Treatment of pediatric urolithiasis how small is

Authors: Mahesh Desai

Publish Date: 2011/10/30

Volume: 29, Issue: 6, Pages: 705-706

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Abstract

“Big” scars for stone removal are only needed in unusual circumstances This is true given the fact that technology is fast evolving and instruments becoming smaller and smaller The management of urolithiasis in children has undergone a paradigm shift in the past decade Management of pediatric urolithiasis necessitates a balance between stone clearance and morbidity related to the procedure A variety of treatment options are available which include shock wave lithotripsy SWL percutaneous Nephrolithotomy PCNL and retrograde intra renal surgery RIRS and open surgery Concerns regarding endourologic treatment include effect on the renal development and function the side effects of radiation and the implications of residual stones Children with pediatric urolithiasis need to be worked up metabolically to prevent recurrenceThe treatment options should be chosen with prudence as each of the treatment options has its share of problems SWL has been the treatment of choice for renal calculi less than 15 mm in size The stonefree rates range from 68 to 84 1 In our study ESWL was found to be safe and effective in children as was in adults for solitary renal and upper ureteric stones less than 2 cm in size We found that children required fewer and lower energy shock waves to achieve equivalent results Considering that longterm data are awaited regarding functional consequences of shock waves on pediatric kidneys it would be prudent to shock these kidneys as little as possible In this context we feel to minimize the “shock loss” and optimizing the number and energy of shock waves the patient should be given optimum anaesthesia with the use of ultrasound and fluoroscopy for localizing and monitoring of stone fragmentation 2PCNL remains the most effective option for treating large stones in this age group The obvious downside of this approach is the potential for lifethreatening complications such as bleeding hence surgeon experience is paramount in deciding the number and site of access Stonefree rates of more than 90 have been shown in pediatric age group 3 Percutaneous Nephrolithotomy has been described even in children as small as 11 months having complex calyceal stones and/or staghorn calculi The method to gain access ultrasound or fluoroscopy is a matter of experience and personal preference Ultrasound offers the advantage of visualization of spleen and liver and avoids injury It also minimizes radiation to these kids The key to success in PCNL in these small patients is staging the procedure if required miniaturization of instruments and using ultrasound as the method of achieving access PCNL offers a good clearance rates with acceptable morbidity Miniaturization of instruments particularly smaller nephroscopes and newer energy sources will decrease the morbidity of PCNL The question is how small is small enough In this regard in our opinion microperc is the “new kid on the block” It has a role to play in percutaneous management of these small patients Essentially “microperc” involves performing the procedure through the eye of the needle The microoptics of 09 mm diameter are used The assembly has a integrated light head inserted through the working sheath of the needle and PCNL can be done through the same needle sheath with a 3way needle allowing irrigation passage of flexible telescope and a laser fibre 4 Although investigational larger multicentre trials that are already underway will prove its utilityLower ureteric stones can be managed with semirigid ureteroscope and access to the upper tract may be difficult due to narrow delicate ureters The newer sleak flexible ureteroscopes with improved deflection mechanism will change the way we manage these stonesSurgeon experience and instrumentation are “key” to complete stone clearance with minimal morbidity The future lies with newer generation SWL machines smaller flexible ureteroscopes “all see needles” and nephroscopes We believe that “Small” is the next “Big” thing in managing pediatric stones

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