Management of Pediatric Calcular Disease

Abstract

Summary I n the past few decades pediatric urolithiasis has become more frequent. The reason for this increase is not completely clear but has been attributed to changes in climate, nutritional habits and possibly other environmental factors. Although less frequent than adult stone disease, urolithiasis in the pediatric age group is also related to significant morbidity, particularly since stones tend to recur, and, thus, should not be underestimated. Most children with idiopathic stone disease have an underlying metabolic abnormality substantiating the importance of metabolic evaluation already following initial diagnosis of urolithiasis. Identification of the metabolic abnormality allows for more specific prescription of non pharmacological and pharmacological interventions aimed at preventing recurrent stone formation. A better understanding of the causes of kidney stone disease will provide better strategies for stone prevention in children. Urolithiasis and nephrocalcinosis are more frequent in children then currently anticipated, but still remain under- or misdiagnosed in a significant proportion of patients, since symptoms and signs may be subtle or misleading. All children with colicky abdominal pain or macroscopic hematuria should be examined thoroughly for urolithiasis. Also, other, more general, abdominal manifestations can be the first symptoms of renal stones. The patients and their family histories, as well as physical examination, are important initial steps for diagnostic evaluation. Thereafter, diagnostic imaging should be aimed at the location of calculi but also at identification of urinary tract anomalies or acute obstruction due to stone disease. This can often be accomplished by ultrasound examination alone, but sometimes radiological methods such as plain abdominal films or more sensitive non-enhanced computed tomography are necessary. Since metabolic causes are frequent in children, diagnostic evaluation should be meticulous so that metabolic disorders that cause recurrent urolithiasis or even renal failure, such as the primary hyperoxalurias and others, can be ruled out. The stone is not the disease itself; it is only one serious sign! Therefore, thorough and early diagnostic examination is mandatory for every infant and child with the first stone event, or with nephrocalcinosis. Pediatric urolithiasis poses a technical challenge to the urologist. Aims of the management should be complete clearance of stones, preservation of renal function and prevention of recurrence. Despite the consensus of SWL being the initial treatment of choice for most stones in pediatric patients, there are certain indications for other modalities as well. With improvement in instrumentation and technology, endoscopic management has become safe and effective. Percutaneous nephrolithotomy and SWL are safe and efficacious in managing pediatric stones of 1-2cm. Indications for PCNL in children are large stone burden, significant renal obstruction and renal infection. Ureteroscopy provides efficient stone clearance in mid and lower ureteric stones. Transurethral cystolithotripsy is generally avoided in pediatric patients, but is feasible in single vesical stone less than 1cm. Percutaneous cystolithotomy or open cystolithotomy is generally the alternative for pediatric vesical stones.