Pediatr Clin N Am 53 (2006) 465 477

Surgical Management of Urolithiasis

Charles T. Durkee, MDT, Anthony Balcom
Department of Urology, Medical College of Wisconsin, 9000 West Wisconsin Avenue, #606, Milwaukee WI 53226, USA

There is an increase in the number of cases of urolithiasis being seen at pediatric centers and a perception that the overall incidence of stones is also increasing [1,2]. Admissions for stone disease are between 1 per 1000 to 1 per 7600 patients to pediatric centers, with rates showing a geographic variation. This rate is one tenth of that seen in the adult population [3]. This rate, along with a continued evolution in the evaluation and management of stone disease, makes pediatric urolithiasis a timely topic. The signs and symptoms of urolithiasis vary by age group. Infants may present with a urinary tract infection, gross or microscopic hematuria, or nonspecific visceral pain. Associated underlying anatomic abnormalities are much more common in the early childhood group. Renal stones are more prevalent in infants and young children, whereas ureteral calculi are more prevalent in older children and adolescents [4]. Classic renal colic is the more common presentation in older age groups. Hematuria is relatively common throughout all age groups [5]. Differing evaluation and management strategies are required for these groups. The goal of treatment is to achieve a stone-free status whenever possible. If present, anatomic abnormalities are addressed. A complete metabolic evaluation should be undertaken to minimize the risk for recurrent stone formation in all patients, including individuals with anatomic abnormalities. In this section we describe various current surgical approaches and their indications.

Shock wave lithotripsy The introduction of shock wave lithotripsy (SWL) in 1982 has revolutionized the surgical treatment of urolithiasis [6]. Although there are various types of
T Corresponding author. E-mail address: cdurkee@chw.org (C.T. Durkee). 0031-3955/06/$ see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pcl.2006.02.009 pediatric.theclinics.com

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machines, all units function on the principle of generating and focusing shock wave energy at a focal point that is directed at the stone. The stone is pulverized and the resulting fragments are passed. Important variables in the design of the machine include the type of shock wave generator technology, the size of body surface area through which the energy is delivered, the size of the focal area where the energy is concentrated, the method by which a patient is coupled to the machine, and the imaging device. The safety and efficacy of SWL are well established in the adult population. Results in the adult literature show that the success rate approaches 80% when the stone burden is smaller than 2 cm [7]. The rate of residual fragments increases significantly as stone burden increases. Although the pediatric experience is more limited, available data point to a safety and efficacy profile similar to adult outcomes. In one large series, 344 children were treated over a 12-year period. They achieved a 92% stone-free rate for stones located in the renal pelvis that were smaller than 1 cm, 68% stonefree rate for stones from 1 to 2 cm, and a 50% stone-free rate for stones larger than 2 cm. Stone-free rates were lower for patients when the stones were located in the calyces. An average of 1.9 treatment sessions was required to achieve these results [8]. Young children and even infants can be treated safely [9]. Precautions for children include the use of foam tape or similar modifications for protection of the lungs to prevent contusion and lower power settings during treatment. Power settings equal to those used on adult patients have been well tolerated without increased complications, however, presumably because the high water content of the tissue in young children makes the tissue more resilient and less vulnerable to damage [10,11]. In a series of 40 consecutive pediatric patients, immediate renal ultrasounds after treatment found six small hematomas. All hematomas resolved on follow-up. This same study showed no change in the glomerular filtration rate of the treated kidney as determined by technetium 99m diethylenetriaminepentaacetic acid (DPTA) scanning [12]. Pretreatment and posttreatment technetium 99m dimercaptosuccinic acid (DMSA) scanning also have shown no evidence of renal parenchymal scars developing after SWL [13]. The use of stents remains controversial. Most centers do not routinely place stents when stone burden is less than 2 cm. Removal of a stent in this population does require a second anesthetic agent in most cases, although pullout strings are tolerated in some children [14].

Percutaneous lithotripsy Percutaneous techniques for renal stone removal were introduced in the late 1970s, shortly before the advent of SWL. It was not until the 1990s that specific instrumentation was adapted to pediatric patients [15]. This approach may be used solely or in conjunction with SWL in patients with a large stone burden, such as staghorn calculi. The procedure consists of gaining access to the

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collecting system of the kidney percutaneously, advancing a wire, and, using a Seldinger technique, sequentially dilating the tract. Under the same setting or during a second procedure, a nephroscope is introduced through the tract into the kidney. Stones are then removed or pulverized under direct vision. Percutaneous nephrolithotomy (PNL) is currently the main approach to complex upper tract stones. Most adult and pediatric centers perform access and tube placement in radiology the day before the planned intervention, although some centers proceed under a single anesthetic [16,17]. Rigid and flexible miniaturized scopes are then introduced into the kidney (Fig. 1). Modalities for stone removal include the Holmium laser, ultrasonic lithotripsy probes, and direct grasping and removal. PNL also can be used in combination with SWL, with the major stone debulking performed percutaneously. Stone-free rates can be expected in 80% to 90% of cases [15,16]. Rates may very depending on the experience of the operator and the complexity of stones that are treated. Stones within horseshoe kidneys also have been treated successfully. Anomalous anatomy makes access and treatment more challenging [18]. Major complications reported from the adult experience occur in approximately 4% to 5% of cases [19], including urosepsis, bleeding, perforation of the renal pelvis, and injury to adjacent organs. There is an occasional need for conversion to an open procedure [17]. Follow-up DMSA and DTPA scanning have shown no postoperative scarring and no compromise of renal function [16]. Although placement of a nephrostomy tube postoperatively has been standard management, this concept is being challenged. In a small, prospective series in adults, there were no increased complications, and a significant decrease in postoperative pain and recovery time with the use of small tubes or no tubes compared with the use of a traditional large nephrostomy tube [20]. Fibrin

Fig. 1. Percutaneous nephroscopy.

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sealants also have proved to be effective hemostatic agents and urinary sealants, obviating the need for a postoperative nephrostomy tube [21].

Ureteroscopy Ureteroscopy is ideally suited for removal or fragmentation of distal ureteral stones. It is also being used with increased frequency for smaller upper tract stones when SWL is not effective because of inability to visualize the stone or because stone composition or location makes it resistant to SWL fragmentation. The evolution of progressively smaller diameter ureteroscopic instrumentation rigid and flexiblehas made the pediatric ureter and kidney more accessible to endoscopic examination. Rigid scopes can bend without losing visualization and have improved optics and larger working channels. Flexible scopes have true active deflectionup to 2708along with improved optics and larger working channels. Flexible scopes, in particular, remain fragile and may require frequent repair. Once visualized, a stone can be removed effectively. The Holmium laser, with energy delivered through fibers as small as 200 mm, fragment virtually all stones visualized (Fig. 2) [22,23]. Newer generation nitinol stone baskets also have enhanced flexibility, smaller diameters, and wire memory that minimize distortion of the basket and allow safe removal of fragments. The smaller diameter ureteroscopes can be passed safely in most cases without the need for surgical dilation of the system. In some cases, balloon dilation of the distal ureter is performed. A semi-rigid access sheath occasionally is used for flexible ureteroscopy. Preoperative ureteral stenting can be performed to dilate the ureter, with a return to the operating room within a few days if initial instrumentation cannot be accomplished safely.

Fig. 2. Holmium laser lithotripsy of ureteral stone.

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Postoperative stenting is controversial. Stents are placed after instrumentation because of minor trauma to the ureteral wall, postoperative edema to the ureteral wall that obstructs the ureter, or facilitation of passage of small residual stone fragments. Children can experience significant discomfort from the stents and seem to tolerate the stents more poorly than their adult counterparts. The adult experience has shown that patients with stents placed after uncomplicated distal ureteroscopy have more flank pain, bladder pain, urinary symptoms, and narcotic usage than unstented patients in a randomized prospective study [24]. Most surgeons opt for not placing a stent in simple, uncomplicated ureteroscopy in which the scope passed easily. Complications are uncommon in contemporary series [14,25]. Simple perforation can occur and is easily managed by a temporary stent. More significant tears and ureteral avulsion are rarely encountered. Instrumentation never should be forced, and if difficulties are encountered, a stent should be left indwelling for passive dilation of the ureter with a return to the operating room a few days later. Postoperative stricture or ureteral reflux is rarely encountered, and postoperative imaging is reserved for more complicated cases.

Laparoscopy The role of laparoscopy in the treatment of renal and ureteral calculi has not yet been well defined and continues to evolve. With increasing sophistication of laparoscopic techniques and instrumentation, indications for laparoscopic stone removal may expand. For example, laparoscopic stone removal and concomitant pyeloplasty for ureteropelvic junction obstruction have been reported in a series of 19 adult patients [26]. Successful transperitoneal laparoscopic pyelolithotomy has been described in eight failed pediatric percutaneous cases. These patients primarily had a large stone burden in nondilated systems. An 87% success rate was achieved without major complications [27].

Management of renal stones In the absence of major medical contraindications to therapy, almost all patients are candidates for treatment once a renal stone has been identified. The high rate of associated metabolic abnormalities, structural anomalies, and likely growth of a retained stone all dictate an active approach in pediatric patients. The goal of surgical therapy is to achieve a stone-free status. Balanced against this is the attendant risk to patients of prolonged or multiple interventions. The current surgical modalities allow effective treatment with minimal morbidity and maximum safety. Open surgery rarely becomes required. Treatment choices are somewhat dictated by the experience of the operator. Important variables in deciding on the best treatment option include size of the stone, location of the stone, and, if known, stone composition. Renal anatomy, including the presence or absence of hydronephrosis, other associated anomalies,

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Table 1 Primary surgical treatment options versus stone size and location Stones Renal b1 cm 12 cm N2 cm Lower pole b1 cm N1 cm Ureteral Proximal Distal Shock wave lithotripsy Most common Most common Optional Most common Optional Most common Optional Ureteroscopy Optional Optional Rare Optional Optional Optional Most common Percutaneous nephrolithotomy Optional Optional Most common Optional Most common Occasional Rare

and the medical condition of the patient enter into the surgical decision-making process. Age of a patient is not a major determinant in most cases, because all modalities have been used safely in all age groups (Table 1). It is useful to stratify some of these variables into categories for treatment options.

Stone treatment by size Stones smaller than one centimeter There is near unanimity on the use of SWL on a small renal calculus, regardless of age. Success rates defined as a stone-free status of 80% to 90% are achievable [7]. Stents are rarely placed. Stones one to two centimeters Approximately two thirds of stones can be expected to clear with SWL in this category. There is a higher retreatment rate and the need for ancillary procedures. Lower pole calculi clear less effectively as stone size approaches 2 cm. Invasive techniques, particularly PNL, become more effective modalities. In most cases, a stent is not placed. Stones larger than two centimeters In most cases, PNL is the treatment of choice. Success rates with SWL monotherapy start to fall below 50%, and multiple treatments become the norm [7]. One subgroup, however, deserves particular mention. Children younger than age 5 with staghorn calculi have a high success rate with SWL. In one series, 87.5% of patients were stone free after one or two sessions. Stents were not routinely placed. Success rates diminish as a child becomes older and PNL again becomes a more attractive option [28]. Staghorn calculi in adults typically do not respond well to SWL monotherapy.

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Special considerations Ureteropelvic junction (UPJ) obstruction Stones are present in up to 8% of cases of UPJ obstruction [29]. Most patients undergo an open pyeloplasty and successful removal of the stones. The dilated anatomy lends itself to successful removal of the stones. The hydronephrotic kidney is also amenable to percutaneous access, which facilitates PNL and endoscopic incision of the UPJ obstruction. Laparoscopy may play an increasing role in the future [26]. Metabolic evaluation and follow-up are important. In a group of 22 patients with stones and a coexisting UPJ obstruction, 68% had recurrent stones and 87% had an identifiable metabolic abnormality [30]. Calyceal diverticulum A calyceal diverticulum is a congenital outpouching of the calyx, typically with a narrow neck leading to the diverticulum. Although they are uncommon, diverticula are at risk for developing stones. The narrow neck prevents effective stone passage with SWL, and in most centers PNL is the preferred treatment [31]. This approach also allows ablation of the diverticulum to prevent future stone formation [32]. Lower pole calculus Controversy exists regarding the efficacy of SWL of lower pole stones. Although fragmentation can be achieved, their passage may be impeded by the dependent location of the calyx and a frequently associated narrow infundibulum. Multiple studies, including a meta-analysis, have shown decreased lower pole clearing rates of stones compared with other locations within the kidney [33]. Other studies have shown similar clearance rates regardless of location [34,35]. PNL has been the standard treatment option, although continued refinement of the flexible ureteroscope has made ureteroscopy a viable option [36]. Infants Stones and the subsequent need for treatment in infants are uncommon (Fig. 3). Treatment also may be delayed in asymptomatic infants with sterile urine to a later age if carefully monitored. SWL is commonly the preferred treatment modality when intervention is indicated. Safety and efficacy have been demonstrated [9,28], and age alone does not represent a contraindication to treatment. The infant body size requires modifications of positioning and coupling to the shock wave generator and protection of the lung fields with foam tape. PNL may be an alternative modality in this age group, especially when hydronephrosis is present [37]. In the absence of a dilated ureter, ureteroscopy may be more problematic in the infant ureter. The small ureteral diameter can be overcome

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Fig. 3. Obstructing ureteral calculus in a premature infant.

partially by placing a stent to dilate the ureter passively before the definitive ureteroscopic procedure. Stone composition Certain types of stones are less amenable to fracturing. Stone matrix may influence the propagation of the shock wave energy inside the stone [38]. Cystine, brushite, and calcium oxalate monohydrate stones are all resistant to fracturing by SWL (Fig. 4). Invasive techniques are more likely to be required in these cases. Struvite, calcium oxalate dihydrate, and uric acid stones are relatively fragile and break more readily with SWL [39].

Fig. 4. Cystine staghorn calculus.

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Management of ureteral stones Ureteral calculi are invariably symptomatic. Younger patients have less localizing symptoms and less ability to convey these symptoms. Younger patients are less likely to present with a ureteral calculus, however, and are more likely to have renal stones that often have less symptoms. In one study that involved children younger than 5 years old, 68% presented with renal calculi and 32% had ureteral calculi. Children aged 6 to 10 presented with ureteral calculi 64% of the time, and children over age 10 presented with ureteral calculi in 82% of cases [4]. Stone size is a major determinant in predicting spontaneous stone passage. Ureteral stone size at presentation is remarkably consistent regardless of age of presentation. Ureteral stones averaged 4.5 mm for children younger than age 5 compared with 3.2 to 3.5 mm for older children [4]. The ureter in a pediatric patient is nearly as efficient at passing fragments as the adult ureter. For example, upper tract stones treated with SWL pass as efficiently with no increase in complications compared with adults with similar stone burden [40]. In guidelines established for the treatment of ureteral calculi in adults, 71% to 98% of stones smaller than 5 mm spontaneously pass [41]. Pediatric patients also effectively pass stones up to 5 mm, and this passage rate is independent of age [4]. One speculation is that the pediatric ureter is more distensible than the adult ureter and is more efficient at passing stones [42,43]. Stone location at presentation is another important factor. Stones located in the proximal ureter have a significantly lower likelihood of spontaneous passage (29%48%), whereas stones in the distal ureter or at the ureterovesical junction have a passage rate of 75% to 98% [41,44]. Duration of symptoms also has been shown to be another important independent variable for spontaneous passage. An artificial neural network model in adults deemed duration of symptoms to be the single most important variable in predicting passage [45]. A review article found that stones rarely passed if symptoms persisted beyond 4 weeks [46]. In the absence of complicating factors such as a urinary tract infection or unrelenting pain, observation is initially recommended for stones 5 mm or smaller. In adults, 95% of spontaneously passed stones do so within the first 40 days [47]. An observation period of 6 weeks seems reasonable in uncomplicated cases. Permanent adverse effects on the kidney after a period of observation are rarely reported. Presumably, in a patient with minimal symptoms, the ureter has become dilated and high-grade obstruction does not persist. Alpha-adrenergic blockers, such as tamsulosin, terazosin, and doxazosin, have been shown to facilitate stone passage in adults by decreasing ureteral pressure below the stone and decreasing the frequency of the peristaltic contractions of the obstructed ureter [48]. These agents decrease the amount of pain experienced by a patient, decrease the time of passage of the stone, and increase the spontaneous passage rate [49]. Their safety and efficacy have not been demonstrated in children.

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When intervention is indicated, the variables described previously dictate choices. Patients with infection and sepsis must be drained immediately with either a ureteral stent or nephrostomy tube, and definitive treatment is typically delayed until the infection is controlled. Most patients with a proximal ureteral stone are candidates for SWL if the stone is visualized on a plain film of the abdomen [41]. The distal ureteral calculus can be treated with either ureteroscopy or SWL. Ureteroscopy has a marginally higher success rate with a single treatment but also has a marginally higher complication rate than SWL [41]. Although no adverse effects have been proven, it is attractive to avoid the increased radiation exposure and scatter effects of SWL in the pelvis with the proximity of the gonads (Table 1).

Residual fragments after treatment A stone-free status is the preferable outcome after treatment. Failure of all stone fragments to clear completely has led to the concept of insignificant fragments, generally defined as fragments smaller than 5 mm, although no absolute standard exists. Even the definition of stone free is problematic. Fragments will clear for months after SWL treatment of larger stones. Time of follow-up influences outcome. It can be difficult at times to distinguish between residual fragments and new stones. Results also vary widely depending on the imaging modality used. Spiral CT scanning is considered the most accurate imaging modality available. The radiation dosage and cost are significantly higher than in other imaging techniques, however. Compared with spiral CT, a KUB detected only 48% of stones in adults [50]. In one group of children younger than 8 years old, spiral CT detected 57 stones, whereas ultrasound detected only 34 stones [51]. Patients with residual fragments are at risk for growth of the fragments and symptomatic episodes. A group of 160 adult patients who had residual fragments 4 mm or smaller after SWL was followed for 1.6 to 88.8 months (mean, 23 months). Forty-three percent of the patients had a symptomatic episode or required intervention, and 18% demonstrated growth of the fragments [52]. Data are relatively sparse on the outcomes of pediatric patients with residual stone fragments. In a group of 83 pediatric patients with 88 involved renal units treated with SWL, 26 units were left with fragments of 5 mm or smaller. With a follow-up of 3 to 198 months (mean, 46 months), 69% had either symptomatic episodes or fragment growth [53]. Most residual fragments are not insignificant. Equally important is the recognition of metabolic disorders in patients with residual fragments. The presence of metabolic disorders is a strong predictor of growth of residual fragments in pediatric patients [53]. In adults, patients on medical therapy had a 16% incidence of stone growth of residual fragments compared with a more than 50% growth rate in patients not on therapy [54].

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Summary Pediatric patients who have urolithiasis present unique challenges. Interventional techniques developed for adult patients have been adopted and adapted to facilitate effective and safe treatment in this population. Management must be stratified and individualized, taking into account the many factors described in this article. Long-term follow-up and metabolic evaluation are essential components of the overall treatment strategy. Interventional management will continue to evolve with progressive refinements in instrumentation and techniques.

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