Pediatric urolithiasis

Spectrum of pediatric urolithiasis in western India

Of 1,211 patients with urolithiasis treated at this institution over a nine years period, there were 77 (6.4%) pediatric cases. The commonest age group was 6-10 years (55.8%). Male:female ratio was 7.6:1. Hindus constituted 72.7% of the patients. There was no significant seasonal variation. The commonest site was urinary bladder (67.5%). The upper: lower urinary tract stone ratio was 1:2.85. Majority belonged to the lower-middle or poor income groups having a cereal based diet with minimal or poor protein intake. The common constituents of stones were calcium (98.7%), oxalate (87%), phosphate (84.4%) and uric acid (76.6%). Of all these, uric acid had the richest concentration (grade of ++ or more) in 93.2%. Only 4 stones (5.2%) were "pure": calcium oxalate--3 and calcium phosphate--1; whereas 73 (94.8%) were mixed stones. Of these, 9 (11.7%) were "predominant" mixed stones, with only one constituent having rich concentration (grade of ++ or more) and all others being either trace or +. The rest 64 (83.1%) were "heterogenous" mixed stones having rich concentration of more than one constituent.

Experience with childhood urolithiasis. Report of 196 cases

A total of 196 children with urinary calculi were treated surgically. Their ages ranged from 1 to 14 years. The male:female ratio was 3:1. Stones were located in the kidney in 96 patients, in the bladder in 52 and in the ureters in 32. Multiple organ involvement was present in 16 patients and associated urinary tract anomalies were found in 11. Stone analysis revealed calcium oxalate and phosphate stones in 121 patients, struvite stones in 60 and uric acid stones in 15.

Urolithiasis in childhood

Urolithiasis occurs less frequently in children than it does in adults living in contemporary industrialized nations. However, renal calculi continue to be identified with greater frequency in certain children: those who live in some areas of North America (e.g., the Southeastern United States), in those with relatively common metabolic disorders such as idiopathic hypercalciuria or with congenital urinary tract malformations, and in patients who have remained immobilized for long periods. Evaluation of children with suspected urolithiasis should include a careful history and physical examination to identify associated symptoms and signs and factors known to predispose to calculus formation, appropriate radiographic and blood studies, and timed urine collections. Appropriate management varies with etiology but should include maintaining adequate fluid intake, and long-term monitoring of the activity of the stone disease.

Urolithiasis in childhood: current management

During the past 12 years, 62 children with urinary stones have been treated at the Children's Hospital of Philadelphia. The most common presenting symptoms were abdominal or flank pain (45%), recurrent or persistent pyuria (35%), and gross hematuria (21%). Twenty-two patients had associated congenital urologic anomalies. Infection-related struvite stones were most common and were found in 18 children, of whom 15 were found to have anatomic abnormalities. Eighteen of 28 children evaluated for a metabolic cause were found to have an abnormality, most frequently hypercalciuria. No predisposing factors could be found in 16 of the 62 patients. Forty-four (87%) children had upper urinary tract stones. Twelve of 15 bladder stones were in children with a neuropathic bladder and all were related to infection. Treatment was directed to the correction of anatomic and metabolic predisposing causes, as well as to removing the stones. Fifteen patients passed stones ranging in size from 2 to 6 mm. Forty-six surgical procedures were performed in 43 children. Pyelolithotomy and cystolithotomy were the most frequent procedures. There were three residual stones and five recurrences. Of the 29 operations for upper urinary stones reviewed, 17 might today be considered suitable for percutaneous nephrostolithotripsy or extracorporeal shockwave lithotripsy. Possible future stone management will be discussed in light of this analysis.

Urolithiasis in children. Presenting signs, etiology, bacteriology and localisation

Based on a personal series of 310 observations, the authors have studied the presenting signs, the etiology, the urinary bacteriology and the localization of the stone in children with urolithiasis. Urinary tract infection is the presenting sign in 55% of the cases, hematuria in 23% and abdominal pain in 20%. Urinary malformation is associated in 26% of cases, whatever the age at diagnosis. The urinary bacteria found in 55% of cases is Proteus. Localization was in the kidney in 228 cases, in the ureter in 71 cases, the bladder in 45 cases and in the urethra in 5 cases.

Clinical experience with pediatric urolithiasis

Our clinical experience with 47 pediatric patients with stones is reviewed. Surgical therapy was standard with successful stone manipulation in 12 of 13 patients. In 91 per cent of our patients factors causing or predisposing to stone disease were discovered. A thorough metabolic evaluation, including an oral calcium loading test in 20 children, proved to be helpful. A new patient subgroup relating unexplained hematuria to eventual stone formation is described. Our protocol for metabolic evaluation and recommendations for treatment based on the results of such an evaluation are given. We have found the metabolic evaluation of the child with stones meaningful and particularly helpful in planning subsequent therapy for these patients.

Pediatric urolithiasis in the 1970s

We studied retrospectively 38 children who presented with urolithiasis between 1970 and 1977. The sex ratio was 1:1 and the mean age was 9.4 years. A positive family history was found in 36 per cent. Urinary tract abnormalities predisposing to infective urolithiasis was found in 7 children (18 per cent) but required voiding cystography for detection in 5. Hypercalcemia was found in 3 of 32 (8 per cent), while 28 of the 38 patients (74 per cent) had idiopathic urolithiasis. Idiopathic hypercalciuria was found in 5 of 13 patients (38 per cent) with idiopathic urolithiasis. Investigation of urolithiasis in children should include voiding cystography and measurement of urine calcium, as well as oxalate and uric acid, under home diet conditions.

Stones in orthotopic, non-obstructing ureteroceles

A case is presented in which stones were found bilaterally in orthotopic, non-obstructing ureteroceles in a child. This is apparently the first reported instance of this condition occurring in the presence of sterile urine. A review of related literature gives clues to the possible etiology of such an occurrence.

Anuria in childhood due to bilateral urolithiasis. A report of four cases

Four children with anuria due to occlusion of both ureters by calculi are presented. A plain film of the abdomen revealed faintly radiopaque urinary calculi bilaterally in three patients. In the fourth case, one calculus was visualized in the right ureter, but further contralateral exploration showed an obstructing ureteral calculus in the left ureter as well. It is concluded that in children with acute anuria, the possibility of bilateral ureteral obstruction due to calculi should be the physician's first consideration.

Urolithiasis in children

A 10-year review of stones in children at the St. Louis University Hospitals is presented. Stones related to infection were seen most often and urinary diversion secondary to congenital abnormalities of the urinary tract was the most frequent predisposing cause. The morbidity of stones in children is high.

Unusual aspects of urinary calculi in children

Urinary calculous disease is unusual in children in the United States. During the last 5 years (1972 to 1977) we have examined and treated 35 children with urinary calculi. The predisposing factors to calculus formation have been established in 20 children. Metabolic screening, although mandatory, has proved unrewarding in the evaluation of children with urinary calculi. Obstructive uropathy, immobilization, urinary stasis and infection, previously undiagnosed urologic anomalies, steroid therapy, milk-alkali syndrome, iatrogenic disease and endemic disease have contributed to stone formation. The management of children with urinary calculi generally parallels that of adults but reflects a need for caution when performing transurethral extraction of lower ureteral calculi. Reduction in dairy product intake, fluid diuresis and frequent changes in position may provide adequate prophylaxis against urinary calculi in children who must be immobilized.

Composition of urinary tract calculi in children of different ages

The composition of urinary tract calculi in children in relation to their age has been examined and comparisons have been made with other published series. It is concluded that paediatric stone disease can be divided into two main types: (1) infection stones, composed largely of magnesium ammonium phosphate and occurring mainly in children under 5 years of age, (2) calcium stones, occurring mainly in older children.

Ureteral calculi: review of 17 years of experience at a community hospital

In the last 17 years 3,150 patients have been treated by one or both of us for ureteral calculous disease. Our operative mortality is zero and our operative morbidity is 0.68 per cent, with an over-all morbidity of 0.8 per cent. We believe that stone extractions decrease the length of hospital stay and the time lost from industry, home or school. Thus, it is a worthwhile, effective and safe procedure. We agree with other investigators who believe that ureteral catheters and antibiotics are not necessary for routine stone extraction. We will await further word on the etiology of this endemic disease.

Renal calculi and biochemical abnormalities. In children with myelomeningocele and heoconduit diversion

Of 38 pediatric cases of ileoconduit urinary diversion of myelomeningocele, 4 with renal calculi are presented. An increased risk of renal calculus formation may be imposed on children with myelomeningocele with ileoconduit urinary diversion especially so in functionally and anatomically abnormal kidneys and in chronic renal infection with urea-splitting bacteria. It is not clear why the ileoconduit procedure should increase the incidence of renal calculi in such children.