Experimental as well as clinical findings reported in the literature suggest that treatment with shock wave lithotripsy (SWL) causes renal parenchymal damage mainly by generating free radicals through ischaemia /reperfusion injury mechanism. Although SWL-induced renal damage is well tolerated in the majority of healthy cases with no permanent functional and/or morphologic side effects, a subset of patients with certain risk factors requires close attention on this aspect among which the ones with pre-existing renal disorders, urinary tract infection, previous lithotripsy history and solitary kidneys could be mentioned. It is clear t . . .hat in such patients lowering the number of shock waves (per session) could be beneficial and has been applied by the physicians as the first practical step of diminishing SWL induced parenchymal damage. On the other hand, taking the injurious effects of high energy shock wave (HESW) induced free radical formation on renal parenchyma and subsequent histopathologic alterations into account, physicians searched for some protective agents in an attempt to prevent or at least to limit the extent of the functional as well as the morphologic alterations. Among these agents calcium channel blocking agents (verapamil and nifedipine), antioxidant agents (allopurinol, vitamin E and selenium) and potassium citrate have been used to minimize these unestimated adverse effects. Additionally, therapeutic application of these agents on reducing stone recurrence particularly after SWL will gain more importance in the future in order to limit new stone formation in these cases. Lastly, as experimental and clinical studies have demonstrated, combination of anti-oxidants with free radical scavengers may provide superior renal protection against shock wave induced trauma. However, we believe that further investigations are certainly needed to determine the dose-response relationship between the damaging effects of SWL application and the protective role of these agents
Despite its relatively uncommon incidence, management of the urinary stones in children poses a specific technical challenge to the urologist. Aims of the management should be complete clearance of stones, preservation of renal function and prevention of stone recurrence. In pediatric patients with urinary stones metabolic conditions have been demonstrated in up to 50 % of cases whereas a variety of anatomic anomalies have been found in about 30 % of children with urolithiasis. For this reason in addition to stone removal procedures, treatment of pediatric urolithiasis requires a thorough metabolic and urological evaluation on an in . . .dividual basis. Obstructive pathologies along with the established metabolic abnormalities should be treated on time. Urine volume should be increased encouraging adequate fluid intake evenly distributed to the whole day and medical therapeutic agents which increase urine citrate levels may be considered in the medical management of hypocitraturia. In order to select the most appropriate surgical treatment, location, composition, and size of the stone(s), the anatomy of the collecting system, and the presence of obstruction along with the presence of infection of the urinary tract should be considered. Improvements in technology and growing experience have resulted in greater acceptance of minimally invasive techniques for the management of pediatric stones and currently urologists can benefit from the whole spectrum of stone management alternatives also in children. SWL is the first choice tteatment for upper tract calculi while other minimally invasive methods have more specific indications. Although SWL is safe and efficient in the treatment of both renal and ureteral stones, ureteroscopy and PCNL in expert hands, can be successfully applied in appropriate cases. In fact gue to the technically demanding nature of these procedures prior experience in the adult population is mandatory. With judicious application of these treatment modalities, excellent stone free rates with minimal morbidity could be obtained in this specific patient population. In patients with anatomical abnormalities open surgery will continue to be the preferred treatment alternative
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