Experience on semirigid ureteroscopy and pneumatic lithotripsy in children at a single center

Miniature semi-rigid ureteroscopy with holmium-yttrium-aluminium-garnet laser vs shockwave lithotripsy in the management of upper urinary tract stones >1 cm in children

Objective

To compare the efficacy and safety of miniature semi-rigid ureteroscopy (URS) with holmium (Ho)-yttrium-aluminium-garnet (YAG) laser lithotripsy vs shockwave lithotripsy (SWL) for treating upper urinary tract (UUT) calculi >1 cm in children.

Patients and methods

Children with unilateral single UUT ureteric stones of >1 cm were prospectively enrolled in this study. Patients were randomly divided into two groups: Group 1, treated with SWL; and Group 2, treated with URS (6/7.5 F) and laser lithotripsy. The patients’ characteristics, stones demographics, operative time, adjunctive procedures, stone-free rate (SFR), re-treatment rate, and complications were statistically analysed and compared. Success was defined as stone-free status (no stone residual of ≥0.3 cm) at 1 month from the initial treatment without any auxiliary procedures.

Results

In all, 68 patients with UUT stones met our inclusion criteria. There were no significant differences between the two groups for patient or stone demographics. In Group 1, the SFR was 26/34 (76.4%) and in Group 2 it was 33/34 (97.1%) (P = 0.03). A total of 12 auxiliary procedures in Group 1 and two in Group 2 were needed to reach a 100% SFR (P = 0.014). There were no significant differences between the two groups for operative times, adjunctive procedures, number of complicated cases or complications of Grade ≥III (P = 0.65, P = 0.23, P = 0.77, and P = 0.62, respectively).

Conclusion

Miniature semi-rigid URS with Ho-YAG laser lithotripsy for UUT ureteric stones of >1 cm in children was more effective than SWL in terms of SFR and re-treatment rate, with no significant difference in the rate or grade of complications.

Abbreviations

EQ: efficiency quotient; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; RCT: randomised controlled trial; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy; US: ultrasonography/ultrasound; URS: ureteroscopy; UUT: upper urinary tract; YAG: yttrium-aluminium-garnet

Ureteroscopic lithotripsy for ureteral stones in children using holmium: yag laser energy: results of a multicentric survey

BACKGROUND

Holmium:YAG (Ho:YAG) laser lithotripsy has broadened the indications for ureteroscopic stone managements in adults, but few evidence are currently available in the pediatric population.

OBJECTIVE

This article aimed to assess the outcome of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral stones in different locations in children.

STUDY DESIGN

The medical records of 149 patients (71 boys and 78 girls; median age 9.2 years) treated with Ho:YAG laser ureteroscopic lithotripsy in five international pediatric urology units over the last 5 years were retrospectively reviewed. Exclusion criteria included patients with renal calculi and/or with a history of ipsilateral stricture, renal failure, active urinary tract infection, or coagulation disorder.

RESULTS

Stones were treated with dusting technique in all cases. The median stone size was 10.3 mm (range 5-17). Stones were located in the distal ureter in 77 cases (51.7%), in the middle ureter in 23 cases (15.4%), and in the proximal ureter in 49 cases (32.9%). The median operative time was 29.8 min (range 20-95). Intra-operative complications included five bleedings (3.3%) and seven stone retropulsions (4.7%). Overall stone-free rate was 97.3%. Overall postoperative complications rate was 4.0% and included two cases of stent migration (1.3%) (Clavien II) and four residual stone fragments (2.7%) that were successfully treated using the same technique (Clavien IIIb). On multivariate analysis, re-operation rate was significantly dependent on the proximal stone location and presence of residual fragments >2 mm (P = 0.001).

DISCUSSION

This study is one of the largest pediatric series among those published until now. The study series reported a shorter operative time, a higher success rate, and a lower postoperative complications rate compared with previous series. A limitation of this study is that stone-free rates may be somewhat inaccurate using ultrasonography and plain X-ray compared with computed tomography (CT); the study's 97.3% success rate may be overestimated because no CT scan was done postoperatively to check the stone-free rate. Other limitations of this article include its retrospective nature, the multi-institutional participation, and the heterogeneous patient collective.

CONCLUSION

The Ho:YAG laser ureteroscopic lithotripsy seems to be an excellent first-line treatment for children with ureteral stones, independently from primary location and size. However, patients with proximal ureteral stones and residual fragments >2 mm reported a higher risk to require a secondary procedure to become stone-free. Combination of techniques as well as appropriate endourologic tools are key points for the success of the procedure regardless of stones' size and location.

Ureteroscopy for Stone Disease in Paediatric Population is Safe and Effective in Medium-Volume and High-Volume Centres: Evidence from a Systematic Review

Purpose of Review

The incidence of urinary stone disease among the paediatric population is increasing. Whilst there has been a rise in the number of original studies published on ureteroscopy (URS) in children, critical review still remains under-reported.

Recent Findings

A Cochrane style systematic review was performed to identify all original articles on URS (minimum of 25 cases) for stone disease in paediatric patients between Jan. 1996 and Dec. 2016. Based on the number of reported cases, centres were divided into medium (25–49 cases) and high (≥ 50 cases) volume studies.

Thirty-four studies (2758 children) satisfied our search criteria and were included in this review. The mean stone size was 8.6 mm with an overall stone-free rate (SFR) of 90.4% (range 58–100). Medium-volume centres reported a mean SFR of 94.1% (range 87.5–100), whilst high-volume centres reported a mean SFR of 88.1% (range 58–98.5). Mean number of sessions to achieve stone-free status in medium-volume and high-volume groups was 1.1 and 1.2 procedures/patient respectively. The overall complication rate was 11.1% (327/2994). Breakdown by Clavien grade was as follows: Clavien I 69% and Clavien II/III 31%. There were no Clavien IV/V complications, and no mortality was recorded across any of the studies. The overall failure to access rate was 2.5% (76/2944).

Medium-volume and high-volume studies had overall complication rates of 6.9% (37/530) and 12.1% (287/2222) respectively, but there was no significant difference in major or minor complications between these two groups.

Summary

Ureteroscopy is a safe and effective treatment for paediatric stone disease. Medium-volume centres can achieve equally high SFRs and safety profiles as high-volume centres. Despite the rarity of paediatric stone disease, our findings might increase the uptake of paediatric URS procedures.

Effectiveness of ureteroscopy among the youngest patients: One centre's experience in an endemic region in Turkey

BACKGROUND

In recent years, the incidence of urinary stone disease reportedly has been increasing. The use of shockwave lithotripsy has seen low success rates, the inefficacy of a single session, and the need for general anaesthesia in children; additionally, children are exposed to radiation. These suboptimal treatment conditions have all led to ureteroscopy (URS) becoming the treatment method of choice for paediatric ureter stones. The aim of this study is to examine the effectiveness of 4.5-Fr URS when used on children younger than 1 year of age.

PATIENTS AND METHODS

The operation results of 34 patients (12 girls and 22 boys) who had undergone intervention for ureter stones at our clinic were retrospectively evaluated. For URS, a 4.5-Fr semi-rigid ureteroscope was used; a Holmium:YAG laser machine was used as a lithotripter.

RESULT

The mean patient age was 9.6 months (range 4-12 months) (Table). The mean stone surface area was 25.39 mm² (range 11.84-84.78 mm²). In six cases, a ureteral catheter was inserted, because of minimal oedema in the ureters; in nine cases, a Double J (DJ) stent was inserted. The mean operation time was 45.3 min (range 22-87 min). In the first week of control with urinary ultrasonography and kidney-ureter and bladder radiograph, a stone-free condition was determined in 28 (82.3%) patients. In two cases-in which sufficient fragmentation could not be achieved, because of minimal bleeding during operation-during the exertion of a DJ stent, another URS was performed. In the first postoperative month, a stone-free condition was established in 32 (94.1%) patients. The mean hospital stay period was 28.6 h (range 12-72 h). There were seven cases (20.5%) with Clavien II-III complications.

CONCLUSION

Use of a ureteroscope is safe and effective with paediatric patients: we found that a 4.5-Fr ureteroscope can be safely used on children under 1 year of age. We therefore consider a 4.5-Fr ureteroscopic instrument to be an appropriate tool for treating URS in children within this age range.

A comparison of efficacies of holmium YAG laser, and pneumatic lithotripsy in the endoscopic treatment of ureteral stones

OBJECTIVE

We aimed to compare the effectiveness of holmium YAG laser and pneumatic lithotripsy in the treatment of ureteral stones.

MATERIAL AND METHODS

A total of 216 patients who had established indications of ureteroscopy between November 2011 and June 2012 were included in this study. Patients' files were retrospectively reviewed by dividing cases as groups that underwent pneumatic (PL) or laser lithotripsy (LL) procedures. Age, sex, stone burden and localization, duration of follow-up, operative times were evaluated. Stone-free rates were evaluated by ureteroscopical examination, postoperative scout films and ultrasonography.

RESULTS

Group PL consisted of 109 and group LL of 107 patients. Median age was 43.93±15.94 years in Group PL and 46.15±14.54 years in Group LL. Male to female ratio, stone burden and localization were similar for both groups. Overall success rate was 89.9% in Group PL and 87.9% in Group LL, respectively (p<0.791). With the aid of additional procedures, success rate was 100% for both groups at the end of the first month. Groups were not different as for operative time, rate of insertion of an ureteral catheter and its removal time. Hospitalization period was apparently somewhat shorter in Group LL (p=0.00).

CONCLUSION

Pneumatic lithotripsy can be as efficacious as laser lithotripsy and be used safely in the endoscopic management of ureteral stone. In comparison of both methods, we detected no differences as to operative time, success of operation and the time to removal of the catheter, however, hospitalization period was shorter in Group LL.

Are Adult Ureteroscopes Safe in the Management of Urolithiasis in a Pediatric Population?

INTRODUCTION

Debate remains regarding the optimal caliber of ureteroscopes in the management of pediatric urolithiasis, ranging from pediatric scopes to standard scopes. The aim of this study was to assess the safety and efficacy of stone management in a pediatric population using standard adult ureteroscopes.

METHODS

A retrospective review of all ureteroscopic procedures in patients under the age of 16 years was carried out. Standard adult 7.5 French semi-rigid and 6 French flexible ureteroscopes were used.

RESULTS

During the study period, 8 patients underwent 21 ureteroscopic procedures. Two patients had rigid ureteroscopy, seven had flexible ureterorenoscopy and one had a subsequent open procedure. No patients required ureteric dilation. Double J ureteric stents were utilized in 7 patients. There were no complications. All patients required extra corporeal shock wave lithotripsy. Stone clearance was achieved in all patients.

CONCLUSION

Our series demonstrates that, in skilled hands, adult ureteroscopes can be use safely for the treatment of urolithiasis in pediatric patients.

Percutaneous nephrolithotomy and ureteroscopy in children: evolutions

The increasing incidence of pediatric stone disease has coincided with significant advances in technology and equipment, resulting in drastic improvements in management. Miniaturization of both ureteroscopes and percutaneous nephrolithotomy (PCNL) equipment has facilitated access to the entirety of the urinary tract and has made ureteroscopy a first-line therapy option along with shock-wave lithotripsy for kidney and ureteral stones. Advances in PCNL have decreased patient morbidity while preserving stone clearance rates. In this review, the advances in operative approach for ureteroscopy and PCNL in children and its applicability to current surgical management of pediatric stone disease are discussed.

Efficacy of extracorporeal shock wave lithotripsy in pediatric and adolescent urolithiasis

PURPOSE

To retrospectively evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) by age and current condition as a first-line treatment for pediatric and adolescent urolithiasis.

MATERIALS AND METHODS

The computerized records of 55 children were retrospectively reviewed from March 1991 to July 2007. The children were below 18 years of age and had undergone ESWL monotherapy for urolithiasis. There were 36 boys (65.5%) and 19 girls (34.5%), with a mean age of 8.5 years (range, 0.5-18 years). There were 24 patients aged 7 years or less and 31 patients aged more than 7 years.

RESULTS

The mean size of the stones was 9.48 mm (range, 4-22 mm). The overall success rate of ESWL was 90.9% (50 children). The mean number of ESWL sessions was 2.02 (range, 1-10). The mean number of ESWL sessions for the patient group aged 7 years or less was 1.16 (range, 1-2) and that for the patient group aged more than 7 years was 2.97 (range, 1-10; p=0.037). There was also a statistically significant difference in the mean number of ESWL sessions between the younger and older patients who needed general anesthesia (1.16 vs. 2.2 sessions, respectively; 0.042).

CONCLUSIONS

In the patient group aged 7 years or less, the number of ESWL sessions and the complication rate were comparable with those for endoscopic management. Thus, ESWL is an effective first-line treatment modality for patients aged less than 7 years.

Holmium:YAG laser ureteroscopic lithotripsy for ureteric calculi in children: predictive factors for complications and success

OBJECTIVES

To evaluate the impact of age, stone size, location, radiolucency, extraction of stone fragments, size of ureteroscope and presence and degree of hydronephrosis on the efficacy and safety of holmium:YAG (Ho:YAG) laser lithotripsy in the ureteroscopic treatment of ureteral stones in children.

METHODS

Between October 2011 and May 2013, a total of 104 patients were managed using semirigid Ho:YAG ureterolithotripsy. Patient age, stone size and site, radiolucency, use of extraction devices, degree of hydronephrosis and size of ureteroscope were compared for operative time, success and complications.

RESULTS

In all, 128 URS were done with a mean age of 4.7 years. The mean stones size was 11 mm. Success rate was 81.25 %. Causes of failure were 12.5 % access failure, 1.5 % extravasation and 4.7 % stone migration. Overall complications were 23.4 %. Failure of dilatation and extravasation were detected only in children <2 years old. Extravasation was significantly higher in smaller ureters and cases with stone size >15 mm. Stone migration was significantly higher in upper ureteric stones.

CONCLUSIONS

Failure and complications rates in Ho:YAG ureterolithotripsy were significantly affected by younger age (<2 years), upper ureteric stones and smaller ureters but were not related to stone radiolucency or degree of hydronephrosis. Larger stones (>15 mm) were associated with increased complications. After multivariate analysis, the age of the patients remained significant predictor for failure of dilatation and stone migration, while size of the ureter was the only significant predicting factor for failure.

Comparison of a 4.5 F semi-rigid ureteroscope with a 7.5 F rigid ureteroscope in the treatment of ureteral stones in preschool-age children

The aim of this study was to compare the success and complication rates of a 4.5 F ureteroscope with a 7.5 F ureteroscope in the treatment of urolithiasis in preschool-age children. We retrospectively reviewed 69 ureteroscopy (URS) procedures in a pediatric population (40 boys, 29 girls). We divided the patients into two groups according to the type of ureteroscope used: group 1 (n = 42, Storz 7.5 F) and group 2 (n = 27, Wolf 4.5 F). We statistically compared all the procedures performed in both groups regarding patient age, complication rates, whether the procedure was therapeutic, and whether we used a guidewire. Additionally, in cases with ureteral stones, we also compared the stone clearance rate and the necessity of X-ray imaging between the two groups. The mean patient age was 56.04 months in group 1 and 47.48 months in group 2 (p = 0.057). The stone-free rate was 78.6 % in group 1 and 92.6 % in group 2 (p > 0.05). However, when we compared the stone-free rates for patients younger than 3 years, the rate was 66.7 % in group 1 and 93.8 % in group 2 (p < 0.05). The difference was not statistically significant for patients between the ages of 4 and 7 years. The success and failure rates revealed better outcomes for treatment of ureteral stones with a 4.5 F ureteroscope. We recommend the use of the mini-ureteroscope, especially in infants and preschool-age children.