Urinary bladder stones in aboriginal

children.
Wisniewski ZS, Brockis JG, Ryan GD.
Primary bladder stones are described as
occurring in aboriginal children from native
reserves. Here breast feeding is supplemented
early in life with white flour and little else. A
comparison is made between this diet and that
of children in endemic bladder stone regions,
and reasons are advanced for the formation of
these stones, with biochemical evidence to
support the thesis that ammonium acid urate
precipitation is the initiating factor.

urography (Fig.1). Possible symptoms include

dull, suprapubic pain and haematuria. Up to
50% of bladder stones may not be discernable
on plain radiographs. When visible, stones may
be single or multiple, small or large, smooth or
spiculated. Ultrasound reliably demonstrates
bladder stones as echogenic lesions with
acoustic shadowing. Mobility aids in the
distinction from calcified bladder tumour.
Stones can also be demonstrated by CT or MRI

PMID: 6942810 [PubMed - indexed for

MEDLINE]
..
Calculus, bladder,
stone formation in the bladder, classified as
secondary, migrant, or endemic. Bladder calculi
are usually secondary to bladder pathology,
commonly bladder outlet obstruction, resulting
in calcium oxalate or calcium phosphate
stones. Other causes include bladder infection
with urea-splitting organisms (results in triple
phosphate stones), long-term catherization,
bladder wall sutures and self-introduced foreign
bodies. Migrant bladder stones originate in the
kidney and pass into the bladder via the ureter.
These are usually small and transient, exiting
per urethra. However, if there is co-existent
bladder outlet obstruction, such migrant stones
may remain and grow in the bladder. Primary
endemic bladder calculi were common in
England and France during the 19th century,
but are not now seen in the western world,
probably due to nutritional and dietary
improvements. Endemic bladder calculi still
occur in children in countries such as Thailand
and Indonesia.
Many bladder stones are asymptomatic and
discovered incidentally on plain radiographs or

Extracorporeal Shock Wave Lithotripsy In Children.

Vincent C. Onuora FRCS(Ed);? Abdelmoniem H. Koko FRCS(Ed)
Mohammed Al Turki FACHARTZ;? Nasser Al Jawini FACHARTZ.
Department of Urology, Riyadh Medical Complex, Riyadh,
Saudi Arabia.

All Correspondence:
Dr V C Onuora,
P O Box 29765,
Riyadh 11467.
Saudi Arabia
Tel/Fax: 966 1 435 6172
email: vconuora@deltasa.com
Abstract.
Between 1993 and 1998, 67 children with stones in the urinary
tract were treated by ESWL in our department. ?There were 38
boys and 29 girls and their ages ranged from 5-16 years (mean
12.9).? The majority of the children presented with pain (79 %) or
haematuria (13.4 %).? Diagnosis was established by the use of
sonography and intravenous urography (IVU).? Stone disease was
associated with horseshoe kidney, posterior urethral valve, pelviureteric junction obstruction and external meatal stenosis in one
child each.? There were 56 renal (37 pelvic, 16 calyceal and 3
staghorn); eleven ureteric and 3 bladder stones. The stone sizes
ranged from 4 mm to 40 mm (mean 16) in the largest diameter.?
ESWL was done as an outpatient procedure in 20 children (30 %),
and the rest required admission to the hospital.? Double J stents
were placed in 15 children with stones larger than 20 mm.?
General anaesthesia was used in 19 children, usually those below
the age of twelve.? The others received intravenous pethidine for
sedation and analgesia.? The mean number of shocks delivered
was 3000 and the generator voltage ranged from 16 to 19 kV.?
Most of the patients required only one ESWL session (mean 1.7).?
The overall stone free rate was 82 % and this was achieved
during a mean period of twelve weeks.? Four children developed
febrile urinary tract infection and 2 steinstrasse.? Follow-up was
poor.? Our results suggest that at short term, ESWL was an
effective and safe treatment modality for urinary lithiasis in
children.
Key words:? Extracorporeal shockwave lithotripsy; children;
Saudi Arabia
Introduction.
???? The advent of extracorporeal shock wave lithotripsy (ESWL)
as a non-invasive technique has revolutionalised the
management of urinary tract calculi.? It is considered a safe and
effective treatment for urinary lithiasis in adults.? However, the
application of this modality of treatment in children followed
rather slowly.? Although evidence has accumulated on the
efficacy of ESWL in treating calculi in children (1-3), the effects of
shock wave on the paediatric urinary tract still need to be
clarified.? Indeed, ESWL was considered by some to be contraindicated in children (4).o:p>
??? As a contribution to the growing data in this field, we report
our experiences on the use of a second-generation lithotriptor
(Siemens Lithostar) in the treatment of renal calculi in children in
Saudi Arabia.
Patients and Methods.
??? Between January 1993 and December 1998, 67 children with
stones in the urinary tract were treated by ESWL using the
Siemens Lithostar lithotriptor.? There were 38 boys and 29 girls
and their ages ranged from 5-16 years (mean 12.9).? Prior to
shock wave treatment, all patients underwent renal and bladder
sonography, intravenous urography (IVU), blood tests for renal
function, coagulation profile, urine analysis and urine culture.?
Patients with allergy had a dimercapto succinic acid (DMSA) renal
scan.? Fifty-three children (79%) presented with pain; 8 with
micro-haematuria; one with gross haematuria.? Urine culture was
positive in eight children (12%) and they received appropriate
antibiotic therapy before stone treatment.
??? Stone disease was associated with horseshoe kidney in one
case; three other children had previously undergone surgery for
posterior urethral valve, pelvi-ureteric junction obstruction and
meatal stenosis respectively.
??? There were 56 renal stones (37 pelvic, 16 calyceal, and 3
staghorn). Eleven children had ureteric and three bladder
stones.? Only three children had radiolucent calculi. Renal calculi
were bilateral in three others. The stone size ranged from 4 to 40
mm (mean 16) in the largest diameter.? ESWL was done as an
out patient procedure in 20 children.? Fifteen patients with bulky
stones (> 20 mm) had internal stents before treatment and three
had placement of ureteric catheters for visualization of
radiolucent stones.? General anaesthesia was used in 19
patients, usually those below the age of twelve years.? The rest
received pethidine for sedation and analgesia. The mean number
of shocks delivered was 3000, and the generator voltage ranged
from 16 to 19 kV.? Most of the patients required only one ESWL
session (mean 1.7)

??? Plain abdominal x-ray was done on the day after treatment
and repeated monthly in the outpatient department.? Patients
with radiolucent stones and those with bulky stones were
followed with ultrasound scans. A patient was regarded as stone
free if no stone fragment was discernible and the time to this
status was noted.?? A ?successful outcome? was defined to
include stone free patients and those patients with stone
fragments less than 4 mm which were deemed passable.
?
Results.
??? Sixty-seven reno-ureteral units and three bladders were
treated. ESWL resulted in complete stone fragmentation in 53
units (79 %) and one bladder stone, usually after one session
(mean 1.7).? However, 21 units required multiple shock wave
sessions.? One child with staghorn stone needed eight sessions
and received a total of 14,000 shocks spread over three months.?
He had DJ internal stenting but still developed ureteric
obstruction from steinstrasse. He underwent two sessions of
ureteroscopic stone extraction before achieving a stone free state
after 52 weeks.
??? Fifty-five reno-ureteral units (82 %) were stone free after 12
weeks.? Residual fragments (< 4 mm), which required no further
treatment, were present in five units.? Hence the success rate for
ESWL was 89.6 %.? The procedure failed in two units (1 pelvic
and 1 upper ureteric). In both cases, the stone was removed by
open surgery because of lack of necessary paediatric endoscopic
instruments.? Five children (5 units) failed to come for any followup.?
??? ESWL was successful in treating one bladder stone but it
failed in two cases.? In both failures the stone was more than 30
mm in size and had to be removed by open surgery.
??? Auxiliary procedures were required in 20 children and
included placement of DJ stents in 15, ureteric catheters in 2 and
ureteroscopic stone removal in 3.? Four children developed
febrile urinary tract infection; two steinstrasse and one child had
impacted urethral stone.?
??? There was one stone recurrence and it occurred at 18
months.? However, most of the patients abandoned follow-up
once a stone free status was achieved.? One child was lost for
two years with a DJ stent in place.? Amazingly, this was
successfully removed in one piece.
Discussion.
??? In this study, the 12-week stone clearance rate was 82 % and
most of the patients required only one session of ESWL.? If the
five children with small stone fragments were regarded as
successful outcome, the overall success rate would rise to 89.6
%.? Five children failed to attend follow-up clinic altogether.? It is
conceivable that some or all of them achieved stone free status.?
Thus ESWL was highly effective in the treatment of ureterorenal
stone disease in this group of children.? Our results compare
favourably with those of others (5,6).? The ease with which stone
fragments pass through the small ureters of children has been
ascribed to several factors.? Children are more mobile than adults
and mobility is known to favour stone passage.? Another factor is
that stones in the urinary tract of children have not had time to
impact firmly.? Although this was not our experience, congenital
anomaly has been cited as the most common cause of urolithiasis
in children (7).? Children with anomalies in the urinary tract and
concomitant urinary stones would be best managed by open
operation.
??? We encountered minor and infrequent complications using
the Siemens Lithostar machine. Four children developed febrile
urinary tract infection and responded readily to antibiotic
treatment. We usually administered antibiotics to cover the ESWL
session and continued treatment with oral drugs for a few days
post lithotripsy.? An untreated urinary infection is a
contraindication for lithotripsy in our unit.? The occurrence of
urinary infection despite these precautions emphasizes the need
for antibiotic therapy to cover lithotripsy.? Fragmentation of
infectious stones can lead to the development of septicaemia
(8).? The other complications we encountered related to the
passage of stone fragments.? Steinstrasse occurred in two
ureters and needed stent insertion.? A stone fragment impacted
in the urethra in one child necessitating extraction under general
anaesthesia.? Nevertheless, this low complication rate is
significant since endo-urological procedures on children have
their limitations owing to the small sizes of the patients.
??? The Siemens Lithostar proved to be an effective secondgeneration lithotriptor for ESWL of renal and ureteric stones in
children.? Because the focal zone is small, there was no need for
lung shielding from the shock waves.? However, the long-term
effects of ESWL on the developing renal parenchyma in children

are not clear.? Although many investigators (9,10,11) have

reported shock wave lithotripsy to be safe, doubt still persists
(12).? It might be prudent to use open surgery or percutaneous
nephrolithotomy for large staghorn calculi (13) that would require
patient and parents and could be a factor for abandonment of
treatment.? Long-term follow-up was poor among our
population.? This is a common finding in our community.? Need to
travel long distances and little health consciousness mitigate
against prolonged outpatient treatment.? Thus it was difficult to
convince stone free patients to make further attendances to the
hospital.? One child in this study was lost for two years with a
double-J stent.? These shortcomings prevented us from doing a
proper evaluation of stone recurrence.? Other studies reported a
recurrence rate of 10 to 20 % following ESWL (14,15).? Before
embarking on shock wave treatment, it is wise to advise the
parents on the need for follow-up.? This is especially so in
developing communities.
??? Our experience with bladder stones is too limited to draw any
conclusions.? ESWL failed to fragment the stones in two of three
children.? These were large calculi measuring more than 30 mm.?
Each was removed by supra pubic percutaneous cystolithotomy.?

many sessions of shock wave treatment.? One of our patients

with a large stone burden required eight sessions of ESWL.?
Repeated hospital attendances place a lot of strain on both
More experience is needed to determine the effectiveness of
shock wave lithotripsy for bladder stones in children.
??? In conclusion, ESWL was found to be a safe and effective
primary treatment modality for renal and ureteric stones in
children. It had a high success rate and minimal short-term
complications.? However, long-term follow-up is necessary to rule
out later complications.? Large staghorn calculi required multiple
shock wave sessions and exposed the ?young? kidneys to
possible hazards.? Lack of follow-up with the associated neglect
of internal stents was a complication peculiar to practice in
developing communities.? Every effort should be made to
educate parents regarding need for adequate follow-up visits
before embarking on ESWL.
Acknowledgement:
We are very grateful to Ms Maricar Bomban for her assistance in
the collection of data.
Competing interests: none declared

The symptoms of bladder stones can be alarming. If you notice blood in your urine, consult
your healthcare provider promptly, even if you have no pain.