4/12/2015

Acutemanagementofnephrolithiasisinchildren

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Acutemanagementofnephrolithiasisinchildren
Authors
ThomasSLendvay,MD,FACS
JodiSmith,MD,MPH
FBruderStapleton,MD

SectionEditor
LaurenceSBaskin,MD,FAAP

DeputyEditor
MelanieSKim,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2015.|Thistopiclastupdated:Jun09,2015.
INTRODUCTIONThemanagementofpediatricnephrolithiasisisdividedintotwoparts.
AcuteepisodeDuringtheacutephasewhenthestoneisbeingpassed,managementisdirectedtowards
paincontrol,andfacilitatingpassageorremovalofthestone(s).
PreventionofrecurrentdiseaseAftertheacuteepisode,managementisdirectedtowardspreventionof
recurrentstonedisease.Thisincludesanevaluationtoidentifyanyunderlyingcauseorriskfactorsforstone
formation.Baseduponthisassessment,interventionsaretailoredtoreducetheriskofrecurrentstone
formation.
Theacutemanagementofchildhoodnephrolithiasiswillbereviewedhere.Thepreventionofrecurrentdisease,
epidemiology,riskfactors,clinicalmanifestations,anddiagnosisofnephrolithiasisinchildrenarediscussed
separately.(See"Preventionofrecurrentnephrolithiasisinchildren"and"Epidemiologyofandriskfactorsfor
nephrolithiasisinchildren"and"Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren".)
OVERVIEWTheacutemanagementofnephrolithiasisdependsupontheseverityofthepain,andthepresence
ofobstructionorinfection.Insomepatients,outpatientmedicalmanagementwithoralanalgesicsandhydrationis
possible.However,inothers,especiallythosewithnausea,vomiting,andseverepain,hospitalizationisrequired
forparenteralfluidandpainmedication.Otherindicationsforhospitalizationincludeurinaryobstruction,solitary
kidney,andinfection.
Urologicremovalofstonesmayberequiredinpatientswithunremittingseverepainthatisrefractorytoanalgesic
therapy,orinthosewithobstructionorinfection.(See'Indications'below.)
MEDICALMANAGEMENT
SupportivecareSupportivemanagementincludessymptomatictreatmentandaggressivehydration.Inour
center,westartintravenoushydrationat1.5to2timesthemaintenancerateasquicklyaspossible.Nauseaand
vomitingshouldbetreatedwithintravenousantiemetics.Painassociatedwithrenalcolicisbesttreatedwith
narcoticanalgesicscombinedwithnonsteroidalantiinflammatorymedications.
PaincontrolBothnonsteroidalantiinflammatorydrugs(NSAIDs)andopioidtherapyareusedtocontrolpain
associatedwithnephrolithiasis.Instudiesofadultpatients,bothclassesofanalgesicsareeffectiveinpainrelief.
Combinationtherapyofthetwohasalsobeenreportedtobeeffectiveandinsomecasessuperiortoeitheragent
alone.Inadults,thecombinationofmorphineandketorolachasbeenshowntobeaneffectivecombinationto
controlpaininpatientswithrenalcolic.(See"Diagnosisandacutemanagementofsuspectednephrolithiasisin
adults",sectionon'Paincontrol'and"Pharmacologicagentsforpediatricproceduralsedationoutsideofthe
operatingroom",sectionon'Analgesicagents'and"Selectionofmedicationsforpediatricproceduralsedation
outsideoftheoperatingroom",sectionon'Analgesia'.)
Atourinstitution,inpatientswithlessseverediseasewhocanbemanagedasanoutpatient,weinitiatepainrelief
withNSAIDsifrenalfunctionisnotimpaired.Ifpainreliefisnotachieved,thepatientmayrequirehospitalization
formoreaggressivetherapy.Inthehospitalizedpatient,weusehydration,intravenousketorolac,andopioid
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therapyasfollows:
MorphineForchildren>6monthsofageand50kg,intravenousmorphineisgivenas0.05to0.1mg/kg
perdoseeverytwotofourhoursasneeded.
KetorolacForchildren>2yearsofage,intravenousketorolacisgivenas0.5mg/kgperdoseeverysix
hourswithamaximumdoseof30mg.Kerorolacisautomaticallydiscontinuedafter72hoursofintravenous
administration.
TheuseofNSAIDsshouldbestoppedthreedaysbeforeaurologicintervention,ifpossible,tominimizetheriskof
bleeding.(See"Diagnosisandacutemanagementofsuspectednephrolithiasisinadults",sectionon'Pain
control'.)
UrinecultureBecauseurinarytractinfection(UTI)isoftenpresentinchildrenwithnephrolithiasis,aurine
cultureshouldbeobtained.IfaUTIisdiagnosed,appropriateantibiotictherapyshouldbeinitiated.(See
"Epidemiologyofandriskfactorsfornephrolithiasisinchildren",sectionon'Infection'and"Urinarytractinfections
ininfantsolderthanonemonthandyoungchildren:Acutemanagement,imaging,andprognosis",sectionon
'Antibiotictherapy'.)
StonepassageThemajorityofstoneslessthan5mmindiameterwillpassspontaneously,eveninsmall
children[1,2].Hydrationincreasesurinaryflowandisthoughttofacilitatestonepassage.Inchildren,
ultrasonographyandasinglekidneyureterbladder(KUB)radiograph(ifthestoneisradiopaque)aregenerallyused
tomonitorstonepassagebecausenoncontrasthelicalcomputedtomography(CT)ismorecostlyandis
associatedwithhigherradiationexposure.CT,however,isthemostsensitiveimagingmodalityinthedetectionof
renalorurinarytractstonesandisusedinthediagnosisofnephrolithiasis,especiallywhentruestoneburdenand
exactstonelocationarerequiredforsurgicalmanagement.Imagingistypicallyperformedafteratwoweekperiod
ofobservationtoconfirmstonepassage.(See"Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren",
sectionon'Imaging'.)
Inadults,severalmedicalinterventionshavebeenusedtoincreasethepassagerateofureteralstones,including
antispasmodicagents,calciumchannelblockers,andalphablockers.Dataarelimitedontheuseoftheseagents
inchildren.
Inonesmallclinicaltrialof39patients,childrenwithdistalureteralstonesthatweresmallerthan10mm
wererandomlyassignedtoeitherdoxazosin(analphablocker)atadailydoseofabout0.03mg/kgor
ibuprofen[3].Therewerenodifferencesbetweenthedoxazosinandibuprofengroupsintherateofstone
passage(84versus70percent)orinthemeantimeforstoneexpulsion(5.9versus6.1days).
Incontrast,anothertrialof45children(ages3to15years)reportedincreasedexpulsionratesforpatients
withdistalureteralstoneswhoreceivedbothdoxazosinandibuprofencomparedwiththosewhoonly
receivedibuprofen(71versus29percent)[4].
Tamsulosin,analphablocker,wasstudiedinaprospectivecontrolledtrialin61childrenwithdistalureteral
stones<12mmindiameter.Inthissmallstudy,childrenwhoreceivedtamsulosinandstandardanalgesia,
comparedwiththosetreatedwithplaceboandstandardanalgesia,hadahigherstonefreerateattheendof
thefourweektrial(88versus64percent)andashortermeanstoneexpulsiontime(8.2versus14.5days)
[5].Thesefindingswereconfirmedbyaretrospectivestudyof274childrenthatshowedagreaterlikelihood
ofstonepassageinpatientswhoreceivedtamsulosin(n=99)versusthosewhoonlyreceivedanalgesics(n
=175)[6].
Inourpractice,wehaveusedalphablockerstofacilitatestonepassageinchildrenwithdistalureteralstones.
AlthoughtheUSFoodandDrugAdministrationhasnotapprovedtheuseofalphablockersinchildren,basedon
theabovedata,wewillusetamsulosininchildrenolderthanfiveyearsofagewithsymptomaticureterovesical
stones.Weuseadoseof0.4mgoftamsulosingivenintheeveningbeforebedtime.Iftherehasbeenno
spontaneouspassagebyoneortwoweeks,wewillintervenesurgically.Thesemedicationshavebeenwell
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tolerated,andwehavenotseenorthostatichypotension,eventhoughthisisapotentialsideeffectofalpha
blockers.(See"Diagnosisandacutemanagementofsuspectednephrolithiasisinadults",sectionon'Facilitating
stonepassage'and'Urologicintervention'below.)
StoneretrievalThefamily/patientshouldbeinstructedtostrainthechild'surineforseveraldays,inorderto
retrievethestone.Ifthestoneoranyfragmentisrecovered,itshouldbesentforstoneanalysis.Theknown
compositionofthestonecanguidefurtherevaluationandpreventivemeasurestopreventrecurrentstones.
Urinarystrainersareavailablefrommedicalsupplycompanies.Ifaurinarystrainercannotbeobtained,a
receptaclecoveredbyacheeseclothorfinemeshsheetcanbeused.Afishnetusedforhomeaquariumsisalso
agoodalternative.(See"Preventionofrecurrentnephrolithiasisinchildren",sectionon'Evaluationforunderlying
riskfactors'.)
UROLOGICINTERVENTION
IndicationsIndicationsforurologicinterventionarebaseduponobservationalevidencethatisprimarilyfrom
adultstudies.Althoughsimilardataarenotavailableforchildren,webelievethisindirectevidenceisapplicableto
childrenwithnephrolithiasis.Inourpractice,urologicinterventionisperformedversuscontinuedobservationwith
medicalmanagementinthefollowingsettings:
UnremittingseverepainSeverepaindespiteadequateanalgesiaismostoftenduetoaureterovesical
(UVJ)orureteropelvicjunction(UPJ)stone,whichisusuallyaccompaniedbyobstruction.Inthesepatients,
painisrelievedwithatemporizingureteralstentandsubsequentstoneremoval,regardlessofthesizeofthe
stone.
UrinaryobstructionObstructionfromrenalcalculicanresultinrenalparenchymalinjuryandadecreasein
renalfunction[7].Interventioninpatientswithmildrenalinsufficiencydemonstratesbothaninitial
improvementinrenalfunctionduetothereliefoftheobstructionandsubsequentimprovementthoughttobe
duetorecoveryofinjuredrenaltissue[8,9].Withoutrelief,persistentobstructioncanresultinpermanent
scarringandlossofrenaltissue[7].
Nevertheless,becauseofthehighspontaneousstonepassageratesforsmallercalculi,aswellasthecostand
potentialcomplicationsfromurologicprocedures,itisgenerallyacceptedthatanobservationperiodwithadequate
paincontrolshouldbegiven.Theoptimallengthoftimeforobservationpriortointerventionremainsuncertain
however,inourpractice,anobservationperiodofuptotwoweeksisemployed.Thegoalofmanagementisto
minimizerenalinjury,whichrequiresbalancingtheriskofaurologicprocedure(ie,urinarydrainageorstone
removal)versuspotentialchronicrenalinjuryfromcontinuedobstruction.
Inourpractice,surgicalinterventionisconsideredinthefollowingsettings:
SurgicalremovalIftherearesignsofinfection,completeobstruction,partialobstructionbyastoneina
solitarykidney,orrenalinsufficiency,orifthestoneisgreaterthan5mmindiameter,asitisunlikelytopass
spontaneously.Theseabovecriteriaareabsoluteindicationsandleadustointervenewithoutatrialof
medicalobservationandtreatment,aswefeelthesesituationscanleadtosignificantmorbidity.
Struvitestones(magnesiumammoniumphosphateandcalciumcarbonateapatite)areoftenassociated
withanunderlingUTI,andtendtobranchandenlargeresultinginafillingoftherenalcalycesproducing
a"staghorn"appearance(image1andimage2).Urologicremovalofstruvitecalculiisgenerally
requiredtoeradicatetheunderlyinginfection[10].Persistentinfection,usuallyduetoaurease
producingbacteria(eg,ProteusorKlebsiella),isariskfactorforrecurrentstoneformation.(See
"Epidemiologyofandriskfactorsfornephrolithiasisinchildren",sectionon'Infection'and
"Pathogenesisandclinicalmanifestationsofstruvitestones"and"Managementofstruviteorstaghorn
calculi".)
SymptomaticstonesthatfailtopassafteratrialofconservativetherapySurgicalinterventionisperformed
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ifthereisnoimprovementafteratrialofmedicaltherapyaftertwoweeksforsymptomaticpatientswithout
anunderlyingUTI,andforthosewithevidenceofradiographicallyconfirmedobstructionorwhohavemild
proximalurinarytractdilationthatismanagedwithoralanalgesicsthatdonotimpairdailyactivities.
AsymptomaticpatientsWeofferurologicinterventiontoasymptomaticchildrenwithstonesthatdonot
spontaneouslypassaftertwoweeksofmedicaltherapyandobservation.Thesestonesareoftenlocatedin
thekidneyandgenerallydonotresultinsymptoms.However,theirremovalcouldpreventapotentialacute
episodeofrenalcolicduetoobstructionoftheurinarytract.Alternatively,patientscanbetreated
conservativelywithhydrationandpaincontrolasneeded.Inpatientswithuricacidstones,urine
alkalinizationincreasesthesolubilityofuricacidandmayresultinadecreaseinstonesizewithsubsequent
passage.(See"Preventionofrecurrentnephrolithiasisinchildren",sectionon'Hyperuricosuria'.)
UrosepsisAlthoughnotcommonlyseeninchildren,urosepsisisaseriousandlifethreateningcomplication
ofnephrolithiasis.Inadultpatients,urinarydrainageisusedtolowertheintrarenalpelvicpressuredueto
stoneinducedobstruction,whichisthoughttoimprovedeliveryofantibioticstotheinfectedkidney[11].
BecausewefeeltheriskofalowerUTIexpandingtourosepsisissignificantinthesettingofstaticurine
frompartiallyorcompletelyobstructivestones,werecommendsurgicalinterventionforstonesinthefaceof
concomitantlowerUTIaswell.Furthermore,clearanceofUTIswithonlyantibiotictherapyisdifficultin
patientswithsymptomaticstones.
ProceduresOverthepasttwodecades,thefollowingnewurologicproceduresforstoneremovalhavebeen
developedandadaptedtochildren[1215].Theseprocedureshavegenerallyreplacedopensurgicalrepairandcan
beusedinchildrenofallages,includingsmallchildrenandinfants.However,theexperienceandcomfortofthe
surgeonaswellastheequipmentavailableshouldbeconsideredinthedecisionofwhichinterventiontouse.
Manyoftheseinterventionsarelimitedbythesizeoftheinstrumentsavailable.Ourgrouphasusedeachofthe
threemodalitiesbelowtotreatchildrenaslittleasinfants,butothermedicalcentersmaybeconstrainedbytheir
pediatricsizedresources.
Extracorporealshockwavelithotripsy(ESWL)
Percutaneousnephrostolithotomy(PCNL)
Ureteroscopy
ExtracorporealshockwavelithotripsyExtracorporealshockwavelithotripsy(ESWL)employshigh
energyshockwavesproducedbyanelectricaldischarge.Historically,thechildwasplacedinawaterbathandthe
shockwavesweretransmittedthroughthewateranddirectlyfocusedontothestonewiththeaidofbiplanar
fluoroscopy.Secondandthirdgenerationlithotriptorsdonotrequirethewaterbath,bututilizeacontainedfluid
interfacewiththepatienttotransmittheshockwaves.Thechangeintissuedensitybetweenthesoftrenaltissue
andthehardstonecausesareleaseofenergyatthestonesurface,whichfragmentsthestone.
Forstonesthatarelessthan2cmindiameter,theresultingfragmentsareusuallypassedwithoutdifficulty.
Stentscanbeplacedwhenthestoneisgreaterthan2cmtoreducetheriskofobstruction[16].However,in
children,theplacementandremovalofthestentgenerallyrequiresconscioussedationorgeneralanesthesia.In
onecaseseriesof24children(agerange2to14years),stonesbetween2.5and3.5cm(mean3.1cm)were
treatedbyESWLwithouttheuseofstents[17].Attheendoftherapy,theoverallstonefreeratewas83percent,
andcomplicationsoccurredinsixpatients,includingureterobstructionbystonefragments,alsoreferredtoas
steinstrasse(n=4),andrenalcolic(n=2).Ofthefourwithsteinstrasse,onepatientrequiredureteroscopyto
relievetheobstruction,andspontaneousstonepassageoccurredintheotherthreepatients.However,becauseof
theincreasedmorbidityassociatedwithsteinstrasse,wecontinuenottorecommendstentlessESWLforstones
greaterthan2cmindiameter.
WeusegeneralanesthesiaforESWLduetotherequirementsofacompletelystationarypatientduringthe
procedureandtheminimalskinsensation,whichanawakechildwouldperceiveattheentrancesiteoftheshock
wave.
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ESWLhasbeenshowntobeaneffectiveandsafeprocedureforremovingstonesinchildren[12,18,19],including
smallchildrenandinfants[13,2022].However,modificationstoensureproperpositioningofthechildand
appropriatedoseofelectricaldischargetothesizeofthepatientarerequiredtoreducethelikelihoodof
complicationssuchashematomasorlungcontusions[16].Typically,theshockwavesaredeliveredina
synchronizedmannerwiththeelectrocardiogram(gated).However,inasmallclinicaltrialusingungatedESWL,
slowingtheshockwaveratefrom120to80wavesperminuteimprovedstoneclearanceinchildrenwithstones
thatwerelessthan20mmindiameterafteronesession(26versus60percent)[23].However,thetimeofgeneral
anesthesiawaslongerinthegroupofpatientswhoreceivedESWLusingaslowerwavefrequency.Further
researchinlargercohortstudiesisneededtodeterminetheoptimaldeliveryandrateofshockwavesforlithotripsy
inchildren.
Inalargecaseseries,344Turkishchildren(agerange6monthsto14years)weretreatedwithESWLovera12
yearperiod[12].ESWLwasperformedasanoutpatientprocedurewithadministrationofconscioussedation,
generalanesthesia,andnoanesthesiain40,38,and22percentofchildren,respectively.Thefollowingfindings
werenotedatthreemonthfollowup:
AfterESWL,theoverallstonefreeratewas73percent.Stonefreeratesvarieddependinguponthesizeof
thestonesandwere92,68,and50percentforstoneswithdiameterssmallerthan1cm,between1and2
cm,andgreaterthan2cmindiameter,respectively.
Theoverallstonefreerateforcalycealstoneswas56percent.Ahigherrateof63percentwasassociated
withsmallstoneslessthan1cmandalowerrateof40percentwithstoneswithdiametersequaltoor
greaterthan1cmindiameter.ESWLwasmorelikelytofailwhenstoneswerelocatedinthelowerversus
upperpolecalyx.
Stonefreeratesweregreaterthan90percentforureteralandbladderstonesregardlessoftheirsize.
TheaveragenumberofESWLsessionsperpatientwas1.9.
Complicationswereobservedin10percentofcases(n=33).Steinstrasse(obstructionbystonefragments)
occurredin13of167childrentreatedforrenalpelvicstones.Ofthe13patientswithobstruction,9had
stonesgreaterthan2cm,and4hadstonesbetween1and2cmindiameter.Othercomplicationsincluded
stentingforhydronephrosisandUTIs.Therewerenoepisodesofperirenalhematomaordermalecchymosis.
Inanotherstudy,anomogramwasdevelopedtopredictstonefreeratesafterESWLin412children.Theresults
showthattheoverallstonefreeratewas76.7percentfollowingthefirstESWL.Multivariateanalysisshowedthat
apriorhistoryofipsilateralrenalstonetreatmentorincreasedstoneburdenwasassociatedwithlowerstonefree
rates[24].
AlthoughastonefreestatusisthepreferredoutcomeafterESWL,somepatientswillhaveresidualfragments
aftertheprocedure.Insomecases,thesefragments(usuallylessthan4mmindiameter)willpasswithout
symptoms,sometimestakingseveralmonthstoclear.However,inothercases,residualfragmentsmaygrowin
sizeandbeassociatedwithanincreasedriskofrecurrentsymptomaticepisodes[25].(See"Clinicalsignificance
ofresidualstonefragmentsfollowingstoneremoval".)
ComplicationsInchildren,limiteddatasuggesttherearefewshorttermandnolongtermadverse
effectsofESWLuponrenalfunctionasdemonstratedbythefollowingstudies:
Inaretrospectivereviewof128childrentreatedwithESWL,22patients(18percent)hadcomplicationsin
thepostoperativeweekincluding5withsteinstrasse,14withdecreasedoralintakerequiringintravenous
hydration,7withsidepain/renalcolicrequiringparenteralanalgesics,12withgrosshematuria,and3with
fever[26].
Inaprospectivestudyof50children,renalultrasonographyperformedafterESWLin40patients
demonstratedperirenalhematomasinthreepatients,intrarenalhematomaintwo,andsubcapsularhematoma
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inonepatient.Allhematomasresolvedspontaneously[19].Glomerularfiltrationratemeasuredbeforeand
afterESWLby99mTcdiethylenetriaminepentaaceticacidrenalscan(DTPA)remainedunchanged.
Inaretrospectivestudy,99mTcdimercaptosuccinicacid(DMSA)renalscansperformedin94of182
childrenbeforeandsixmonthsafterESWLdetectednonewscarformationonpostDMSAscans[27].
Relativerenalfunctionofthetreatedsideremainednormalin66patients,wasreducedpreESWLand
remainedunchangedin18patients,showedimprovementafterESWLin7patients,anddeterioratedin2
patients.
Inaprospectivestudyof100childrenwithameanageof8years(range3to14years)treatedfrom2005to
2008,DMSArenalscansperformedbeforeandsixmonthsafterESWLdetectednonewscarformation[28].
TherewasalsonodecreaseinthesplitkidneyfunctionasmeasuredbyDTPAscanafterESWLwithmean
GFRvaluesof113mL/minper1.73m2bothbeforeandafterthelastESWLsession.Theaveragenumberof
ESWLsessionswas1.53andtheoverallstonefreeratewas88percent.Therewerecomplicationsin11
patientsduetostonepassageincludingrenalcolic(n=8),andlowertractobstructionrequiringureteroscopy
forstoneremoval(n=3).
Inaretrospectivereviewof341renalunits,steinstrasse(ureteralobstructionbystonefragments)occurredin
26renalunits(8percent).Logisticregressionanalysisshowedthattheinitialstoneburdenwasassociated
withsteinstrasse.SuccessfulinterventionsincludedrepeatESWLin17renalunits,ureteroscopyafterfailure
ofESWLinfourrenalunitsandwithoutESWLin1renalunit,andconservativemanagementintheremaining
fourunits.
RenalgrowthFollowupstudieshaveshownnoadverseeffectonsubsequentrenalgrowth.
In74childrentreatedatameanageofnineyears(range9monthsto14years)withESWLatatertiary
centerintheUnitedStates,evaluationofrenalgrowthwasperformedbymeasuringrenallengthby
ultrasonographyatthetimeofdiagnosisandfollowup[29].Therewasnodifferenceintherateofrenal
growthbetweenthetreatedanduntreatedkidneysatameanfollowupof6.2years(range1.3to13.1years).
InaprospectiveEgyptianstudyof150childrenwhounderwentESWLbetween2005and2010,therewasno
differenceinrenalgrowthbasedonrenalultrasoundassessmentsbetweenpatients12monthsafterESWL
andcontrols[30].
PercutaneousnephrostolithotomyAlthoughpercutaneoustechniquesforstoneremovalwereinitially
introducedinthelate1970s,itwasnotuntilthe1990sthatinstrumentationwasadaptedtopediatricpatients[31].
Percutaneousnephrostolithotomy(PCNL)entailsobtainingpercutaneousaccesstothecollectingsystem,dilating
thetractwithaballoondilator,andextractingthestonewithgraspingforcepsorfragmentingthestonewitha
LASER,ultrasonic,pneumatic,hydraulic,orcombinedlithotripsyprobe.PCNLcanbeperformedinconjunction
withESWL.
Stonefreeratesof70to90percenthavebeenreported.Ratesvarydependingupontheexperienceofthe
clinician,thecomplexityofthestones,andthepresenceofanunderlyingstructuralabnormality[14,32,33].Inone
retrospectiveEgyptianstudyofchildrenwithrenalstonesbetween1and2cmindiameter,thestonefreerates
betweenasinglePCNLandoneESWLsessionwerecomparable(87versus85percent,respectively)atamean
followupof31months(range6to84months)[14].
Inchildren,dataoncomplicationratesarelimited.Seriousadverseeventsappeartobesimilartothosereportedin
adults(whohaveacomplicationrateof4to5percent)andincludeurosepsis,bleeding(sometimesrequiringred
bloodcelltransfusions),renalpelvicperforation,andinjurytoadjacentorgans(eg,hydrothoraxandcolon
perforation)[14,16,32].
Followupdataregardingrenalfunctionarealsolacking.Onestudyusing9mTcdimercaptosuccinicacid(DMSA)
andDTPArenalscansreportednoevidenceofpostoperativescarringafterPCNLorimpairmentofglomerular
filtrationratewhenevaluatedsixmonthsaftertheprocedure[33].
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UreteroscopyUreteroscopicinstrumentationhasbeenadaptedforuseinpediatricpatientsasfirstline
therapyandisusefulforthemanagementofchildrenwithcalculiwhohavefailedESWL,especiallythosewith
ureteralstones[16,34].Oncethestoneisvisualized,itisextractedwithgraspingforcepsorbasket,orfragmented
withLASER,ultrasonic,orelectrohydrauliclithotripsy.(See"Optionsinthemanagementofrenalandureteral
stonesinadults",sectionon'Ureteroscopy'.)
Althoughdataarelimitedregardingstonefreeratesinchildren,asystematicreviewoftheliteraturereportedstone
freeratesaround90percentinchildrenwithameanageof7.8years[34].Inthisreview,themeanstonesizewas
9.8mmandthemajorityofthestoneswereintheureter(83percent).Thesuccessratewaslowerinchildrenless
thansixyearsofage.
Ureteroscopyisnotassuccessfulintheremovalofstaghorncalculi.Thiswasillustratedinacaseseriesof19
childrenwith23renalcalculithatdemonstratedclearanceofrenalpelvicstonesinsixofeightchildren(mean
numberofsessions1.5),successfulclearanceofstonesinallfourchildrenwithpolarstonesaftermultiple
sessions,andclearanceinonlyoneofsevenchildrenwithstaghorncalculi[35].Theseresultssuggestthat
ureteroscopydoesnothavearoleintreatingchildrenwithstaghorncalculi.(See"Managementofstruviteor
staghorncalculi".)
StentingTheneedforstentinginchildrenwhoundergoESWLorureteroscopyiscontroversial[16].Stents
areusedtopreventuretericobstructioneitherfromedemaduetoureteralinjuryorresidualfragmentsinESWL.
Studiesinadultshavedemonstratedthatpatientswithstentsversusthosewithoutstentsweremorelikelyto
havelowerurinarytractsymptoms(dysuria,frequency,orurgency),whiletherewasnodifferenceinstonefree
rate,andtheratesofUTIs,uretericstructures,andanalgesicadministration.Similardatainchildrenarelacking.In
practice,mostpediatricurologistsdonotplaceastentinsimple,uncomplicatedcasesofureteroscopyorina
patientwithastonelessthan1.5to2cmindiameterwhoistreatedwithESWL[16].
However,prestenting(thepracticeofplacingastentaweekortwopriortotheureteroscopicprocedureto
facilitateeaseofpassageoftheureteroscopes)hasbeenemployedforpassivedilationoftheureter.Thisdoes
placethechildatahigherriskforlowerurinarytractsymptomsandpossibleinfection,butminimizestheneedfor
ureteraldilationatthetimeofureteroscopy.
ChoiceofprocedureChoiceoftreatmentisdictatedbytheexperienceoftheclinicianandtheavailabilityof
instrumentationadaptedforpediatriccases.Incenterswherethedifferentproceduresareavailable,treatment
choicesarebaseduponthestonesizeandlocation,presenceofananatomicalabnormality,and,ifknown,stone
compositionasfollows[14,16]:
SizeESWListhepreferredprocedurewhenstonesareradiopaqueandsmall(lessthan1cmindiameter)
intherenalpelvis,butnotdistalureteralstonesingirlsbecauseofthepositionoftheovaries.Itistheleast
invasiveprocedurewithfewerseriouscomplications.
Forpatientswithstonesgreaterthan2cmindiameterinthekidney,PCNListhepreferredmodalityfor
successfulstoneremovalbecauseofthelowstonefreeratesanddifficultyofhighstoneburden
passageproducedbyESWL.
Inpatientswithstonesbetween1and2cmindiameter,itisuncertainwhichisthebestmodality.As
discussedpreviously,aretrospectivestudyreportedcomparablestonefreeratesforESWLandPCNL
inchildrenwithstonesbetween1and2cmindiameter[14].IfclearancewithESWLisimpaired,such
asinachildwithcalycealdiverticulum,PCNLmaybepreferred.Otherwise,ESWLasaninitialtherapy
issuggestedbecauseitislessinvasiveandhasalowerrateofsignificantcomplications.
LocationPoorerclearanceofrenalstonefragmentsfromthelowerpolecomparedwithotherlocationshas
beenreportedinadultsafterESWL.Similarresultshavebeennotedinseveralcaseseriesinchildren
[12,36].Incontrast,asinglereportof126childrenfromatertiarycenterinEgyptdemonstratedsimilar
clearanceratesregardlessofthestonelocationwithinthekidney[37].
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StructuralabnormalityChildrenwithunderlyingstructuralabnormalities,suchasureteropelvic(UPJ)
obstructionandcalycealdiverticulum,areatincreasedriskfordevelopingrenalstones.Inaddition,the
underlyinganatomicaldefectpreventseffectivepassageofstonefragmentswithESWL.Inmostcenters,
PCNListhepreferredprocedureforpatientswithcalycealdiverticulum,andinchildrenwithUPJobstruction,
eitherPCNLorureteroscopyisusedforstoneremoval.Additionally,calycealdiverticularstonesmaybe
accessedfromalaparoscopicapproachwithanincisionbeingmadeoverthedilatedstoneladencalyxand
directlyextractingthestones.
CompositionofstoneStonesofhardercomposition,suchascystineandcalciumoxalatemonohydrate
stones,arelessamenabletofractionatingwithESWL.Asanexample,inpatientswithcystinestones,the
stonefreesuccessrateisonly50percentwithESWL,evenafterfoursessions[38].Asaresult,PCNLor
ureteroscopyandLASERlithotripsyarethepreferredprocedureinthesepatients.Incontrast,struvite,
calciumoxalatedihydrate,anduricacidstonesbreakmorereadilywithESWLandhaveahighstonefree
successratewithESWL[39].
Opensurgicalrepairisrarely,ifever,performedtodayandisreservedforchildrenwhohavefailedother
urologicproceduresorthosewithcomplexrenalorureteralanatomicabnormalities.
RecommendedapproachIninstitutionswheredifferenttreatmentoptionsareavailable,therapycanbe
individualizedbaseduponthefactorsdiscussedintheprevioussectionasfollows:
Inpatientswithstonesupto2cmindiameter,ESWLorureteroscopywithlithotripsyarebothreasonable
optionsforstoneremoval.
Inpatientswithstonesgreaterthan2cmindiameter,wesuggestureteroscopywithlithotripsy,orPCNL.If
thestoneisinthelowerpolecalyces,theseinterventionshaveagreatersuccessratethanESWL.
Inpatientswithanunderlyingstructuralabnormality,thechoiceoftherapyisindividualizedbaseduponthe
anatomy,andthesizeandlocationofthestone.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Kidneystonesinchildren(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Kidneystonesinchildren(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONSTheacutemanagementofnephrolithiasisinchildrenisdirected
towardspaincontrolandfacilitatingpassageorremovalofthestone(s).Therapeuticchoicesaredependentupon
theseverityofpain,thepresenceofobstructionorinfection,andthesizeandlocationofthestone.
Indicationsforhospitalizationincludeurinaryobstruction,infection,solitarykidney,theneedforparenteral
analgesiabecauseofseverepain,orinabilitytotakeoralanalgesics(eg,vomiting).(See'Overview'above.)
Oneofthemaingoalsofmedicalmanagementistoprovideadequatepaincontrol.Thechoiceofanalgesic
agentisdependentupontheseverityofpainandtheabilityofthechildtotakeoralmedications.Both
nonsteroidalantiinflammatorydrugs(NSAIDs)andopioidsareusedincontrollingpaininchildrenwith
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nephrolithiasis.Inourpractice,wegenerallyuseNSAIDsinpatientswhoaremanagedasanoutpatient.In
hospitalizedpatients,toradolandopioidtherapyareusedforpainmanagement.NSAIDsshouldbestopped
threedaysbeforeanticipatedurologicinterventiontominimizetheriskofbleeding.(See'Paincontrol'above
and"Diagnosisandacutemanagementofsuspectednephrolithiasisinadults",sectionon'Paincontrol'.)
Wesuggestobservationwithpaincontrolinpatientswithstoneslessthan5mmindiameterversusurologic
intervention(Grade2C).Renalultrasonographyisusedtomonitorstonemovementandpassage.(See
'Stonepassage'above.)
Duringthisperiodofobservation,thepatientisinstructedtostrainhis/herurineforstoneretrieval.Ifthe
stoneisretrieved,stonecompositionisdeterminedbylaboratoryanalysis.(See'Stoneretrieval'above.)
Childrenwithseveredebilitatingpainrefractorytoparenteralanalgesictherapyrequireurologicstoneremoval
forpainrelief.(See'Indications'above.)
Otherindicationsforurologicinterventionversusobservationwithmedicalmanagementforpediatric
nephrolithiasisincludethefollowing:
Inchildrenwithsignificanturinaryobstruction,wesuggestimmediateurologicstoneremoval(Grade
2C).
Inchildrenwithstruvitestones,werecommendurologicstoneremoval(Grade1B).(See"Management
ofstruviteorstaghorncalculi",sectionon'Treatmentoptions'.)
Insymptomaticchildrenwhofailtopassastoneaftertwoweeks,wesuggeststoneremoval(Grade
2C).(See'Indications'above.)
Inchildrenwithasolitarykidneywithpartialortotalobstruction,wesuggeststoneremoval(Grade2C).
Thechoiceofurologicprocedureisdeterminedbytheexperienceoftheclinicianandtheavailabilityof
instrumentationadaptedforpediatriccases.Surgicaloptionsincludeextracorporealshockwavelithotripsy
(ESWL),percutaneousnephrostolithotomy(PCNL),andureteroscopy.Theseprocedureshavegenerally
replacedopensurgicalrepairandcanbeusedinchildrenofallages,includingsmallchildrenandinfants.
(See'Procedures'above.)
Incentersthathavedifferenturologicproceduresavailableforstoneremovalinchildren,thechoiceofthe
procedureisgenerallybasedonthesize,location,presenceofananatomicalabnormality,and,ifknown,
stonecomposition.(See'Choiceofprocedure'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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30. FayadA,ElSheikhMG,ElFayoumyH,etal.Effectofextracorporealshockwavelithotripsyonkidney
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32. BilenCY,KoakB,KitirciG,etal.Percutaneousnephrolithotomyinchildren:lessonslearnedin5yearsata
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anatomicalandfunctionalresults.JUrol2004172:1078.
34. IshiiH,GriffinS,SomaniBK.Ureteroscopyforstonediseaseinthepaediatricpopulation:asystematic
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35. DaveS,KhouryAE,BragaL,FarhatWA.Singleinstitutionalstudyonroleofureteroscopyandretrograde
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36. TanMO,KiracM,OnaranM,etal.Factorsaffectingthesuccessrateofextracorporealshockwave
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37. DemirkesenO,OnalB,TansuN,etal.Efficacyofextracorporealshockwavelithotripsyforisolatedlower
calicealstonesinchildrencomparedwithstonesinotherrenallocations.Urology200667:170.
38. SlavkoviA,RadovanoviM,SiriZ,etal.Extracorporealshockwavelithotripsyforcystineurolithiasisin
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39. AlBusaidySS,PremAR,MedhatM.Pediatricstaghorncalculi:theroleofextracorporealshockwave
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Topic6114Version27.0

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GRAPHICS
KUBshowingstaghorncalculi

Theplainfilmoftheabdomenintheanteroposteriorprojectionrevealsastaghorncalculus.
Notecalcifications(arrows)intheoppositekidneyaswell.
Graphic62009Version4.0

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CTscanshowinglargerenalpelvicstone

CTscanwithoutcontrastshowsalargecalculusintherightrenal
pelvis(arrow).
CTscan:computedtomographicscan.
CourtesyofMarkDAronson,MD.
Graphic72669Version6.0

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Disclosures
Disclosures:ThomasSLendvay,MD,FACSNothingtodisclose.JodiSmith,MD,MPHNothingtodisclose.FBruderStapleton,MD
Nothingtodisclose.LaurenceSBaskin,MD,FAAPNothingtodisclose.MelanieSKim,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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