Percutaneous Nephrolithotomy vs Ureteroscopy for Kidney Stones in Children

Abstract

Importance: Based on expert opinion, clinical guidelines recommend percutaneous nephrolithotomy or shockwave lithotripsy for children and adolescents with kidney stones 20 mm or larger, without mention of ureteroscopy as an alternative.

Objective: To compare clinical and patient-reported outcomes for percutaneous nephrolithotomy vs ureteroscopy in children and adolescents with kidney and/or ureteral stones.

Design, setting, and participants: This prospective cohort study was performed at 31 medical centers in the US and Canada. Participants included patients aged 8 to 21 years undergoing surgery for kidney and/or ureteral stones between March 16, 2020, and July 31, 2023.

Exposures: Percutaneous nephrolithotomy vs ureteroscopy.

Main outcomes and measures: Stone clearance assessed by ultrasonography 6 (±2) weeks postoperatively. Secondary outcomes included patient-reported outcomes 1 week after surgery.

Results: The study enrolled 1039 eligible patients (median age, 15.6 [IQR, 12.5-17.3] years; 629 female [60.5%]; 40 Black [3.8%]; 128 Hispanic [12.3%]; and 792 White [76.2%]). One hundred twenty-six urologists performed percutaneous nephrolithotomy for 98 kidneys and/or ureters and ureteroscopy for 1069, including 36 undergoing percutaneous nephrolithotomy and 43 undergoing ureteroscopy for stones larger than 15 mm. Stone clearance was 67.2% (95% CI, 46.0%-88.4%) for percutaneous nephrolithotomy and 73.4% (95% CI, 69.4%-77.4%) for ureteroscopy, a difference that was not statistically significant (risk difference, -6.2%; 95% CI, -27.7% to 15.4%). For stones larger than 15 mm, stone clearance was 94.0% (95% CI, 83.3%-100%) for percutaneous nephrolithotomy and 55.0% (95% CI, 32.9%-77.1%) for ureteroscopy, a statistically significant difference (risk difference, 39.0%; 95% CI, 14.4%-63.5%). Compared with ureteroscopy, percutaneous nephrolithotomy had significantly lower pain intensity (T score difference, -5.42; 95% CI, -10.38 to -0.46), pain interference (T score difference, -5.88; 95% CI, -11.02 to -0.75), anxiety (T score difference, -5.74; 95% CI, -9.26 to -2.22), psychological stress experiences (T score difference, -7.90; 95% CI, -13.13 to -2.67), sleep disturbance (T score difference, -5.57; 95% CI, -8.56 to -2.58), and urinary symptoms (symptom score difference, -6.37; 95% CI, -11.71 to -1.03) 1 week after surgery.

Conclusions and relevance: Compared with ureteroscopy, percutaneous nephrolithotomy had similar stone clearance and better lived experiences for children and adolescents and was associated with greater stone clearance of kidney stones larger than 15 mm. A future adequately powered prospective clinical trial is needed to reaffirm these results.

Figure.. Study Flowchart

The total enrolled 1228 patients include those with shockwave lithotripsy, a procedure that was not included in the reported current analysis. PRO indicates patient-reported outcome. ^aParticipants who withdrew but allowed data collection remained in the analysis cohort. ^bParticipants did not receive ureteroscopy, shockwave lithotripsy, or percutaneous nephrolithotomy. ^cTreatment group allocation and PRO evaluation are at the patient level. ^dStone clearance was evaluated at the kidney level. ^eUltrasonographic studies reported either “no stone present” or “had measured stone size.”