Ripa F. et al., 2025: Imaging during pediatric stone management and follow up.

Francesco Ripa, Edoardo Bonacina, Stefano Paolo Zanetti, Giorgio Mazzon, Simon Choong 
World J Urol. 2025 Oct 31;43(1):656. doi: 10.1007/s00345-025-06041-1

Abstract

Purpose The rising incidence of pediatric urolithiasis, especially in adolescents, underscores the need for optimized imaging strategies in diagnosis, management, and follow-up. This study aims to review the current imaging modalities used in pediatric stone disease, evaluate their efficacy, safety, and radiation risks, and explore strategies for reducing radiation exposure while ensuring effective clinical outcomes.
Methods This narrative review synthesizes existing literature and clinical studies on imaging modalities, the use of radiological imaging during shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), with a focus on radiation safety and adherence to the “As Low As Reasonably Achievable” (ALARA) principles. Data on radiation exposure, stone-free rates, and complication rates related to ultrasound-guided and fluoroscopy-guided approaches were reported and discussed.
Results Ultrasound-guided SWL, URS, and PCNL demonstrated comparable efficacy to fluoroscopy-guided techniques, with stone-free rates ranging from 82% to 96%, and significantly reduced radiation exposure. Introduction of radiation reducing protocols, such as pre-fluoroscopy checklists and dose optimization techniques, led to up to 88% reduction in radiation dose during endourological procedures. Furthermore, metabolic evaluation and tailored preventive strategies were shown to lower recurrence rates, minimizing the need for repeated imaging.
Conclusion Imaging in pediatric urolithiasis must balance diagnostic efficacy with long-term safety. Ultrasound-guided
interventions and radiation-reducing strategies effectively minimize radiation risk without compromising clinical outcomes. Comprehensive metabolic management further supports reduced imaging frequency. Interdisciplinary collaboration is essential to optimize pediatric stone care while adhering to radiation safety principles.

Comment Hans-Göran Tiselius

This is an article that should be carefully read and considered by everyone who is involved in surgical treatment of children with stones. The information covers important issues such as radiation safety in general, imaging particularly for SWL-treatment and, which is unusual, recommendations on recurrence prevention.
It should be emphasized that modern lithotripters are equipped with devices for real-time ultrasound as well as fluoroscopic imaging. Different results have been reported with the two imaging methods. The relatively slow introduction of ultrasound is explained by the easy interpretation of fluoroscopy compared with ultrasound.
It is not mentioned how continuous ultrasound imaging was used to follow the treatment. But such procedures obviously can be used both at the treatment table and remote. It is for instance mentioned that ultrasound guided SWL of cystine stones was superior to that of fluoroscopic guided treatment.
It is unknown to me how common ultrasound imaging is used today, but whatever the situation is, it is of great importance to prefer ultrasound imaging in children.
Radiation safety is discussed in a special chapter in which the principles of ALARA (as low as reasonably acceptable) are presented. The basic principle is to minimize radiation exposure. In general, repeated exposures should be avoided.
One point that, unfortunately, is commonly neglected is the need of ACCURATE COLLIMATION. This method always should be applied and ideally as early as possible during the procedure and with application of a fluoroscopic field as small as possible.
The readers are asked to carefully consider the details necessary to maintain radiation safety discussed in the article.
One of the final sub-chapters in the article deals with metabolic preventive measures. Efforts spent on procedures aiming at reduced rate of stone formation will result in lower need of follow-up imaging either with ultrasound or fluoroscopy. But the basic message is that in children ultrasound should be the preferred imaging modality.

Hans-Göran Tiselius