Endoscopic manipulation of ureteral calculi in children by rigid operative ureterorenoscopy

Primary versus secondary ureteroscopy for pediatric ureteral stones

OBJECTIVE

To evaluate the outcome of primary versus secondary ureteroscopy for pediatric ureteral stones.

PATIENTS AND METHODS

A retrospective chart review study that included 66 children aged less than 12 years, who were subdivided into two groups: Group A, which included 42 children who had undergone primary ureteroscopy without pre-stenting; and Group B, which included 24 children who had undergone ureteroscopy after ureteric stenting. Kidneys, ureters and bladder radiographs were done on the first postoperative day to assess the degree of stone clearance and stent position.

RESULTS

Age, gender, stone location and stone size were not significantly different between both groups. In Group A, 31 (73.8%) children required ureteric dilation, 13 (31%) had a tight ureter that failed to respond to dilation, 25 (59.5%) displayed complete stone clearance, and of these, 13 (52%) needed postoperative stenting. One child experienced ureteric injury during stone disintegration and was stented for two weeks. Children in Group B experienced a 95.8% complete stone clearance rate, with no ureteric injury reported; postoperative stenting was performed in three (12.5%) children..

CONCLUSION

Secondary ureteroscopy is preferable over primary ureteroscopy in pediatric populations because of a significantly lower need for ureteric dilation, shorter procedure time and better stone clearance rate..

Minimally invasive approaches and their efficacy in pediatric urolithiasis

OBJECTIVE

We compared the frequency of usage and success of minimally invasive approaches in the management of pediatric urolithiasis in our clinic.

MATERIAL AND METHODS

Data from pediatric patients (≤16 years of age) who had undergone percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS), and extracorporeal shock wave lithotripsy (ESWL) between January 2001 and December 2011 were retrospectively investigated.

RESULTS

In this study, 415 pediatric patients, who were treated for 291 renal, and 124 ureteral stones, were evaluated. The patients were treated with PNL (n=148; 82 boys, 66 girls), URS (n=99; 58 boys, and 41 girls) or ESWL (n=168; 91 boys, and 77 girls). The mean patient ages were 7.3 (1-16), 9.1 (1-16), and 8.8 (1-16) years in the PNL, URS, and ESWL groups, respectively. The stone-free rates after treatment with PNL, URS, and ESWL were 77, 83.8 and 88.7%, respectively.

CONCLUSION

It is important that selected therapies are properly planned, and the use of minimally invasive approaches is important in pediatric patients due to potentially high recurrence rates. Currently, ESWL, PNL and URS are performed with high success rates for the treatment of stones, and open surgery is rarely used due to the success obtained with minimally invasive approaches.

Factors affecting complication rates of ureteroscopic lithotripsy in children: results of multi-institutional retrospective analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society

PURPOSE

We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi.

MATERIALS AND METHODS

We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates.

RESULTS

A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate.

CONCLUSIONS

Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Ureteroscopy: The standard of care in the management of upper tract urolithiasis in children

Objectives

Advances in technology and the continued evolution in the design of ureteroscopes now permit a primary endoscopic approach to the upper urinary tract of pediatric patients on a routine basis to treat a diverse group of conditions that include urolithiasis, hematuria and strictures. The purpose of this review article is to demonstrate that ureteroscopic lithotripsy is now to be considered the standard of care in the management of upper tract urolithiasis in the pediatric patient, replacing shockwave lithotripsy (ESWL) as the first line of therapy. Additionally, the article will discuss the available endoscopic equipment and the lessons learned over the years to optimize the success of these procedures in children.

Materials and Methods

A systematic review of articles written about ureteroscopy (URS) in the contemporary urological literature (1990-2009) on PubMed was undertaken. The success rates and complications of pediatric ureteroscopic procedures were abstracted from the identified publications and the results were tabulated and compared with the success rates of shockwave lithotripsy.

Results

In over 832 URS cases, there was a 5.9% complication rate and a stone-free rate of 93.4%. The stone-free rates of URS are superior to those obtained with the published success rates with ESWL of 80.3% in 1,839 cases.

Conclusions

The safety and outcomes of ureteroscopic lithotripsy in the management of pediatric urolithiasis now justify that this treatment modality be considered the standard of care and first line of therapy in the management of children who present with upper tract stones.

Surgical management of pediatric urolithiasis

Pediatric urolithiasis poses a technical challenge to the urologist. A review of the recent literature on the subject was performed to highlight the various treatment modalities in the management of pediatric stones. A Medline search was used to identify manuscripts dealing with management options such as percutaneous nephrolithotomy, shock wave lithotripsy, ureteroscopy and cystolithotripsy in pediatric stone diseases. We also share our experience on the subject.

Shock wave lithotripsy should be the treatment modality for renal stone less than 1cm or < 150 mm² and proximal non-impacted ureteric stone less than 1 cm with normal renal function, no infection and favorable anatomy. Indications for PCNL in children are large burden stone more than 2cm or more than 150mm² with or without hydronephrosis, urosepsis and renal insufficiency, more than 1cm impacted upper ureteric stone, failure of SWL and significant volume of residual stones after open surgery. Shock wave lithotripsy can be offered for more soft (< 900 HU on CT scan) renal stones between 1-2cm. Primary vesical stone more than 1cm can be tackled with percutaneous cystolithomy or open cystolithotomy. Open renal stone surgery can be done for renal stones with associated structural abnormalities, large burden infective and staghorn stones, large impacted proximal ureteric stone. The role of laparoscopic surgery for stone disease in children still needs to be explored.

Operative management of pediatric urolithiasis

Surgical management of urinary stones in children remains challenging due to the smaller caliber of the urinary tract. Specific instruments have been designed to overcome some of the issues related to pediatric stone management. Endoscopic and percutaneous modalities for stone management have been shown to be as safe and effective in providing stone clearance in children as in adults. Technologies that have been shown to be safe in adults are being miniaturized for use in children. The current literature regarding pediatric urolithiasis was reviewed in an effort to identify trends in operative management. Additionally, techniques used successfully at our institution are described. Although not an exhaustive review of all available modalities and instruments, this review will provide an overview of the current techniques for the management of pediatric urolithiasis.

[Place of the ureteroscopy in the treatment of the children urolithiasis]

OBJECTIVE

To determine the efficiency and the role of ureteroscopy in the treatment of urolithiasis in children.

METHODS

A multicenter retrospective study was conducted between January 2006 and March 2008 in the department of pediatric surgery and urology of Besançon, Lyon and Grenoble. The clinical data of 17 children having benefited from one or more ureteroscopy procedures for urolithiasis were analyzed. These data concerned age, sex, antecedents of metabolic diseases, existence of a malformed uropathy, how the urolithiasis was discovered, therapeutic indications, endoscopic procedures, type of endoscopic treatment for urolithiasis, results and complications.

RESULTS

Twenty-six ureteroscopies were carried out for 17 children (eight girls and nine boys) aged between 9 months and 12 years (mean: 5 (1/2) years old) as a first-line treatment or after extracorporeal shock wave lithotripsy. A 6/7,5 Fr semi-rigid ureteroscope was used in all case. Only once, the operator chose a flexible ureteroscope. Lithotripsy was carried out 15 times with YAG Holmium laser, four times with Swiss Lithoclast and six times by simple extraction with a Dormia type basket .A stent probe was left in place after endoscopy for 14 children. The "stone free" rate was 88% with an average hindsight of 11 months. Two incidents without major complication were recorded: a section of the guide by the laser beam and a perforation with extravasation of the contrast agent.

CONCLUSION

Ureteroscopy is the first-line treatment in isolated ureteral urolithiasis. On the other hand, LEC remains the treatment of choice for Starghon calculi, since LIC should be offered only in the event of failure of LEC.

Ureteroscopic management of lower-pole stones in a pediatric population

PURPOSE

We report our experience with ureteroscopy to treat lower-pole calculi in children.

PATIENTS AND METHODS

A retrospective review was conducted of all ureteroscopic procedures for lower-pole stone disease at a pediatric institution from 2000 through 2005. A total of 13 girls and 8 boys with a mean age of 15 years (range 1-20 years) underwent flexible ureteroscopy for lower-pole calculi. The mean stone burden was 12 mm. Stone-free status was defined by postoperative abdominal radiography, CT, or ultrasonography.

RESULTS

Ureteral stenting was performed preoperatively in 38% and postoperatively in 71% of the patients. Ureteral-access sheaths were placed in 43%. There were no intraoperative or postoperative complications. With a mean follow-up of 11 months, 76% of the children were stone-free. The success rate for stones <15 mm was 93% v 33% for stones > or =15 mm (P = 0.01).

CONCLUSION

Ureteroscopy and laser lithotripsy are safe and effective in children with lower-pole calculi. Ureteroscopy can be considered a primary treatment option for children with lower-pole calculi <15 mm.

Is ureteroscopy first line treatment for pediatric stone disease?

PURPOSE

We report our current outcomes for ureteroscopic management of pediatric stone disease.

MATERIALS AND METHODS

We carried out a retrospective review of all ureteroscopic procedures for kidney or ureteral calculi performed between 2001 and 2005. Stone location and size, preoperative and postoperative stenting, intraoperative dilation, use of ureteral access sheath, stone-free rates and complications were noted.

RESULTS

A total of 100 patients (58% female, mean age 13.2 years) underwent 115 procedures. Stones were located in the renal pelvis in 6% of patients, upper pole in 10%, mid ureter in 11%, lower pole in 17%, proximal ureter in 19% and distal ureter in 37%. Mean stone size was 8.3 mm (median 7.0), with a mean of 1.5 stones per patient. Preoperative stenting was used in 54% of patients, and a stent was placed postoperatively in 76%. Ureteral coaxial dilators and ureteral access sheaths were used in 70% and 24% of patients, respectively. There were no major intraoperative complications, although 5 patients required stent placement for ureteral perforation or extravasation. One patient had a ureteral stricture requiring ureteral reimplantation. Mean followup was 10.1 months (median 2.6). Stone-free rate was 91% on followup ultrasound, abdominal radiography or computerized tomography. Seven patients required staged ureteroscopic procedures to achieve stone-free status. While the number of percutaneous nephrolithotomy and shock wave lithotripsy cases remained stable, the number of ureteroscopic cases increased 7-fold during this period.

CONCLUSIONS

Improved ureteroscopic access to stones throughout the pediatric urinary tract and stone-free rates that are comparable to the adult population have led to the adoption of ureteroscopy as first line therapy in children at our institution.

Efficacy and safety of endoscopic treatment of ureteral stones in pediatric age

Ureteroscopy procedures in pediatric age are becoming more and more common thanks to the availability of smaller caliber instruments, and of improved endoscopic techniques. The efficacy of this procedure in pediatric age is still discussed nowadays. This paper aims at reviewing all cases of ureteral lithiasis treated by ureteroscopy plus intracorporeal lithotripsy (ULT), as well as verifying efficacy and safety of this procedure in pediatric age.

Materials and Methods

From July 2002 to May 2006, 37 patients (26 female, 11 male; mean age 7.4 years; range 2–17) were treated by ULT for ureteral stones: 30 in distal, 4 in middle and 3 in proximal ureter. Median size of stones was 7mm (range 3–13mm). Dilation of the ureteral meatus was necessary in 2 patients only. Endoscopic procedure was similar to adult patients. Outcomes were statistically compared with current literature data.

Results

In 36 (97.3%) out of 37 patients ULT proved successful. All patients having stones in distal (30) and middle (4) ureter were stone-free at the end of treatment. Stone migration into the kidney pelvis occurred in 1 patient with proximal ureter stones (66.7% stone-free rate): an ESWL treatment was therefore performed. 1 case only (2.7%) developed a perioperative complication (stone migration). Hematuria and flank pain in 4 patients (10.8%) were the most common reported post-operative complications. A stone-free state was confirmed at 1 and 3 months for all 36 patients. There was no evidence of ureteral strictures and/or ureteral refluxes.

Conclusions

Smaller caliber ureteroscopes confirmed ULT as the first-choice treatment procedure in children affected by ureteral lithiasis, thanks to its efficacy and safety.

Management of pediatric stone disease

Pediatric and adult stone disease differs in both presentation and treatment. Children can present with a wide range of symptoms varying from flank pain and hematuria to nonspecific symptoms such as irritability and nausea. Although ultrasonography and plain radiographs can play a role in diagnosis and follow-up, the standard of care for a child who presents to the emergency department with a history suggestive of a stone is noncontrast spiral CT. Because there is a high yield in identifying predisposing factors in children with urolithiasis and high recurrence rates, metabolic evaluation of every child with a urinary stone should be undertaken and medical treatment should be given if necessary. With recent advances in technology, stone management has changed from an open surgical approach to less invasive procedures such as extracorporeal shock-wave lithotripsy and endoscopic techniques. Herein, we present a review of the recent literature and offer our own preferences to approaches for treatment.

Hydrodilation of the Ureteral Orifice in Children Renders Ureteroscopic Access Possible Without any Further Active Dilation

PURPOSE

We review our experience with hydrodilation of the ureteral orifice for ureteroscopic access in children.

MATERIALS AND METHODS

We retrospectively reviewed the results of 30 ureteroscopic procedures performed in 26 children who were followed for 6 months. Ureteral access was obtained with the assistance of a hand irrigation pump without any further active dilation in all cases.

RESULTS

A total of 26 patients (86.7%) were completely stone-free after 1 procedure. There was no major complication such as ureteral perforation or avulsion. Mild flank pain was observed in 8 cases (26.7%). Predominant symptoms of bladder spasm were observed in 6 cases (20%). At 6-month followup no patient had pyelonephritis or demonstrated hydronephrosis related to ureteral stricture.

CONCLUSIONS

Our study shows that hydrodilation of the ureteral orifice in children renders ureteroscopic access possible with no additional active dilation and no associated complications.

Safety and Outcome of Rigid Ureteroscopy for Management of Ureteral Calculi in Children

PURPOSE

To present our experience with ureteroscopy for the treatment of pediatric ureteral calculi.

PATIENTS AND METHODS

The records of 32 children with an average age of 8.7 years (range 2-15 years) treated with rigid ureteroscopy between June 1994 and July 2003 were reviewed. In 33 ureteral units, 8F rigid ureteroscopy was carried out 35 times to treat stone disease. Stones were located in the upper ureter in 2 cases, the middle ureter in 2 cases, and the lower ureter in 29 cases. Stone size ranged from 4 to 15 mm (mean 7 mm). Dilatation of the ureteral orifice was necessary in 10 procedures.

RESULTS

The management of stone in 29 children (90.7%) was straightforward, and a single procedure was sufficient to clear the ureters. In 2 children (6.2%), repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%), it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 2 cases and with the holmium laser in 9; in the remaining 22 cases, the stones were removed without fragmentation. Intraoperative complications occurred in 3 children (9.3%) and consisted of extravasation (1 patient) and stone migration (2 patients). The early postoperative complications were hematuria in one patient and renal colic in another. Of the patients, 28 were followed 3 to 48 months. No stricture was detected at the site of stone impaction in any patient.

CONCLUSION

In the hands of an experienced surgeon, ureteroscopy can be a safe and efficient treatment for ureteral stones in children.

Retrograde ureteroscopy for distal ureteric stone removal in children

OBJECTIVE

To compare the efficacy and safety of ureteroscopy plus intracorporeal lithotripsy (ULT) with extracorporeal shock wave lithotripsy (ESWL) for treating distal ureteric calculi in childhood, as such stones are commonly treated by ESWL as the first option in adults but there is no agreement on the method of treating them in children.

PATIENTS AND METHODS

From July 2002 to July 2003, children presenting with ureteric stones were consecutively randomized for treatment using ULT or ESWL. The two groups were matched for age, sex and stone position in the distal ureter. A 7.5 F ureteroscope combined with a ballistic lithotripter or holmium-YAG laser was used for ULT. ESWL was administered using a second-generation lithotripter. The success rate, effectiveness quotient, complication rate and hospitalization were evaluated and compared using Student's t-test (chi-square) and Fisher's exact test as appropriate. In all, 31 patients (21 girls and 10 boys, mean age 7.2 years, range 2-17) were treated, by ULT in 17 (12 girls and five boys) and ESWL as a primary procedure in 14 (five boys and nine girls).

RESULTS

After one ULT, all the girls and four boys, and after ESWL, four girls and two boys, were rendered stone-free at the first treatment. The total stone-free rate was 16 of 17 for ULT and six of 14 for ESWL (P = 0.004). Eight patients had a second ESWL and three then became stone-free. The five patients in whom both ESWL treatments failed had a successful ULT. There was no significant difference between the groups in complication rate and hospitalization. General anaesthesia was required in all patients <12 years old treated by ULT or ESWL. The calculated efficiency quotient for treating distal ureteric calculi was significantly lower for ESWL than ULT (P < 0.05).

CONCLUSIONS

ULT should be recommended as the treatment of choice for distal ureteric calculi in children; using small ureteroscopes the target stone was treated safely and effectively.

Ureteroscopy in the Management of Pediatric Urinary Tract Calculi

PURPOSE

To report our experience with ureteroscopy in the treatment of pediatric urinary tract calculi and present a review of the literature.

PATIENTS AND METHODS

Between 1988 and 2003, 52 ureteroscopic procedures were performed in 25 male and 10 female children aged 11 months to 15 years (mean 5.9 years). Using a semirigid 6.8F 43-cm ureteroscope and routine antibiotic prophylaxis, stones were fragmented with a pulsed-dye laser (N = 14; stone size 6-15 mm with a mean of 9.6 mm), electrohydraulic lithotripsy (EHL) (N = 26; stone size 3-20 mm with a mean of 8.4 mm), or a holmium laser (N = 7; stone size 5-15 mm with a mean of 10 mm); removed by basket extraction (N = 5; stone size 5-8 mm with a mean of 7 mm); or both. Stenting or ureteral dilatation was not performed routinely.

RESULTS

With the pulsed-dye laser, there was an overall stone-free rate of 72%. Complications consisted of one ureteral perforation and one stenosis of the intramural portion of a megaureter (14% complication rate). With EHL, the overall stone-free rate was 92%. Complications consisted of one case each of ureteral perforation and incipient urinary retention and five of mild fever (27%). With the holmium laser, the overall stone-free rate was 100%, and there were no complications. Basketing likewise produced a 100% stone-free rate, and there was one complication, a mucosal tear in a patient who also underwent pulsed-dye laser lithotripsy.

CONCLUSION

Ureteroscopy is a safe and effective means of treating the majority of pediatric ureteral calculi, although retreatment rates are higher with multiple stones and in younger children. Dilatation of the vesicoureteral junction is usually not necessary with ureteroscopes <8F, nor is ureteral drainage required after uncomplicated ureteroscopy. The holmium laser is the most effective and safest method of fragmentation regardless of stone composition. Ureteroscopy for this indication should be performed only by an experienced endoscopist.

Retrograde Ureteroscopy for Distal Ureteral Stones Removal in Childhood

Distal ureteral stones are commonly treated by extracorporeal shock wave lithotripsy (ESWL) as first option in adult age patients, but no agreement is achieved about the treatment in children. Efficacy and safety of ureteroscopy with ureterolithotripsy (ULT) was compared with ESWL results for distal ureteral calculi treatment in childhood.

Materials e Methods

From July 2002 to July 2003, paediatric patients presenting ureteral stones were consecutively randomized for treatment, using ULT or ESWL. The success rate, effectiveness quotient, complication rate and hospitalization length were evaluated. T-Student test (chi-square) was adopted for statistical analysis.

Results

A total of 31 patients, aged 2 to 17 years (mean age 7.2 years) were recruited. ULT was performed in 17 children. All the females (100%) and 4 males (80%) were stone-free in a single endoscopic procedure. ESWL was performed as a primary procedure in 14 cases, 5 males and 9 females. Four females (44.4%) and 2 males (40%) resulted stone-free at first treatment. The total stone-free rate was 94.1% for ULT and 42.8% for ESWL (p=0.004). Eight patients (57%) underwent a second ESWL and 3 of them (37.5%) became stone-free súbsequently. The 5 patients (62.5%) with failed double ESWL underwent ULT successfully. The calculated efficiency quotient for treating distal ureteral calculi was significantly lower in the ESWL than in the ULT group (p=0.05).

Conclusions

ULT should be recommended as treatment of choice for distal ureteral calculi in childhood. Using small ureteroscopes the target stone was treated safety and effectively in our patients.

Surgical management of children with urolithiasis

The management of urolithiasis in children poses specific technical challenges that require planning before endoscopy and that affect the risks and outcomes of these procedures. The indications for operative intervention in children and adults are similar:infection, persistent symptoms of flank pain, nausea, and vomiting, as well as the failure to pass a ureteral stone after an appropriate trial of observation (3-6 weeks). Specific adjustments for performing extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and cystolithotomy in children are discussed.

RIGID URETEROSCOPY FOR THE TREATMENT OF URETERAL CALCULI IN CHILDREN

PURPOSE

We assess the safety and efficacy of rigid ureteroscopy for the treatment of pediatric ureterolithiasis.

MATERIALS AND METHODS

The records of 33 children with an average age of 7.4 years (range 9 months to 15 years) treated with rigid ureteroscopy between May 1995 and July 2003 were reviewed. In 35 ureteral units use of a rigid 6.9 to 10Fr ureteroscope was planned for treating stones at various levels of the ureter. Stones were located in the upper ureter in 6 cases, middle ureter in 3 and lower ureter in 26. Dilatation of the ureteral orifice was necessary in 11 cases.

RESULTS

Stone size varied from 3 to 10 mm (mean 5.3). In 33 patients (94%) all stone fragments were removed successfully. Stones were fragmented with pneumatic lithotripsy in 20 cases and removed by forceps without fragmentation in 13. In 1 child an upper ureteral stone migrated up to the kidney during ureteroscopy but following extracorporeal shock lithotripsy therapy she was rendered stone-free. In another child it was not possible to remove the stone. In a 9-month-old female patient with bilateral stones it was not possible to enter the left ureter because of a tight orifice resistant to balloon dilation. At the end of the procedure a 3 or 4Fr ureteral or a 4.8Fr Double-J (Medical Engineering Corp., New York, New York) stent was left in place for 3 days to 3 weeks in 12 cases. There were no cases of ureteral perforation. Of the patients 31 were followed for 1 to 36 months. No incidence of vesicoureteral reflux was detected in 9 who underwent postoperative cystography.

CONCLUSIONS

After becoming experienced and meticulously working with finer instruments in adults, rigid ureteroscopy can be a safe and efficient treatment for ureteral stones in every location in children.

Use of the holmium:YAG laser for ureterolithotripsy in children

OBJECTIVE

To review our experience with rigid ureteroscopy and holmium:YAG laser for treating ureteric calculi in children.

PATIENTS AND METHODS

The study included 35 children who were treated with rigid ureteroscopy for ureteric calculi between November 1997 and June 2003 (15 boys and 20 girls; mean age 6.2 years, range 1-14). The mean (range) stone size was 8 (4-15) mm and the duration of anaesthesia 46.6 (15-90) min. The stone was in the distal third of the ureter in 33 children and in the proximal third in two. We used a 7.5/8/10 F rigid ureteroscopes with routine dilatation of the ureteric orifice. For lower ureteric stones, lithotripsy was carried out with holmium:YAG laser in 29 cases, a pneumatic impactor in two and forceps extraction in two. Both stones in the proximal ureter were pushed back into the collecting system. All the ureters were stented using JJ stents in 31 and ureteric catheters in four cases. The mean postoperative follow-up was 12 (2-30) months.

RESULTS

Excluding the two stones pushed back, the stone-free rate after a one-stage procedure was 82% (27/33). With repeated procedures in the six (ESWL in two) remaining cases the success rate was 97% (32/33). The ureter was perforated in two patients within the first five in the series. There was no pyelonephritis or gross haematuria after surgery.

CONCLUSION

Ureteroscopy and lithotripsy using the holmium:YAG laser is effective and safe for treating ureteric stones in children, in experienced hands. The results would be even better using smaller and flexible ureteroscopes.

Ureteral Ultrasonic Lithotripsy Revisited: A Neglected Tool?

BACKGROUND AND PURPOSE

Ultrasonic lithotripsy was one of the first modalities used for treating renal and ureteral stones. However, in recent years, it has been largely replaced by newer techniques such as laser lithotripsy with rigid as well as flexible ureteroscopes. The aim of this study was to review the results and our current indications for ureteroscopic ultrasonic lithotripsy (UUL).

PATIENTS AND METHODS

Between October 2000 and May 2002, 340 ureteroscopies were performed for the treatment of ureteral stones in the Rabin Medical Center. Of this series, 9 patients (2.6%) underwent UUL using a semirigid 8F ureteroscope (Wolf) and an Olympus ultrasonic lithotripter (LUS-1) with a 4.5F hollow probe. Four patients had Steinstrasse following shockwave lithotripsy, four had large (1-2-mm) ureteral stones, and one had an impacted calcified ureteral double-J stent. Stones >5 mm were initially fragmented by the holmium laser (550-microm fiber). A double-J stent was placed in all patients. The mean follow-up time was 20 months.

RESULTS

The mean operative time was 84 minutes. No intraoperative complications occurred. The mean hospital stay was 3.9 days. Eight patients became stone free after the first procedure, and the other underwent secondary ureteroscopy, which rendered him stone free.

CONCLUSIONS

Patients in whom UUL is performed are relatively complex stone patients. The use of ultrasonic lithotripsy following, or in combination with, laser or ballistic devices utilizes the unique properties of UUL, which combines stone fragmentation and efficient removal of small fragments. The technique was particularly useful in patients with Steinstrasse or a large stone burden. Thus, UUL has a limited but significant role in the treatment of ureteral stones.

Pediatric ureteroscopy

Endoscopic evaluation and management of the diverse conditions involving the upper urinary tract of children is now feasible and has been shown to be safe and efficacious. This modality should be considered an essential part of the armamentarium of any urologist involved in the care of children. Continued technological advances will allow the indications for pediatric ureteroscopy to evolve. The benefits of minimally invasive surgery that have been proved in adult patients can now be offered to pediatric patients. A thorough knowledge of available equipment and the anatomic and physiologic differences of pediatric patients will ensure a successful outcome with minimal morbidity.

Extracorporeal shock-wave lithotripsy for treatment of ureteral calculi in paediatric patients

Our objective was to determine the efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of paediatric ureteral calculous disease. We reviewed the records of 41 (23 boys, 18 girls) paediatric patients admitted to our clinic for the treatment of ureteral calculi between between 1989-2001. Patients' age varied between 4-16 years. The majority of the patients, 38 (92.7%) cases were treated initially with ESWL whereas 3 (7.3%) cases were subjected to ureterolithotomy. The mean age of the patients was found as 12.8+/-3.86 (4-16) years. Most calculi were located at either upper or lower ureter. The mean stone burden was 45.16+/-30.65 mm2 and the mean shock wave number per session and power as 2826.72+/-605.18 and 17.69+/-1.11 kV respectively. Minor complications included skin ecchymosis at the site of entry of shock waves in all cases and renal colic that responded to analgesics and emetics in 3 (7.9%) patients. The overall stone-free rate after ESWL was found to be 81.6%. Two (5.3%) cases have residual fragments that escaped to lower calices after lithotripsy for upper ureteral calculi and are still followed. There were 5 (13.2%) failures who were treated with ureterolitotomy for 1 upper and 1 lower ureteral calculi and with ureteroscopy for the rest. It appears that ESWL is still a good option for the initial treatment of most ureteral calculi in children as it is less invasive than ureteroscopy and has a high success rate as a first-line therapy.

Ureteroscopy for the treatment of urolithiasis in children

PURPOSE

Ureteroscopy for treating urolithiasis in prepubertal children has become more common with the advent of smaller instruments. We reviewed our experience with ureteroscopy for urolithiasis in this cohort of patients as well as the literature using this treatment modality in children.

MATERIALS AND METHODS

Between 1994 and 2000 we performed 27 ureteroscopic stone extractions in 25 children. Ureteroscopy was done in a manner similar to that in adults. Ureteral dilation was performed when necessary to access the ureter. A stent was placed postoperatively if there was significant ureteral trauma.

RESULTS

Of the 25 children 13 were male and 12 were female. Average age was 9.2 years (range 3 to 14). Stones were 2 to 12 mm. in greatest diameter (average 6). Of the 27 procedures the ureteral orifice was dilated before stone treatment in 15 (56%), while in 19 (70%) a stent was placed afterward. No intraoperative and 2 postoperative complications were identified. Overall 92% of the children were rendered stone-free after 1 procedure and 100% were stone-free after 2.

CONCLUSIONS

Ureteroscopy for urolithiasis in prepubertal children is safe and effective. Routine ureteral dilation and ureteral stent placement are not always necessary in these patients.

The management of paediatric urolithiasis

OBJECTIVE

To evaluate the efficacy and safety of the management of paediatric urolithiasis by extracorporeal shock wave lithotripsy (ESWL), endoscopic ureterolithotomy, percutaneous nephrolithotomy (PCNL) and open nephrolithotomy.

PATIENTS AND METHODS

In a 3-year period (1997-1999), 59 children were treated for urolithiasis and underwent a total of 79 procedures. Thirty-two ESWL sessions were performed in 23 children (mean age 7.4 years, median 6.0). PCNL was undertaken in 30 renal units in 25 children (mean age 6.4 years, median 4.0). Eight patients (mean age 7.8 years, median 5) underwent 17 ureteroscopic procedures, six of which involved the use of a holmium laser. Three children with staghorn calculi underwent open nephrolithotomy under conditions of renal ischaemia and hypothermia.

RESULTS

Of the 23 children treated using ESWL, 21 (91%) became stone-free; 17 underwent one ESWL session (74%), three had two sessions and three (13%) had three sessions. All eight patients who underwent ureteroscopy became stone-free. Four patients in whom the stone could not be reached by ureteroscopy initially had a JJ stent inserted, and the stone and stent subsequently removed. Stones were cleared using PCNL in 27 of 30 renal units (90%); three patients who had residual stone fragments were rendered stone-free by ESWL. Two of three children undergoing open nephrolithotomy were stone-free after surgery and the remaining one rendered stone-free with ESWL. Metabolic evaluation showed that 25 of 45 children (55%) had a urinary infection, eight (18%) had hyperoxaluria, three (7%) had hypercalciuria, two (4%) had cystinuria, and no identifiable cause was found in seven (16%). Treatment by a single modality rendered 52 of the 59 children (88%) stone-free; when the different modalities were combined, 57 of 59 patients (97%) were cleared of their stones.

CONCLUSIONS

Technological advances in ESWL, ureteroscopy and PCNL have had a significant effect on the management of urolithiasis in children, allowing a safe and successful outcome. The comprehensive care of children with urolithiasis should include a full metabolic evaluation. Anatomical anomalies contribute to the complexity of many cases, necessitating a close liaison between adult and paediatric urologists, nephrologists and radiologists to optimize stone management in children.

Minimally invasive treatment of urinary tract calculi in children

OBJECTIVE

To report experience of a broad multimodality approach to the treatment of calculi in children using extracorporeal shock wave lithotripsy (ESWL), ureteroscopy/laser lithotripsy, lithoclast and percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

The treatment and outcome were reviewed in 43 children managed by a range of minimally invasive modalities, either singly or in combination, between 1990 and 1997. These patients represent a selected group deemed suitable for minimally invasive management during a period of developing experience with these techniques. Of this cohort, six children had previously undergone open stone surgery and contributory metabolic abnormalities were identified in seven. ESWL was the sole treatment modality in 24 children (56%). In five children (12%) ureteroscopy/laser lithotripsy was combined with ESWL, eight (18%) underwent ureteroscopy/laser lithotripsy alone, whilst three with bladder stones were treated with the lithoclast. Combined therapy including PCNL was required in three patients.

RESULTS

Of the 43 children treated, 38 (88%) were rendered stone-free. Metabolic disorders accounted for three of the five cases of residual calculi. Complications requiring intervention occurred in two children (7%) and three subsequently underwent open pyelolithotomy or ureterolithotomy after unsuccessful minimally invasive treatment.

CONCLUSIONS

Used selectively, the range of minimally invasive procedures available for adults, including ureteroscopy and PCNL, can be safely and effectively extended to the treatment of urinary tract calculi in children. The role of open surgery will diminish further with the availability of specialized instruments for paediatric PCNL.

Pediatric ureteroscopy: technique and preliminary results

Ureteroscopic management of ureteral obstruction in children presents a challenge to the urologist because of the use of relatively large instruments in smaller anatomy. The authors present our initial experience and describe the technique and equipment found to be most useful. Eleven ureteroscopic procedures were performed in ten patients, either for stone extraction or diagnostic evaluation of ureteral obstruction. Six of seven patients with ureteral stones became stone free, and the stone load was reduced to 25% in the remaining patient. Diagnostic ureteroscopy for ureteral obstruction was successfully performed in four patients. There were no intraoperative ureteral injuries and no postoperative complications. Pediatric ureteroscopy appears to be safe and effective for the diagnosis and treatment of distal ureteral obstruction. Further studies and longer follow-up are necessary to determine whether this technique will prove as successful in children as it has been in the adult population.

Pediatric urolithiasis

Urolithiasis in childhood is of diverse etiology requiring carefully planned individualized diagnostic and management protocols. The efficiency in diagnosis and management of urolithiasis in childhood follows a learning curve, especially when using the more recent technical innovations for management of urinary calculi. With current technical sophistication of transurethral and percutaneous techniques and ESWL, management of urolithiasis during childhood should be relatively straightforward as monotherapy using a single modality or as a combined approach with one or more techniques, saving open surgical intervention for situations where the new technology is either unavailable or inappropriate, or when surgical reconstruction of the urinary tract is necessary to forestall recurrent calculus formation. Postoperative morbidity after management of urinary calculi during childhood appears insignificant; calculus recurrence is uncommon. Long-term postoperative follow-up is mandatory, especially after using the newer technical innovations for urinary calculus management during childhood.

Treatment update on pediatric urolithiasis

At the doorstep of the twenty-first century the role of extracorporeal shock-wave lithotripsy (ESWL) as the treatment of choice for more than 80% of all stones in children is established. ESWL is safe and effective, with very few differences in success rates being observed among different lithotriptors. The present problem with ESWL appears to be the residual stone fragment, which has a proven clinical significance. A thorough metabolic evaluation and metaphylaxis is indicated in all children, and this will enable physicians to deal with the residual fragments in a more cause-specific manner and prevent regrowth. Another subject that needs prospective randomized studies to be unveiled is the assumption that a specific or universal metaphylaxis, possibly with alkaline citrates, will enhance stone clearance, lower the incidence of residual stone fragments, and optimize the ESWL results. Finally, both percutaneous nephrolithotomy and ureteroscopic stone removal have been established in children as safe and effective treatment options. This gives the clinician the opportunity to choose from a wide range of treatment alternatives, including open surgery, and only this approach will ensure 100% stone removal in individual patients along with the prevention of recurrence and, thus, the elimination of long-term morbidities in this vulnerable patient population.

Endoscopic treatment of pediatric urolithiasis

Children have been slow to benefit from the improvements in stone therapy. Despite the success of less invasive techniques, open surgery for pediatric urolithiasis is still commonly practiced. The authors' goal was to evaluate the indications, efficacy, and complications of endourologic surgery in the treatment of pediatric urolithiasis. They reviewed the treatment of 53 children who had upper tract calculi. Open nephro- and ureterolithotomy were avoided in all cases. The management of 25 children whose stones were not amenable to extracorporeal shock wave lithotriopsy is presented. Seventeen children (19 stones) were treated with miniature ureteroscopes and lasertripsy. Only one (6%) of the patients required ureteral dilation, and only five (29%) needed a postoperative internal stent. Eight children with large renal calculi were treated percutaneously, without transfusion, complication, or evidence of persistent renal damage. All 25 patients were rendered stone-free. The hospital stay was shorter and secondary procedures were less common in comparison to other series of endoscopic lithotripsy. With significant experience in adult endourology and proper instrumentation, one can apply the same techniques to children and achieve equal if not greater benefit. Nephrolithiasis in children is uncommon and should be managed in an institution where endourologists and multiple treatment modalities are available.

Urethroscopy in small neonates with posterior urethral valves and ureteroscopy in children with ureteral calculi

OBJECTIVES

To describe our recent experience using a 6.9F cytoscope in the fulguration of posterior urethral valves (PUVs) in premature neonates and distal ureteroscopy with stone extraction in children.

METHODS

Fulguration of PUVs was performed in 3 premature neonates born at 34 to 36 weeks' gestation with weights of 2480 to 2900 g. The PUVs were fulgurated during a single endoscopic procedure using a 6.9F cystoscope and a 3F bugbie electrode. In addition, 11 children (8 girls, 3 boys; mean age, 11.1 years; range 5 to 16) with symptomatic calculi underwent 15 distal ureteroscopic procedures using the 6.9F cystoscope.

RESULTS

In the neonates with fulguration of PUVs, vesicostomy, the only reasonable alternative, was avoided, and each infant now voids with an excellent stream 3 to 16 months later, without evidence of stricture or residual valves. In the children with distal ureteroscopy, the ureteral calculi were retrieved using a 3F four-wire stone basket. With one exception, distal ureteroscopy was performed without dilation of the ureteral orifice. Extracorporeal shock-wave lithotripsy (ESWL) was not recommended because of stone position and difficult radiographic visualization. Nine children were rendered stone free with one procedure. Two procedures were required in 1 child and three in another. In both cases, ureteral edema was present, and the stone was embedded in the ureteral wall. One child underwent separate procedures for bilateral calculi. In all cases general anesthesia was used, with a mean duration of 63 minutes (range 28 to 96). Temporary ureteral stenting was performed in 10 (93%) patients, and 9 (81%) were discharged home on the same day or the next morning. A mean follow-up period of 8.5 months (range, 0.5 to 22) has failed to show any problems related to ureteral stricture or injury.

CONCLUSIONS

Endoscopic fulguration of PUVs is now possible in small neonates and is minimally invasive compared with vesicostomy. Distal ureteroscopy with stone retrieval should be considered in children, especially those with calculi that are not suitable for ESWL.

Ureterolithotripsy in children

OBJECTIVES

The pediatric application of ureteroscopy was initially hindered by the size of the instruments and the fear of damaging the urethra and ureterovesical junction during endoscopic maneuvers. This review of our experience is focused on the usefulness of thin and ultrathin ureteroscopes such as the 7 F Gautier rigid ureteroscope with rod lens optics (Wolf) or the new, ultrathin 4.8 F Wolf ureteroscope, semirigid, fiberoptic, in conjunction with atraumatic sources of energy such as pulsed dye laser or ballistic lithotripter, for the treatment of ureteral stones in children.

METHODS

Between 1989 and 1994, we performed ureteroscopy and ureterolithotripsy on 7 children less than 10 years old. There were 6 male patients and 1 female patient, with a mean age of 6 years (range, 3.5 to 10). We used the pulsed dye laser Pulsolith and the ballistic lithotripter Lithoclast, the Gautier (Wolf) rigid, rod lens ureteroscope (7 F), without the sheath or the blunt needle 4.8 F semirigid (Wolf), fiberoptic ureteroscope. In all cases a double pigtail ureteral catheter was left in situ.

RESULTS

In all 7 cases, the treatment was successful without early or delayed complications. In particular, no case of vesicoureteral reflux was observed in any of the children during subsequent follow-ups.

CONCLUSIONS

This article demonstrates the feasibility of ureteroscopy and ureterolithotripsy in children less than 10 years old with ureteral stones. We believe that because of the fragility of the ureter in the pediatric age group, ureteroscopic maneuvers should be performed and handled by experienced endourologists in well-equipped centers.

Pediatric urolithiasis: review of research and current management

The treatment of urolithiasis in children has changed dramatically in recent years. With the proven safety and efficacy of extracorporeal shock wave lithotripsy (ESWL), percutaneous lithotripsy and ureteroscopy in adults, these modalities are now in the forefront of the treatment of pediatric urinary stones. Our research in the juvenile non-human primate with ESWL indicates that renal damage in most cases is neither significant or persistent. In addition, technological advances in instrumentation have cleared the way for the use of percutaneous lithotripsy and ureteroscopy in most pediatric patients. Today, open surgical procedures for stone disease in children should be a last resort.

Percutaneous transvesical ureteroscopy for removal of distal ureteral stone in reimplanted ureter

In the past two decades, the widespread use of cross-trigonal ureteral reimplants for the treatment of children with vesicoureteral reflux has resulted in a large population of patients with transversely lying ureters. As this population gets older they will consequently be entering an age group at higher risk for stone and urothelial cancer formation, with the potential for diagnostic and/or therapeutic ureteroscopy. The anatomic orientation of the ureters resulting from a cross-trigonal reimplantation may create difficulty or even inability to perform transurethral ureteroscopy. This case presents the technique of percutaneous transvesical ureteroscopy for stone extraction in a seventeen-year-old male with a lower ureteral stone following cross-trigonal ureteral reimplantation. The described technique may serve as an addition to the current endoscopic methods.

Safety and efficacy of pediatric ureteroscopy for management of calculous disease

Ureteral calculi, although relatively uncommon in children in the United States, have traditionally been managed with open surgical removal. Innovations in managing ureteral stones in the adult population have not readily been used to manage such problems in children due to unknown effects on the ureterovesical junction and to the unavailability of smaller caliber ureteroscopes. We report on the technique and long-term (average 26 months, range 3 to 56) safety following 18 successful ureteroscopic procedures for stone removal in 16 patients 16 months to 15 years old. All children were rendered stone-free. Followup quantitative renal scans and excretory urography showed adequate renal growth. No incidence of vesicoureteral reflux occurred in 9 of the 14 patients (64%) available for followup who underwent postoperative cystograms. These results suggest that judicious use of smaller caliber instruments, improved ancillary equipment and experience in such procedures make ureteroscopy a safe procedure for management of ureteral calculi in children.