SWL literature
SWL Literature

Tekgül S. et al., 2021: European Association of Urology and European Society for Paediatric Urology Guidelines on Paediatric Urinary Stone Disease

Tekgül S, Stein R, Bogaert G, Nijman RJM, Quaedackers J, 't Hoen L, Silay MS, Radmayr C, Doğan HS.
Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey.
Department of Pediatric, Adolescent and Reconstructive Urology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
Department of Urology, University of Leuven, Leuven, Belgium.
Department of Urology and Pediatric Urology, University Medical Centre, Groningen, The Netherlands.
Department of Urology, Erasmus MC, Rotterdam, The Netherlands.
Department of Urology, Istanbul Biruni University, Istanbul, Turkey.
Department of Urology, Medical University of Innsbruck, Innsbruck, Austria.
Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey.

Abstract

Context: Paediatric stone disease is an important clinically entity and management is often challenging. Although it is known that the condition is endemic in some geographic regions of the world, the global incidence is also increasing. Patient age and sex; the number, size, location, and composition of the stone; and the anatomy of the urinary tract are factors that need to be taken into consideration when choosing a treatment modality.

Objective: To provide a general insight into the evaluation and management of urolithiasis in the paediatric population in the era of minimally invasive surgery.

Evidence acquisition: A nonsystematic review of the literature on management of paediatric urolithiasis was conducted with the aim of presenting the most suitable treatment modality for different scenarios.

Evidence synthesis: Because of high recurrence rates, open surgical intervention is not the first option for paediatric stone disease, except for very young patients with very large stones in association with congenital abnormalities. Minimally invasive surgeries have become the first option with the availability of appropriately sized instruments and accumulating experience. Extracorporeal shockwave lithotripsy (SWL) is noninvasive and can be carried out as an outpatient procedure under sedation, and is the initial choice for management of smaller stones. However, for larger stones, SWL has lower stone-free rates and higher retreatment rates, so minimally invasive endourology procedures such as percutaneous nephrolithotomy and retrograde intrarenal surgery are preferred treatment options.

Conclusions: Contemporary surgical treatment for paediatric urolithiasis typically uses minimally invasive modalities. Open surgery is very rarely indicated.

Patient summary: Cases of urinary stones in children are increasing. Minimally invasive surgery can achieve high stone-free rates with low complication rates. After stone removal, metabolic evaluation is strongly recommended so that medical treatment for any underlying metabolic abnormality can be given. Regular follow-up with imaging such as ultrasound is required because of the high recurrence rates.

Keywords: Minimally invasive surgery; Paediatric stone disease; Percutaneous nephrolithotomy; Retrograde intrarenal surgery; Shockwave lithotripsy; Urolithiasis.
Eur Urol Focus. 2021 May 26:S2405-4569(21)00158-9. doi: 10.1016/j.euf.2021.05.006. Online ahead of print. PMID: 34052169 Review.

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Comments 1

Hans-Göran Tiselius on Friday, August 13 2021 08:30

There is an increasing incidence of stones in children. Accordingly, it is necessary for urologists in all parts of the world to get familiar with the principles of stone treatment in their young patients. In several, but not in all, regards is the treatment similar to that applied in adults. For the clinical management of stones in children this EAU guideline summary is useful reading.
The stone diagnosis usually should be established with ultrasound or as a second option with low-dose NCCT.
It is noteworthy that symptoms in children differ from those in adults and for young children micro-hematuria combined with non-specific symptoms should be observed.
The use of stenting is mentioned as a useful tool, but my own experience is that the capacity to clear stone fragments via the ureter in children is considerably superior to that in adults. For the same reason I do not agree that the first line treatment for stones >10 mm should be PCNL. Stones larger than that can be disintegrated with SWL and fragment passage in mobile children can be quite impressive. Although patients with cystine stones generally are less suitable candidates for SWL this is not necessarily so for young children. Cystine stones that have developed in the renal collecting system for short periods might be relatively brittle and surprisingly easy to disintegrate. The same is to some extent true also for COM-stones.
It is correct that SWL does not require heavy anesthesia, but the age at which treatment with analgesics and sedatives is enough might vary significantly between patients.
Why endoscopy generally is the best alternative for mid and distal ureteral stones is something that can and should be discussed.

Hans-Göran Tiselius

There is an increasing incidence of stones in children. Accordingly, it is necessary for urologists in all parts of the world to get familiar with the principles of stone treatment in their young patients. In several, but not in all, regards is the treatment similar to that applied in adults. For the clinical management of stones in children this EAU guideline summary is useful reading. The stone diagnosis usually should be established with ultrasound or as a second option with low-dose NCCT. It is noteworthy that symptoms in children differ from those in adults and for young children micro-hematuria combined with non-specific symptoms should be observed. The use of stenting is mentioned as a useful tool, but my own experience is that the capacity to clear stone fragments via the ureter in children is considerably superior to that in adults. For the same reason I do not agree that the first line treatment for stones >10 mm should be PCNL. Stones larger than that can be disintegrated with SWL and fragment passage in mobile children can be quite impressive. Although patients with cystine stones generally are less suitable candidates for SWL this is not necessarily so for young children. Cystine stones that have developed in the renal collecting system for short periods might be relatively brittle and surprisingly easy to disintegrate. The same is to some extent true also for COM-stones. It is correct that SWL does not require heavy anesthesia, but the age at which treatment with analgesics and sedatives is enough might vary significantly between patients. Why endoscopy generally is the best alternative for mid and distal ureteral stones is something that can and should be discussed. Hans-Göran Tiselius
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Sunday, November 28 2021

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