Endourologic Management Of Pediatric Urolithiasis: Proposed Clinical Guidelines

UroToday.com- Endourology has evolved in the management of pediatric stone surgery. Nonetheless because of the size of the patients, the procedures are challenging at times. The advent of refined and smaller instrumentation has advanced this minimally invasive approach. This group from India analyzed the results of various techniques selected prospectively for their pediatric stone patient population.

The group analyzed the results of percutaneous nephrostolithotomy, ureteroscopy, and extracorporeal shockwave lithotripsy in a total of 45 children treated at their institution. There were 35 boys and 10 girls ranging form age 12 months to 17 years with a median age of 8.2 years. Over half of these children were under the age of 8. Stone free rates, complications, and hospital stay were all assessed.

The group found that extracorporeal shockwave lithotripsy was performed in 13 children (a total of 15 kidneys) with an average stone surface area of 5.08 ± 3.58 cm2. The stone free rate in this group was 92.3%. The total number of shocks per treatment ranged from 450 to 1400 shocks with a mean of 856. Multiple treatments were necessary to achieve the stone free rate of 92.3%. A total of 25 percutaneous nephrostolithotomies were performed. Stone extraction was completed in a single stage procedure in 20 kidneys (80%) where 5 kidneys (20%) required a second stage to complete the stone removal. The stone free rate overall in this group was 95.8%. The stone free rate was per kidney and not per patient. There were 9 ureteroscopic procedures planned in 8 children. Rigid ureteroscopy was employed and only successful in 6 patients (66.7%).

The group concluded that with the availability of various alternative approaches, proper treatment planning and judicious use of minimally invasive techniques can cure most pediatric stone patients. They conclude that with their experience, they can recommend and algorithm for the management of pediatric stone disease where it appears that shockwave lithotripsy can be used for the majority of stones with an excellent success rate seconded by percutaneous nephrostolithotomy. It is my opinion that if you include flexible ureteroscopy, the success rate of the ureteroscopic group would also have been higher and approached that of percutaneous nephrostolithotomy and shockwave lithotripsy with one procedure. If you were to break down shockwave lithotripsy, percutaneous nephrostolithotomy and ureteroscopy based on only one procedure, you would most likely find that the ureteroscopic group would end up being the most successful. I am hesitant to say that based on 45 children, we could actually propose true clinical guidelines. A larger surgical cohort as well as a cohort that underwent observation with spontaneous stone passage rates would be critical to propose clinical guidelines for pediatric urolithiasis. Although not optimal, this can be achieved in a retrospective fashion so we can get a large number of patients that would increase the power of the study and be of more statistical significance.

Gotov Erdenetsesteg, T. Manohar, Harban Singh, Mahesh R. Desai
Journal of Endourology 20(10):737-748, October 2006.

Reviewed by UroToday.com Medical Editor Pasquale Casale, MD

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