Urolithiasis

The initial aim in stone management is relief of symptoms. Secondary aims: 1. Achieve stone-free status. 2. Reduce or prevent stone recurrence. Summary of evidence for these aims: The most common presenting complaint is abdominal pain. Our review found no study evaluating medical therapy to control acute renal colic in children. Although studies in adults conclude that alpha-blockers promote spontaneous stone passage, evidence in children is not conclusive. Two studies reported spontaneous stone passage in 34 and 47 % of children. Reported stone-free rates for renal stones <1 cm were 63-86 % for shock wave lithotripsy (SWL) and 50-90 % for ureteroscopy. Efficiency quotients (EQ) were only reported for SWL, with approximately 25 % needing additional procedures. However, at least a third of patients undergoing ureteroscopy needed a period of stenting to dilate the ureter before the stone could be accessed, and most had postoperative stents, meaning some had as many as three procedures to achieve stone-free status. Unlike adults, lower pole stones in children are as effectively treated by SWL as those in other renal locations. One trial compared monotherapy percutaneous nephrolithotomy (PCNL) to SWL for renal stones 1-2 cm, finding stone-free rates greater with PCNL, 95 % versus 85 %. One trial found no difference in stone recurrence in those stone-free versus having fragments <5 mm after SWL. Recurrence after stone-free status occurred in ≤10-33 % of patients. One study reported significantly fewer recurrences with potassium citrate therapy. Low-sodium high-potassium diet resolved hypercalciuria in 50 % of children, but was difficult to maintain. Indications and duration of medical therapy with potassium citrate or thiazides are not defined for children. Our review found no study evaluating stone recurrence rates in children with versus without 24-h urine stone-risk profile determinations in first-time pediatric stone formers.