Application of Pneumatic Lithotripter and Holmium Laser in the Treatment of Ureteral Stones and Kidney Stones in Children

Surgical treatment of pediatric urolithiasis

Introduction: Surgical treatment of urolithiasis in children is quite complex and specific due to certain anatomical and functional features of childhood. Methods of surgical treatment at this age are: extracorporeal lithotripsy (ESWL), intracorporeal (endoscopic) lithotripsy - pneumatic and laser, percutaneous nephrolithotripsy (PCNL) and open surgery. Aim: The aim of this study was evaluation of the effects of ureterorenoscopy and endoscopic lithotripsy in children, as methods of minimally invasive surgical treatment. Material and methods: The retrospective study was conducted at the Institute for Mother and Child Health Care of Serbia "Dr Vukan Cupic" in Belgrade from 2010 to 2020. The study included 112 patients (50 boys and 62 girls) aged 1-18 years with urolithiasis, treated by endoscopic (laser or pneumatic) lithotripsy. The retrospective study was conducted at the Institute for Mother and Child Health Care of Serbia "Dr Vukan Cupic" in Belgrade from 2010 to 2020. The study included 112 patients (50 boys and 62 girls) aged 1-18 years with urolithiasis, treated by endoscopic (laser or pneumatic) lithotripsy. Results: After one ureterorenoscopy, the calculus was successfully disintegrated in 87 (78%) patients: in the renal pelvis in 22 (79%), in the upper pole calices of the kidney in 14 (100%), in the lower pole calices in 10 (50%), in the proximal segment of the ureter in 10 (83%), in the distal segment of the ureter in 27 (79%), in the bladder in 4 (100%) cases. In 19 (17%) patients the second intervention was necessary: in the renal pelvis in 28 (100%), in the upper pole calices in 14 (100%), in the lower pole calices in 14 (70%), in the proximal segment of the ureter in 12 (100%), in the distal segment of the ureter in 34 (100%) and in the bladder in 4 (100%) patients. Conclusion: The primary treatment of pediatric urolithiasis is ureterorenoscopy in combination with pneumatic or laser lithotripsy. It is successfully used in all segments of the urinary tract. The procedure is partially limited in the lower pole calices of the kidney, due to anatomical circumstances and mechanical limitations of the instruments.

Comparison of mean operative time in patients undergoing Ho: YAG laser lithotripsy and pneumatic lithotripsy in ureterorenoscopy for ureteric calculus

Objective

To compare the mean operative time (MOT) in patients undergoing Ho: YAG laser lithotripsy (LL) and pneumatic lithotripsy (PL) for ureteric stones.

Methods

This randomized study was conducted at Armed Forces Institute of Urology (AFIU) Rawalpindi, Pakistan from July 2016 to November 2018. Non probability consecutive sampling technique utilized to enroll 60 patients of both gender aged 18-60 years, having ureteric calculus ≤1.5cm. Randomization was done into group I (LL) and II (PL) via computer generated number tables. Six Consultant Urologists performed surgeries under spinal anesthesia utilizing Swiss Lithoclast^® Master (EMS⁺ S.A. Switzerland) in group II and holmium laser fiber (365μm, 8-10Hz, 9.6-16W, 2100nm wavelength) in group I respectively. MOT was noted from insertion of cystoscope till removal out of meatus. Data obtained was analyzed through IBM SPSS 24.0.

Results

Analysis involved 60 patients (30 each group) having similar baseline characteristics (age, gender, laterality, location). There was statistically significant different MOT between LL & PL (25.48±6.99 vs 34.83± 7.47 minutes, p < 0.001). Data stratification with respect to age, gender, laterality and stone location revealed similar trend. Lithotripsy technique significantly affected MOT (p < 0.001) on Multiple Linear Regression Analysis.

Conclusions

Ho: YAG LL is an efficient technique when compared with PL in terms of MOT for ureteric stones.

Ho:YAG laser versus pneumatic lithotripsy for management of pediatric ureteral stones: a prospective-comparative analysis with adults

BACKGROUND

There are limited number of studies comparing the results of Holmium:YAG laser lithotripsy (LL) and pneumatic lithotripsy (PL) for pediatric ureteral stones.

OBJECTIVES

To perform a comparative analysis of LL and PL in the management of ureteral stones in children and adults.

STUDY DESIGN

Ninety-eight children (56 boys and 42 girls) and 623 adults (360 men and 263 women), who were treated for ureteral stones at our clinic between 2017 and 2019, were the subjects of this study. Patients were grouped according to their age as group 1 (n:98, pediatric [<18 age]) and group 2 (n:623, adult [≥18 age]). The patients were then grouped according to lithotripter type as laser (n:580) and pneumatic (n:141). The effects of lithotripter type, stone size and location, and operative times on success and complication rates were investigated.

RESULTS

In both groups, mean operation time was in favor of PL (14.6 vs 22.8 min, p = 0.042 and 26.4 vs 36.3 min, p = 0.013, respectively). In both groups, overall stone-free rates (SFR) were in favor of LL (86.8% vs 66.7%, p < 0.001, and 83% vs 73.9%, p = 0.005, respectively), but there was no significant difference in overall SFRs between adults and children (78.4% vs 76.7, p = 0.390). Retreatment rates were higher in the pneumatic group in both children and adults (p = 0.026 and p = 0.041, respectively). While there was no significant difference in the overall complication rates between adults and children (53.5% vs 40.6%, p = 0.816), the rate of complications with LL was lower in adults (37.7% vs 69.4%, p < 0.001) (TABLE).

DISCUSSION

This paper is the first to report a comparative analysis of factors affecting URS success in adults and children. SFRs were higher in all ureteral locations for LL. LL, lower ureteral location, and <6 mm ureteral stone were determined as the predictors of success for both pediatric and adult patients. The presence of multiple surgeons with different levels of experience is the main limitation of this study.

CONCLUSION

Both LL and PL are safe in children and adults with similar clinically insignificant complication rates. However, in the short term, LL provides better SFRs in both children and adults, especially in the upper ureteral stones. Surgeons should decide the energy technique to be used in URS according to the characteristics of the stone rather than the patient's age group.

Laser Versus Pneumatic Lithotripsy With Semi-Rigid Ureteroscope; A Comparative Randomized Study

Introduction: Ureteral stones are among the most common disorders in the urologic field. Miniaturization of endoscopic devices in urology and extracorporeal shock wave lithotripsy (ESWL) has revolutionized the management of ureteral stones. The aim of this study was to compare the efficacy and results of laser versus pneumatic lithotripsy (PL) with semi-rigid ureteroscope in a randomized prospective clinical trial in removing stones. Methods: 117 adult patients underwent transurethral lithotripsy (TUL) in a single academic center and by a single surgeon. The patients were randomized in 2 groups: In group 1, 58 patients with ureteral stones underwent ureteroscopy and stone fragmentation was done by Ho: YAG laser lithotripsy (LL) and in group 2, 59 patients underwent PL (Swiss LithoClast) by using the same ureteroscope. Results: Mean age was 41.77 years and 41.1years in group one and 2 respectively (P=0.79), there was no significant difference in male to female ratio and mean stone in both groups. The success rate for stone clearance was 79.31% and 77.96% in group 1 and 2 respectively (P=0.52). No difference between complications was seen in both groups, but the duration of operations was different (significantly lower in group 2). Conclusion: In both techniques, acceptable results were achieved. We have found a significant statistical difference in duration of operation between our results (P=0.001) and similar studies, while this was shorter in the pneumatic group in our study, it was longer in other similar ones. This might be a result of more experience in working with PL in our center.

Update on Surgical Management of Pediatric Urolithiasis

Urolithiasis has always been a fascinating disease, even more so in children. There are many intriguing facets to this pathology. This article is a nonsystematic review to provide an update on the surgical management of pediatric urolithiasis. It highlights the pros and cons of various minimally invasive surgical options such as extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), laparoscopy, and robotics. This article also describes the various intracorporeal disintegration technologies available to fragment the stone, including the newer advancements in laser technology. It also emphasizes the cost considerations especially with reference to the emerging economies. Thus, this manuscript guides how to select the least-invasive option for an individual patient, considering age and gender; stone size, location, and composition; and facilities and expertise available.