1. Urinary Tract Stones in Children
Mr. Stephen Griffin – Consultant Paediatric Urologist, Southampton Children’s Hospital
Dr. Paul Cook – Consultant Biochemist, UHS
Dr. Shuman Haq – Consultant Paediatric Nephrolgist,

2. Is the incidence of stone disease in children….
Increasing
Decreasing

3. What is likely the commonest aetiology for stone disease in children?
Idiopathic
Infective
Metabolic

4. 12-yo girl c/o abdominal pain. Renal tract calculus is on your DDx
12-yo girl c/o abdominal pain. Renal tract calculus is on your DDx. Which imaging modality do you request as first line investigation?
MRI Urogram
Non-contrast CT KUB
Plain KUB
Renal tract USS

5. Epidemiology
It’s somewhat ironic that I stand here today with Jonathan as approximately 10 years ago I sat down with a consultant paed nephrologist from the Evelina at a pre consultant interview meeting. ‘What can you bring to this post?’ she inquired. ‘The incidence of paed stone disease is rising,’ I replied. ‘My background in adult urology and experience in stone management would be helpful in growing this service here.’ I didn’t get the job.

6. Paediatric stone disease incidence is rising
Olmsted County, Minnesota from 1984
to 2008.
Dwyer et al
J Urol 2012: 188: 247
However, only a few years later, evidence from that region beloved of all BPH epidemiologists – Olmsted County, proved my point! Paediatric stone disease incidence is rising – in this study spanning 25 years, particularly in the adolescent population.

7. Stone Prevalence – HES data UK 2000-2010
Annual Prevalence
0.166%
Life time Prevalence (to 70 years)
11.6%
Childhood Prevalence (<14 years)
1-2%
Turney et al BJUI 2012; 109:1082-7
Nearer home, Turney and colleagues analysis of Hospital Episode Statistics (HES) data through the ‘00s also reported almost 20% increase in number of paediatric patients (<15years) diagnosed with renal tract stones between and Using this data childhood prevalence for renal tract stones is 1-2%.
Additionally, recurrence rates for children are high at 50%, 3-5 years after initial stone episode.
WHY you may ask? Increasing childhood obesity? (Note BMIs were not raised in Olmsted County) Improved / increased detection? Environmental factors?
Recurrence – circa 50% at 3-5 years
Tasian et al J Urol 2017; 197:246-52

8. Changing aetiologies Coward et al Arch Dis Child 2003; 88:962-65
Majority of metabolic abnormalities were hypercalciuria
Coward et al Arch Dis Child 2003; 88:962-65

9. Presentation

10. NB. May be LATE Incidental UTI Generalised sepsis Pain Haematuria FTT
Renal failure
Mass (XGP)
15-75%
NB. May be LATE. I have had one patient a referred nearly 2 years post initial symptoms. Approx 20% in the Olmsted County study presented to a primary care facility.

11. Associated ‘Anatomical’ abnormalities
10-40%
VUR
PUJO
VUJO
Megaureter
Horseshoe kidney
SOUTHAMPTON 38% (Chedgy et al Urol Int 2015;95:320-3)
(Immobility)
(Bladder augmentation)
Anatomical abnormalities are congenital and acquired

12. Associated Metabolic and Other Abnormalities
Ones I’ve seen…Idiopathic hypercalciuria, primary hyperoxaluria, cystinuria, Infective stones…and in the drugs list loop diuretics, Topiramate…
Dietary ketogenic diet. Global warming of course in not a factor in the US as Mr. Trump does not believe in this phenomenum!
Bastug et al Nat Rev Urol 2012;9:

13. Investigation

14. Imaging
USS sensitivity – Renal to 90%, ureteral 45-90%, CT 95%+ (Palmer J Urol 2005; 174:1413-6)
DDS = Duplex Doppler scan, measure RI - of benefit if obstructed
CDS = Colour Doppler Scan, enables Twinkling artefact evaluation
‘a child’s small ureter with little surrounding fat reduces the diagnostic potential of CT, particularly when using an unenhanced low-dose technique.’
ESPR uroradiology task force recommendations for imaging stones in children

15. Medical Management

16. Medical Management ACUTE LONG TERM Analgesia Consider fluids
Consider antibiotics
α blocker therapy
LONG TERM
Specific metabolic treatment
Adequate fluid intake (Lemonade)
Lower sodium intake
Lower animal protein intake

17. Surgical management

18. SWL - Chaussy et al, Lancet 1980
Developed in the 19970’s Dornier, a company in the airline industry, were investigating pitting in aircraft fuselage. High speed rain droplets and micrometeors were found to cause SW’s which caused the damage.
They developed a shock wave generator using an under water high-voltage condensor spark discharge (F1). The ellipsoidal reflector reflects the wave which collects at a fixed point (F2). Imaging allows F2 to be focused at the position of the stone.

19. URS + in situ lithotripsy

20. PCNL
BJUI 2007; 99:213-31