Contemporary Minimally Invasive Surgical Management of Urinary Stones in Children

Abstract

With increasing incidence of pediatric urolithiasis over the past two decades, surgical management poses specific challenges for urologists because of the high risk of stone recurrence in this population. Keeping this in mind, management aims should be complete stone-free status, preservation of renal function, and prevention of stone recurrence. The incidence of metabolic problems is up to 50%, and ∼30% of cases involve anatomic anomalies. Therefore, in addition to stone removal procedures, treatment of pediatric urolithiasis requires a thorough metabolic and urologic evaluation on an individual basis. Obstructive pathologies and established metabolic abnormalities should be managed. Urine volume should be increased by encouraging adequate fluid intake, and medical therapeutic agents to increase urinary citrate levels may be considered. To select the most appropriate surgical treatment, the location, composition, and size of the stone(s), the anatomy of the collecting system, and the presence of obstruction or any infection in the urinary tract should all be considered. Improvements in instrument technology and increasing experience with adult cases mean that all contemporary endourologic procedures are currently being applied in the management of pediatric urolithiasis in a safe and effective manner. Shockwave lithotripsy is still the first choice for the majority of cases involving upper tract calculi; other minimally invasive methods such as ureterorenoscopy and percutaneous nephrolithotomy require more expertise, but can be successfully applied for excellent stone-free rates with minimal morbidity. In patients with complex and large stones as well as anatomic abnormalities, open surgery will continue to be the preferred treatment option for children.