Editorial Comment for Hatipoglu et al.

D etermining the appropriate surgical treatment for nephrolithiasis in the pediatric patient population can be problematic, because the condition is infrequently encountered even at high-volume stone centers and standard treatment protocols are lacking. Care must be taken to weigh the risks and benefits of each treatment modality, including success rate, potential complications, radiation and anesthesia exposure, and surgeon experience. Furthermore, the surgical treatment should be tailored to each patient and stone situation. Because of the low prevalence of childhood nephrolithiasis, few comparative treatment studies exist in the literature to guide the urologist through the therapeutic decision-making process.

Hatipoglu and colleagues present their study comparing treatment outcomes of microperc and shockwave lithotripsy (SWL) for nephrolithiasis in 145 pediatric patients. Microperc is an exciting new technology that allows for visual directed laser stone fragmentation without tract dilation. Because the stones are not actually extracted through the tract, the patient must still pass stone fragments down the ureter much like SWL; however, the irrigation at the time of stone fragmentation facilitates early passage of debris. The current study is unmatched, with the microperc group having older children (mean 8.4 vs 5.9 years) and larger stones (mean 14.78 mm vs 11.32 mm) compared with the SWL group.

Despite the study limitation, valuable information on risks and treatment outcomes was obtained. First, there was no difference in overall stone-free rates (89% vs 88%) or complications rates (21% vs 16%) between the two treatments, despite microperc being more invasive and having an 8% case conversion rate to mini-percutaneous nephrolithotomy for bleeding. These findings are a testament to the safety of the appropriately performed microperc and perc techniques, but perhaps just as important, the results highlight the excellent stone-free outcomes that can be obtained with minimally invasive SWL in the pediatric population. It must be pointed out, however, that some children in the SWL group did require a second and even a third procedure to achieve the high stone-free rate, which ultimately increased their anesthetic exposure time.

Second, the mean hospitalization time for the microperc was 2 days compared with 8 hours in the SWL group. In the current era of cost containment, the ability to perform a procedure as an outpatient must seriously be taken into consideration. Furthermore, in the pediatric population the amount of stress to the patient and family is potentially limited when they are able to return to their home environment after treatment.

Third, the total radiation exposure for the microperc was substantially greater than for SWL. Every attempt should be made to limit radiation exposure for all patients, adult and pediatric alike. However, if a treatment option provides a clear benefit in terms of stone-free outcomes or decreased morbidity, then it is reasonable to accept the higher radiation exposure. In the same regard, when outcomes are similar, then the treating physician should seriously consider choosing the surgical treatment option that decreases radiation exposure to the patient.

Taken in total, the current study demonstrates that microperc is an excellent new technology that is safe and highly effective. It should have a place in the surgeon's treatment armamentarium for pediatric nephrolithiasis along with SWL and ureteroscopy. Until prospective randomized studies demonstrate a clear treatment benefit, however, microperc should not be considered a replacement for less invasive treatment modalities, but rather be used in the appropriately selected patient.