Professional Documents
Culture Documents
8. Pediatric urolithiasis
Introduction
While pediatric urinary stone disease once considered rare, now is evident
that children form urinary tract stones and the incidence of this disease is
increasing, particularly in females. There are many opinions regarding the
management of the pediatric patient who is presented with a stone, but any
patient who has a surgically active stone should have it removed expeditiously.
With the technological advance, stone management has transformed into
techniques that are significantly less invasive. A number of factors must be
taken into account when selecting ones choice of therapy for urinary tract
stone in children such as the size of the stone, its location, composition, and
the anatomy of the urinary tract.
Epidemiology
Between 5 and 10% of the human population suffer from urinary stone
disease during their lifetime, and of these cases 2-3% are children [1].
Although a rare disease in children living in developed countries, with a
prevalence of between 1:1000 and 1:7,600 in different parts of the USA, the
number of pediatric patients per capita, has increased (2-4). In Europe, kidney
Correspondence/Reprint request: Dr. Nikolaos Partalis, Pediatric Surgery, University Hospital, Heraklio, Greece.
80 Nikolaos Partalis & George Sakellaris
Pathogenesis
The underlying causative factors that have been found to be responsible
for the etiology of the disease are metabolic abnormalities, urinary tract
infections, anatomical abnormalities and endemic factors. In two large
pediatric series, metabolic conditions were found to be responsible for more
than 50% of diagnoses and varieties of urinary tract anomalies have been
found in about 30% of children with urolithiasis (1,7,9).
Hypercalciuria is the most common metabolic abnormality accounting for
up to 34% of all pediatric stones with hyperuricosuria (usual in Lesch-Nyhan
disease) following in 8% of all cases. Although infection-related stones have
an incidence of 2-24%, as many as 75% of stones in European children have
been found to be associated with urinary tract infections, usually in boys
younger than six years of age and with associated genitourinary anomalies.
Cystinuria accounts for 2-7% of children with metabolic urolithiasis in
industrialized countries. Last but not least, calcium oxalate calculi are found in
primary hyperoxaluria and stones consisting of 2,8-dihydroxyadenine in
children suffering from 2,8-Dihydroxyadeninuria (9, 10).
In some patients the development of stones is secondary to the presence of
another condition or disease. For instance immobilization, hyperparathyroidism
Pediatric urolithiasis 81
Pharmacological intervention
Treatment of patients with calcium stones due to idiopathic hypercalciuria
with potassium (K)-citrate has the dual advantage of decreasing urine calcium
and increasing urine citrate. Furthermore, it improves the bone mineral status
of these patients (23). Thiazides are time-proven preparations for the treatment
of hypercalciuria and it may be advantageous to use them in combination with
plus k-sparing diuretics such as amiloride or with k-citrate. Approximately
one-third of hypercalciuric children have decreased bone mineral density but
Pediatric urolithiasis 83
Percutaneous nephrolithotomy
According to the guidelines of the European Association of Urology,
ESWL should be the first choice for most renal pediatric stones, but a
percutaneous approach could be used for bigger and more complex calculi.
The gradual acceptance of this technique in children was due to concerns
regarding long-term renal damage, small kidney size, relatively large
instruments, radiation exposure and the risk of major complications such as
bleeding. However, as the experience in this field grew, the results of relatively
large series demonstrated that there can be only minimal scarring and
insignificant loss of renal function after PCNL. Radioisotope scans before and
after PCNL have revealed unchanged differential function and no evidence of
significant renal scars (1). Indications for PCNL in children include a large
stone burden, significant renal obstruction with urinary infection, failure of
ESWL and significant volume of residual stones after open surgery. With the
availability of smaller instruments and with ultrasound guidance, the procedure
can now be performed safely in experienced hands. With the clinical
introduction of smaller nephroscopes, miniperc procedures are feasible
where hol: YAG laser, smaller pneumatic lithoclast and ultrasound probes can
Pediatric urolithiasis 85
Uretero-renoscopy
Today, ureteroscopy may be applied for diagnostic and/or therapeutic
purposes, and with the clinical introduction of fine, smaller-calibre instruments
this modality has become the treatment of choice in middle and distal ureteric
stones in children. Currently, calculi throughout the entire upper urinary tract
in children can be treated endoscopically using semi-rigid or flexible
ureteroscopes with proven effectiveness and safety (33,34), and by using
mostly Holmium:YAG laser lithotripsy-the intracorporeal lithotriptor of choice
(35). The efficacy is good particularly for mid- and lower ureteral stones, with
the reported success rate ranging from 87.5 to 100%. However, the results
obtained in upper ureteral stones are less encouraging, with smaller success
(1). The stone-free rate following ureteroscopic lithotripsy for ureteral stones
has been reported as high as 98.5-100%. Intraoperative complications, defined
as ureteral injury (ischemia, perforation, and avulsion) or postoperative
complications (mainly ureteral stricture) have shown to be extremely rare (0%
to 5.2%). To achieve access to pediatric ureter either active dilatation is used
or, alternatively, a (1-2 weeks) pre-stenting with an indwelling ureteral stent is
followed (35).
Ureteroscopy may provide more efficient stone clearance, and should be
preferred for distal ureteral stones, larger stones and impacted stones.
Complications may occur after ureteroscopy in 07% of the patients, and
include ureteral avulsion, perforation, hematuria, infection and ureteral
stricture (36).
Laparoscopic/open surgery
In developed countries, open surgery remains the treatment of choice for
0.35.4% of children. In general patients with anatomical abnormalitiesi.e.
ureteropelvic junction obstruction, obstructive megaureter, urolithiasiswill
receive open surgery if stone removal and anatomical correction can be
86 Nikolaos Partalis & George Sakellaris
Cystolithotomy
The majority of the stones located in the bladder is usually large and hard,
and can be treated by either transurethral or percutaneous suprapubic
lithotripsy or litholopaxy. The major concern with the transurethral approach is
the possible damage to the male urethra. Nowadays suprapubic cystolithotomy
has evolved to a safe and effective alternative technique in such cases that
could even be performed on an outpatient basis. Approaches for bladder stones
are the endoscopic, suprapubic percutaneous access and open surgery routes.
Subrapubic cystolithotomy is appropriate in cases of large, hard vesical calculi
(38, 39).
Conclusion
The management of stones in children poses a specific technical challenge
to the urologist. Improvements in technology (i.e. availability of smaller-
calibre, rigid and actively deflectable endoscopes) and growing experience,
along with the refinement of ESWL and improvements to PCNL and URS
techniques, have resulted in greater acceptance of minimally invasive
techniques.
References
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Pediatric urolithiasis 87
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