Urinary Tract Calculi in Children

Urinary Tract Calculi in Children

THE JOURNAL OF UROLOGY Vol. 109, February Copyright © 1973 by The Williams & Wilkins Co. Printed in U.S.A. URINARY TRACT CALCULI IN CHILDREN ALAN ...

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Vol. 109, February

Copyright © 1973 by The Williams & Wilkins Co.

Printed in U.S.A.




From the Department of Sur{?ery, Children's Hospital Medical Center and Peter Bent Bri{?ham Hospital, Harvard Medical School, Boston, Massachusetts

Since Myers' report in 1957 on 85 children with renal calculi 1 only 78 additional cases have been described in the American literature. 2-• Prior to this century, and especially in England and Turkey, urinary tract calculi in children were endemic and primarily located in the bladder. These endemic calculi were composed mainly of uric acid and have been gradually disappearing since World War I. 7 • 8 Williams' recent series of 133 cases of childhood calculi describes the majority of stones to be renal in origin, either related to some anatomic defect or idiopathic but with urinary infection, the bulk being made up of calcium phosphate and magnesium ammonium phosphate oftentimes in a matrix of uncalcified material.• Sterile stones were less common, primarily ureteral and resembled the small calcium oxalate stones seen in adults. In the United States, stones in the pediatric age group have never been endemic and have the same make-up as calculi found in the adult population. However, as late as 1963 Campbell reported that childhood stones were composed of uric acid in a third to a half of patients. 1 0 The incidence of renal calculous disease in children in this country ranges from 1 per 1,000 to 8,000 pediatric admissions to the hospital. Our study describes a 25-year experience with 100 urinary tract stones in 76 pediatric patients at the Children's Hospital Medical Center in Boston. The incidence of patients with urinary calculi in this series is 1 per 3,000 hospital admissions. The age of these patients ranged from 7 Accepted for publication July 7, 1972. 1 Myers, N. A. A.: Urolithiasis in childhood. Arch. Dis. Child., 32: 48, 1957. 2 Beane, H. C., Magoss, I. V., Staubitz, W. J. and Jewett, T. C., Jr.: Urolithiasis in childhood. J. Urol., 97: 537, 1967.

'Bass, H. N. and Emanuel, B.: Nephrolithiasis in childhood. J. Urol., 95: 749, 1966. •Delta, B. G. and McKendry, J. B.: Urolithiasis in children: report of three cases and review of the literature. Canad. Med. Ass. J., 82: 352, 1960. 5 Daeschner, C. W., Singleton, E. B. and Curtis, J. C.: Urinary tract calculi and nephrocalcinosis in infants and children. J. Pediat., 57: 721, 1960. 'Troup, C. W., Lawnicki, C. C., Bourne, R. B. and Hodgson, N. B.: Renal calculus in children. J. Urol., 107: 306, 1972.

'Winkel Smith, C. C.: On urinary lithiasis in childhood. Clinical study of 71 cases of urinary calculi in children. Acta Chir. Scand., 90: 179, 1944. •Williams, D. I.: Paediatric Urology. New York: Appleton-Century-Crofts, chapt. 22, 1968. 'Williams, D. I.: Matrix calculi. Brit. J. Urol., 35: 411, 1963.

1 ° Campbell, M. F.: Urology. Philadelphia: W. B. Saunders Co., 1963.


months to 20 years, the average being 9 years. Forty-five (60 per cent) of the group were boys and all 76 were white. Fifty-five children had unilateral stones without recurrences, 13 had bilateral stones and 8 patients had unilateral recurrent stones. Sixty patients had renal calculi, 13 had ureteral stones, 2 had bladder calculi and 1 stone formed in an ileal conduit. The patients are divided into 3 etiologic categories: 1) stasis, 2) metabolic and 3) idiopathic groups (table 1). Two-thirds of these cases were in the stasis group. The majority of the congenital anomalies associated with stone formation were ureteropelvic strictures (table 2). A number of other miscellaneous congenital lesions contributed to stasis with resultant stone formation. In 16 older children (average age 13) stones developed after the patient had undergone ureterosigmoidostomy for exstrophy of the bladder. These stones were all associated with increasing obstruction and infection and were composed mostly of magnesium ammonium phosphate. Most patients with ureterosigmoidostomy in whom stones developed were operated upon prior to 1953; after that time the combined technique of a submucosal tunnel with a mucosa-to-mucosa anastomosis was routinely used. 11 The number of complications including obstruction, infection and stone formation in these children was subsequently markedly reduced. 12 Stones that formed as a _result of immobilization also occurred in older children (average age 13) with fractures or having orthopedic procedures that required prolonged periods of traction or casts (table 3). The shortest time of immobilization in this group before symptoms of stone formation occurred was 3 weeks in a patient with a fractured humerus. Several other orthopedic patients had stones within 2 months of being immobilized. All stones in this group of patients (8 stones from 9 patients) that were available for analysis were composed of calcium oxalate. In the metabolic category 5 patients had cystinuria and 4 had uric acid stones. Two of the uric acid stones developed in patients with fatal acute leukemia. The calculi were incidental findings in patients with leukemia and had no bearing on the clinical course. Two patients with regional enteritis had stones. One passed spontaneously and 11 Leadbetter, W. F. and Clarke, B. G.: Five years' experience with uretero-enterostomy by the 'combined' technique. J. Urol., 73: 67, 1955. '"Hennett, A. H.: Long-term evaluation of ninetyfour children with exstrophy of the bladder treated by ureterosigmoidostomies. Unpublished data.




Stasis group: Congenital abnormality After uret~rosigmoidostomy Immobilization Stone in ilea! conduit Foreign body (silk stitch in bladder) Idiopathic group Metabolic group: Cystinuria Uric acid Regional enteritis


20 16

12 1

1 15 5 6


2. Congenital abnormalities

Ureteropelvic stricture Ureterovesical stricture Aberrant ureter Megaureter Rectovesical fistula Double ureter with "Yo-Yo" Meningomyelocele

13 2



3. Stones formed durin1; immobilization

Poliomyelitis Scoliosis (cast) Dermatomyositis-in traction Fracture of humerus Fracture of lumbar vertebra Acute paraplegia (trauma)

4 4

1 1 1 1


one had to be removed by a pyelolithotomy. Deren described a 6.3 per cent incidence of stones in 221 patients with regional enteritis. About half of these stones were uric acid, the remainder were calcium oxalate. 13 The 2 patients in this series with regional enteritis had uric acid stones. (There have been 50 patients seen with regional enteritis.) Both patients had been on courses of glucocorticoids and this together with the systemic acidosis and compensatory acid urine commonly noted in these patients may be the explanation of the uric acid stone formation. The majority of the stones in the 15 patients in the idiopathic group were composed of calcium salts (table 4). Although there was a strong family history of stone disease in 6 patients, no chemical or metabolic abnormalities could be found at the time the stone was discovered by the usual screening procedures, which included several urinary and serum collections for calcium, phosphorus and uric acid. One hundred stones were found in these 76 patients and 74 were analyzed: 45 stones (62 percent) were composed mainly of calcium oxalate, 18 (25 per cent) of magnesium ammonium phos13 Deren, J. J., Porush, J. G., Levitt, M. F. and Khilnani, M. T.: Nephrolithiasis as a complication of ulcerative colitis and regional enteritis. Ann. Intern. Med., 56:

843, 1962.

phate, 6 of uric acid and 5 of cystine. All but 2 of the magnesium ammonium phosphate stones were associated with infection. Twenty-nine patients initially complained of pain, 21 presented with infection and 10 had hematuria. One stone was found in a diagnostic study for familial stone disease. Sixteen patients were asymptomatic and the stone was an incidental finding during an evaluation of the genitourinary tract for other reasons. Twenty-nine patients had a urinary tract infection concurrently with the stone and 26 of these had stasis calculi. Recurrence of stones occurred in 8 patients: 5 with persistent stasis and infection, 1 in continuous orthopedic traction, 1 with cystinuria and 1 with no underlying structural or metabolic defect but with a strong family history of recurrent idiopathic stones. Fifty-seven operations were performed on the 76 patients for stone removal (table 5). Six stones passed spontaneously: 5 in immobilized patients and 1 in a patient with regional enteritis. Three patients had contraindications to an operation such as the presence of metastatic neuroblastoma, multiple congenital anomalies incompatible with survival and chronic renal failure owing to other causes. One patient refused an operation. Twelve patients underwent pyeloplasty following pyelolithotomy and 4 ureteral reimplantations were performed following stone removal. Seven deaths occurred in the group, none of which was directly related to the stone or its removal. The causes of death were chronic renal failure after ureterosigmoidostomy for exstrophy in 3, acute leukemia in 2, meningitis in 1 and neuroblastoma in 1. CONCLUSION

Urinary tract calculi in children may be associated with stasis, certain metabolic disorders or may be idiopathic. Calculi occur in patients at


4. Patients with idiopathic stones

Initial Diagnosis

No. Pts.

Failure to thrive


Normal except for stone


Wilson's disease Obesity. diabetes


Family History

Type Stone Ca oxalate MgNHJ'O, Ca oxalate Uric acid Ca oxalate

3 2 7

2 3

1 0

5. Surgical procedures for stone removal

Nephrolithotomy Pyelolithotomy Ureterolithotomy N ephrectomy Suprapubic cystolithotomy Stone manipulation

21 20 6 4 3

3 57



any age and patients present initially with pain, hematuria or urinary infection, although several pr:esent without symptoms referable to the stone it,l'elf. Most stones are unilateral, due to stasis aQd located in the kidney. Most children with c~kulous disease come to open operation for stone removal. Recurrences are low owing to the elimination of the underlying cause at the time of

stone removal. In children who must be immobilized for prolonged periods of time, appropriate measures should be taken to prevent formation of urinary calculi. They should have a limited calcium intake and an increased fluid intake and their urine should be acidified. Any child discovered to have a calculus should have a thorough urinary tract and metabolic investigation.