrated by Dogan et al who achieved stone-free rates of almost 90% [9]. Nevertheless, the occurrence of significant complications such as colonic perforations and blood transfusions supports the plea of Desai et al to perform ultrasoundguided puncture and to use miniaturized instruments [10].…”