Minevich E, 2010: Management of ureteric stone in pediatric patients
Division Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
The management of ureteral stones in children is becoming more similar to that in adults. A number of factors must be taken into account when selecting one's choice of therapy for ureteral stone in children such as the size of the stone, its location, its composition, and urinary tract anatomy. Endoscopic lithotripsy in children has gradually become a major technique for the treatment of ureteral stones. The stone-free rate following urteroscopic lithotripsy for ureteral stones has been reported in as high as 98.5-100%. The safety and efficacy of Holmium:YAG laser lithotripsy make it the intracorporeal lithotriptor of choice. Given its minimally invasive features, extracorporeal shock wave lithotripsy (ESWL) has become a primary mode of treatment for the pediatric patients with reno-ureteral stones. Stone-free rates have been reported from 59% to 91% although some patients will require more than one treatment session for stone clearance. It appears that the first-line of therapy in the child with distal and mid-ureteral stones should be ureteroscopic lithotripsy. While ESWL is still widely considered the first-line therapy for proximal ureteral calculi, there is an increasing body of evidence that shows that endoscopic or ESWL are equally safe and efficacious in those clinical scenarios. Familiarity with the full spectrum of endourological techniques facilitates a minimally invasive approach to pediatric ureteral stones.
Indian J Urol. 2010 Oct;26(4):564-7. doi: 10.4103/0970-1591.74462
PMID:21369391 [PubMed - in process] PMCID: PMC3034067
From review of the literature the author comes to the conclusion that the best treatment for mid and distal ureteral stones in children is ureteroscopy, whereas ESWL should be the primary choice for treating stones in the proximal ureter. Experience has shown that very high stone-free rates can be achieved with ureteroscopy and that the re-treatment rate is low. Accordingly ureteroscopy seems as an excellent method for removing stones from the ureter, particularly regarding distal and mid ureteral stones. It is however, an invasive technique that is applied for ureters with a small dimension and the late effects of ureteroscopy in children is poorly studied.
There is a wide variability of results reported for distal, mid and proximal ureteral stones in children treated with ESWL. In the literature repeated treatment sessions and low stone-free rates often is referred to. It is, however, my own experience that provided care is taken to avoid shielding skeletal structures and other obstacles for a free shockwave path and provided the ESWL is carried out in an optimal way, stones in the whole ureter can be efficiently disintegrated with ESWL and repeated sessions is only very occasionally necessary. The ureter in children is powerful and can eliminate the stone fragments very fast.
So, how stones in the ureter best should be treated remains controversial and there is no solid evidence in the literature that endoscopic stone removal in children definitely is better than ESWL if that method is used with optimal technique and equipment.