Review article
Surgical management of children with urolithiasis

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Diagnosis and follow-up

Renal calculi in neonates and younger children are often diagnosed using ultrasound, and the size of the stone is accurately measured. Ureteral calculi can be seen at the ureteropelvic junction or in the intramural ureter of the bladder. Hydroureteronephrosis may suggest the presence of a stone, but the lack of dilation does not mean that a stone is not present. Repositioning the patient may help determine whether an echogenic focus with posterior shadowing is a single stone or several smaller

Antibiotic use

If the urine is sterile at the time of diagnosis and there is partial obstruction, the use of antibiotics is optional. Antibiotics are generally indicated in patients with high-grade obstruction and in patients who have an indwelling ureteral stent. Similar to the experience in adults, antibiotics are not necessary for ESWL if the urine is sterile, although there is evidence of higher infection rates after ESWL in patients who do not receive antibiotic prophylaxis [2]. Every effort should be

Equipment

ESWL can be performed using any lithotriptor, but experience with the Dornier HM3 (Dornier MedTech America, Kennesaw, Georgia) and second- and third-generation lithotriptors suggests that, similar to the adult experience, stone-free rates are higher with use of the HM3 [3]. The gantry can be modified to fit the pediatric patient [4]. For patients less than 120 cm tall, the HM3 requires an additional Styrofoam sheet to protect the lungs, which, in children, have a relatively larger excursion

Stone size

It has long been appreciated that children can pass relatively large stones. Younger patients are more likely to have renal than ureteral stones. Renal stones less than 3 mm are likely to pass, and the chance of passing a ureteral stone less than 5 mm in diameter is about 70% [7]. When stone-free rates after ESWL were compared in a group of children and adults who had stones that were matched for size, the children cleared a slightly greater proportion of stone fragments than adults (95% versus

Results of extracorporeal shock wave lithotripsy

Stone-free rates after one session of ESWL are in the mid-80% range [9], [10], [11], [12], [13], [14], [15]. The main concern with the use of ESWL in pediatric kidneys has been the long-term risk of hypertension, loss of renal function, and hyperfiltration. Short-term follow-up to date has failed to show differences in body growth or renal function (glomerular filtration rate determination or dimercaptosuccinic acid/pentetic acid scan) using first-, second-, and third-generation lithotriptors

Technique and results using ureteroscopy

Ureteroscopy is generally indicated for ureteral calculi below the iliac crests, which can be difficult to target with ESWL in children. Ureteroscopy also can be used for upper ureteral and renal calculi, especially after ESWL failure. In smaller children, a period of prestenting with a 3.7F or 5F ureteral stent for 1 to 2 weeks will dilate the ureter sufficiently to allow passage of the flexible or semirigid ureteroscope. Access is gained by passage of a 0.035 guidewire, followed by the

Technique and results of percutaneous nephrolithotomy

Percutaneous nephrolithotomy is the procedure of choice for a renal stone burden greater than 2 cm, for stones associated with ureteropelvic junction obstruction if endopyelotomy is considered, and for anatomic situations that make stone fragment passage less likely (reconstructed exstrophy, long reimplants). Access can be gained by interventional radiology or in the operating room. Some data suggest that transfusion rates are lower if access is placed preoperatively, and the accuracy of

Cystolithotomy

Patients who perform clean intermittent catheterization can form stones in the bladder owing to the introduction of hair, chronic bacteriuria, or mucus from a bladder augmentation. The surgical approach is complicated by augmentation cystoplasty, bladder neck reconstruction or division, or construction of a continent catheterizable stoma. The lack of an easy access route, such as the native urethra, and the ability to use larger endoscopes and instruments makes a percutaneous approach optimal.

Cystic fibrosis

Patients with cystic fibrosis are at higher risk for renal stone formation. The etiology of the stones has been attributed to hypocitraturia and the lack of oxalobacter formigenes, the latter possibly owing to recurrent antibiotic treatments for pneumonia [37], [38]. These patients can be managed with any of the usual methods for urolithiasis. The only unusual perioperative issues are related to pulmonary function; therefore, it is wise to maximize pulmonary function tests before subjecting

Chemotherapy

Patients undergoing chemotherapy are at risk for uric acid stone formation owing to cell lysis. They are usually given allopurinol once their level of serum uric acid begins to rise. Patients with symptomatic urolithiasis during treatment can be managed with ureteral stenting and alkalinization of the urine. Percutaneous procedures should only be undertaken in rare circumstances, because the myelosuppression caused by the chemotherapy puts the patient at higher risk for sepsis, and the risk of

Ureteropelvic junction obstruction

Children can present with urolithiasis and ureteropelvic junction obstruction. The difficulty in treatment is deciding whether the stone arose owing to the ureteropelvic junction obstruction, or whether the ureteropelvic junction is edematous owing to impaction of the stone. The situation is best assessed antegrade at the time of percutaneous nephrolithotomy. If there is convincing evidence of a high insertion of the ureter, one can incise the ureteropelvic junction posteriorly and leave a

Complications

Because the techniques used in adults and children are the same, the complications are the same. Gross hematuria and bruising of the flank are expected after ESWL. Perinephric hematoma is less commonly encountered, and transfusion is rare. The rate of ureteral injury from ureteroscopy should be approximately 5% and is generally managed by stenting, except in the case of avulsion, which may require open repair, transureteroureterostomy, or ureteral replacement. Bleeding during percutaneous

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