Contemporary minimal invasive surgical management of stones in children

Although urinary tract stone disease is less common in the pediatric age group than in adults, the increasing incidence of this problem in the last two decades, higher rate of recurrences and the difficulty of interventions make the this population very special for urologists from certain aspects. Continuity of normal renal functional status, complete stone elimination and prevention of stone recurrence are the most important parameters of treatment strategies for urologists. It has been well indicated that management and prevention of stone disease may cause serious morbidity along with a considerable financial cost. When compared with adult ones, based on the well documented metabolic derangements in approximately fifty per cent and anatomical abnormalities in approximately one third of the patients, pediatric stone formers require a detailed urological and metabolic evaluation. In order to plan the best surgical treatment, anatomical characteristics of the urinary system, the presence of obstruction and infection and the location as well as the size of the stone(s), must be taken into consideration. Anatomical and metabolic abnormalities should be treated in an effective manner on time. In addition to a vigorous medical treatment to alkalinize the urine and increase urinary citrate levels in certain cases; adequate fluid intake to increase urine volume and necessary lifestyle changes should be strongly recommended. With respect to the endourological stone management, all available alternatives can be performed in an effective and safe manner in these cases based on the technological advances, improvements in surgical instruments and most importantly experience gained from the adult population. Today, minimal (non) invasive management options for pediatric stones include extracorporeal shock wave lithotripsy (ESWL), semirigid ureteroscopy (URS), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), laparoscopic, robot-assisted laparoscopic and open surgery. While URS, RIRS, PCNL, and laparoscopic procedures require more expertise, SWL is still the first most practicle, non-invasive choice for the vast majority of pediatric stones with its highly effective and safe nature resuting in higher stone-free rates. Open surgery always remains as an alternative treatment option for large and complicated stones with anatomical abnormalities.