2 year child - 10mm PUJ stone -treatment options

Male child of 2 years with pain and occasional vomiting. 

No UTI. 
Attaching USG and single plate IVU with plain X ray KUB for review... 
Relavent questions :
How you would have investigated :
Limited plate IVP,  PLAIN CT,  CT IVP?  Why 
Or nothing more than well documented USG? 
treatment options :
And why? 

2 year child - 10mm PUJ stone -treatment options 2 year child - 10mm PUJ stone -treatment options 2 year child - 10mm PUJ stone -treatment options 2 year child - 10mm PUJ stone -treatment options View DocumentView Document


  • Ashish parikh
    Ashish parikh
    10 Mar 2020 03:56:05 PM

    Dear sir, 

    Here is answer of ur question, if i  wrong, pl correct me.
    My teacher told me during urology residency, that, before planning for surgical intervention in endourology, - functional study is  must.- rule of thumb.
    i prefer CT IVP as no need for bowel preparation, well taken in paediatric age group. and even if there is non functional renal unit, we delineate the renal anatomy very well. also very well know about the lower ureter and its configurance and relevant pathology.
    In Endourology by CT, we can know the HU value of stone, skin to stone distance, infundibulopelvic angle, if considered for outcome of ESWL.
    all the option of management given are justifiable, personally i prefer ESWL for this pt under GA.
    Thank you sir.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    10 Mar 2020 04:15:12 PM

    Thanks  Dr.  Ashish Parikh. 

    Why not limited plate ( single plate)  IVU in this set up where kidney is otherwise alright on USG. 
    Except HU it will give almost all details at very low dose of radiation? 

  • Gyanendra Sharma
    Gyanendra Sharma
    10 Mar 2020 05:10:23 PM

    I agree with Dr. Ashish that a functional study is a must in such cases

    But I would not do a CT IVU as 
    1. The dose of radiation is high
    2. Cost is high
    3. Often Radiologist will insist on a GA for a 2 year old child
    I prefer doing a limited plate IVU--at times more than 1 film  sothat I get the information I am looking at
    As regards management--I would go ESWL as the size is 10mm  and very often under anesthesia ESWL gives good results ( as the respiratory movements are under control and number shocks hitting the calculus are high)

  • Rahul Kapoor
    Rahul Kapoor
    10 Mar 2020 11:06:12 PM


    I agree limited Plate IVP is enough. 
    Will surely discuss options... 

    ESWL or Mini PERC
    Both have pros and cons and need to be told to assess parents expectation 

  • Utsav Shah
    Utsav Shah
    11 Mar 2020 11:16:38 AM

    A mini perc would be the best option for complete clearance. 

    ESWL in a 2 year old child will also require anesthesia. 
    Better to use that anaesthesia to achieve complete clearance. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    11 Mar 2020 11:21:59 AM


    Utsav, can you please post some literature discussions on clearance rate of ESWL in similar cases? Against overall safety and complications? This is just for benefit of all members.

  • Utsav Shah
    Utsav Shah
    11 Mar 2020 11:32:48 AM

    A recent article in BMC Urology by Quing et al where they have performed a review of best treatment option for pediatric upper urinary tract stones has suggested that ‘PCNL exhibits a higher SFR and EQ than SWL; nevertheless, it has a longer operative time and fluoroscopy time than the other two procedures. RIRS offers a similar SFR as PCNL but a lower efficiency than PCNL.’

  • Dr. Md. Mazedur Rahman
    Dr. Md. Mazedur Rahman
    12 Mar 2020 10:13:36 PM

    Single shot IVU at 10 minutes will be more beneficial for this boy. After Acute symptomatic management ESWL is choice of stone management in addition with metabolic evaluation is mandatory.

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    23 Mar 2020 10:29:04 AM

    Dr Rahman sir,what metabolic evaluation u will do?basic or specific metabolic evaluation?what is ur algorithm for metabolic evaluation?

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    27 Mar 2020 08:13:11 AM

    In this child with a 9mm, minimally obstructing PUJ calculus, my treatment would be ESWL.

    I do not think CT Urography is a good functional test. CT can delineate opacification even in patients with very poor function. CT is more a anatomical test than a functional test. No investigation better to give me all the anatomical information that i need to plan my treatment. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    27 Mar 2020 10:17:33 AM

    "I do not think CT Urography is a good functional test. CT can delineate opacification even in patients with very poor function."

    Dr. Pankaj Maheshwari
    Very important statement, those who are not agree please post your expert comments or else stop commenting on function when you see excretion of contrast and also commit to use CT judiciously at least in paediatric population.
    Thanks Sir

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    28 Mar 2020 12:42:34 PM


    I am happy you picked up this statement and raised a question on this. Let me explain what i mean by this. 
    In IVU, if there is opacification of the PCS, we presume that the function of that renal unit is more than 30%. We can not say similar about CT. CT can pick up enhancement and opacification at much poorer renal function. So visual appearance of opacification may not mean good function. 
    It is possible to calculate precise GFR by CT scan (Comparable to nuclear scan) but it will need specific calculations that are not routinely done. 
    I have attached a recent article that shows how the function can be calculated on a contrast CT.  

    View Document

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    28 Mar 2020 12:43:42 PM

    one more article attached

    View Document

  • Lotfy Bendary
    Lotfy Bendary
    28 Mar 2020 05:23:06 PM

    KUB and U/S is enough for this case provided that the renal parenchyma is normal on ultrasound and normal Sr.Cr.

    I think ESWL is the right choice because the stone is located in the renal pelvis. 

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