What are the guidelines for managing pediatric bladder stones?

Management of Pediatric Bladder Stones

For pediatric bladder stones, minimally invasive surgical approaches are recommended as first-line treatment, with the specific technique determined by stone size: endourological management for stones <10mm, and robotic cystolithotomy or percutaneous cystolithotomy (PCCL) for larger stones >15-20mm. 1, 2

Diagnostic Approach

• CT scan is the gold standard for detecting urinary stones with approximately 97% sensitivity 3
• Ultrasound is preferred for follow-up monitoring and has lower radiation exposure, making it suitable for the pediatric population
• Urine culture should be obtained prior to intervention to rule out infection 3

Treatment Algorithm

Stone Size-Based Approach:

1. Stones <10mm:

   • Endourological treatment with holmium laser lithotripsy
   • Advantages: Most cost-effective, shorter hospital stay, minimal invasiveness 2

2. Stones 10-15mm:

   • Endourological approach or PCCL depending on stone characteristics and surgeon expertise
   • Consider patient-specific factors (anatomy, prior surgeries)

3. Stones >15-20mm:

   • Robotic cystolithotomy or PCCL
   • Robotic approach allows removal of large stones without crushing and facilitates precise bladder wall closure 2
   • PCCL is effective but may require longer catheterization and hospital stay 4, 2

Special Considerations

Underlying Conditions

• Evaluate for predisposing factors:
  • Congenital urological abnormalities (present in ~15% of cases) 5
  • Neurogenic bladder (associated with higher risk of bladder stones) 5, 6
  • Metabolic disorders (hypercalciuria, hyperoxaluria, cystinuria) 5
  • Recurrent urinary tract infections

Perioperative Management

• Antibiotic prophylaxis for patients with:

  • Active UTI
  • History of recurrent UTIs
  • Infected stones
  • Obstructed collecting system with signs of infection 3

• Post-procedure care:

  • Indwelling catheter duration varies by procedure:
    • Endourological/robotic approaches: ~16 hours
    • PCCL: ~72 hours 2
  • Hospital stay:
    • Endourological/robotic approaches: ~4-5 days
    • PCCL: ~7-8 days 2

Outcomes and Follow-up

• Stone-free rates are excellent with all minimally invasive approaches 4, 2
• Complication rates are generally low but slightly higher with PCCL 2
• Follow-up imaging (ultrasound) is recommended to confirm stone clearance
• Metabolic evaluation should be considered to prevent recurrence

Caveats and Pitfalls

• Blind access PCCL (without ultrasound or fluoroscopic guidance) has been reported as safe and effective for large bladder stones in children, but requires surgical expertise 4
• Stenting is not routinely recommended following uncomplicated procedures 3
• Consider the potential for stone recurrence, especially in patients with underlying metabolic or anatomical abnormalities
• In patients with neurogenic bladder, more vigilant follow-up may be needed due to higher risk of stone formation 5, 6

While the American Urological Association guidelines provide detailed recommendations for ureteral stones in children, specific guidelines for bladder stones are more limited. The treatment approach should be guided by stone size, available technology, and surgeon expertise, with minimally invasive techniques being the current standard of care.