Medical expulsive treatment in pediatric urolithiasis

Abstract

The frequency of stone disease in childhood ranges between 0.1-5 percent. Stone disease occurs as a result of enviromental, metabolic, anatomical, infectious and nutritional factors. Percutaneous nephrolitotomy, uretherorenoscopy, laparoscopic surgery, open surgery and extracorporeal shock wave lithothripsy are treatment alternatives for stone disease during childhood. However, these methods are not completely innocent. Some complications may occur after these procedures. These procedures are generally not cost-effective. Even invasive procedures have high success rates, so medical expulsive treatment modalities have become an alternative for a group of patients. Nonsteroidal anti-inflammatory drugs, antimuscarinic drugs, phospodiesterase type 5 inhibitors, steroids, calcium channel blockers and alpha blockers are treatment alterneatives used for this modality in the literature. The drug is chosen according to the location, size, and composition of the stone, recent technology, cost, surgeon's experience and surgeon's and the parents' preferences. In this review article the following topics will be discussed such as "Why medical expulsive treatment is needed during childhood? Which drug should be chosen for which stone type? How long should a treatment of urolithiasis last?

Impaction and Prediction: Does Ureteral Wall Thickness Affect the Success of Medical Expulsive Therapy in Pediatric Ureteral Stones?

“…Regarding this issue, evaluation of the published data demonstrated well that while the use of alpha blocking agents may facilitate spontaneous passage of ureteric stones in the majority of the cases, the effect of these agents on the stone expulsion time and analgesic need seemed to be variable in different studies [36][37][38][39][40][41] . In other words, data derived from these studies demonstrated that despite the limited data with inconsistent and/or incomplete reporting, treatment of ureteral stones with MET in children results in increased odds of spontaneous ureteral stone passage and a low rate of adverse events [21][22][23] .…”

“…Although MET has been applied in an extensive manner in adults, studies focusing on the role of a-blockers in the management of pediatric ureteric calculi are limited with inconsistent and/or incomplete data reported [21][22][23] . However, these studies demonstrated that treatment with MET is associated with a clear and cumulative positive effect on stone passage in this specific population also.…”

The Evidence Paradox of the Effectiveness between the Paediatric and Adult Stone-Forming Population: A Narrative Review

“…In more detail, 11 articles actually dealt with the effects of α-blockers on ureteric stones in the paediatric population. Two meta-analyses of randomized studies were identified (level of evidence, LE: 1a) [6,7], 4 prospective randomized studies (LE: 1b) [8][9][10][11], one well-designed cohort study (LE: 2b) [12], one systematic literature review (LE: 3) [4] and 3 expert panel reports (LE: 4) [13][14][15]. Three articles that discussed the metabolic evaluation and medical treatment of paediatric nephrolithiasis were identified and they consisted 2 welldesigned cohort studies (LE: 2b) [16,17] and one expert panel report (LE: 4) [18].…”

“…It was only when the analysis was adjusted for stone size and location that tamsulosin was associated with better spontaneous passage, notably with a wide confidence interval (OR 3.31, 95% CI 1.49-7.34) (LE: 2b). Of the remaining articles, the majority favour MET, with the exception of the review by Atan and Balcı [13] who support that in the face of limited comprehensive studies, calculi <10 mm should either be allowed to pass spontaneously or treated aggressively when symptomatic (LE: 4).…”

Pediatric renal stone disease

“…The use of nonsteroidal anti inflammatory drugs may be indicated as the first choice. Renal stone expulsive treatment may be managed with open surgery, extracorporeal shock wave lithotripsy, laparoscopic or robot-assisted uretero-pyelolithotomy, percutaneous nephrolithotomy, rigid and/or flexible ureteroscopy and medical expulsive treatment (MET) [40]. Choice of treatment for a specific patient is determined based on the renal stone location, its size and composition, urinary system anatomy, as well as available technology, cost of the treatment, experience of the physician, and preferences of both the physician and the patient's parents [40].…”