From the 10-20 mm gray zone to a 15 mm stone size cutoff for pediatric urolithiasis management: do guidelines need revisiting? . A systematic review and meta-analysis by the EAU Section of Endourology.

Authors

Selcuk Guven, Mehmet G Sonmez, Atinc Tozsin, Gernot Ortner, Burak Akgul, Nurmanbet Turaliev, Omer F Cavdar, Panagiotis Kallidonis, Theodoros Tokas, Thomas Knoll, Selcuk Silay, Muhammad I Omar, Yuhong Yuan, Kamran Ahmed, Bhaskar Somani

Published in

Minerva urology and nephrology. Jun 29, 2026. Epub Jun 29, 2026.

Abstract

Pediatric urolithiasis guidelines recommend ESWL, RIRS, or PCNL for stones within the 10-20 mm range but this broad interval often complicates treatment selection. This systematic review aimed to define a clearer, evidence-based stone size cutoff to improve clinical decision-making.
A systematic review and meta-analysis were performed (PROSPERO CRD420251012163) according to PRISMA 2020 guidelines. Pediatric studies published from 2014 to 2025 were searched across major databases. Eligible studies reported stone size and at least one outcome, including stone-free rate, residual fragments, retreatment, or complications. Studies without quantitative data were excluded. Early and long-term complications as well as instrumentation were analyzed. Pooled estimates were calculated using random-effects models. Risk of bias was assessed using the Newcastle-Ottawa Scale.
Seventy-six study arms (N.=5294) reported stone size data. The pooled mean was 16.03 mm (95% CI 14.60-17.47; I²=99.9%). Stones treated with ESWL averaged 12.29 mm, RIRS 12.49 mm And PCNL 20.16 mm, indicating PCNL was used for larger stones (P<0.001). In 113 studies reporting SFR, pooled rates were 0.801 for ESWL, 0.826 for RIRS And 0.893 for PCNL, with PCNL showing higher SFRs. Considerable heterogeneity was observed And differences in complication profiles and instrumentation were identified as important factors influencing treatment outcomes beyond stone-free rates alone.
A 15-mm stone size threshold appears clinically meaningful and provides clearer guidance than the traditional 10-20 mm range in children. ESWL and RIRS are appropriate options for stones <15 mm, whereas PCNL is more suitable for larger stones. Beyond stone-free rates, complication profiles and instrumentation should be considered when selecting treatment. Study heterogeneity and potential publication bias remain important limitations.

PMID:
42371402
Bibliographic data and abstract were imported from PubMed on 29 Jun 2026.

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