Treatment update on pediatric urolithiasis.

At the doorstep of the twenty-first century the role of extracorporeal shock-wave lithotripsy (ESWL) as the treatment of choice for more than 80% of all stones in children is established. ESWL is safe and effective, with very few differences in success rates being observed among different lithotriptors. The present problem with ESWL appears to be the residual stone fragment, which has a proven clinical significance. A thorough metabolic evaluation and metaphylaxis is indicated in all children, and this will enable physicians to deal with the residual fragments in a more cause-specific manner and prevent regrowth. Another subject that needs prospective randomized studies to be unveiled is the assumption that a specific or universal metaphylaxis, possibly with alkaline citrates, will enhance stone clearance, lower the incidence of residual stone fragments, and optimize the ESWL results. Finally, both percutaneous nephrolithotomy and ureteroscopic stone removal have been established in children as safe and effective treatment options. This gives the clinician the opportunity to choose from a wide range of treatment alternatives, including open surgery, and only this approach will ensure 100% stone removal in individual patients along with the prevention of recurrence and, thus, the elimination of long-term morbidities in this vulnerable patient population.