Kidney Stones in Children: Treatment and Surgery (3 of 5)

Author: The Children's Hospital of Philadelphia

Once we understand what the diagnosis is and where the patient is after their workup process, now we can better manage them to whether or not they need simple medical management or whether or not we need to have surgical intervention. When kids present with pain from a kidney stone, the first question is the size of the stone, the location of the stone, and is it causing an obstruction. It is rare for a child to present with kidney stone pain and have to go right to the operating room. When you do have a stone they're often very small stones that the child would be able to pass on their own. We try and use medications, which can both make the ureter or tube which connects the kidney and the bladder more relaxed and more able to dilate and pass the kidney stone. The majority of children are able to avoid a surgical intervention, but a significant minority of patients will require surgery if it's a large stone and depending on the location of the stone.

If a stone has lodged in the ureter and is blocking the flow of urine from the kidney down into the bladder, we would simply need to place a stent to allow the urine to bypass that obstructing stone and then that allows us to plan the definitive surgery at a later time. We go into the bladder with a very small scope and we're able to see where the ureter enters into the bladder. We'll then put in a very soft wire that goes all the way up to the kidney, and then over that wire we'll thread that stent, and a stent is a hollow soft plastic tube that allows the urine to drain both through the stent and then also around it. There are two curls on the stent, one is up in the kidney and then one is in the bladder, and that allows the stent, once we place it, to remain in place. So the surgical options that are available for kidney stones that occur in children are really the same options that you'd have in adults, but we've been able to refine the process here to be able to make it particularly effective for children.

Probably the most commonly-utilized method of taking care of a kidney stone is called ureteroscopy. What a ureteroscope is, is really a long sort of telescope that we use to simply go into the bladder and then up the ureter and into the kidney where the stone is without making an incision to visualize the stone and then use usually lasers to break up the stone and then extract those fragments of the kidney stone should they exist. When we extract those fragments, we then send them off for analysis to know what type of stone it is. Not leaving fragments after surgery in stone surgery is the most important factor that prevents the next stone from forming.

So if you leave a stone fragment behind, that's a crystal. You've laid the seed for the next stone to form. The other option that we sometimes use in the appropriate situations is called percutaneous nephrolithotomy. Percutaneous means through the skin. Nephro means kidney. Lithotomy means kidney stone removal. We'll use various types of specialized endourologic scopes in that case to go directly through the flank of the child into the kidney and break the stone up, and bypass the ureter and get that stone out directly.

Kidney Stones in Children: Treatment and Surgery (3 of 5)

We reserve that approach to children that have huge stone burden that's located in the kidney. Robotic surgery is another option that we have for treating children with kidney stones. I particularly like the robotic approach if there's another operation that we have to do on the kidney. When you're dealing with small spaces and those spaces tend to be smaller in children, the robotic surgery platform allows us to use very small incisions with instruments that we control, but through this robotic interface. Another modality that can be used to treat children with kidney stones is called ESWL, which allows us to focus sound waves on the kidney stone thus breaking it up and then the child would pass those fragments on their own.

But, at that point, they're small enough that they can fit down the ureter. So within the Kidney Stone Center at CHOP, we have every possible modality that could be used to treat children with kidney stones from the surgical interventions to the medical interventions to the way that we image children. Every possible technology is at our disposal and that allows us to tailor the therapy to that child because no two children are alike. They're not just little adults, they're individuals with very different metabolic systems, very different anesthesia requirements, very different endoscopic requirements. You really cannot find a more committed, more professional, more well-trained staff than there is in the operating rooms at CHOP.

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