Acute Management of Nephrolithiasis in ChildrenUPTODATE NOV 2015 (1)

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4/12/2015 Acute management of nephrolithiasis in children

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Offi cial reprint from UpToDatewww.uptodate.com ©2015 UpToDate

AuthorsThomas S Lendvay, MD, FACSJodi Smith, MD, MPHF Br uder Stapleton, MD

Section Editor Laurence S Baskin, MD, FAAP

Deputy Editor Melanie S Kim, MD

Acute management of nephrolithiasis in children

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2015. | This topic last updated: Jun 09, 2015.

INTRODUCTION — The management of pediatric nephrolithiasis is divided into two parts.

The acute management of childhood nephrolithiasis will be reviewed here. The prevention of recurrent disease,

epidemiology, risk factors, clinical manifestations, and diagnosis of nephrolithiasis in children are discussed

separately. (See "Prevention of recurrent nephrolithiasis in children" and "Epidemiology of and risk factors for

nephrolithiasis in children" and "Clinical features and diagnosis of nephrolithiasis in children".)

OVERVIEW — The acute management of nephrolithiasis depends upon the severity of the pain, and the presence

of obstruction or infection. In some patients, outpatient medical management with oral analgesics and hydration is

possible. However, in others, especially those with nausea, vomiting, and severe pain, hospitalization is required

for parenteral fluid and pain medication. Other indications for hospitalization include urinary obstruction, solitary

kidney, and infection.

Urologic removal of stones may be required in patients with unremitting severe pain that is refractory to analgesic

therapy, or in those with obstruction or infection. (See 'Indications' below.)

MEDICAL MANAGEMENT

Supportive care — Supportive management includes symptomatic treatment and aggressive hydration. In our

center, we start intravenous hydration at 1.5 to 2 times the maintenance rate as quickly as possible. Nausea and

vomiting should be treated with intravenous antiemetics. Pain associated with renal colic is best treated with

narcotic analgesics combined with nonsteroidal antiinflammatory medications.

Pain control — Both nonsteroidal antiinflammatory drugs (NSAIDs) and opioid therapy are used to control pain

associated with nephrolithiasis. In studies of adult patients, both classes of analgesics are effective in pain relief.Combination therapy of the two has also been reported to be effective and in some cases superior to either agent

alone. In adults, the combination of morphine and ketorolac has been shown to be an effective combination to

control pain in patients with renal colic. (See "Diagnosis and acute management of suspected nephrolithiasis in

adults", section on 'Pain control' and "Pharmacologic agents for pediatric procedural sedation outside of the

operating room", section on 'Analgesic agents' and "Selection of medications for pediatric procedural sedation

outside of the operating room", section on 'Analgesia' .)

At our institution, in patients with less severe disease who can be managed as an outpatient, we initiate pain relief

with NSAIDs if renal function is not impaired. If pain relief is not achieved, the patient may require hospitalization

for more aggressive therapy. In the hospitalized patient, we use hydration, intravenous ketorolac, and opioid

®

®

Acute episode – During the acute phase when the stone is being passed, management is directed towards

pain control, and facilitating passage or removal of the stone(s).

●

Prevention of recurrent disease – After the acute episode, management is directed towards prevention of

recurrent stone disease. This includes an evaluation to identify any underlying cause or risk factors for stone

formation. Based upon this assessment, interventions are tailored to reduce the risk of recurrent stone

formation.

●

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therapy as follows:

The use of NSAIDs should be stopped three days before a urologic intervention, if possible, to minimize the risk of

bleeding. (See "Diagnosis and acute management of suspected nephrolithiasis in adults", section on 'Pain

control'.)

Urine culture — Because urinary tract infection (UTI) is often present in children with nephrolithiasis, a urine

culture should be obtained. If a UTI is diagnosed, appropriate antibiotic therapy should be initiated. (See

"Epidemiology of and risk factors for nephrolithiasis in children", section on 'Infection' and "Urinary tract infections

in infants older than one month and young children: Acute management, imaging, and prognosis", section on

'Antibiotic therapy'.)

Stone passage — The majority of stones less than 5 mm in diameter will pass spontaneously, even in small

children [1,2]. Hydration increases urinary flow and is thought to facilitate stone passage. In children,

ultrasonography and a single kidney-ureter-bladder (KUB) radiograph (if the stone is radiopaque) are generally usedto monitor stone passage because noncontrast helical computed tomography (CT) is more costly and is

associated with higher radiation exposure. CT, however, is the most sensitive imaging modality in the detection of

renal or urinary tract stones and is used in the diagnosis of nephrolithiasis, especially when true stone burden and

exact stone location are required for surgical management. Imaging is typically performed after a two-week period

of observation to confirm stone passage. (See "Clinical features and diagnosis of nephrolithiasis in children",

section on 'Imaging'.)

In adults, several medical interventions have been used to increase the passage rate of ureteral stones, including

antispasmodic agents, calcium channel blockers, and alpha blockers. Data are limited on the use of these agents

in children.

In our practice, we have used alpha blockers to facilitate stone passage in children with distal ureteral stones.

Although the US Food and Drug Administration has not approved the use of alpha blockers in children, based on

the above data, we will use tamsulosin in children older than five years of age with symptomatic ureterovesical

stones. We use a dose of 0.4 mg of tamsulosin given in the evening before bedtime. If there has been no

spontaneous passage by one or two weeks, we will intervene surgically. These medications have been well

Morphine − For children >6 months of age and ≤50 kg, intravenous morphine is given as 0.05 to 0.1 mg/kg

per dose every two to four hours as needed.

●

Ketorolac – For children >2 years of age, intravenous ketorolac is given as 0.5 mg/kg per dose every six

hours with a maximum dose of 30 mg. Kerorolac is automatically discontinued after 72 hours of intravenous

administration.

●

In one small clinical trial of 39 patients, children with distal ureteral stones that were smaller than 10 mm

were randomly assigned to either doxazosin (an alpha blocker) at a daily dose of about 0.03 mg/kg or

ibuprofen [3]. There were no differences between the doxazosin and ibuprofen groups in the rate of stone

passage (84 versus 70 percent) or in the mean time for stone expulsion (5.9 versus 6.1 days).

●

In contrast, another trial of 45 children (ages 3 to 15 years) reported increased expulsion rates for patients

with distal ureteral stones who received both doxazosin and ibuprofen compared with those who only

received ibuprofen (71 versus 29 percent) [4].

●

Tamsulosin, an alpha blocker, was studied in a prospective controlled trial in 61 children with distal ureteral

stones


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tolerated, and we have not seen orthostatic hypotension, even though this is a potential side effect of alpha

blockers. (See "Diagnosis and acute management of suspected nephrolithiasis in adults", section on 'Facilitating

stone passage' and 'Urologic intervention' below.)

Stone retrieval — The family/patient should be instructed to strain the child's urine for several days, in order to

retrieve the stone. If the stone or any fragment is recovered, it should be sent for stone analysis. The known

composition of the stone can guide further evaluation and preventive measures to prevent recurrent stones.

Urinary strainers are available from medical supply companies. If a urinary strainer cannot be obtained, a

receptacle covered by a cheese cloth or fine mesh sheet can be used. A fish net used for home aquariums is alsoa good alternative. (See "Prevention of recurrent nephrolithiasis in children", section on 'Evaluation for underlying

risk factors'.)

UROLOGIC INTERVENTION

Indications — Indications for urologic intervention are based upon observational evidence that is primarily from

adult studies. Although similar data are not available for children, we believe this indirect evidence is applicable to

children with nephrolithiasis. In our practice, urologic intervention is performed versus continued observation with

medical management in the following settings:

Nevertheless, because of the high spontaneous stone passage rates for smaller calculi, as well as the cost and

potential complications from urologic procedures, it is generally accepted that an observation period with adequate

pain control should be given. The optimal length of time for observation prior to intervention remains uncertain;

however, in our practice, an observation period of up to two weeks is employed. The goal of management is to

minimize renal injury, which requires balancing the risk of a urologic procedure (ie, urinary drainage or stone

removal) versus potential chronic renal injury from continued obstruction.

In our practice, surgical intervention is considered in the following settings:

Unremitting severe pain – Severe pain despite adequate analgesia is most often due to a uretero-vesical

(UVJ) or uretero-pelvic junction (UPJ) stone, which is usually accompanied by obstruction. In these patients,pain is relieved with a temporizing ureteral stent and subsequent stone removal, regardless of the size of the

stone.

●

Urinary obstruction – Obstruction from renal calculi can result in renal parenchymal injury and a decrease in

renal function [7]. Intervention in patients with mild renal insufficiency demonstrates both an initial

improvement in renal function due to the relief of the obstruction and subsequent improvement thought to be

due to recovery of injured renal tissue [8,9]. Without relief, persistent obstruction can result in permanent

scarring and loss of renal tissue [7].

●

Surgical removal – If there are signs of infection, complete obstruction, partial obstruction by a stone in a

solitary kidney, or renal insufficiency, or if the stone is greater than 5 mm in diameter, as it is unlikely to pass

spontaneously. These above criteria are absolute indications and lead us to intervene without a trial of

medical observation and treatment, as we feel these situations can lead to significant morbidity.

●

Struvite stones (magnesium ammonium phosphate and calcium carbonate-apatite) are often associated

with an underling UTI, and tend to branch and enlarge resulting in a filling of the renal calyces producing

a "staghorn" appearance (image 1 and image 2). Urologic removal of struvite calculi is generally

required to eradicate the underlying infection [10]. Persistent infection, usually due to a urease-

producing bacteria (eg, Proteus or Klebsiella), is a risk factor for recurrent stone formation. (See

"Epidemiology of and risk factors for nephrolithiasis in children", section on 'Infection' and

"Pathogenesis and clinical manifestations of struvite stones" and "Management of struvite or staghorn

calculi".)

•

Symptomatic stones that fail to pass after a trial of conservative therapy – Surgical intervention is performed●

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Procedures — Over the past two decades, the following new urologic procedures for stone removal have beendeveloped and adapted to children [12-15]. These procedures have generally replaced open surgical repair and can

be used in children of all ages, including small children and infants. However, the experience and comfort of the

surgeon as well as the equipment available should be considered in the decision of which intervention to use.

Many of these interventions are limited by the size of the instruments available. Our group has used each of the

three modalities below to treat children as little as infants, but other medical centers may be constrained by their

pediatric-sized resources.

Extracorporeal shock wave lithotripsy — Extracorporeal shock wave lithotripsy (ESWL) employs high

energy shock waves produced by an electrical discharge. Historically, the child was placed in a water bath and the

shock waves were transmitted through the water and directly focused onto the stone with the aid of biplanar

fluoroscopy. Second and third generation lithotriptors do not require the water bath, but utilize a contained fluid

interface with the patient to transmit the shockwaves. The change in tissue density between the soft renal tissue

and the hard stone causes a release of energy at the stone surface, which fragments the stone.

For stones that are less than 2 cm in diameter, the resulting fragments are usually passed without difficulty.

Stents can be placed when the stone is greater than 2 cm to reduce the risk of obstruction [ 16]. However, in

children, the placement and removal of the stent generally requires conscious sedation or general anesthesia. In

one case series of 24 children (age range 2 to 14 years), stones between 2.5 and 3.5 cm (mean 3.1 cm) weretreated by ESWL without the use of stents [17]. At the end of therapy, the overall stone-free rate was 83 percent,

and complications occurred in six patients, including ureter obstruction by stone fragments, also referred to as

steinstrasse (n = 4), and renal colic (n = 2). Of the four with steinstrasse, one patient required ureteroscopy to

relieve the obstruction, and spontaneous stone passage occurred in the other three patients. However, because of

the increased morbidity associated with steinstrasse, we continue not to recommend stentless ESWL for stones

greater than 2 cm in diameter.

We use general anesthesia for ESWL due to the requirements of a completely stationary patient during the

procedure and the minimal skin sensation, which an awake child would perceive at the entrance site of the shock

wave.

if there is no improvement after a trial of medical therapy after two weeks for symptomatic patients without

an underlying UTI, and for those with evidence of radiographically-confirmed obstruction or who have mild

proximal urinary tract dilation that is managed with oral analgesics that do not impair daily activities.

Asymptomatic patients − We offer urologic intervention to asymptomatic children with stones that do not

spontaneously pass after two weeks of medical therapy and observation. These stones are often located in

the kidney and generally do not result in symptoms. However, their removal could prevent a potential acute

episode of renal colic due to obstruction of the urinary tract. Alternatively, patients can be treated

conservatively with hydration and pain control as needed. In patients with uric acid stones, urine

alkalinization increases the solubility of uric acid and may result in a decrease in stone size with subsequent

passage. (See "Prevention of recurrent nephrolithiasis in children", section on 'Hyperuricosuria'.)

●

Urosepsis – Although not commonly seen in children, urosepsis is a serious and life-threatening complication

of nephrolithiasis. In adult patients, urinary drainage is used to lower the intrarenal pelvic pressure due to

stone-induced obstruction, which is thought to improve delivery of antibiotics to the infected kidney [ 11].

Because we feel the risk of a lower UTI expanding to urosepsis is significant in the setting of static urine

from partially or completely obstructive stones, we recommend surgical intervention for stones in the face of

concomitant lower UTI as well. Furthermore, clearance of UTIs with only antibiotic therapy is difficult in

patients with symptomatic stones.

●

Extracorporeal shock wave lithotripsy (ESWL)●

Percutaneous nephrostolithotomy (PCNL)●

Ureteroscopy●

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ESWL has been shown to be an effective and safe procedure for removing stones in children [ 12,18,19], including

small children and infants [13,20-22]. However, modifications to ensure proper positioning of the child and

appropriate dose of electrical discharge to the size of the patient are required to reduce the likelihood of

complications such as hematomas or lung contusions [16]. Typically, the shock waves are delivered in a

synchronized manner with the electrocardiogram (gated). However, in a small clinical trial using ungated ESWL,

slowing the shock wave rate from 120 to 80 waves per minute improved stone clearance in children with stones

that were less than 20 mm in diameter after one session (26 versus 60 percent) [ 23]. However, the time of general

anesthesia was longer in the group of patients who received ESWL using a slower wave frequency. Further

research in larger cohort studies is needed to determine the optimal delivery and rate of shock waves for lithotripsyin children.

In a large case series, 344 Turkish children (age range 6 months to 14 years) were treated with ESWL over a 12-

year period [12]. ESWL was performed as an outpatient procedure with administration of conscious sedation,

general anesthesia, and no anesthesia in 40, 38, and 22 percent of children, respectively. The following findings

were noted at three month follow-up:

In another study, a nomogram was developed to predict stone-free rates after ESWL in 412 children. The results

show that the overall stone-free rate was 76.7 percent following the first ESWL. Multivariate analysis showed that

a prior history of ipsilateral renal stone treatment or increased stone burden was associated with lower stone-free

rates [24].

Although a stone-free status is the preferred outcome after ESWL, some patients will have residual fragments

after the procedure. In some cases, these fragments (usually less than 4 mm in diameter) will pass without

symptoms, sometimes taking several months to clear. However, in other cases, residual fragments may grow in

size and be associated with an increased risk of recurrent symptomatic episodes [ 25]. (See "Clinical significance

of residual stone fragments following stone removal".)

Complications — In children, limited data suggest there are few short-term and no long-term adverse

effects of ESWL upon renal function as demonstrated by the following studies:

After ESWL, the overall stone-free rate was 73 percent. Stone-free rates varied depending upon the size of

the stones and were 92, 68, and 50 percent for stones with diameters smaller than 1 cm, between 1 and 2

cm, and greater than 2 cm in diameter, respectively.

●

The overall stone-free rate for calyceal stones was 56 percent. A higher rate of 63 percent was associatedwith small stones less than 1 cm and a lower rate of 40 percent with stones with diameters equal to or

greater than 1 cm in diameter. ESWL was more likely to fail when stones were located in the lower versus

upper pole calyx.

●

Stone-free rates were greater than 90 percent for ureteral and bladder stones regardless of their size.●

The average number of ESWL sessions per patient was 1.9.●

Complications were observed in 10 percent of cases (n = 33). Steinstrasse (obstruction by stone fragments)

occurred in 13 of 167 children treated for renal pelvic stones. Of the 13 patients with obstruction, 9 had

stones greater than 2 cm, and 4 had stones between 1 and 2 cm in diameter. Other complications included

stenting for hydronephrosis and UTIs. There were no episodes of perirenal hematoma or dermal ecchymosis.

●

In a retrospective review of 128 children treated with ESWL, 22 patients (18 percent) had complications in

the postoperative week including 5 with steinstrasse, 14 with decreased oral intake requiring intravenous

hydration, 7 with side pain/renal colic requiring parenteral analgesics, 12 with gross hematuria, and 3 with

fever [26].

●

In a prospective study of 50 children, renal ultrasonography performed after ESWL in 40 patients

demonstrated perirenal hematomas in three patients, intrarenal hematoma in two, and subcapsular hematoma

●

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Renal growth — Follow-up studies have shown no adverse effect on subsequent renal growth.

Percutaneous nephrostolithotomy — Although percutaneous techniques for stone removal were initially

introduced in the late 1970s, it was not until the 1990s that instrumentation was adapted to pediatric patients [ 31].

Percutaneous nephrostolithotomy (PCNL) entails obtaining percutaneous access to the collecting system, dilating

the tract with a balloon dilator, and extracting the stone with grasping forceps or fragmenting the stone with a

LASER, ultrasonic, pneumatic, hydraulic, or combined lithotripsy probe. PCNL can be performed in conjunction

with ESWL.

Stone-free rates of 70 to 90 percent have been reported. Rates vary depending upon the experience of the

clinician, the complexity of the stones, and the presence of an underlying structural abnormality [ 14,32,33]. In one

retrospective Egyptian study of children with renal stones between 1 and 2 cm in diameter, the stone-free rates

between a single PCNL and one ESWL session were comparable (87 versus 85 percent, respectively) at a mean

follow-up of 31 months (range 6 to 84 months) [ 14].

In children, data on complication rates are limited. Serious adverse events appear to be similar to those reported in

adults (who have a complication rate of 4 to 5 percent) and include urosepsis, bleeding (sometimes requiring red

blood cell transfusions), renal pelvic perforation, and injury to adjacent organs (eg, hydrothorax and colon

perforation) [14,16,32].

Follow-up data regarding renal function are also lacking. One study using 9mTc-dimercaptosuccinic acid (DMSA)

and DTPA renal scans reported no evidence of postoperative scarring after PCNL or impairment of glomerular

filtration rate when evaluated six months after the procedure [33].

in one patient. All hematomas resolved spontaneously [19]. Glomerular filtration rate measured before and

after ESWL by 99mTc-diethylenetriamine pentaacetic acid renal scan (DTPA) remained unchanged.

In a retrospective study, 99mTc–dimercaptosuccinic acid (DMSA) renal scans performed in 94 of 182

children before and six months after ESWL detected no new scar formation on post-DMSA scans [ 27].

Relative renal function of the treated side remained normal in 66 patients, was reduced pre-ESWL and

remained unchanged in 18 patients, showed improvement after ESWL in 7 patients, and deteriorated in 2

patients.

●

In a prospective study of 100 children with a mean age of 8 years (range 3 to 14 years) treated from 2005 to2008, DMSA renal scans performed before and six months after ESWL detected no new scar formation [ 28].

There was also no decrease in the split kidney function as measured by DTPA scan after ESWL with mean

GFR values of 113 mL/min per 1.73 m both before and after the last ESWL session. The average number of

ESWL sessions was 1.53 and the overall stone-free rate was 88 percent. There were complications in 11

patients due to stone passage including renal colic (n = 8), and lower tract obstruction requiring ureteroscopy

for stone removal (n = 3).

●

2

In a retrospective review of 341 renal units, steinstrasse (ureteral obstruction by stone fragments) occurred in

26 renal units (8 percent). Logistic regression analysis showed that the initial stone burden was associated

with steinstrasse. Successful interventions included repeat ESWL in 17 renal units, ureteroscopy after failure

of ESWL in four renal units and without ESWL in 1 renal unit, and conservative management in the remainingfour units.

●

In 74 children treated at a mean age of nine years (range 9 months to 14 years) with ESWL at a tertiary

center in the United States, evaluation of renal growth was performed by measuring renal length by

ultrasonography at the time of diagnosis and follow-up [29]. There was no difference in the rate of renal

growth between the treated and untreated kidneys at a mean follow-up of 6.2 years (range 1.3 to 13.1 years).

●

In a prospective Egyptian study of 150 children who underwent ESWL between 2005 and 2010, there was no

difference in renal growth based on renal ultrasound assessments between patients 12 months after ESWL

and controls [30].

●

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Ureteroscopy — Ureteroscopic instrumentation has been adapted for use in pediatric patients as first line

therapy and is useful for the management of children with calculi who have failed ESWL, especially those with

ureteral stones [16,34]. Once the stone is visualized, it is extracted with grasping forceps or basket, or fragmented

with LASER, ultrasonic, or electrohydraulic lithotripsy. (See "Options in the management of renal and ureteral

stones in adults", section on 'Ureteroscopy'.)

Although data are limited regarding stone-free rates in children, a systematic review of the literature reported stone-

free rates around 90 percent in children with a mean age of 7.8 years [ 34]. In this review, the mean stone size was

9.8 mm and the majority of the stones were in the ureter (83 percent). The success rate was lower in children less

than six years of age.

Ureteroscopy is not as successful in the removal of staghorn calculi. This was illustrated in a case series of 19

children with 23 renal calculi that demonstrated clearance of renal pelvic stones in six of eight children (mean

number of sessions 1.5), successful clearance of stones in all four children with polar stones after multiple

sessions, and clearance in only one of seven children with staghorn calculi [35]. These results suggest that

ureteroscopy does not have a role in treating children with staghorn calculi. (See "Management of struvite or

staghorn calculi".)

Stenting — The need for stenting in children who undergo ESWL or ureteroscopy is controversial [16]. Stents

are used to prevent ureteric obstruction either from edema due to ureteral injury or residual fragments in ESWL.

Studies in adults have demonstrated that patients with stents versus those without stents were more likely tohave lower urinary tract symptoms (dysuria, frequency, or urgency), while there was no difference in stone-free

rate, and the rates of UTIs, ureteric structures, and analgesic administration. Similar data in children are lacking. In

practice, most pediatric urologists do not place a stent in simple, uncomplicated cases of ureteroscopy or in a

patient with a stone less than 1.5 to 2 cm in diameter who is treated with ESWL [ 16].

However, pre-stenting (the practice of placing a stent a week or two prior to the ureteroscopic procedure to

facilitate ease of passage of the ureteroscopes) has been employed for passive dilation of the ureter. This does

place the child at a higher risk for lower urinary tract symptoms and possible infection, but minimizes the need for

ureteral dilation at the time of ureteroscopy.

Choice of procedure — Choice of treatment is dictated by the experience of the clinician and the availability of

instrumentation adapted for pediatric cases. In centers where the different procedures are available, treatment

choices are based upon the stone size and location, presence of an anatomical abnormality, and, if known, stone

composition as follows [14,16]:

Size – ESWL is the preferred procedure when stones are radiopaque and small (less than 1 cm in diameter)

in the renal pelvis, but not distal ureteral stones in girls because of the position of the ovaries. It is the least

invasive procedure with fewer serious complications.

●

For patients with stones greater than 2 cm in diameter in the kidney, PCNL is the preferred modality for

successful stone removal because of the low stone-free rates and difficulty of high stone burden

passage produced by ESWL.

•

In patients with stones between 1 and 2 cm in diameter, it is uncertain which is the best modality. As

discussed previously, a retrospective study reported comparable stone-free rates for ESWL and PCNL

in children with stones between 1 and 2 cm in diameter [ 14]. If clearance with ESWL is impaired, such

as in a child with calyceal diverticulum, PCNL may be preferred. Otherwise, ESWL as an initial therapy

is suggested because it is less invasive and has a lower rate of significant complications.

•

Location – Poorer clearance of renal stone fragments from the lower pole compared with other locations has

been reported in adults after ESWL. Similar results have been noted in several case series in children

[12,36]. In contrast, a single report of 126 children from a tertiary center in Egypt demonstrated similar

clearance rates regardless of the stone location within the kidney [37].

●

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Recommended approach — In institutions where different treatment options are available, therapy can be

individualized based upon the factors discussed in the previous section as follows:

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and

"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5 to 6 grade

reading level, and they answer the four or five key questions a patient might have about a given condition. These

articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond

the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written

at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable

with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these

topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on

"patient info" and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS — The acute management of nephrolithiasis in children is directed

towards pain control and facilitating passage or removal of the stone(s). Therapeutic choices are dependent upon

the severity of pain, the presence of obstruction or infection, and the size and location of the stone.

Structural abnormality – Children with underlying structural abnormalities, such as ureteropelvic (UPJ)

obstruction and calyceal diverticulum, are at increased risk for developing renal stones. In addition, the

underlying anatomical defect prevents effective passage of stone fragments with ESWL. In most centers,

PCNL is the preferred procedure for patients with calyceal diverticulum, and in children with UPJ obstruction,

either PCNL or ureteroscopy is used for stone removal. Additionally, calyceal diverticular stones may be

accessed from a laparoscopic approach with an incision being made over the dilated stone-laden calyx and

directly extracting the stones.

●

Composition of stone – Stones of harder composition, such as cystine and calcium oxalate monohydrate

stones, are less amenable to fractionating with ESWL. As an example, in patients with cystine stones, the

stone-free success rate is only 50 percent with ESWL, even after four sessions [ 38]. As a result, PCNL or

ureteroscopy and LASER lithotripsy are the preferred procedure in these patients. In contrast, struvite,

calcium oxalate dihydrate, and uric acid stones break more readily with ESWL and have a high stone-free

success rate with ESWL [39].

●

Open surgical repair is rarely, if ever, performed today and is reserved for children who have failed other

urologic procedures or those with complex renal or ureteral anatomic abnormalities.

●

In patients with stones up to 2 cm in diameter, ESWL or ureteroscopy with lithotripsy are both reasonable

options for stone removal.

●

In patients with stones greater than 2 cm in diameter, we suggest ureteroscopy with lithotripsy, or PCNL. If

the stone is in the lower pole calyces, these interventions have a greater success rate than ESWL.

●

In patients with an underlying structural abnormality, the choice of therapy is individualized based upon the

anatomy, and the size and location of the stone.

●

th th

th th

Basics topics (see "Patient information: Kidney stones in children (The Basics)")●

Beyond the Basics topics (see "Patient information: Kidney stones in children (Beyond the Basics)" )●

Indications for hospitalization include urinary obstruction, infection, solitary kidney, the need for parenteral

analgesia because of severe pain, or inability to take oral analgesics (eg, vomiting). (See 'Overview' above.)

●

One of the main goals of medical management is to provide adequate pain control. The choice of analgesic

agent is dependent upon the severity of pain and the ability of the child to take oral medications. Both

nonsteroidal antiinflammatory drugs (NSAIDs) and opioids are used in controlling pain in children with

●

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Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

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nephrolithiasis. In our practice, we generally use NSAIDs in patients who are managed as an outpatient. In

hospitalized patients, toradol and opioid therapy are used for pain management. NSAIDs should be stopped

three days before anticipated urologic intervention to minimize the risk of bleeding. (See 'Pain control' above

and "Diagnosis and acute management of suspected nephrolithiasis in adults", section on 'Pain control' .)

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'Stone passage' above.)

●

During this period of observation, the patient is instructed to strain his/her urine for stone retrieval. If thestone is retrieved, stone composition is determined by laboratory analysis. (See 'Stone retrieval' above.)

Children with severe debilitating pain refractory to parenteral analgesic therapy require urologic stone removal

for pain relief. (See 'Indications' above.)

●

Other indications for urologic intervention versus observation with medical management for pediatric

nephrolithiasis include the following:

●

In children with significant urinary obstruction, we suggest immediate urologic stone removal (Grade

2C).

•

In children with struvite stones, we recommend urologic stone removal (Grade 1B). (See "Managementof struvite or staghorn calculi", section on 'Treatment options' .)•

In symptomatic children who fail to pass a stone after two weeks, we suggest stone removal (Grade

2C). (See 'Indications' above.)

•

In children with a solitary kidney with partial or total obstruction, we suggest stone removal (Grade 2C).•

The choice of urologic procedure is determined by the experience of the clinician and the availability of

instrumentation adapted for pediatric cases. Surgical options include extracorporeal shock wave lithotripsy

(ESWL), percutaneous nephrostolithotomy (PCNL), and ureteroscopy. These procedures have generally

replaced open surgical repair and can be used in children of all ages, including small children and infants.

(See 'Procedures' above.)

●

In centers that have different urologic procedures available for stone removal in children, the choice of the

procedure is generally based on the size, location, presence of an anatomical abnormality, and, if known,

stone composition. (See 'Choice of procedure' above.)

●

http://-/?-http://-/?-http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=PEDS/6114http://-/?-http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=PEDS/6114http://www.uptodate.com/contents/management-of-struvite-or-staghorn-calculi?source=see_link&sectionName=TREATMENT+OPTIONS&anchor=H3#H3http://www.uptodate.com/contents/grade/2?title=Grade%201B&topicKey=PEDS/6114http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=PEDS/6114http://-/?-http://-/?-http://-/?-http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=PEDS/6114http://www.uptodate.com/contents/diagnosis-and-acute-management-of-suspected-nephrolithiasis-in-adults?source=see_link&sectionName=Pain+control&anchor=H19#H19http://www.uptodate.com/contents/acute-management-of-nephrolithiasis-in-children/abstract/6http://www.uptodate.com/contents/acute-management-of-nephrolithiasis-in-children/abstract/5http://www.uptodate.com/contents/acute-management-of-nephrolithiasis-in-children/abstract/4http://www.uptodate.com/contents/acute-management-of-nephrolithiasis-in-children/abstract/3http://www.uptodate.com/contents/acute-management-of-nephrolithiasis-in-children/abstract/2http://www.uptodate.com/contents/acute-management-of-nephrolithiasis-in-children/abstract/1http://www.uptodate.com/contents/license


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27. Griffin SJ, Margaryan M, Archambaud F, et al. Safety of shock wave lithotripsy for treatment of pediatricurolithiasis: 20-year experience. J Urol 2010; 183:2332.

28. Fayad A, El-Sheikh MG, Abdelmohsen M, Abdelraouf H. Evaluation of renal function in children undergoingextracorporeal shock wave lithotripsy. J Urol 2010; 184:1111.

29. Reisiger K, Vardi I, Yan Y, et al. Pediatric nephrolithiasis: does treatment affect renal growth? Urology 2007;69:1190.

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32. Bilen CY, Koçak B, Kitirci G, et al. Percutaneous nephrolithotomy in children: lessons learned in 5 years at asingle institution. J Urol 2007; 177:1867.

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37. Demirkesen O, Onal B, Tansu N, et al. Efficacy of extracorporeal shock wave lithotripsy for isolated lower caliceal stones in children compared with stones in other renal locations. Urology 2006; 67:170.

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Topic 6114 Version 27.0

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GRAPHICS

KUB showing staghorn calculi

The plain film of the abdomen in the anteroposterior projection reveals a staghorn calculus.

Note calcifications (arrows) in the opposite kidney as well.

Graphic 62009 Version 4.0


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CT scan showing large renal pelvic stone

CT scan without contrast shows a large calculus in the right renal

pelvis (arrow).

CT scan: computed tomographic scan.

Courtesy of Mark D Aronson, MD.

Graphic 72669 Version 6.0


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Disclosures: Thomas S Lendvay, MD, FACS Nothing to disclose. Jodi Smith, MD, MPH Nothing to disclose. F Bruder Stapleton, MD

Nothing to disclose. Laurence S Baskin, MD, FAAP Nothing to disclose. Melanie S Kim, MD Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a

multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced

content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

Disclosures
http://www.uptodate.com/home/conflict-interest-policy

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