Management of Pediatric Urolithiasis in an Italian Tertiary Referral Center: A Retrospective Analysis

Background and Objectives: In recent years, the prevalence of pediatric urolithiasis has increased in North America and Western countries, though it is endemic in developing countries. The aim of this study is to describe the experience of a tertiary pediatric referral center in the surgical management of pediatric urolithiasis. Materials and Methods: We retrospectively reviewed the experience of patients ≤ 16 years old affected by urinary stones who underwent surgery. Results: From April 2021 to September 2023, 31 pediatric patients underwent surgical procedures for stone diseases at our department: 13 preschool-aged (1-5 years) and 18 school-aged (6-16 years) children. During this period, 12 URSs, 17 RIRSs, and 2 PCNLs were recorded. Five patients had residual fragments at first, so three of them underwent a second endourological lithotripsy (2 RIRSs and 1 URS). Complete clearance was finally achieved in 27 patients. The stone composition was evaluated in 25 cases. Conclusions: Numerous innovations in the surgical treatment of pediatric urolithiasis have resulted from the development of smaller devices and new technology. Our results show how, in experienced centers, retrograde and percutaneous lithotripsy are safe and effective procedures for use in pediatric populations.

Calcium Carbonate Urolithiasis in a Pediatric Patient: A Case Report

Urinary stones composed of calcium carbonate are extremely rare, accounting for 0.01%-1.4% of urolithiasis (UL) cases. Urolithiasis is an infrequent condition in the pediatric population worldwide and in Mexico; nevertheless, the incidence in the Yucatán Peninsula is higher than that reported in other areas of Mexico and the world. Urolithiasis is the second most common urinary disease among pediatrics in the Yucatán Peninsula, which makes it an endemic region for this disease. We describe the case of a five-year-old male from the southeast region of Mexico who presented with signs and symptoms of urinary tract infection (UTI) and was diagnosed with bilateral staghorn stones of calcium carbonate, successfully treated by mini endoscopic combined intra-renal surgery, and dietary adjustments to prevent recurrence.

Use of whole-exome sequencing to identify novel monogenic gene mutations and genotype-phenotype correlations in Chinese Han children with urolithiasis

The incidence of urolithiasis (UL) in children has been increasing. Although the pathogenesis of pediatric UL is controversial and remains unclear, multiple monogenic causes of UL have been identified. We aim to investigate the prevalence of inherited UL causes and explore the genotype-phenotype correlation in a Chinese pediatric group. In this study, we analyzed the DNA of 82 pediatric UL patients using exome sequencing (ES). The data of metabolic evaluation and genomic sequencing were subsequently analyzed together. We detected 54 genetic mutations in 12 of 30 UL-related genes. A total of 15 detected variants were described as pathogenic mutations, and 12 mutations were considered likely pathogenic. Molecular diagnoses were made in 21 patients with pathogenic or likely pathogenic variants. Six novel mutations that were not previously reported were identified in this cohort. Calcium oxalate stones were detected in 88.9% cases (8/9) with hyperoxaluria-related mutations, while 80% of individuals (4/5) with cystinuria-causing defects were diagnosed with cystine stones. Our study highlights the significant genetic abnormalities in pediatric UL and demonstrates the diagnostic power of ES for screening patients with UL.

Retrograde Intrarenal Surgery in Children: Evolution, Current Status, and Future Trends

Introduction: Incidence of urolithiasis in children has increased in recent years and with technological advancements and miniaturization of surgical instruments, pediatric urologists have acquired an impressive arsenal for their treatment. Retrograde intrarenal surgery (RIRS) has gained widespread popularity as it is a natural extension of semirigid ureteroscopy and can be done through natural orifice minimizing the morbidity of percutaneous access. The aim of this narrative review is to describe how RIRS has evolved over the decades in children and if the age-related anatomical difference impacts reported outcomes especially stone-free rate (SFR) and complications. Materials and Methods: An electronic literature search from inception to October 15, 2021 was performed using Medical Subject Heading terms in several combinations on PubMed, EMBASE, and Web of Science without language restrictions. A total of 2022 articles were founded and 165 articles were full-text screening. Finally, 2 pediatric urologists included 51 articles that summarize the available literature regarding the development and use of RIRS in children. Results: RIRS as of today is well established as a superior modality for all stones in all locations compared with extracorporeal shockwave lithotripsy both in children and adults. The passive dilation has decreased the need of active ureteral dilation, but the need to perform prestenting is not defined yet. Regarding the use of the ureteral access sheath, the literature tends to lean toward its placement in most cases, but we do not know its long-term effects over the growth of children. Finally, the SFR has increased as the experience of pediatric urologists increases, as well as the number of complications has decreased. Conclusion: RIRS in pediatrics has crossed many milestones, yet many areas need further research and larger data are required to make RIRS the procedure of choice for renal stone management in children across all age groups.

Comparison of the Safety and Efficacy of Laser Versus Pneumatic Intracorporeal Lithotripsy for Treatment of Bladder Stones in Children

This study aimed to compare the safety and efficacy of laser lithotripsy and pneumatic lithotripsy, the two most commonly used transurethral lithotripsy methods for treating bladder stones in children in Iraq. Between January 2013 and December 2016, 64 children with bladder stones were included in this prospective randomized study, after ethical committee approval and written consent from the children’s parents or caregivers were obtained. Patients were assigned randomly by computer software to two groups treated with either pneumatic cystolithotripsy or laser lithotripsy. A 9 Fr. semirigid ureteroscope was used to pass the lithotripter through and fragment the stone. A catheter of 8–12 Fr. was then introduced and kept in place for 24 h. All children were hospitalized for 24 h, and the catheter was removed the next morning. Outpatient follow-up was maintained for 6–12 months. In terms of operation outcomes and complications, the laser lithotripsy group had a significantly longer duration of operation (74.5 ± 26.6 min vs. 51.5 ± 17.2 min, p = 0.001), whereas the number of patients requiring an extended hospital stay was significantly higher in the pneumatic lithotripsy group (48.5% vs. 16.1%, p = 0.006). Moreover, pneumatic lithotripsy was associated with a significantly greater risk of having at least one adverse effect (64% greater than that in the laser group). Stone clearance rates did not significantly differ between treatment groups. In conclusion, both pneumatic and laser lithotripters can be used to treat children with bladder stones with high efficacy and safety.

Pediatric Urolithiasis: Current Surgical Strategies and Future Perspectives

New technological innovations and cutting-edge techniques have led to important changes in the surgical management of pediatric urolithiasis. Miniaturized technologies and minimally invasive approaches have been increasingly used in children with urinary stones to minimize surgical complications and improve patient outcomes. Moreover, the new computer technologies of the digital era have been opening new horizons for the preoperative planning and surgical treatment of children with urinary calculi. Three-dimensional modeling reconstructions, virtual, augmented, and mixed reality are rapidly approaching the surgical practice, equipping surgeons with powerful instruments to enhance the real-time intraoperative visualization of normal and pathological structures. The broad range of possibilities offered by these technological innovations in the adult population finds increasing applications in pediatrics, offering a more detailed visualization of small anatomical structures. This review illustrates the most promising techniques and devices to enhance the surgical treatment of pediatric urolithiasis in children, aiming to favor an early adoption and to stimulate more research on this topic.

Meta-Analysis of the Safety and Efficacy of α-Adrenergic Blockers for Pediatric Urolithiasis in the Distal Ureter

OBJECTIVE

Pediatric urolithiasis is a common condition, and medical expulsive therapy has grown to be accepted by many parents. We carried out a meta-analysis to identify the efficacy and safety of α-adrenergic blockers for the treatment of pediatric urolithiasis.

METHODS

We identified related articles from the PubMed, Embase, and Cochrane Library databases. All published randomized controlled trials (RCTs) describing the use of α-adrenergic blockers and placebo treatment for pediatric distal urolithiasis were involved. The outcomes included stone expulsion rate, stone expulsion time, pain episodes, need for analgesia, adverse events, and related subgroup analyses.

RESULTS

A total of nine RCTs were involved in our study, including 586 patients. We found that α-adrenergic blockers could significantly increase the rate of stone expulsion [odds ratio (OR), 3.49; 95% confidence interval (CI), 2.38-5.12; p < 0.00001], reduce the stone expulsion time [mean difference (MD), -5.15; 95% CI, -8.51 to -1.80; p = 0.003], and decrease pain episodes (MD, -1.02; 95% CI, -1.33 to -0.72; p < 0.00001) and analgesia demand (MD, -0.92; 95% CI, -1.32 to -0.53; p < 0.00001) but had a higher incidence of side effects (MD, 2.83; 95% CI, 1.55 to 5.15; p = 0.0007). During subgroup analyses, different medications (tamsulosin, doxazosin, and silodosin) also exhibited better efficiencies than placebo, except for doxazosin, which showed no difference in expulsion time (MD, -1.23; 95% CI, -2.98 to 0.51; p = 0.17). The three kinds of α-adrenergic blockers also appeared to be better tolerated, except for tamsulosin with its greater number of adverse events (MD, 2.85; 95% CI, 1.34 to 6.03; p = 0.006). Silodosin led to a better expulsion rate than tamsulosin (OR, 0.42; 95% CI, 0.20 to 0.92; p = 0.03). In addition, α-adrenergic blockers increased the stone expulsion rate regardless of stone size and decreased the expulsion time of stones measuring <5 mm (MD, -1.71; 95% CI, -2.91 to -0.52; p = 0.005), which was not the case for stones measuring >5 mm in expulsion time (MD, -3.61; 95% CI, -10.17 to 2.96; p = 0.28).

CONCLUSION

Our review suggests that α-adrenergic blockers are well-tolerated and efficient for treating pediatric distal urolithiasis. We also conclude that silodosin is the best choice of drug, offering a better expulsion rate, but it remains to be evaluated further by future studies.

Laparoscopic Surgery in Pediatric Upper Tract Urolithiasis: An Alternate Modality

Introduction

Incidence of pediatric urolithiasis has increased over the last few decades. Procedures such as extracorporeal short wave lithotripsy, percutaneous nephrolithotripsy, and ureterorenoscopic lithotripsy are not widely available for pediatric age group in many developing countries. It is desirable that advantages of minimally invasive surgery be offered to selected cases with urolithiasis.

Materials and Methods

All patients with pediatric upper tract urolithiasis managed laparoscopically from January 2015 to April 2020 were retrospectively reviewed.

Results

A total of 38 patients were included. The mean age of the patients was 8 ± 2.85 years. Thirty-four patients (renal and upper ureteric) were managed through retroperitoneal approach, while those with lower ureteric calculi (n = 4) were approached transperitoneally. A total of eight patients required conversion to open technique. The stone clearance rate was 79% by laparoscopic approach alone. There were no procedure-related complications.

Conclusion

Our study suggests that laparoscopic management for pediatric upper tract urolithiasis is a radiation-free, single-time curative treatment and is feasible in centers where facilities for other endoscopic procedures are unavailable.

Urethral obstruction and urolithiasis associated with patent urachus in a 12-week-old kitten

Case summary

A 12-week-old intact male domestic shorthair kitten presented for dysuria. The patient had a urethral obstruction that was relieved with urinary catheter placement. A cutaneous opening at the umbilicus was identified. Three-view abdominal radiographs and a contrast study revealed a patent urachus with no evidence of urine leakage into the abdomen. An exploratory laparotomy was performed that confirmed a patent urachus, which was excised, and cystic and urethral calculi, which were removed via cystotomy. The patient recovered well from surgery, with a 12 h period of stranguria occurring 2 days postoperatively, attributed to residual inflammation. Calculi analysis revealed struvite stones, likely secondary to infection and inflammation. At the time of writing, 3 months postoperatively, the kitten had one episode of hematuria and inappropriate urination, which resolved with a short course of non-steroidal anti-inflammatory drugs, but had been otherwise been asymptomatic and healthy.

Relevance and novel information

To our knowledge, this is the first report of urolithiasis and patent urachus in a pediatric feline patient. Based on the occurrence of struvite stones in the presence of a patent urachus in an animal of this age, we suspect that chronic infection and inflammation led to the development of urolithiasis. Correction of the patent urachus resulted in almost complete resolution of clinical signs and no crystal formation was appreciated on recheck urinalysis.

The Experience of Two Italian Centers of Pediatric Surgery

Background: Over the last 30 years, the incidence of pediatric urolithiasis (PU) has been increasing and the surgical management has evolved toward a minimally invasive approach (MIA). We reported the experience of two Centers of Pediatric Surgery in the management of PU, focusing on MIA as first choice in treatment. Methods: Data were retrospectively analyzed from October 2009 to October 2019 in children with urolithiasis who were admitted to two referral Italian Centers of Pediatric Surgery. Demographic and clinical data of the patients, features of the urolithiasis, type of surgery were considered. Results: Seventy patients (7.3 ± 5.0 years) with normal renal function were treated for calculi in the pyelocaliceal system (45.7%), ureter (34.3%), bladder (4.3%), urethra (1.4%), and multiple locations (14.3%). Size of calculi was >10 mm in 55.7% of cases (kidney>bladder/urethra>multiple>ureter, p = 0.01). Symptoms were present in 75.7% of patients. Family history was positive in 16.9% of cases. MIA was performed in 59 patients (84.3%): 11.8% shockwave lithotripsy (kidney>ureter>multiple); 32.2% ureteral retrograde surgery (ureteral>other localizations); 30.5% retrograde intrarenal surgery (kidney>other localizations); and 25.4% other procedures including percutaneous nephrolithotomy, cystoscopic bladder stone removal or laser cystolithotripsy (kidney>bladder>multiple). Preoperative stenting was necessary in 52.8% of cases. Four MIA procedures (6.9%, kidney>ureter/multiple) were converted to open surgery. Open surgery was required as first approach in 15.7% of patients (kidney>ureter>multiple) who needed urgent surgery or had associated congenital renal anomalies. In 18/70 of children (25.7%), with prevalence of stones in kidney and multiple location (p < 0.01), a second procedure completed the treatment (88.8% MIA). Intraoperative difficulties were recorded in 8.5% of cases, without difference between location and size of calculi. Late complications (5.7%) were related to displacement and infection of the ureteral stent. Conclusions: MIA resulted to be feasible in more than 75% of primary surgery and in more than 85% of cases requiring a second procedure. Preoperative stent was mandatory in more than 50% of children. The technological evolution allowed to overcome many of the technical difficulties related to the approach to the papilla and lower calyxes. Open surgery is reserved for selected cases and endoscopic surgery represents the best choice of treatment for PU.

Update on Surgical Management of Pediatric Urolithiasis

Urolithiasis has always been a fascinating disease, even more so in children. There are many intriguing facets to this pathology. This article is a nonsystematic review to provide an update on the surgical management of pediatric urolithiasis. It highlights the pros and cons of various minimally invasive surgical options such as extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), laparoscopy, and robotics. This article also describes the various intracorporeal disintegration technologies available to fragment the stone, including the newer advancements in laser technology. It also emphasizes the cost considerations especially with reference to the emerging economies. Thus, this manuscript guides how to select the least-invasive option for an individual patient, considering age and gender; stone size, location, and composition; and facilities and expertise available.

Ultrasound-guided minimally invasive percutaneous nephrolithotomy in the treatment of pediatric patients <6 years: A single-center 10 years' experience

Owing to the fragile kidney and relative small collecting system of pediatric patients, urologists were always reluctant to treat pediatric urolithiasis with PCNL. Here we conduct a study to assess the effectiveness and safety of pediatric patients with renal calculi <6 years.A total of 88 pediatric patients (99 kidney units) <6 years underwent the ultrasound (US)-guided minimally invasive percutaneous nephrolithotomy in our institute from March 2006 to April 2016. The mean age was 30.9 months (range, 7-72 months). The mean stone size was 19.5 mm (range, 10-50 mm). The group included single stone in 35 kidney units, upper ureteral stone in 12 kidney units, multiple stone in 43 kidney units, and staghorn stone in 9 kidney units. The procedure of puncture and dilation were guided by US solely.The mean operation time was 52.3 minutes (range, 15-140 minutes). The mean postoperative length of stay was 6.0 days (3-16 days). Besides, the initial stone free rate (SFR) was 90.9% (90/99) and the final SFR was 96.0% (95/99). The mean hemoglobin drop was 10.9 g/L (range, 1-25 g/L). Postoperative complications occurred in 12 patients including fever in 11 cases and active pleural effusion in 1 case.The US-guided MPCNL is an effective and safety procedure to treat pediatric patients with stone <6 years.

Two-year-old girl with impacted ureteral stone successfully treated with a single session of combined percutaneous nephrostomy and ureteroscopy

Impacted stones frequently cause changes in the ureter, including edema of the ureteral wall, stone embedding in the ureteral mucosa or ureteral bending, which often preclude spontaneous passing of the stone and increase the risk of complications during surgery. When stone impaction is suspected preoperatively, management should be adapted accordingly. However, surgical treatment strategies remain controversial in pediatric patients because of the scarcity of cases reported. We describe the case of a 2-year-old girl with a right impacted ureteral stone who presented with gross hematuria and pyuria, but no metabolic risk factors or hematological abnormalities. Ureteroscopy was carried out in the presence of a percutaneous nephrostomy catheter. At the 7-month follow up, hydronephrosis had improved from grade 3 to grade 1, and the ureter was free from residual or recurrent stones. No complications were noted. We believe that percutaneous nephrostomy before the lithotripsy facilitates treatment for impacted stones in pediatric patients.

Minimal access surgery in the management of pediatric urolithiasis

BACKGROUND

In contrast to adult patients, a relatively large number of open surgical procedures are still needed in the treatment of urolithiasis in children. Since almost all open surgical techniques may be reproduced by minimal access surgery (MAS), there is a rationale to apply the latter in the management of pediatric urolithiasis. Our study aimed to assess the feasibility and outcome of MAS in the treatment of pediatric urinary calculi.

METHODS

The charts of patients with urolithiasis submitted to MAS between 1994 and 2007 were retrospectively reviewed. The inclusion criteria were contraindication for and failure of lithotripsy or endourology techniques. Demographic data, lithiasis characterization (location, dimension, composition), predisposing factors (anatomic or metabolic) and surgical approach (technique and outcome) were evaluated.

RESULTS

Fifteen consecutive patients (eight girls, seven boys) with a median age of 108 months (range: 10-297 months) were elected for MAS. Eleven (73%) children had associated urogenital malformations and three (20%) presented metabolic abnormalities. A total of 17 procedures were performed laparoscopically: three nephrolithotomy (one transperitoneal, two by retroperitoneoscopy), four pyelolithotomies (retro), three ureterolithotomy (trans) and seven cystolithotomies (suprapubic approach). Five patients underwent concomitant correction of urological anomalies (three calyceal diverticula, one obstructive megaureter, one ureteropelvic junction obstruction). Complete removal of calculi was accomplished in 14 (82%) procedures. There were two perioperative complications (one intraperitoneal vesical perforation and one perivesical urinoma). At a median follow up of 4 years (range, 1 month to 11 years), four patients have developed recurrence.

CONCLUSIONS

MAS is an effective and safe approach for urolithiasis in children who are not candidates for minimally invasive modalities.

Percutaneous nephrolithotomy in children: A preliminary report

Objectives:

The recurrence of pediatric nephrolithiasis, the morbidity of repeated open surgical treatment as well as our experience in percutaneous nephrolithotomy (PNL) in adult patients, all derived us to shift to PNL for managing renal stones >1.5 cm in pediatric patients. Our aim of this study is to evaluate the safety and efficacy of PNL in pediatric patients.

Materials and Methods:

During the period of the month between May 2011 and April 2013, 38 children (47 renal units) underwent PNL for renal stones 1.5-5 cm in length. Patient demographics, stone characteristics, and clinical outcome were prospectively studied. Data of those who underwent conventional and tubeless PNL were compared. Median follow-up period was 12 months (range: 6-24).

Results:

The median age at presentation was 8-year (range: 3-12). The operative time ranged from 30 to 120 min (median 90). Overall stone clearance rate was 91.5% after single PNL. The median hospital stay was 3 days. Auxiliary procedures were successful for the remaining 4 patients (nephroscopic clearance in one and shockwave lithotripsy in 3). Tubeless PNL was performed in 17 renal units with a comparable outcome to conventional ones. The perioperative complications were noted in 5/47 (10.6%) of all procedures (Clavien Grade II in 4 and Clavien Grade IIIa in 1) and were managed conservatively.

Conclusions:

Percutaneous nephrolithotomy for renal stones in pediatric patients is safe and feasible if performed by a well-experienced endourologist. Tubeless PNL is a better choice for children.

Evolution of pediatric urology at sindh institute of urology and transplantation

Sindh Institute of Urology and Transplantation was started in 1972 as an eight bedded department of genitourinary surgery in a government hospital by its pioneer and present director Syed Adib ul Hassan Rizvi. Responding to the socioeconomic dynamics and the needs of the patient population the facility grew into the largest tertiary care Urology, Nephrology, and Transplant center of south Asia. One of the salient components has been the evolution of the Department of Pediatric Urology, which in itself has shown a tremendous growth into an internationally recognized center for pediatric urology services taking care of all aspects including center of excellence for pediatric stone disease. The guiding mission of this institute remains to provide free medical services at zero cost without any discrimination to all who come to its doorstep and matching with high standard of care without compromising their dignity and self-respect. This institute highlights the fact that lack of resources is no excuse and is a role model for developing countries, where national and international support, motivation, and cooperation can offer more advanced and better quality medical services to our children.

Minimally invasive approaches and their efficacy in pediatric urolithiasis

OBJECTIVE

We compared the frequency of usage and success of minimally invasive approaches in the management of pediatric urolithiasis in our clinic.

MATERIAL AND METHODS

Data from pediatric patients (≤16 years of age) who had undergone percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS), and extracorporeal shock wave lithotripsy (ESWL) between January 2001 and December 2011 were retrospectively investigated.

RESULTS

In this study, 415 pediatric patients, who were treated for 291 renal, and 124 ureteral stones, were evaluated. The patients were treated with PNL (n=148; 82 boys, 66 girls), URS (n=99; 58 boys, and 41 girls) or ESWL (n=168; 91 boys, and 77 girls). The mean patient ages were 7.3 (1-16), 9.1 (1-16), and 8.8 (1-16) years in the PNL, URS, and ESWL groups, respectively. The stone-free rates after treatment with PNL, URS, and ESWL were 77, 83.8 and 88.7%, respectively.

CONCLUSION

It is important that selected therapies are properly planned, and the use of minimally invasive approaches is important in pediatric patients due to potentially high recurrence rates. Currently, ESWL, PNL and URS are performed with high success rates for the treatment of stones, and open surgery is rarely used due to the success obtained with minimally invasive approaches.

Management of ureteric stone in pediatric patients

The management of ureteral stones in children is becoming more similar to that in adults. A number of factors must be taken into account when selecting one's choice of therapy for ureteral stone in children such as the size of the stone, its location, its composition, and urinary tract anatomy. Endoscopic lithotripsy in children has gradually become a major technique for the treatment of ureteral stones. The stone-free rate following urteroscopic lithotripsy for ureteral stones has been reported in as high as 98.5-100%. The safety and efficacy of Holmium:YAG laser lithotripsy make it the intracorporeal lithotriptor of choice. Given its minimally invasive features, extracorporeal shock wave lithotripsy (ESWL) has become a primary mode of treatment for the pediatric patients with reno-ureteral stones. Stone-free rates have been reported from 59% to 91% although some patients will require more than one treatment session for stone clearance. It appears that the first-line of therapy in the child with distal and mid-ureteral stones should be ureteroscopic lithotripsy. While ESWL is still widely considered the first-line therapy for proximal ureteral calculi, there is an increasing body of evidence that shows that endoscopic or ESWL are equally safe and efficacious in those clinical scenarios. Familiarity with the full spectrum of endourological techniques facilitates a minimally invasive approach to pediatric ureteral stones.

Operative management of pediatric urolithiasis

Surgical management of urinary stones in children remains challenging due to the smaller caliber of the urinary tract. Specific instruments have been designed to overcome some of the issues related to pediatric stone management. Endoscopic and percutaneous modalities for stone management have been shown to be as safe and effective in providing stone clearance in children as in adults. Technologies that have been shown to be safe in adults are being miniaturized for use in children. The current literature regarding pediatric urolithiasis was reviewed in an effort to identify trends in operative management. Additionally, techniques used successfully at our institution are described. Although not an exhaustive review of all available modalities and instruments, this review will provide an overview of the current techniques for the management of pediatric urolithiasis.

Pediatric urolithiasis: the current surgical management

Children represent about 1% of all patients with urolithiasis, but 100% of these children are considered high risk for recurrent stone formation, and it is crucial for them to receive a therapy that will render them stone free. In addition, a metabolic workup is necessary to ensure a tailored metaphylaxis to prevent or delay recurrence. The appropriate therapy depends on localization, size, and composition of the calculus, as well as on the anatomy of the urinary tract. In specialized centers, the whole range of extracorporeal shock-wave lithotripsy (ESWL), ureterorenoscopy (URS), and percutaneous nephrolithotomy (PCNL) are available for children, with the same efficiency and safety as in adults.