Strategies for managing upper tract calculi in young children.

Abstract

Pediatric urolithiasis is relatively uncommon and there is little information on the application of modern surgical procedures in young children. We present a single center experience with the surgical management of upper tract calculi in this age group. We reviewed presentation, co-morbidity, treatment, outcome and complications in all prepubertal patients who required surgical treatment for ureteral or renal calculi during a 4-year period. The series consists of 24 girls and 17 boys 17 months to 14 years old (mean age 7.5 years). A total of 26 children were anatomically normal, and 4 had myelomeningocele, 4 had ureteropelvic junction obstruction (in a pelvic kidney in 1), 2 had cloacal anomalies, 2 had vesicoureteral reflux, and 1 each had nonrefluxing megaureter, orthotopic ureterocele and a functioning renal transplant. Extracorporeal shock wave lithotripsy was performed in 24 patients. Stents or nephrostomy tubes were only used in the 4 patients who presented with pyonephrosis. Of the 41 cases 17 were rendered stone-free, 3 had a decreased stone burden and 4 were failures. Ureteroscopic extraction of distal ureteral calculi was successful in 11 of 12 children, of whom the youngest was 2.5 years old. No child had postoperative infection or evidence of ureteral obstruction. Stent placement facilitated stone passage or dissolution in 2 patients, a renal calculus was percutaneously extracted in 2 and 7 required open surgery, mostly for correcting simultaneous anatomical abnormalities or after minimally invasive surgery failed. Some metabolic abnormality was detected in 80% of the children tested. The surgical management of upper urinary tract calculi in young children parallels that in adults. Minimally invasive surgical methods may be safely used even in young infants. Most children do not need elective stenting before lithotripsy. Open procedures are still required in 17% of cases. The majority of children have definable metabolic abnormalities.