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Kidney stones in children are endemic in developing countries. Recurrences may be frequent, and patients will usually require surgical intervention more than once in their lifetime. The majority of kidney stones in children can be managed using less invasive techniques. Proper treatment planning and the use of appropriate instrumentation are critical for optimal outcomes. Surgeons who perform percutaneous surgery in pediatric patients are more experienced in developing countries because of the large number of cases found there.

The prevalence of obesity has significantly increased over recent decades in the United States and other developed western countries. With the rates of obesity and rates of nephrolithiasis rising in parallel, there is a suggestion that the two processes share a common pathophysiology. Obesity presents numerous challenges to the clinician. bese stone formers have been shown to have high stone recurrence rates after treatment compared to nonobese patients with nephrolithiasis. Surgical management of nephrolithiasis in obese individuals may be more laborious, may require additional procedures to achieve similar results, and may pose a higher risk of procedural morbidity to the patient. Herein, we present clinical scenarios of how an obese patient can complicate PCNL and suggest various techniques to overcome these challenges.

Percutaneous nephrolithotomy (PCNL) was introduced in the 1970s as a minimally invasive procedure in the treatment of renal stones, with further development in its technique in the ensuing years. Indications for PCNL have diminished with the appearance of extracorporeal shock wave lithotripsy (ESWL) in the early years of 1980s, but then they gradually increased. Currently, the role of PCNL is mainly in the treatment of large, multiple, complex, and lower calyceal stones. The efficacy of PCNL has increased with the improvement and introduction of new instruments such as the flexible nephroscope, the ureteroscope, and intracorporeal lithotripsy technology (ultrasound, pneumatic, and laser devices).

Advances in minimally invasive technology have resulted in the development of endoscopic management modalities for ureteropelvic junction obstruction. In selected cases, endopyelotomy has been shown to have a decreased cost, length of hospitalization, and postoperative pain compared to open and laparoscopic pyeloplasty. However, the procedure is demanding and requires careful patient selection to achieve excellent outcomes. From a technical standpoint, there are several minor variations in surgical technique and postoperative management that will be discussed in this chapter.

Tubeless percutaneous nephrolithotomy (PCNL) is a viable option and is actually preferred over the standard technique of nephrostomy tube placement by many surgeons. This chapter suggests modifications in the technique that allow tubeless PCNL to be performed safely.

Patients with nephrolithiasis can develop ureteral stricture or sustain ureteral injury during attempts at stone removal. While some of these can be addressed with an endourologic approach, certain patients will need to undergo a major ureteral reconstructive procedure such as ileal ureter and other bowel substitution of the ureter, Boari flap, or autotransplantation. An extremely small number of patients may benefit from ileal ureter substitution to facilitate stone passage. The indications, techniques, and results of these various operations are reviewed in this chapter.

Urinary calculus in childhood is not common. The incidence in Great Britain is two cases per million per year, and it occurs more frequently in boys than girls (1.5:1). Nearly 62% of the stones are located in the kidney, and spontaneous passage is less frequent than recorded in adult series (35%–50%).

The technique of percutaneous nephrolithotomy (PCNL) has been developed over the past 5 years and is now established as a standard method of removing stones from the kidney (Reddy et al. 1985; Segura et al. 1985; Whitfield 1983a). Firstly0, a transparenchymal track must be established between the collecting system of the kidney and the skin. Secondly, the stone must be removed. These two steps may be performed under the same general or epidural anaesthetic as a one–stage procedure; alternatively, the track may be established under local anaesthesia and kept patent for 48–72 h by a nephrostomy tube before the stone is removed.