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Schlomer BJ., 2019: Urologic treatment of nephrolithiasis

Schlomer BJ.
University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Abstract

PURPOSE OF REVIEW:
The purpose of this review is to describe the options and recent developments in the urologic treatment of nephrolithiasis in children. The prevalence of nephrolithiasis in children has increased over time. The urologic treatment of nephrolithiasis ranges from observation to medical expulsive therapy with an alpha blocker for a stone in a ureter to a variety of procedures for stone removal.

RECENT FINDINGS:
Observation for small, asymptomatic renal stones is a reasonable strategy in children. Medical expulsive therapy with an alpha blocker may have a beneficial effect for passage of ureteral stones in children. Extracorporeal shock wave lithotripsy (ESWL) remains an important treatment for nephrolithiasis in children. Advances in ureteroscopy with clearer digital imaging and single use ureteroscopes have made ureteroscopy more attractive. Percutaneous nephrolithotomy is a more invasive treatment modality but remains a good choice for children with large-stone burdens and instruments are getting smaller. Open or laparoscopic stone surgery should be reserved for unique cases.

SUMMARY:
Nephrolithiasis is increasing in children with differing urologic management options depending on the clinical scenario. A shared decision-making process with discussion of risks and benefits should be used to help patients and families choose a treatment option.
Curr Opin Pediatr. 2019 Nov 26. doi: 10.1097/MOP.0000000000000849. [Epub ahead of print]

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Comments 1

Hans-Göran Tiselius on Thursday, February 20 2020 08:30

This article is an excellent review on how to manage stone problems in children.
For asymptomatic stones observation is recommended for stones with diameters up to 4-5 mm. This approach is less likely to be successful with diameters of 7-10 mm. In case of stones > 20 mm, active stone removal will be necessary.
The urgency of combined obstruction, caused by a ureteral stone, and infection requires rapid drainage.
For small asymptomatic stones treatment with alpha-receptor antagonists might be successful and is recommended for children > 2 years.
I partly disagree with the statement that SWL cannot be used for children with stones composed of COM and cystine. My own experience is that such stones in children have not achieved the same density and hardness that usually is the case in adults. It is thus possible to avoid repeated invasive procedures in this group of children in whom recurrent stones can be expected. Also, distal ureteral stones can successfully be treated with SWL provided adequate positioning can be obtained. SWL is a good alternative to URS! This is emphasized by the fact that the authors raise the problem with URS in the narrow ureters in children.

This article is an excellent review on how to manage stone problems in children. For asymptomatic stones observation is recommended for stones with diameters up to 4-5 mm. This approach is less likely to be successful with diameters of 7-10 mm. In case of stones > 20 mm, active stone removal will be necessary. The urgency of combined obstruction, caused by a ureteral stone, and infection requires rapid drainage. For small asymptomatic stones treatment with alpha-receptor antagonists might be successful and is recommended for children > 2 years. I partly disagree with the statement that SWL cannot be used for children with stones composed of COM and cystine. My own experience is that such stones in children have not achieved the same density and hardness that usually is the case in adults. It is thus possible to avoid repeated invasive procedures in this group of children in whom recurrent stones can be expected. Also, distal ureteral stones can successfully be treated with SWL provided adequate positioning can be obtained. SWL is a good alternative to URS! This is emphasized by the fact that the authors raise the problem with URS in the narrow ureters in children.
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