Pediatric stone disease: a urologist’s perspective

Pediatric urolithiasis is increasing in prevalence worldwide and differs from adult stone disease because of its strong associations with metabolic abnormalities, genetic disorders, congenital urinary tract anomalies, and a lifelong risk of recurrence. Urologic management extends beyond stone removal to achieve durable stone-free status while preserving the developing urinary tract and minimizing cumulative treatment burden, including radiation exposure, repeated general anesthesia, reintervention, and stent-related morbidity. Ultrasonography is the first-line imaging modality, whereas low-dose noncontrast computed tomography should be reserved for cases with equivocal ultrasonographic findings or complex stones requiring operative planning. Small, uncomplicated stones may initially be managed expectantly, with selective use of medical expulsive therapy. Shock wave lithotripsy remains a useful option for selected small renal and proximal ureteral stones. Ureteroscopy is effective for midto- distal ureteral stones, while retrograde intrarenal surgery has expanded the treatment options for renal stones, particularly in older children. Miniaturized percutaneous nephrolithotomy offers high single-session stone clearance rates for large, lower- pole, and complex stones. Routine prestenting is not supported by current evidence and should be reserved for cases in which ureteral access or drainage is problematic. Stone analysis, metabolic evaluation, and long-term ultrasound-based surveillance are essential components of postoperative care. This review summarizes surgical decision-making, procedure-specific considerations, and emerging technologies in pediatric urolithiasis from a urologist’s perspective.