ABSTRACT
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.
ABSTRACT
BACKGROUND: Paediatric urolithiasis remains endemic in low resource countries. This review highlights the epidemiology, causation and management of urolithiasis in an Asian country in the context of emerging economies. METHODS: A literature review of recent articles with key words paediatric urolithiasis, developing countries, endemic stone disease, stone composition, metabolic risk factors, management of paediatric urolithiasis was undertaken and 51 relevant articles were selected with the main focus on experience of this center in managing stone disease in the last two decades. RESULTS: Prevalence of paediatric urolithiasis is high upto 15% affecting children under 15 years with male predominance. Bladder stones still constitutes 10-70% of the burden. Etiology remains unknown where 55% are considered idiopathic, 25% metabolic, 7% infection and 12% due to anatomical abnormalities. Hot climate, poor nutrition, diarrheal diseases are the major causative factors. Chemical composition of stones showed CaOX in 30-63%, AAU in 17-55%, struvite in 8-9%, uric acid in 3-6% and cystine in 1%. Important metabolic risk factors are hypocitraturia in 63-87%, hyperoxaluria in 40-43%, hypocalciuria in 20%, hyperuricosuria in 27%, hyperammonuria in 11-51% and hypovolemia in 31%. Minimally invasive surgery is the mainstay of surgical management. ESWL provides excellent free rates of 84% for smaller stones. PCNL is the option for majority of renal stones with success rates of 89% for simple and 71.5% for complex stones. For bladder stones PUCL and PCCL success rates were 100%. URS for ureteric stones showed clearance rate of 90%. Open surgery is required in 12% of patients with large stone burden. CONCLUSION: Paediatric urolithiasis remains a devastating health problem in low resource settings. MIS offers relief to majority of patients with excellent stone free rates and short hospital stay. Preventable strategies have to be put in place by improving nutrition and eliminating risk factors by diet and medical intervention.
Subject(s)
Cost of Illness , Health Care Costs , Urolithiasis/economics , Child , Costs and Cost Analysis , HumansABSTRACT
PURPOSE: We evaluated the role of clean intermittent self-catheterization through a continent catheterizable Mitrofanoff channel in an augmented bladder in children with bladder dysfunction and outlet obstruction. MATERIALS AND METHODS: We retrospectively analyzed the records of 82 patients treated at a public sector hospital with pediatric urology services in a developing country. Patients came from all provinces of the country with diverse ethnic, cultural, linguistic, socioeconomic and educational backgrounds. RESULTS: Mean +/- SD patient age was 9.07 +/- 3.38 years (range 2.5 to 15) with a male-to-female ratio 2.5:1.0. The main congenital and acquired abnormalities were posterior urethral valves in 29% of patients, neuropathic bladder in 22%, nonneurogenic neurogenic bladder in 17%, exstrophy plus epispadias in 10% and urethral stricture in 7%. Augmentation cystoplasty was performed using various bowel segments. The Mitrofanoff channel was made using appendix in 70 cases and by the spiral Monti method in 12. A stoma was created in the right iliac fossa using VQZ plasty in 72 patients and an umbilical stoma was created in 10. Complications included bladder calculus in 3 patients, stomal stenosis in 2, subacute intestinal obstruction in 4 and acute intestinal obstruction in 1. Compliance was observed in greater than 90% of the patients at a mean followup of 860 days. CONCLUSIONS: In a developing country setting with a low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self-catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of pediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance.
