INTRODUCTION — The management of pediatric nephrolithiasis is divided into two parts.
●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.
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 "Kidney stones in children: Prevention of recurrent stones" and "Kidney stones in children: Epidemiology and risk factors" and "Kidney stones in children: Clinical features and diagnosis".)
OVERVIEW — The acute management of nephrolithiasis depends upon the severity of the pain, and the presence of obstruction or infection. Medical management is focused on alleviating pain and facilitating the spontaneous passage of the stone. However, in some cases, urologic intervention is needed for stone removal for patients with unremitting severe pain that is refractory to analgesic therapy, or in those with obstruction or infection. (See 'Indications' below.)
Hospitalization versus outpatient management — The acute management of nephrolithiasis depends upon the severity of the pain and the presence of obstruction or infection. In most patients, outpatient medical management with oral analgesics and hydration is sufficient while awaiting spontaneous passage of the stone. Indications for hospitalization include urinary obstruction with impairment of kidney function, infection, solitary kidney with ureteral obstruction, the need for parenteral fluid and pain medications because of severe pain, or inability to take oral analgesics or fluids (eg, vomiting).
MEDICAL MANAGEMENT
Supportive care — Supportive management includes symptomatic treatment and hydration. Data are insufficient to determine if high-volume fluid therapy facilitates stone passage. In the authors' practice, intravenous (IV) fluids are administered primarily to replete fluid loss due to poor oral intake and emesis associated with the renal colic symptoms, as opposed to promoting stone passage. Nausea and vomiting should be treated with IV antiemetics. Pain associated with renal colic is best treated with nonsteroidal antiinflammatory medications combined with narcotic analgesics.
Pain control — Both nonsteroidal anti-inflammatory 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. (See "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 'Approach' and "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Pain control'.)
At our institution, patients who arrive in the emergency department receive a combination of NSAIDs and IV narcotics as initial management. For patients who are hospitalized, we use IV ketorolac and opioid therapy as follows:
●Morphine − For children >6 months of age, IV morphine is given as 0.05 to 0.1 mg/kg per dose every two to four hours as needed up to a maximum of 2 mg per dose.
●Ketorolac – For children >2 years of age, IV ketorolac is given as 0.5 mg/kg per dose every six hours with a maximum dose of 30 mg. Ketorolac is automatically discontinued after 72 hours of IV administration.
Outpatient management for those without kidney function impairment include NSAIDs, acetaminophen, and oral narcotics. Notably, opioid-reduction strategies for adults with renal colic have been successfully implemented within acute care settings, although not yet replicated in children [1]. As such, this approach would also be reasonable given the current health care focus on opioid stewardship.
The use of NSAIDs should be stopped three days before a urologic intervention, if possible, to minimize the risk of bleeding. (See "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Pain control'.)
Management of urinary tract infection — Because urinary tract infection (UTI) may be a concomitant finding in children with nephrolithiasis (see "Kidney stones in children: Epidemiology and risk factors", section on 'Infection'), urine and blood cultures should be obtained. If a UTI is suspected, empiric antibiotic therapy is initiated while awaiting culture results. The choice of antibiotic, which can be given orally or parenterally based on the clinical setting, is guided by the likely pathogens and the likelihood of drug resistance.
Although not commonly seen in children, urosepsis is a serious and life-threatening complication of nephrolithiasis. In the setting of a ureteral stone or obstruction in a child with suspected (eg, fever) or confirmed urosepsis, emergent drainage is necessary using either a ureteral stent of percutaneous nephrostomy tube [2]:
●Patients with a ureteral calculus or urinary obstruction (partial or complete) and suspected UTI are managed with prompt parenteral antibiotic therapy, and urinary decompression and drainage with stenting to lower the intrarenal pelvic pressure due to stone-induced obstruction. This is followed by staged calculi removal [2]. In our institution, children with obstruction are initially treated empirically with IV ceftriaxone pending urine culture results based on the likely pathogens and their resistance pattern observed in our locale, which is then modified or discontinued based on urine culture results.
●For patients with a non-obstructing renal calculus and suspected UTI, empiric antibiotic therapy is provided pending urine culture results. Clearance of UTIs with only antibiotic therapy is difficult in patients with symptomatic stones, therefore these patients need close interval follow-up with a urological surgeon. In cases where there is not resolution infection or subsequent obstruction, surgical removal of the stone is warranted.
Antibiotic therapy for UTI is discussed in greater detail separately. (See "Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis", section on 'Antibiotic therapy'.)
Ureteral stone passage — The majority of ureteral stones <5 mm in diameter will pass spontaneously, even in small children [3,4]. Follow-up imaging should be performed after a two- to four-week period of observation to confirm stone passage. In children, ultrasonography and a single kidney-ureter-bladder (KUB) radiograph (if the stone is radiopaque) are generally used to monitor stone passage. Although computed tomography (CT) is the most sensitive imaging modality in the detection of renal or urinary tract stones, it is more costly and is associated with higher radiation exposure. As a result, CT is reserved for children with a nondiagnostic ultrasound and/or KUB and a continued high index of suspicion for nephrolithiasis. In addition, CT is sometimes needed to determine true stone burden and exact stone location for surgical management. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Imaging'.)
Medical expulsive therapy — 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. Collectively, these treatments are known as "medical expulsive therapy." Although data are limited, systematic reviews of the literature that include small randomized trials and cohort studies suggest administration of adrenergic alpha-antagonists is an effective and safe intervention for ureteral stone passage in children with nephrolithiasis [5-7]. However, these results need to be confirmed with larger randomized control trials especially as the use of medical expulsive therapy remains controversial in adults. (See "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Medical expulsive therapy'.)
In our practice, we have used alpha blockers to facilitate stone passage in children with 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 two years of age with symptomatic ureterovesical stones. We use a dose of 0.2 mg of tamsulosin for children between two to four years of age, and 0.4 mg of tamsulosin for children who are five years and older. Tamsulosin is given as a single dose in the evening before bedtime. Tamsulosin comes only in capsule form. It can be broken and placed onto foods such as yogurt or applesauce for children who cannot swallow pills [8]. One should be cautious in children with enteric feeding tubes as administering this medication can result in clogging the lumen of these tubes.
These medications have been well-tolerated, and we have not seen orthostatic hypotension, even though this is a potential side effect of alpha blockers. Nevertheless, these agents should be used under the supervision of a clinician experienced in medical expulsive therapy.
If there has been no spontaneous passage by two to four weeks, we will intervene surgically. (See 'Urologic intervention' below.)
Uric acid stones — 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. Because of the duration of alkalinization necessary for stone dissolution, this treatment would not be appropriate for ureteral calculi but has been shown to be of similar efficacy to surgical options for renal calculi [9]. (See "Kidney stones in children: Prevention of recurrent stones", section on 'Hyperuricosuria'.)
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. (See "Kidney stones in children: Prevention of recurrent stones", section on 'Evaluation for underlying risk factors'.)
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 also a good alternative.
Follow-up — For children who have spontaneously passed a ureteral calculus, confirmation of a successfully passed calculus is important. This should include resolution of symptoms and either a documented "stone in hand" that can be analyzed or imaging that confirms passage of the calculus and resolution of associated hydronephrosis [10]. At our institution, ultrasound is the preferred imaging modality for follow-up unless the patient has brought a passed stone into clinic. Alternatively, a KUB could be performed in follow-up if an initial CT scout image revealed a visible calculus. CT scan in follow-up is limited to children with persistent symptoms and non-conclusive US and/or KUB imaging studies.
UROLOGIC INTERVENTION
Indications — Because of the high spontaneous stone passage rates for smaller calculi, as well as the cost and potential complications from urologic procedures in children, it is generally accepted that an observation period with adequate pain control should be given. The optimal length of time for observation prior to urologic intervention remains uncertain; however, in our practice, an observation period of up to two weeks is usually 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 kidney injury from continued obstruction, and to provide symptomatic relief of pain.
In our practice, indications for surgical intervention are as follows:
●Surgical removal without trial of medical management – Indications for surgical intervention without a trial of medical observation include:
•Urinary obstruction – Complete obstruction from renal calculi can result in renal parenchymal injury and a decrease in kidney function especially if there is evidence of impaired kidney function [11]. Intervention in patients with mild kidney dysfunction demonstrates both an initial improvement in kidney function due to the relief of the obstruction and subsequent improvement thought to be due to recovery of injured kidney tissue [12,13]. Without relief, persistent obstruction can result in permanent scarring and loss of kidney tissue [11].
We also consider urologic intervention for patients with partial obstruction of a solitary kidney.
•Urinary tract infection – Urinary tract infection in the setting of a partial or completely obstructing ureteral calculus is an indication for decompression. Those patients with non-obstructing calculi, while not requiring urgent intervention, should have close interval follow-up with a urologic surgeon. (See 'Management of urinary tract infection' above.)
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 [14]. Persistent infection, usually due to a urease-producing bacteria (eg, Proteus or Klebsiella), is a risk factor for recurrent stone formation. (See "Kidney stones in children: Epidemiology and risk factors", section on 'Infection' and "Kidney stones in adults: Struvite (infection) stones".)
●Symptomatic stones with 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.
●Symptomatic stones that fail to pass after a trial of conservative therapy – Surgical intervention is performed if there is no improvement after a trial of medical therapy for two to four weeks for symptomatic patients without an underlying UTI and for those successfully managed with oral analgesics that do not impair daily activities who have evidence of radiographically-confirmed obstruction or who have mild proximal urinary tract dilation.
We offer urologic intervention to asymptomatic children with stones that do not spontaneously pass after two to four weeks of medical therapy and observation. Asymptomatic calculi within the kidney, which usually do not pass spontaneously, can also be treated in order to prevent future symptom development.
Procedures — Several minimally-invasive options for removal of kidney or ureteral calculi are available for surgical management in children [15]. These procedures have generally replaced open surgical stone removal 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 including infants, but other medical centers may be constrained by their pediatric-sized resources.
●Extracorporeal shock wave lithotripsy (SWL)
●Percutaneous nephrostolithotomy (PCNL), including miniature PCNL
●Ureteroscopy
Extracorporeal shock wave lithotripsy — Extracorporeal shock wave lithotripsy (SWL) employs high-energy shock waves produced by an electrical discharge.
Efficacy — SWL has been shown to be an effective and safe procedure for removing stones that are less than 20 mm in diameter in children, including small children and infants [16,17]. The efficacy of SWL is dependent on the size and location of the stone. SWL is most effective without subsequent obstruction when the stones are less than 10 mm in diameter and are located in the ureter [16].
Procedure — Historically, SWL was performed with the patient placed in a water bath. 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. Rather, they utilize a contained fluid interface with the patient to transmit the shock waves. 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. However, later-generation lithotriptors are associated with lower efficacy and increased need for retreatment [18].
Proper positioning of the child and appropriate power and frequency of the shock waves to the size of the patient are required to reduce the likelihood of complications such as hematomas or lung contusions [19]. In addition, general anesthesia is required so that the patient remains still during the procedure preventing the risk of movement due to the minimal skin sensation, which an awake child would perceive at the entrance site of the shock wave. The shock waves are delivered in a synchronized manner with the electrocardiogram (gated).
However, in a small clinical trial using ungated SWL, 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 [20]. This increase in efficacy was balanced against prolonged anesthetic time in the group of patients who received SWL using a slower wave frequency. Further research in larger cohort studies is needed to determine the optimal delivery and rate of shock waves for lithotripsy in children.
Like all surgical interventions, the goal of SWL is complete stone clearance. However, some patients will have residual fragments after the procedure and have recurrent symptoms as well potential new stone growth [21]. Residual fragments that are less than 25 mm in diameter usually pass without difficulty although retreatment may be necessary. For larger fragments, stents should be considered to reduce the risk of obstruction [22]. However, in children, the placement and removal of the stent generally requires conscious sedation or general anesthesia.
Complications — In children, short-term complications include steinstrasse, decreased oral intake, pain requiring parenteral analgesics, gross hematuria, fever, and hematomas [16,23]. Data on long-term outcome are limited in the pediatric population and further study is needed to confirm the long-term safety of SWL in these children.
At follow-up after SWL, limited data from pediatric case series reported no adverse renal effects:
●No evidence of new renal scar formation at six months follow-up [24,25].
●Relative renal function of the treated side remained normal and unchanged based on comparisons of 99mTc–dimercaptosuccinic acid (DMSA) renal scans performed before and after the procedure [24,25].
●No adverse effect on subsequent renal growth [26,27].
Data from a population-based study, adjusting for patient age, showed SWL was associated with a risk of developing hypertension in patients who did not have pre-existing hypertension or chronic kidney disease [28]. In contrast, there was no increased risk of developing CKD in patients undergoing URS.
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 [29]. Percutaneous nephrostolithotomy (PCNL) entails obtaining percutaneous access to the collecting system, dilating the tract with serial Amplatz or Alken dilators or balloon dilators, and extracting the stone with grasping forceps or fragmenting the stone with a laser, ultrasonic, pneumatic, hydraulic, or combined lithotripsy probe.
Stone clearance of 70 to 95 percent have been reported. Success varies depending upon the experience of the clinician, the complexity of the stones, and the presence of an underlying structural abnormality [15]. One systematic review reported that PCNL had greater stone clearance than SWL, including calculi <2 cm in diameter (OR 2.69, 95% CI 1.48 to 4.91) [30]. However, PCNL was associated with a longer operative time and hospital stay and had a higher complication rate for children with stones <2 cm in diameter.
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) [31,32].
Follow-up data regarding renal function are limited. One study using 9mTc-dimercaptosuccinic acid (DMSA) and diethylenetriaminepentaacetic acid (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].
Miniature PCNL — An important advancement in percutaneous instrumentation is the introduction of smaller nephroscopes and ultrasonic lithotripsy probes used in performing miniature (or mini) PCNL. Mini-PCNL is performed in a percutaneous tract less than 24F, typically using an 11 to 15F nephroscope while micro-PCNL is accomplished via a 4.85F "all-seeing needle". A systematic review of mini- and micro-PCNL series, including 14 studies in total, found that in moderate to large calculi (mean diameter between 1.2 and 4.1 cm) stone clearance ranged from 80 to 100 percent with a mean complication rate of 11.2 percent. While micro-PCNL was associated with a lower complication rate overall, it should be noted that the stone burden was lower in these series and the availability of the "all-seeing needle" was not universally available at the time of this publication or commercially available in the United States [34].
Ureteroscopy — Ureteroscopic instrumentation has been adapted for use in pediatric patients of all ages as a first-line therapy, along with SWL, for calculi <20 mm in diameter. It may also be an option, potentially as staged therapy for the management of children with calculi greater than 20 mm in diameter, especially in those children for whom PCNL is not considered feasible [3,35]. Once the stone is visualized, it is extracted with grasping forceps or basket, or fragmented with laser, ultrasonic, or electrohydraulic lithotripsy. (See "Kidney stones in adults: Surgical management of kidney and ureteral stones", 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 [35]. 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. For preschool children with moderately sized calculi (10 to 20 mm), a prospective study of 60 children (mean age 2.4 years) reported a higher stone-free rates at three-month follow-up for ureteroscopy versus SWL (87 versus 70 percent).
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 [36]. These results suggest that ureteroscopy does not have a role in treating children with staghorn calculi.
Stenting — In practice, most pediatric urologists do not place a stent in simple, uncomplicated cases of ureteroscopy or in the majority of cases treated with SWL [37]. Indications for ureteral stenting vary based on the associated procedure and timing.
●Preprocedure – Preoperatively, stents may be placed to relieve obstruction of a child with infected and/or acutely symptomatic ureteral calculus to relieve symptoms and allow for staged treatment (see 'Management of urinary tract infection' above).
Debate exists regarding whether preplacement of a ureteral stent improves ureteroscopic outcomes in children [38]. Prestenting (the practice of placing a stent a week or two prior to the ureteroscopic procedure) has been used for passive dilation of the ureter to facilitate ease of passage of the ureteroscopes, especially in prepubertal children [3]. 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.
●Post-procedure
•Following URS or PCNL, stents may be placed to prevent ureteral edema and/or aid in passage of blood clots or stone fragments.
•Following SWL, ureteral stents may be placed to enable passage of fragments, especially for treatment of larger stone burdens (see 'Extracorporeal shock wave lithotripsy' above). Stents are used to prevent ureteric obstruction either from edema due to ureteral injury or residual fragments in SWL. Studies in adults have demonstrated that patients with stents versus those without stents were more likely to have 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.
Open surgical repair — 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.
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 [39,40]:
●Size of stone:
•For stones less than 10 mm, SWL and ureteroscopic lithotripsy have similar efficacy, when controlling specifically for stone size and location, with reported stone-free rates of up to 90 percent [35,41]. The stone location, age of the patient, and expertise of the urologist and availability of appropriate-size instrumentation clinical center are the major factors in decision-making between the two procedures. PCNL is rarely indicated in removal of these smaller stones, unless they are located within an inaccessible calyx, such as with infundibular stenosis or a calyceal diverticulum.
•In patients with stones between 10 and 20 mm in diameter, it is uncertain what the best urologic procedure is. As discussed above, SWL and ureteroscopy appear to offer similar outcomes within this size range for older children. For preschool children, limited data suggest mini-PCNL is associated with a better stone-free rates for moderately sized calculi with minimal complications [39,40]. The choice of the procedure is based on clinician preference and availability of appropriate equipment for the child, and the preference of the patient and family.
•For patients with stones greater than 20 mm 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 SWL [39,40]. Both SWL and URS are also options but with a higher need for repeat intervention.
●Location – Several pediatric case series have observed poorer clearance of renal stone fragments from the lower pole compared with other locations [42,43]. For patients with lower pole stones, ureteroscopy is the preferred intervention. In addition, distal ureteral calculi are more effectively removed with ureteroscopy than with SWL, the decreased efficacy of SWL in the distal ureter may be due to the presence of the bony pelvis [44]. Ureteroscopy is also associated with a lower radiation risk to the pelvic area, since SWL typically uses fluoroscopy for guidance.
●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 SWL. PCNL, URO, or laparoscopic or robotic-assisted excision may be considered for calyceal diverticulum. In our center, we prefer PCNL, especially for posterior-located diverticula, 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 SWL and repeat sessions are often needed. As an example, in patients with cystine stones, the stone-free success rate may be as low as 60 percent with fluoroscopic-guided SWL [45]. As a result, PCNL or ureteroscopy, and laser lithotripsy are the preferred procedure for patients with these types of stones. In contrast, struvite, calcium oxalate dihydrate, and uric acid stones break more readily with SWL and have a high stone-free success rate with SWL, although ultrasound guidance would be necessary for uric acid calculi, which are radiolucent on fluoroscopy [46].
●Age – Smaller children may have higher failure and complication rates with ureteroscopy [35]. Furthermore, many of these children are at risk for multiple procedures and therefore multiple exposure to general anesthesia, especially if pre-stenting is performed. For this reason, SWL may be preferred to ureteroscopy in children younger than five for similarly sized calculi, especially when the location is in the renal pelvis or proximal ureter.
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 [39,40]:
●In patients with stones up to 20 mm in diameter, SWL or ureteroscopy with lithotripsy are both reasonable options for stone removal. Miniature PCNL is also an a reasonable alternative for stones between 10 to 20 mm in size especially in small preschool children and where stone clearance with a single surgical intervention is highly valued.
●In patients with stones greater than 20 mm in diameter, we suggest ureteroscopy with lithotripsy, or PCNL. SWL can also be considered especially in children with renal pelvic or proximal ureteral calculi. PCNL provides greater stone-free success with a greater risk of complications. If the stone is in the lower pole calyces, these interventions have a greater success rate than SWL.
●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.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Kidney stones" and "Society guideline links: Pediatric nephrolithiasis".)
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 5th to 6th 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 10th to 12th 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.)
●Basics topics (see "Patient education: Kidney stones in children (The Basics)")
●Beyond the Basics topics (see "Patient education: Kidney stones in children (Beyond the Basics)")
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.
●Indications for hospitalization include the need for parenteral fluid and pain medications because of severe pain, or inability to take oral analgesics or fluids (eg, vomiting), and potential urologic intervention due to the presence of urinary obstruction or infection. (See 'Hospitalization versus outpatient management' 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 nephrolithiasis. (See 'Pain control' above.)
●A urine culture should be obtained for all children with nephrolithiasis as a concomitant urinary tract infection is a potential indication for urologic intervention. (See 'Management of urinary tract infection' above.)
●For children with stones less than 10 mm in diameter, we suggest a trial of spontaneous passage with or without medical expulsive therapy, provided that there is no concomitant infection, pain is well controlled, and short-interval urological follow-up is assured (Grade 2C). In most cases, renal ultrasonography is used to monitor stone movement and confirm passage. (See 'Ureteral stone passage' above and 'Follow-up' above.)
During this period of observation, the patient or family is instructed to strain the child's urine for stone retrieval. If the stone is retrieved, stone composition is determined by laboratory analysis. (See 'Stone retrieval' above.)
●Indications for urologic stone removal include (see 'Indications' above):
•For children with significant urinary obstruction (obstruction resulting in acute kidney injury), we suggest urologic stone removal (either immediate removal or urinary decompression with staged urinary stone removal) versus a trial of spontaneous stone passage (Grade 2C).
•For children with urinary tract infection and either partial or complete urinary obstruction, we suggest immediate decompression and subsequent urologic stone removal versus a trial of spontaneous stone passage (Grade 2C).
•For children with severe debilitating pain refractory to parenteral analgesic, we suggest urologic stone removal versus a trial of spontaneous stone passage (Grade 2B).
•For children with struvite stones, we recommend urologic stone removal versus a trial of spontaneous stone passage (Grade 1B). (See "Kidney stones in adults: Struvite (infection) stones", section on 'Treatment'.)
•In symptomatic children who fail to pass a stone after two weeks, we suggest stone removal versus continuing awaiting spontaneous passage (Grade 2C). (See 'Indications' above.)
●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 (SWL), 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.)
