Curr Urol Rep (2014) 15:407 DOI 10.1007/s11934-014-0407-4
MINIMALLY INVASIVE SURGERY (V BIRD AND M DESAI, SECTION EDITORS)
Ureteroscopy for Treatment of Upper Urinary Tract Stones in Children: Technical Considerations Natasha Gupta & Joan Ko & Brian R. Matlaga & Ming-Hsien Wang
Published online: 23 March 2014 # Springer Science+Business Media New York 2014
Abstract The incidence of pediatric urolithiasis is increasing. While many smaller stones may pass spontaneously, surgical therapy is sometimes warranted. Surgical options include shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery. Ureteroscopy represents a minimally invasive approach, and it is increasingly being used to treat pediatric upper tract calculi. Ureteroscopy is performed under anesthesia and fluoroscopic guidance, with basket extraction or lithotripsy of the calculi. Technical considerations include active or passive ureteral dilatation, the use of ureteral access sheaths for larger stone burdens, and postoperative stent placement. The current pediatric literature suggests high success rates (equal to or surpassing shock wave lithotripsy) and low complication rates. However, concerns
Natasha Gupta and Joan Ko contributed equally to this manuscript.
remain regarding feasibility in patients with variant anatomies and risk due to intra-operative radiation exposure. Keywords Kidney calculi/surgery . Surgical procedures . Minimally invasive/methods . Ureteroscopy/methods . Ureteroscopes . Treatment outcome
Introduction The current surgical management of pediatric urolithiasis is evolving. Recent advancements in optics and equipment have rendered minimally invasive approaches more feasible in the pediatric population. Therefore, ureteroscopy for upper tract calculi is emerging as an increasingly popular approach, and there have been several recent advancements in the literature regarding safety, efficacy, and future directions.
This article is part of the Topical Collection on Minimally Invasive Surgery N. Gupta The Johns Hopkins University School of Medicine, 733 North Broadway Street, Baltimore, MD 21205, USA e-mail: [email protected] M.1.5 cm), lower pole stones larger than 1 cm in diameter, concurrent anatomic abnormalities that impair urinary drainage and stone passage, or known cystine or struvite stones [22]. For patients with smaller and less complex stone burdens, SWL and URS are more commonly utilized. Since its introduction in the 1980s, SWL has revolutionized minimally invasive treatment of urolithiasis. In 1986, Newman et al. [23] published the initial report on successful use of SWL in children, which was quickly followed by a body of data reporting on its safety and efficacy in comparison to its use in adult patients. However, despite this robust body of literature demonstrating its safety and efficacy, it should be noted that SWL for pediatric urolithiasis is not an FDAapproved indication for this technology. Historically, SWL was indicated for primary therapy for children with upper tract calculi less than 1.5 cm. URS was generally only used for stones below the level of the iliac crests that were difficult to target using SWL and for upper tract stones after SWL failure [24]. URS was not used as first line therapy due to concern for ureteral ischemia, perforation, stricture formation, development of vesicoureteral reflux as a result of dilation of small caliber ureteral orifices, and the large caliber, rigid nature of the endoscopes. However, with recent improvements in visualization and optics, as well as the miniaturization of equipment, the use of URS in upper tract calculi has expanded. As URS has been shown in multiple series to be a safe and efficacious treatment for children with stones [6, 25•, 26, 27, 28•], it is being used for first-line treatment of stones that would have otherwise been treated with SWL in an increasing number of centers [6]. In particular, studies have suggested that URS may yield a higher stone-free rate than SWL. While URS is contraindicated in the setting of staghorn calculi better suited to be removed by PCNL, aberrant anatomy that complicates retrograde access, prior bladder neck reconstruction or closure, prior cross-trigonal reimplant, and prior endoscopic failure [6], it is particularly well-suited for cystine and calcium oxalate monohydrate stones that are resistant to SWL and are not of a size that require PCNL (Table 1). URS is almost always performed under general anesthesia in order to avoid patient movement during ureteral instrumentation. Appropriate pre-operative antibiotics are administered, and patients are placed in the dorsal lithotomy position. An age-appropriate rigid cystoscope (7.5Fr, 11Fr, or 18Fr) is used for cystoscopy with placement of a guidewire into the distal
Page 3 of 5, 407 Table 1 Relative indications and contraindications for pediatric ureteroscopy: stone and patient characteristics Stone characteristics Size
MINIMALLY INVASIVE SURGERY (V BIRD AND M DESAI, SECTION EDITORS)
Ureteroscopy for Treatment of Upper Urinary Tract Stones in Children: Technical Considerations Natasha Gupta & Joan Ko & Brian R. Matlaga & Ming-Hsien Wang
Published online: 23 March 2014 # Springer Science+Business Media New York 2014
Abstract The incidence of pediatric urolithiasis is increasing. While many smaller stones may pass spontaneously, surgical therapy is sometimes warranted. Surgical options include shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery. Ureteroscopy represents a minimally invasive approach, and it is increasingly being used to treat pediatric upper tract calculi. Ureteroscopy is performed under anesthesia and fluoroscopic guidance, with basket extraction or lithotripsy of the calculi. Technical considerations include active or passive ureteral dilatation, the use of ureteral access sheaths for larger stone burdens, and postoperative stent placement. The current pediatric literature suggests high success rates (equal to or surpassing shock wave lithotripsy) and low complication rates. However, concerns
Natasha Gupta and Joan Ko contributed equally to this manuscript.
remain regarding feasibility in patients with variant anatomies and risk due to intra-operative radiation exposure. Keywords Kidney calculi/surgery . Surgical procedures . Minimally invasive/methods . Ureteroscopy/methods . Ureteroscopes . Treatment outcome
Introduction The current surgical management of pediatric urolithiasis is evolving. Recent advancements in optics and equipment have rendered minimally invasive approaches more feasible in the pediatric population. Therefore, ureteroscopy for upper tract calculi is emerging as an increasingly popular approach, and there have been several recent advancements in the literature regarding safety, efficacy, and future directions.
This article is part of the Topical Collection on Minimally Invasive Surgery N. Gupta The Johns Hopkins University School of Medicine, 733 North Broadway Street, Baltimore, MD 21205, USA e-mail: [email protected] M.1.5 cm), lower pole stones larger than 1 cm in diameter, concurrent anatomic abnormalities that impair urinary drainage and stone passage, or known cystine or struvite stones [22]. For patients with smaller and less complex stone burdens, SWL and URS are more commonly utilized. Since its introduction in the 1980s, SWL has revolutionized minimally invasive treatment of urolithiasis. In 1986, Newman et al. [23] published the initial report on successful use of SWL in children, which was quickly followed by a body of data reporting on its safety and efficacy in comparison to its use in adult patients. However, despite this robust body of literature demonstrating its safety and efficacy, it should be noted that SWL for pediatric urolithiasis is not an FDAapproved indication for this technology. Historically, SWL was indicated for primary therapy for children with upper tract calculi less than 1.5 cm. URS was generally only used for stones below the level of the iliac crests that were difficult to target using SWL and for upper tract stones after SWL failure [24]. URS was not used as first line therapy due to concern for ureteral ischemia, perforation, stricture formation, development of vesicoureteral reflux as a result of dilation of small caliber ureteral orifices, and the large caliber, rigid nature of the endoscopes. However, with recent improvements in visualization and optics, as well as the miniaturization of equipment, the use of URS in upper tract calculi has expanded. As URS has been shown in multiple series to be a safe and efficacious treatment for children with stones [6, 25•, 26, 27, 28•], it is being used for first-line treatment of stones that would have otherwise been treated with SWL in an increasing number of centers [6]. In particular, studies have suggested that URS may yield a higher stone-free rate than SWL. While URS is contraindicated in the setting of staghorn calculi better suited to be removed by PCNL, aberrant anatomy that complicates retrograde access, prior bladder neck reconstruction or closure, prior cross-trigonal reimplant, and prior endoscopic failure [6], it is particularly well-suited for cystine and calcium oxalate monohydrate stones that are resistant to SWL and are not of a size that require PCNL (Table 1). URS is almost always performed under general anesthesia in order to avoid patient movement during ureteral instrumentation. Appropriate pre-operative antibiotics are administered, and patients are placed in the dorsal lithotomy position. An age-appropriate rigid cystoscope (7.5Fr, 11Fr, or 18Fr) is used for cystoscopy with placement of a guidewire into the distal
Page 3 of 5, 407 Table 1 Relative indications and contraindications for pediatric ureteroscopy: stone and patient characteristics Stone characteristics Size
![[Flexible laser ureteroscopy in the treatment of upper urinary tract stones: results about 166 interventions].](/assets/img/hold.png)
