Van Batavia JP et al, 2016: Clinical effectiveness in the diagnosis and acute management of pediatric nephrolithiasis.
Van Batavia JP, Tasian GE.
Division of Urology, The Children's Hospital of Philadelphia, USA.
Division of Urology and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, USA; Division of Urology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, USA.
The incidence of pediatric nephrolithiasis has risen over the past few decades leading to a growing public health burden. Children and adolescents represent a unique patient population secondary to their higher risks from radiation exposure as compared to adults, high risk of recurrence, and longer follow up time given their longer life expectancies. Ultrasound imaging is the first-line modality for diagnosing suspected nephrolithiasis in children. Although data is limited, the best evidence based medicine supports the use of alpha-blockers as first-line MET in children, especially when stones are small and in a more distal ureteral location. Surgical management of pediatric nephrolithiasis is similar to that in adults with ESWL and URS first-line for smaller stones and PCNL reserved for larger renal stone burden. Clinical effectiveness in minimizing risks in children and adolescents with nephrolithiasis centers around ED pathways that limit CT imaging, strict guidance to ALARA principles or use of US during surgical procedures, and education of both patients and families on the risks of repeat ionizing radiation exposures during follow up and acute colic events.
Int J Surg. 2016 Nov 14. pii: S1743-9191(16)31039-1. doi: 10.1016/j.ijsu.2016.11.030. [Epub ahead of print]
This review on how to manage stone problems in the paediatric population is valuable reading.
It is emphasized that first line diagnostic imaging procedure should be ultrasound and not CT. This recommendation is of great importance in view of children’s sensitivity to radiation.
It is of note that MET with alpha-receptor antagonists advantageously can be used in children. The reported positive experience is important because personally I have been reluctant to use this kind of medication for patients in this age-group.
Surgical intervention is considered necessary in between 22 and 60% of children with stone disease. The results obtained with SWL, URS and PNL are roughly similar and either URS or SWL are recommended as first line treatment for ureteral stones.
One note of caution is that the long-term effect of SWL is insufficiently known. The risk of developing hypertension needs long-term follow-up, much longer than 5 years and it is important not to overlook that possible problem.