Pediatric urolithiasis: To cut or not to cut

Urolithiasis is a major source of morbidity in children of the third world. Since its advent in 1982 and despite uncertainties about the long-term effects on the kidney, extracorporeal shock wave lithotripsy (ESWL) has rapidly replaced traditional surgery in the management of this condition. A retrospective study was conducted to compare the outcome of ESWL with that of open surgery in the management of paediatric urolithiasis in a single institution between November 1988 and December 1991. Emphasis was placed on the rate of stone clearance, complications, duration of follow-up, and cost of treatment of each modality. A total of 83 patients under 14 years of age underwent management of 101 stones; the stones were located in the kidneys (63), ureters (13), or bladder (25). Thirty-one patients who enrolled directly through the Lithotripsy Clinic underwent a total of 65 ESWL sessions for 44 calculi (mean, 2.1 sessions per patient). The overall stone clearance rate was 82%, with an 83% clearance rate for renal stones. There were three failures. Nine patients did not return after the first ESWL session, and by the end of 6 months, 93.5% were lost to follow-up. The cost of ESWL ranged from $600 to $1,000 (mean, $780). Fifty-two children were managed through the Pediatric Surgery Clinic and underwent open surgery (57 stones). The overall stone clearance rate was 96%, with a clearance of 88% for renal calculi. There were two wound infections and no deaths. All patients returned for the first follow-up visit, but by the end of 6 months, only 34.5% were available for follow-up. The total cost of treatment ranged from $520 to $900 (mean, $580). The authors believe that with the present level of knowledge, use of the lithotriptor should be restricted to children with small stones and/or those for whom long-term follow-up is possible