Open stone surgery in children: is it justified in the era of minimally invasive therapies?

OBJECTIVE: To review experience with open surgery for paediatric urolithiasis during a 10-year period. PATIENTS AND METHODS: The hospital records of patients up to 13 years old and treated between 1990 and 2000 for stones were reviewed; there were 310 patients (98 girls and 212 boys, aged 9 months to 13 years, mean 6.8 years).
RESULTS: The commonest symptoms were renal-ureteric colic (26.7%), gross haematuria (19%), urinary retention (16.7%), and abdominal and/or flank pain (13.2%). Because of poverty and the resultant inability to pay medical fees, 19 children presented very late with pyonephrosis (resembling peritonitis in nine) and obstructive renal atrophy in 23. In 18 other patients the delay was caused by the disappearance of pain. Delayed presentation was the most important factor in developing complications from the stone. The stones were in the calyces in 15 patients, the pelvis in 113, the ureter in 56, the bladder in 71, the urethra in 17 and in a combination of sites in 38. The mean (range, median) stone size was 27 (9-75, 22) mm; 80 (25.8%) were complete staghorn stones. Indications for open surgery were a complex stone burden (62%), ESWL failure (14.5%), need for nephrectomy (1.9%), anatomical abnormalities (2.2%), and unavailability of minimally invasive alternatives (19%). All of the nephrectomized patients underwent unilateral stone removal and contralateral nephrectomy. For parents, the cost and reliability of the result were more important than other considerations, e.g. having a large or small incision. The overall stone-free rate at discharge was 95.4% (100% for single stones). In five cases (1.6%) a repeat open procedure was needed. The mean (range, median) hospital stay was 4 (1-13, 3) days.
CONCLUSIONS: Arguments against open surgery for urolithiasis in adults should not be extrapolated to children, in whom open surgery is safe and effective. In Iran and many 'developing' countries, open surgery is less expensive, more effective, more dependable, and more easily available than minimally invasive alternatives. At least in such countries it deserves to be among the first-line therapies for paediatric urolithiasis, and urologists in less-developed countries should not decline to offer open surgery because it is almost obsolete in developed countries. Delayed presentation (through poverty and/or unawareness) contributes significantly to the morbidity of urolithiasis.