British Journa of Urology ( 1979, 47, 109-1 I6
Urinary Lithiasis in Childhood in the Bristol Clinical Area c.
G.
c.
GACHES, I. R.
s.
GORDON, D. F. SHORE
and
J. B. M . ROBERTS
Bristol Royal Infirmary and Bristol Children’s Hospital, Bristol
The recent literature has contained several papers on the subject of urolithiasis in childhood. Whether these communications have arisen from London (Ghazali, Barratt and Williams, 1973), the Netherlands (Scholten, Bakker and Cornil, 1973), South Africa (Du Preez and Cremin, 1973) or India (Aurora, Taneja and Gupta, 1970) all these series have contained material derived from a considerable area. The wide variations that occur in the types of urolithiasis on a geographical. basis are now well established (Andersen, 1969). Lett, in 1936, showed that vesical calculi had virtually ceased to exist in England by about 1925 and it is still true to say that “stones in the bladder do not ingender oftener in children than in older folke” (after Barrough, 1617). We have undertaken a detailed study of our completely locally derived material in the particular hope that further light might be shed on this condition with regard to aetiological factors. The suspected rising incidence elsewhere of upper urinary tract calculi agrees with the findings of this Bristol series which is now discussed in greater detail.
445,000 100,000 16
-2 ---_>\ %.. %\yo ---------
. r /
440’ooo 98’ooo l4
:
435,000 96,000 12 430,000 94,000 10 425,000 92,000 8 -
Total population
Under 15yrs \%---
b-
0
%-ho
\o
420,000 90,000 6 4-
1;
P’\ 2;+AAr -v -.
0-
Read at the 30th Annual Meeting of the British Association of Urological Surgeons in Torquay, June 1974. 4712-A 109
110
BRITISH JOURNAL OF UROLOGY
Fig. 2. Monthly case presentation graphs.
2
I 0
0 1 2 3 4 5 6 7 8 9 1011 1 2 1 3 1 4 1 5 1 6 Age (years) Fig. 3. Series age and sex distribution.
Patients 59 children presented in the period 1950-73,.65% of whom lived within the recently outdated City and County of Bristol boundary. The annual incidence of referral is shown in Figure 1 with the corresponding and almost linear fall in the city population which occurred during this period. It is worthy of note that the presentations of these patients reached a peak during the latter half of the summer months (Fig. 2). The significance of this association is discussed later. Our peak presentation at the age of 2 to 3 years agrees with that reported by Ghazali et al. (1973), but there is in addition a second smaller rising incidence maximal at the age of 10 years (Fig. 3). 61 % of our cases were under the age of 5 years. The aetiological classification (Table I) indicates that we were able to reach a satisfactory conclusion that congenital anomalies (39 %), metabolic disorders (8.5 %) or primary infective processes (29 %) were together associated with stone formation in 76.5 % of cases. 22 % had to be consigned to the idiopathic group, with no abnormality detected despite careful searching of clinical, radiological and biochemical evidence. Bristol has a smaller
URINARY LITHIASIS IN CHILDHOOD IN THE BRISTOL CLINICAL AREA
111
Table I Aetiological Classification Cases Congenital: 1. Obstructive: Pelvi-ureteric Ureteric Bladder neck Urethral 2. Other: Horseshoe kidney Hypoplastic kidney Duplex system Ectopic ureter Spina bifida Metabolic: Cystinuria Nephrocalcinosis: hyperparathyroidism Adrenogenital syndrome Purine metabolic disorder (leukaemia) Infective (alone) Immobilisation Foreign body Stasis Endemic Idiopathic
23 10 2 2 0 2 2 2 1 2 5
2 1
1 1 17
0 0
0 1 13
59
immigrant population than many other British cities, but the recent arrival of a child in this series together with his endemic bladder calculus derived in the Kashmir, suggests that there may again be a small upsurge of these cases in the United Kingdom.
Symptoms Stone in the urinary tract is the cause of a wide range of symptoms ranging from general ill health to obvious signs of genito-urinary disease with urinary infection and haematuria (Table 11). Haematuria was the commonest symptom and as in the older person this must be the prelude to a full urological investigation. It is interesting to note that below the age of 5 years, the presence of a renal or a ureteric calculus often gives rise to a central or vague abdominal pain. It is only above this age that the ability to lateralise the symptom appears to develop. Infection of the urine was detected in 5 8 % of these children. A Proteus species alone was responsible in 25 patients with an emphasis on the particularly young. A mixed Proteus and coliform infection occurred in 3 and a coliform infection alone in 4 cases. Radiological Findings The differential diagnosis of a urinary calculus in children is usually not difficult, provided that the stone is detected either on the plain film or on excretion urography. Confusing opacities such as phleboliths, vascular calcification and gall-stones do not cause as much difficulty as in the adult. We have found oblique views to be extremely useful, particularly where the calculus overlies a bony structure and is itself not very radio-dense (Fig. 4, A and B). In the very young, even dense calculi can be completely overlooked if there are large amounts of gas and faecal
112
BRITISH JOURNAL OF UROLOGY
Table I1 Presenting Symptoms Number of Patients
Percentage of Total ~
Haematuria Abdominal pain (central or vague) Fever Vomiting Loin pain or lateralised abdominal pain Pain o n micturition Retention of urine Failure to thrive Frequency of micturition Anorexia
32 16
12
55 28 20 11 10
7 3 3 1.5 1.5
Fig, 4. The value of oblique radiographs where a calculus overlies a bony area. oblique presentation. P. K. Age 4 years.
Cystine calculus arrowed. B, Left
material in the bowel. Tomography can be of great value in the localisation of renal calculi in particular (Fig. 5 , A and B), and we would now regard such views mandatory in a similar situation. In this series, excretion urography was performed in all cases and was abnormal in 76% (Table 111). Whilst hydronephrosis and hydroureter, as might be expected, were the commonest abnormalities, the low incidence of demonstrable scarring was most surprising. Of the 17% where the presence of congenital anomalies of the urinary tract were demonstrated, these appeared in most cases to be directly related to the calculi and were previously unsuspected. Occasionally, the excretory urogram will afford useful evidence of the presence of a calculus even when this has not been revealed on the plain radiograph. Non-opaque calculi were present in 4 % of this series (Fig. 6).
URINARY LITHIASIS IN CHILDHOOD IN THE BRISTOL CLINICAL AREA
113
Fig. 5. The value of tomography in a baby to show additional unsuspected calculi. A, Left renal and urethral calculi only visualised on plain radiograph. B, Additional matrix calculus in right renal pelvis on tomogram. A. M. Age 3 months.
Table III Radiological Findings
Normal Hydronephrosis Hydronephrosis Hydroureter Hydroureter Renal scarring Congenital anomaly Delayed or diminished renal function Trabeculated bladder
+
Number of Patients
Percentage of Total
14
24 33 17 12 2 17
19
10 7 1
10 5
9
I
2
The anatomical localisation of these calculi is given in Figure 7.30% of patients had more than one calculus, but in only 10% overall was the condition bilateral. A predominance in the lower elements of the kidney is again noted where an infected urine had been isolated. In the “noninfected” upper urinary tract there were surprisingly few calculi present in the kidney or the renal pelvis.
Treatment In 17% of our children the calculus (or calculi) was passed spontaneously. In the remainder, surgical intervention was necessary (Table IV). During the operation of pyelolithotomy, which can be an extremely difficult and time consuming operation, particularly with matrix calculi, we would like to stress the value of endoscopy of the kidney. This manoeuvre has been of considerable value in 2 recent cases. The Dormia stone extractor has also a part to play in the older
114
BRITISH JOURNAL OF UROLOGY
Infected
Non-infected
Renal
Uretic
Vesical
H
Urethral 3 Fig. 6. Retrograde urography assisting in delineation of a completely non-opaque calculus. A. C. Age 3 years.
I
Bilateral calculi: 4 cases Fig. 7. Anatomical distribution of calculi.
Infected
Non-infected
Table I V
Treatment Breakdown Cases Voided spontaneously Surgical removal : Nephrectomy Partial nephrectomy Nephrolithotomy Pyelolithotomy Ureterolithotomy Dormia extraction Li tholapaxy Lithotomy Trans-urethral extraction
10
6 2 2 21 12 1 1
7 4 Fig. 8. Stone analysis results.
child. We have not so far found chemical analysis of the stone to be of great value. Analysis was completed in 60% of the stones removed (Fig. 8). We would add, however, that the presence of the ammonium radicle in the non-infected group suggests that we have failed to isolate a probable pre-existing urinary tract infection.
URINARY LITHIASIS IN CHILDHOOD IN THE BRISTOL CLINICAL AREA
115
Results We have been gratified with a low recurrence rate of 33%, excluding those patients with cystinuria (Table V). This level is similar to other recent experiences (Ghazali, Barratt and Williams, 1973). A recurrent stone problem was invariably associated with a Proteus infection. The importance of complete eradication of this organism, even in low concentration needs constant emphasis. We would hope that the existing higher standards in radiographic examination of the kidney at the time of surgery, combined with endoscopic examination of the renal pelvis, will eradicate the possibility of incomplete surgical removal.
Table V Follow-up Results. Overall Recurrence Rate 7.0 % (3.5 % Cystinuria) Unsatisfactory follow-up 8.5 %. 5.0 %. Incomplete surgical removal Years after Primary Removal Proteus
--r
Overall recurrence
Renal calculi Ureteric calculi Vesical calculi Urethral calculi
1
2
3
4
5
Total
Infection
0 0 0 0 0
1 1 0 0 0
1 0 0 0 0
0 0 0 0 0
2 2 1 0 1
4 3
2 2
I 0
0 0 0
1
Table VI Bristol Water Sources and Analyses. All Hardness Figures as Parts per Million source
Total hardness caco3 Ca hardness CaCO3 Mg hardness CaCO3 Alkalinity as CaCO3
PH Patients
Stowey
Barrow
Chelvey
Littleton
Carter Spring
Clevedon
134 95 39 77 8.2
200 164 36 169 8.0
206 174 32 28 1 7.3
213 182 31 113 8.0
356 281 75 305 7.3
121 297 7.4
16
4
14
0
0
365
244
3 1
Epidemiological Study With a series of patients which were derived locally, and which in addition belonged to a relatively fixed geographic group, we have looked into the analytical results of the 6 water sources which supply Bristol. The relevant findings are summarised in Table VI. In this area there is a threefold variation in the total hardness of the water as one moves from one part of the city to another (134 to 365 parts per million). We were surprised to find that the areas of great hardness (and which also have a significantproportion of young children) contained no examples of children’s calculous disease. The greater proportion (79%) of these patients with stone formation were living in an
116
BRITISH JOURNAL OF UROLOGY
area where the water was not only hard (200 to 213 p.p.m.) but also alkaline (PH > 8). Whilst we appreciate that our numbers are small, we consider that a wider survey would now yield valuable results and this has been initiated. We are also pursuing the water analysis data as it is our belief that there may be further substantial rises, over and above the mean values quoted, in both the calcium content and the pH values, maximal during the late spring and summer months. It has already been well demonstrated that hypercalciuria per se may not be so important as increase in urinary pH and oxalate ion concentration (Robertson and Nordin, 1968), and it is now suggested that the continuous daily intake of hard, alkaline drinking-water may possibly play a greater part in precipitating stone formation than has hitherto been recognised. Summary A series of 59 consecutive cases of urinary calculi in childhood is presented, being acquired from one local area (Bristol). These children were treated from 1950 to 1973. The peak presentation was in the 2nd and 3rd year of life, with a secondary peak in the 10th year. Anatomical (3979, metabolic (8.5 %) or primary infective abnormalities (29 %) were demonstrable, but 22 % had to be left in an unsatisfactory “idiopathic classification”. The overall recurrence rate of 7 % was reduced to 3.5 % when those patients with cystinuria were excluded. The local water supply areas have been studied and a tentative association is suggested between patients and their environment when they live in an area where the water is not only hard but also alkaline (pH > 8). We would like to thank all our Bristol urological colleagues for their co-operation in this survey; the Medical Illustration Department of Bristol Royal Infirmary for the preparation of the photographs and M r Gary James for the graphs and figures, and finally Miss A Kinghorn for preparation of the manuscript.
References ANDERSON, D. A. (1969). Historical and geographical differences in the pattern of incidence of urinary stones considered in possible relation to aetiological factors. In Proceedings ofthe Renal Stone Research Symposium, Lee&, 1968 (4A. .Hodgkinson and B. E. C. Nordin), London: Churchill, 1969 pp. 7-31. AURORA, A. L., TANUA,0. P. and GUPTA,D. N. (1970). Bladder stone disease of childhood. Acta Paediatrica Scandinavica, 59, 111-184. BARROUGH, PHILIP (1617). Methode of Physick. 5th ed. Lib. 111. Londpn: Field, p. 167. Du PREEZ,H. M.and CREMIN, B. J. (1973). Urinary calculi in childhood. A clinical and radiological study. South African Medical Journal, 41, 1025-1029. GHAZALI, S., BARRATT, T. M. and WILLIAMS, D. I. (1973). Childhood urolithiasis in Britain. Archives of Disease in Childhood, 48, 291-295. LETT, H . (1936). On urinary calculus, with special reference to stone in the bladder. British Journal of Urology, 8, 205-232.
ROBERTSON, W.G. and NORDIN,B. E. C. (1968). Activity products in urine. In Proceedings of the Renal Stone Research Symposium, Lee& (ed. A. Hodgkinson and B. E. C. Nordin), London: Churchill, 1969. pp. 221-232. SCHOLTEN, H. G., BAKKER, N. J. and CORNIL,C. (1973). Urolithiasis in childhood. Journalof Urology, 109,744-745.
The Authors C. G. C. Caches, FRCS, Senior Surgical Registrar in Urology. I. R. S. Gordon, FRCP, DMRD, Consultant Radiologist. D. F. Shore, MB,ChB, Senior House Officer. J. B. M.Roberts, FRCS, Consultant Urological Surgeon.
Urinary Lithiasis in Childhood in the Bristol Clinical Area c.
G.
c.
GACHES, I. R.
s.
GORDON, D. F. SHORE
and
J. B. M . ROBERTS
Bristol Royal Infirmary and Bristol Children’s Hospital, Bristol
The recent literature has contained several papers on the subject of urolithiasis in childhood. Whether these communications have arisen from London (Ghazali, Barratt and Williams, 1973), the Netherlands (Scholten, Bakker and Cornil, 1973), South Africa (Du Preez and Cremin, 1973) or India (Aurora, Taneja and Gupta, 1970) all these series have contained material derived from a considerable area. The wide variations that occur in the types of urolithiasis on a geographical. basis are now well established (Andersen, 1969). Lett, in 1936, showed that vesical calculi had virtually ceased to exist in England by about 1925 and it is still true to say that “stones in the bladder do not ingender oftener in children than in older folke” (after Barrough, 1617). We have undertaken a detailed study of our completely locally derived material in the particular hope that further light might be shed on this condition with regard to aetiological factors. The suspected rising incidence elsewhere of upper urinary tract calculi agrees with the findings of this Bristol series which is now discussed in greater detail.
445,000 100,000 16
-2 ---_>\ %.. %\yo ---------
. r /
440’ooo 98’ooo l4
:
435,000 96,000 12 430,000 94,000 10 425,000 92,000 8 -
Total population
Under 15yrs \%---
b-
0
%-ho
\o
420,000 90,000 6 4-
1;
P’\ 2;+AAr -v -.
0-
Read at the 30th Annual Meeting of the British Association of Urological Surgeons in Torquay, June 1974. 4712-A 109
110
BRITISH JOURNAL OF UROLOGY
Fig. 2. Monthly case presentation graphs.
2
I 0
0 1 2 3 4 5 6 7 8 9 1011 1 2 1 3 1 4 1 5 1 6 Age (years) Fig. 3. Series age and sex distribution.
Patients 59 children presented in the period 1950-73,.65% of whom lived within the recently outdated City and County of Bristol boundary. The annual incidence of referral is shown in Figure 1 with the corresponding and almost linear fall in the city population which occurred during this period. It is worthy of note that the presentations of these patients reached a peak during the latter half of the summer months (Fig. 2). The significance of this association is discussed later. Our peak presentation at the age of 2 to 3 years agrees with that reported by Ghazali et al. (1973), but there is in addition a second smaller rising incidence maximal at the age of 10 years (Fig. 3). 61 % of our cases were under the age of 5 years. The aetiological classification (Table I) indicates that we were able to reach a satisfactory conclusion that congenital anomalies (39 %), metabolic disorders (8.5 %) or primary infective processes (29 %) were together associated with stone formation in 76.5 % of cases. 22 % had to be consigned to the idiopathic group, with no abnormality detected despite careful searching of clinical, radiological and biochemical evidence. Bristol has a smaller
URINARY LITHIASIS IN CHILDHOOD IN THE BRISTOL CLINICAL AREA
111
Table I Aetiological Classification Cases Congenital: 1. Obstructive: Pelvi-ureteric Ureteric Bladder neck Urethral 2. Other: Horseshoe kidney Hypoplastic kidney Duplex system Ectopic ureter Spina bifida Metabolic: Cystinuria Nephrocalcinosis: hyperparathyroidism Adrenogenital syndrome Purine metabolic disorder (leukaemia) Infective (alone) Immobilisation Foreign body Stasis Endemic Idiopathic
23 10 2 2 0 2 2 2 1 2 5
2 1
1 1 17
0 0
0 1 13
59
immigrant population than many other British cities, but the recent arrival of a child in this series together with his endemic bladder calculus derived in the Kashmir, suggests that there may again be a small upsurge of these cases in the United Kingdom.
Symptoms Stone in the urinary tract is the cause of a wide range of symptoms ranging from general ill health to obvious signs of genito-urinary disease with urinary infection and haematuria (Table 11). Haematuria was the commonest symptom and as in the older person this must be the prelude to a full urological investigation. It is interesting to note that below the age of 5 years, the presence of a renal or a ureteric calculus often gives rise to a central or vague abdominal pain. It is only above this age that the ability to lateralise the symptom appears to develop. Infection of the urine was detected in 5 8 % of these children. A Proteus species alone was responsible in 25 patients with an emphasis on the particularly young. A mixed Proteus and coliform infection occurred in 3 and a coliform infection alone in 4 cases. Radiological Findings The differential diagnosis of a urinary calculus in children is usually not difficult, provided that the stone is detected either on the plain film or on excretion urography. Confusing opacities such as phleboliths, vascular calcification and gall-stones do not cause as much difficulty as in the adult. We have found oblique views to be extremely useful, particularly where the calculus overlies a bony structure and is itself not very radio-dense (Fig. 4, A and B). In the very young, even dense calculi can be completely overlooked if there are large amounts of gas and faecal
112
BRITISH JOURNAL OF UROLOGY
Table I1 Presenting Symptoms Number of Patients
Percentage of Total ~
Haematuria Abdominal pain (central or vague) Fever Vomiting Loin pain or lateralised abdominal pain Pain o n micturition Retention of urine Failure to thrive Frequency of micturition Anorexia
32 16
12
55 28 20 11 10
7 3 3 1.5 1.5
Fig, 4. The value of oblique radiographs where a calculus overlies a bony area. oblique presentation. P. K. Age 4 years.
Cystine calculus arrowed. B, Left
material in the bowel. Tomography can be of great value in the localisation of renal calculi in particular (Fig. 5 , A and B), and we would now regard such views mandatory in a similar situation. In this series, excretion urography was performed in all cases and was abnormal in 76% (Table 111). Whilst hydronephrosis and hydroureter, as might be expected, were the commonest abnormalities, the low incidence of demonstrable scarring was most surprising. Of the 17% where the presence of congenital anomalies of the urinary tract were demonstrated, these appeared in most cases to be directly related to the calculi and were previously unsuspected. Occasionally, the excretory urogram will afford useful evidence of the presence of a calculus even when this has not been revealed on the plain radiograph. Non-opaque calculi were present in 4 % of this series (Fig. 6).
URINARY LITHIASIS IN CHILDHOOD IN THE BRISTOL CLINICAL AREA
113
Fig. 5. The value of tomography in a baby to show additional unsuspected calculi. A, Left renal and urethral calculi only visualised on plain radiograph. B, Additional matrix calculus in right renal pelvis on tomogram. A. M. Age 3 months.
Table III Radiological Findings
Normal Hydronephrosis Hydronephrosis Hydroureter Hydroureter Renal scarring Congenital anomaly Delayed or diminished renal function Trabeculated bladder
+
Number of Patients
Percentage of Total
14
24 33 17 12 2 17
19
10 7 1
10 5
9
I
2
The anatomical localisation of these calculi is given in Figure 7.30% of patients had more than one calculus, but in only 10% overall was the condition bilateral. A predominance in the lower elements of the kidney is again noted where an infected urine had been isolated. In the “noninfected” upper urinary tract there were surprisingly few calculi present in the kidney or the renal pelvis.
Treatment In 17% of our children the calculus (or calculi) was passed spontaneously. In the remainder, surgical intervention was necessary (Table IV). During the operation of pyelolithotomy, which can be an extremely difficult and time consuming operation, particularly with matrix calculi, we would like to stress the value of endoscopy of the kidney. This manoeuvre has been of considerable value in 2 recent cases. The Dormia stone extractor has also a part to play in the older
114
BRITISH JOURNAL OF UROLOGY
Infected
Non-infected
Renal
Uretic
Vesical
H
Urethral 3 Fig. 6. Retrograde urography assisting in delineation of a completely non-opaque calculus. A. C. Age 3 years.
I
Bilateral calculi: 4 cases Fig. 7. Anatomical distribution of calculi.
Infected
Non-infected
Table I V
Treatment Breakdown Cases Voided spontaneously Surgical removal : Nephrectomy Partial nephrectomy Nephrolithotomy Pyelolithotomy Ureterolithotomy Dormia extraction Li tholapaxy Lithotomy Trans-urethral extraction
10
6 2 2 21 12 1 1
7 4 Fig. 8. Stone analysis results.
child. We have not so far found chemical analysis of the stone to be of great value. Analysis was completed in 60% of the stones removed (Fig. 8). We would add, however, that the presence of the ammonium radicle in the non-infected group suggests that we have failed to isolate a probable pre-existing urinary tract infection.
URINARY LITHIASIS IN CHILDHOOD IN THE BRISTOL CLINICAL AREA
115
Results We have been gratified with a low recurrence rate of 33%, excluding those patients with cystinuria (Table V). This level is similar to other recent experiences (Ghazali, Barratt and Williams, 1973). A recurrent stone problem was invariably associated with a Proteus infection. The importance of complete eradication of this organism, even in low concentration needs constant emphasis. We would hope that the existing higher standards in radiographic examination of the kidney at the time of surgery, combined with endoscopic examination of the renal pelvis, will eradicate the possibility of incomplete surgical removal.
Table V Follow-up Results. Overall Recurrence Rate 7.0 % (3.5 % Cystinuria) Unsatisfactory follow-up 8.5 %. 5.0 %. Incomplete surgical removal Years after Primary Removal Proteus
--r
Overall recurrence
Renal calculi Ureteric calculi Vesical calculi Urethral calculi
1
2
3
4
5
Total
Infection
0 0 0 0 0
1 1 0 0 0
1 0 0 0 0
0 0 0 0 0
2 2 1 0 1
4 3
2 2
I 0
0 0 0
1
Table VI Bristol Water Sources and Analyses. All Hardness Figures as Parts per Million source
Total hardness caco3 Ca hardness CaCO3 Mg hardness CaCO3 Alkalinity as CaCO3
PH Patients
Stowey
Barrow
Chelvey
Littleton
Carter Spring
Clevedon
134 95 39 77 8.2
200 164 36 169 8.0
206 174 32 28 1 7.3
213 182 31 113 8.0
356 281 75 305 7.3
121 297 7.4
16
4
14
0
0
365
244
3 1
Epidemiological Study With a series of patients which were derived locally, and which in addition belonged to a relatively fixed geographic group, we have looked into the analytical results of the 6 water sources which supply Bristol. The relevant findings are summarised in Table VI. In this area there is a threefold variation in the total hardness of the water as one moves from one part of the city to another (134 to 365 parts per million). We were surprised to find that the areas of great hardness (and which also have a significantproportion of young children) contained no examples of children’s calculous disease. The greater proportion (79%) of these patients with stone formation were living in an
116
BRITISH JOURNAL OF UROLOGY
area where the water was not only hard (200 to 213 p.p.m.) but also alkaline (PH > 8). Whilst we appreciate that our numbers are small, we consider that a wider survey would now yield valuable results and this has been initiated. We are also pursuing the water analysis data as it is our belief that there may be further substantial rises, over and above the mean values quoted, in both the calcium content and the pH values, maximal during the late spring and summer months. It has already been well demonstrated that hypercalciuria per se may not be so important as increase in urinary pH and oxalate ion concentration (Robertson and Nordin, 1968), and it is now suggested that the continuous daily intake of hard, alkaline drinking-water may possibly play a greater part in precipitating stone formation than has hitherto been recognised. Summary A series of 59 consecutive cases of urinary calculi in childhood is presented, being acquired from one local area (Bristol). These children were treated from 1950 to 1973. The peak presentation was in the 2nd and 3rd year of life, with a secondary peak in the 10th year. Anatomical (3979, metabolic (8.5 %) or primary infective abnormalities (29 %) were demonstrable, but 22 % had to be left in an unsatisfactory “idiopathic classification”. The overall recurrence rate of 7 % was reduced to 3.5 % when those patients with cystinuria were excluded. The local water supply areas have been studied and a tentative association is suggested between patients and their environment when they live in an area where the water is not only hard but also alkaline (pH > 8). We would like to thank all our Bristol urological colleagues for their co-operation in this survey; the Medical Illustration Department of Bristol Royal Infirmary for the preparation of the photographs and M r Gary James for the graphs and figures, and finally Miss A Kinghorn for preparation of the manuscript.
References ANDERSON, D. A. (1969). Historical and geographical differences in the pattern of incidence of urinary stones considered in possible relation to aetiological factors. In Proceedings ofthe Renal Stone Research Symposium, Lee&, 1968 (4A. .Hodgkinson and B. E. C. Nordin), London: Churchill, 1969 pp. 7-31. AURORA, A. L., TANUA,0. P. and GUPTA,D. N. (1970). Bladder stone disease of childhood. Acta Paediatrica Scandinavica, 59, 111-184. BARROUGH, PHILIP (1617). Methode of Physick. 5th ed. Lib. 111. Londpn: Field, p. 167. Du PREEZ,H. M.and CREMIN, B. J. (1973). Urinary calculi in childhood. A clinical and radiological study. South African Medical Journal, 41, 1025-1029. GHAZALI, S., BARRATT, T. M. and WILLIAMS, D. I. (1973). Childhood urolithiasis in Britain. Archives of Disease in Childhood, 48, 291-295. LETT, H . (1936). On urinary calculus, with special reference to stone in the bladder. British Journal of Urology, 8, 205-232.
ROBERTSON, W.G. and NORDIN,B. E. C. (1968). Activity products in urine. In Proceedings of the Renal Stone Research Symposium, Lee& (ed. A. Hodgkinson and B. E. C. Nordin), London: Churchill, 1969. pp. 221-232. SCHOLTEN, H. G., BAKKER, N. J. and CORNIL,C. (1973). Urolithiasis in childhood. Journalof Urology, 109,744-745.
The Authors C. G. C. Caches, FRCS, Senior Surgical Registrar in Urology. I. R. S. Gordon, FRCP, DMRD, Consultant Radiologist. D. F. Shore, MB,ChB, Senior House Officer. J. B. M.Roberts, FRCS, Consultant Urological Surgeon.
