In the past few years, a dramatic increase in pediatric urolithiasis has been observed. This observation has been seen in adolescents without any known metabolic disturbances, but it could be due to their sodium and carbohydrate filled diet. The stone diseases can also be caused because of genetic, metabolic, and dietary reasons as well. There are several reasons that contribute in pediatric stone disease, and the medical treatment is done under the endourologic management. Proper diet and medication can completely treat the pediatric stone patient
There are a lot of pediatric patients that have metabolic abnormalities as well. In the initial phases of the pediatric stone disease, it is very common to see 24-hour urine values for creatinine, sodium, calcium, oxalate, uric acid, and even citrate. The 24 hour urine collection lmits its accuracy in the pediatric population, which makes it very cumbersome. Because of the random urine spot sampling, ratios are used, i.e Urine calcium to urine creatinine ratios(Uca : Ucr). They are used with sensitivities and specificities up to 90% and 84% respectively, and evaluates hypercalciuria, which is a known risk factor for urolithiasis.
It is usually advised to measure the intake of urinary supersaturation products, i.e. calcium oxalate, urate, as it helps in identifying the chances of stone formation risks in children. The initial treatment includes conservative management of pediatric nephrolithiasis, provided there is no infection, fever, nausea, anorexia etc. If any such symptoms is seen in the child, then immediate endourologic intervention is needed. When the stone diseases is being managed in the pediatric population, one should keep in mind that the stones with less than 3mm are more likely to spontaneously pass. However, the stones greater than or more than 4mm in the distal ureter require endourologic treatment for the same.
In order to facilitate distal stone passage, with the help of medical expulsive therapy, use of antagonists, calcium channel blockers, and steroids is usually proved to be very effective. Unfortunately, we have also seen a lack of published data capturing the pediatric population which state what method will be better, using these agents or pain medication.
The radiographic assessment of the child with calculus disease should be accurate, safe and economical at the same time. The main aim is to determine the location, size, density and urinary tract anatomy of the stone. The unenhanced helical Computed Tomography (CT) is the most accurate and efficient choice in initial imaging. When it comes to assessment of urolithiasis, ultrasonography is more limited as compared with CT, but it also has this distinct advantage of no associated ionizing radiation, which gives it an upper hand. Therefore ultrasonography should be considered as a screening tool in case of workup for non emergent abdominal or flank pain. Since the children are always at a risk of recurrence of urolithiasis, the radiation exposure should also be limited, particularly the gonadal exposure.
The evolution of new techniques and miniaturization of instruments have completely changed the management of pediatric stone disease. Despite the encouraging results, the concern still remains regarding the safety of endourologic treatment in kids, and how it might affect the growth of the kidney. Although shock wave lithotripsy is still considered first-line therapy for upper tract calculi less than 1.5 cm, evidence is accumulating that ureteroscopy with laser lithotripsy and stone basketing may be more efficacious in treating upper tract stone disease in children. Although percutaneous nephrolithotomy remains the most effective technique for large upper tract stone burdens, there are now reports of laparoscopic and robotic-assisted laparoscopic pyelolithotomy in major pediatric academic centers with extensive laparoscopic and robotic experience.