Stone treatment in children: where we are today?

OBJECTIVE: Stone disease in children differs in pathogenesis, presentation and in treatment from adults. In recent years, big changes on its management have occurred. We reviewed our experience on upper tract urinary calculi in paediatric age.

MATERIAL AND METHODS: Patients observed for upper tract urinary stones from June 2002 to June 2008 were reviewed. Bladder-urethral calculi were excluded. Presenting symptoms had a wide range: macro- or micro-hematuria, recurrent abdominal or flank pain, or non-specific symptoms such as irritability and failure to thrive. Renal and urinary tract ultrasonography, plain abdomen X-ray were performed in case of suggestive symptoms. Spiral CT without contrast was recommended to better define the stone disease. Metabolic evaluation is mandatory for any child presenting history of urinary calculi or nephrocalcinosis. Idiopathic hypercalciuria has been recognized as predominant ethiological factor of paediatric nephrolithiasis, excluding stones correlated with urinary tract malformations (up to 45%).

RESULTS: In a 6-year period, 232 patients, aged 19 months to 18 years, were treated: 195 children (60.8%), mean age 8.3 years, underwent ESWL. Re-do treatments were 233 (2.3 ESWL/patient), with 77% stone free rate. Percutaneous nephrolithotomy (PCNL) was adopted in 33 patients, mean age 13.4 years, with 2 re-treatments. Stone clearance was 74% after single treatment, increased to 88% by secondary ESWL. Blood transfusion was needed in 7 cases (16%). Retrograde ureterolithotripsy (ULT) was performed in 96 patients presenting ureteral stones, for a total of 99 procedures. Stone free rate was 99%, as 1 pushed up stone required subsequent ESWL. No ureteral perforation or other significant complications occurred. Medical treatment was offered as ancillary therapy or to prevent recurrences, according to the metabolic results and the stone biochemistry.

CONCLUSIONS: Stone treatment in children is changing dramatically, thanks to progressive transfer of procedures from adult patients and recent advances in miniaturized new technologies. Surgical approach to renal and urinary tract stones in childhood was recently moving from open surgical procedures (nephrolithotomy, ureterolithotomy, cystolithotomy), to less invasive procedures, such as ESWL and endoscopic approaches, as ULT and PCNL. Mini-invasive procedures present high efficacy and safety, also in young children, but require appropriate instrumentation and specific experience.