Original Article

Laparoscopic Ureterolithotomy in Children: With and Without Stent — Initial Tertiary Care Center Experience with More Than 1-Year Follow-Up Ishwar Ram Dhayal1,

Priyanka Rai2,

1 Department of Urology and Renal Transplant, Dr. Ram Manohar Lohia

Institute of Medical Sciences, Lucknow, Uttar Pradesh, India 2 Department of Surgery, Baba Raghav Das Medical College Ringgold Standard Institution, Gorakhpur, Uttar Pradesh, India, 

Address for correspondence Alok Srivastava, MCh, Urology and Renal Transplant, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh 226010, India (e-mail: [email protected]).

The authors Ishwar Ram Dhayal and Priyanka Rai contributed equally to the article. Eur J Pediatr Surg

Abstract

Keywords

► children ► stent ► laparoscopic ureterolithotomy

Background The purpose of our study was to assess the safety and feasibility of transperitoneal laparoscopic ureterolithotomy (LU) in children with ureteric stones with and without a stent. Method Impacted ureteric stone of size  1.5 cm or ureteric stones that were refractory to shock wave lithotripsy (SWL)/ureteroscopy (URS) were considered for LU. From December 2009 to April 2012, 50 cases of LU were performed with a stent being placed. From May 2012 onward we now perform stentless LU and till now we have done approximately 64 such type of cases. Out of these, 48 have completed more than 1 year of follow-up and we took these as our study group and the previous 50 (LU with stent) as our control group. Baseline characteristics along with certain per- and postoperative findings of the two groups were noted and analyzed. Ultrasonography and X-ray kidney, ureter, and bladder region were done at 3, 9 months, 1 year, and yearly thereafter. Intravenous urography was done at 6 months statistical analysis was performed by using SPSS ver. 21 (SPSS Inc., Chicago, Illinois, United States). The data were analyzed by using the Mann–Whitney test and a p value of < 0.05 was considered significant. Results The baseline characteristics were similar in both the groups with 100% stone clearance in all. LU with stent differed from the stentless group in terms of more requirement of analgesics and the need for a second procedure for stent removal, but with no cases of urine leak in the postoperative period. Conclusion LU in children is a safe and viable option, especially for impacted stones or as a salvage procedure for ureteric stones when SWL or transureteral lithotripsy has failed.

Introduction Approximately 5 to 10% of the human population suffers from urolithiasis in their lifetime, and of these only 1 to 3% are

received August 11, 2015 accepted after revision January 15, 2016

children.1 Pediatric urolithiasis is an uncommon occurrence, but the incidence has been increasing over the last decade. While the disease has been reported to be rather rare in some countries, such as Scandinavia, it is still an endemic problem

© Georg Thieme Verlag KG Stuttgart · New York

DOI http://dx.doi.org/ 10.1055/s-0036-1572551. ISSN 0939-7248.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Alok Srivastava1

in developing ones like Turkey, Iran, Northern India, Pakistan, and the Far East. Stones in children proportionately affect any age group.2 Till a few years back open surgery (OS) was the mainstay of surgical management in children, but improvements in technology and growing experience have resulted in greater acceptance of minimally invasive surgery (MIS) for the management of pediatric stones and currently urologists can benefit from the whole spectrum of stone management alternatives in children. Although MIS is being widely, used in developing countries OS is still being done in approximately 30% of these patients.3 In the developing world about 15% of children who present with urolithiasis have ureteric stones.4 Currently, the majority of ureteric stones in children can be managed either with shock wave lithotripsy (SWL), ureterorenoscopy (URS) or percutaneous nephrolithotomy (PNL) but laparoscopic approach has been rarely used in children, despite being popular in adults. The reason probably could be because of no clear cut indications and lack of logistics and surgical skills. The wide spectrum of pediatric upper urinary tract calculi asks for an approach which is technically feasible, focuses on reducing morbidity and hospital stay, and is also cosmetically acceptable. We are reporting our initial experience with transperitoneal laparoscopic ureterolithotomy (LU) with and without a Stent, with at least 1 year of follow-up. To our knowledge, our study represents the largest published series of LU in children.

Method At our institute the indications of LU in children were impacted ureteric stone of size  1. 5 cm or ureteric stones that were refractory to SWL or had a history of failed URS/PNL or in some cases parent choice. Exclusion criteria were coagulation disorder, active urinary tract infection, and conversion to open. From December 2009 to April 2012, 50 cases of LU were performed with a stent being placed after LU. From May 2012 onwards we now perform stentless LU and by now we have performed approximately 64 cases of LU without placing a stent. Out of these, 48 have completed more than 1 year of follow-up and we took these as our study group and the previous 50 (LU with stent) as our control group. Baseline characteristics, operation time, stone-free status, blood loss, urine leak, drain removal, and postoperative complications of the two groups were noted and analyzed. Radiographic studies by renal ultrasound, plain film were done at 3 , 9 months, 1 year, and yearly thereafter. Intravenous urography was done at 6 months after the procedure. Statistical analysis was performed by using SPSS ver. 21 (SPSS Inc., Chicago, Illinois, United States). The data were analyzed by using the Mann–Whitney test and a p value < 0.05 was considered statistically significant.

Technique of Laparoscopic Ureterolithotomy In supine position with a lateral tilt and head low, conventional three-port laparoscopy is performed. Pneumoperitoneum was kept around 8 to 10 mm Hg for the whole length of the procedure. An umbilical optical port (5 mm, 30-degree European Journal of Pediatric Surgery

Srivastava et al.

telescope) and two 5 mm (3 mm for smaller children) instrument ports in the ipsilateral paraumbilical and suprapubic region are placed for lower ureteric stones. For upper and midureteric stones the two working ports were placed on the lateral border of rectus on opposite sides of the camera port. After reflecting the colon and identifying the ureter a loose knot with a vascular sling is placed proximal to the stone to avoid its slippage into the proximal dilated ureter. A vertical incision is made in the ureter over the stone and the rest of the stone is delivered out. The distal ureter is flushed to check for patency and the ureterotomy is closed with Vicryl 4–0 sutures (Ethicon Inc., Somerville, New Jersey, United States) with care taken not to tie the sutures too tightly. The stent was placed in a supine position after completing the main surgery in the control group.

Results The mean age in both the groups along with other characteristics, such as gender ratio, stone size, history of previous procedures, etc., were similar (►Table 1). The operating time was more in the control group as compared with the study group (80.55  15.65 vs. 71. 11  11.12 minutes) although it was not significant. The stone free rates were 100% in both the groups, but time to drain removal and hospital days (2.89  1.43 vs. 4.11  1.32 days) although insignificant, were more in the nonstent group (►Table 2).There were two cases of prolonged drain output (urine leak) in the nonstent group (4.2%) but the drain output became negligible on conservative management between fifth and sixth day. In the stented group drainage was not more than 50 mL/24 hours, and the drain was removed after approximately 24 hours after the surgery. The analgesia requirements and the use of anticholinergics was more in the stented group. Mild hematuria was noted in six patients of the stent group and subsided on stent removal. All stents had to be removed under anesthesia and required a second admission. The mean follow-up in the stent group was 2.6 years and in the other group was 1.5 years. There was no occurrence of stricture as well as recurrence of stones in the ureter (►Table 3).

Discussion The incidence of urolithiasis in the pediatric population is on the rise. Management of the urinary stones in children poses a specific technical challenge to the urologist as anatomic anomalies and metabolic conditions are found in 30 and 50%, respectively. The aims of the management should be a complete clearance of stones, preservation of renal function, and prevention of recurrence. SWL is the treatment modality for ureteric stone less than 1.5 cm but, there is still a lot of debate on the minimum safe age, number of sittings permitted, and concern about acute or long-term complications. Though SWL is highly successful for ureteric stones < 1cm, its success in stones of size > 1 cm is not so appreciable.5–7 Lima et al in their study found out SWL results for ureteric stones better than those of renal calculi, but they reported a failure rate of 38% for stones > 1 cm. Increase in size means more

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Laparoscopic Ureterolithotomy in Children: With and Without Stent

Laparoscopic Ureterolithotomy in Children: With and Without Stent

Srivastava et al.

Table 1 Characteristics of patients with ureteric stone Patient characteristics

Stented group

Nonstented group

p Value

Age (y)

7.89  1.36 (4.2–13.8)

8.01  1.45 (3.5–14.1)

0.623

Sex

0.724

Female

18

17

Male

32

31

Laterality

0.35 26

Right

24

24

4.33  2.12

4.67  1.89

Duration of symptoms (mo)

24 0.75

Indication

0.88

Size > 1.5 cm

30

30

Failed SWL/URS/PNL

14

14

Parent preference

6

4

Location

0.91

Upper

28

27

Middle

15

14

Lower

7

7

2.17  0.78

2.25  0.35

Size of stone

0.67

Abbreviations: PNL, percutaneous nephrolithotomy; SWL, shock wave lithotripsy; URS, ureterorenoscopy.

Table 2 Perioperative data Stented group

Nonstented group

p Value

Operative time (min)

80.55  15.65

71.11  11.12

0.06

Estimated blood loss (mL)

39.55  9.56

40.01  10.34

0.87

Stone free rate (%)

100

100

Urine leak

0

2

0.41

Time to drain removal (d)

2.11  1.2

3.95  1.4

0.07

Analgesia requirements (acetaminophen)

4,260  850 mg

2,440  720 mg

0.03

Hospital stay (d)

2.89  1.43

4.11  1.32

0.06

Anticholinergic requirement (n)

18

2

< 0.0001

Second procedure (DJR)

50

0

Not needed

Abbreviation: DJR, double J stent removal.

number of sessions under anesthesia8 with increased costs. Also in children, steinstrasse is observed in 5.4 to 10% of patients, a complication related to stone size larger than 20 mm.7,9,10 With the availability of 4.5 and 6F semirigid ureteroscopes and a 6.9F flexible ureterorenoscope with Ho:YAG laser energy source, URS has become more common in children with success rates ranging from 86 to 100% with lower rates for upper ureteral calculi and large stones.11 But miniaturization of instruments has led to increased costs as has the use of lasers. Increased costs and nonavailability of such instruments is a major drawback in the developing world. Also retreatment rates could be high for large, impacted stones and according to some studies there is also a small, although significant risk of vesicoureteral reflux12,13

Unlike in adults where the OS is required in only less than 2 to 3% of cases, the incidence of OS in children ranges from 0.3 to 30%, depending upon certain factors such as complexity, stone burden, availability of logistics, degree of experience, and the socioeconomic status.4,14 In developing countries large stone burden, neglected stones with renal failure and lack of tertiary centers necessitate open surgical procedures as the therapy of choice in a significant number of patients. Since almost all open surgical techniques may be reproduced by laparoscopy and with the increasing experience of laparoscopy in adults more urologists are now applying this art in children.15 LU is ideal in the setting of large impacted stones, stones with previously failed SWL/URS, and in certain anatomical conditions such as stones in implanted ureters. Small incisions, less pain, shorter hospitalization and one time European Journal of Pediatric Surgery

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Left

Table 3 Complications Complications

Stented group

Nonstented group

p Value

Early Fever

3

1

0.64

Ileus

0

2

0.75

UTI

2

0

0.64

Urine leak

0

2

0.73 0.76

Omental prolapse

0

1

Wound complications

1

0

Mild hematuria

6

0

Ureteral stricture

0

0

Port site hernia

0

0

Recurrence of stone

0

0

0.02

Late

Abbreviation: UTI, urinary tract infection.

clearance have made it an attractive option in children. Also the pediatric laparoscopic instrument can be used in a variety of other surgeries apart from urology thus justifying its cost. Ko et al16 compared URS with LU for treatment of large upper ureteric calculi. Stone clearance was significantly higher in the laparoscopy group and therefore they concluded that LU can be performed as a first-line procedure in impacted ureteral stones. Lopes et al17 compared postoperative outcomes of SWL, LU, and URS in treatment of large proximal ureteral stones. They concluded that LU results in greater success and lesser ancillary procedures. Although these series have adult patients we found similar success in our series. In all the patients of both the groups there was 100% stone clearance with no ancillary procedures required and minimal complications. Such results have also been reported by Agarwal et al18 who in the series of laparoscopic lithotomy in children performed 10 LU (without stent) and reported 100% success rate. Whether the ureterotomy should be sutured and whether the ureter should be stented are controversial questions in the literature. We performed the first 50 cases with a stent being placed (after the surgery), but stent removal in children required general anesthesia/sedation and therefore was a drawback. So inspired by some series of successful LU without a stent18–22 we started doing stentless LU and have found it to be equally safe and effective with less pain, stent problems, and procedures performed. In both the groups the ureterotomy was closed with interrupted 4–0 Vicryl sutures taking care that they are not too tight to avoid ischemia. There were no strictures in both the groups, although the follow-up in group 2 was only 1.5 years. We chose a minimum follow-up of 1 year as most of the strictures occur within a period of 1 year.19 There were only two cases in group 2 of prolonged drain output (urine leak) which subsided by day 6. In both the cases the mucosa of the ureter was badly inflamed and taking sutures was a little difficult because of the fragility. Putting in European Journal of Pediatric Surgery

Srivastava et al.

the stent in this case could have decreased the morbidity as two such cases in the control group did not have any significant leak. We, therefore, assume that it is not necessary to stent the ureter routinely until and unless the mucosa is badly inflamed or scarred. Postoperatively, the requirement of analgesia was significantly higher in the stented group as was the need of anticholinergics. Two patients in the above group required, stent removal on 10th day due to severe stent-related symptoms. Mild hematuria was common in group 1 and was a source of anxiety among parents. Hematuria subsided in all such cases after stent removal. The main limitation of our study was the number of patients and for comparison of results, the data available in the literature of laparoscopic management of pediatric urolithiasis are very limited.18,23 From the present series, LU for ureteric stones appears to be safe and effective with a minimal failure rate and complications especially for large-impacted stones. The decision whether a stent is to be omitted, requires further validation in randomized controlled trials on a larger number of patients, but it seems prudent that decision should be on a case-to-case basis and in those whom ureteric mucosa is badly inflamed a stent should be placed.

Conclusion LU is a safe and viable option in children, with stentless LU having the advantage of avoidance of a second procedure under anesthesia, with low requirements of analgesics and anticholinergics. This technique can be used as a first-line treatment for impacted ureteral stones or as a salvage procedure for ureteric stones when SWL or transureteral lithotripsy has failed.

Conflict of Interest None.

References 1 Sarica K. Pediatric urolithiasis: etiology, specific pathogenesis and

medical treatment. Urol Res 2006;34(2):96–101 2 Kroovand RL. Pediatric urolithiasis. Urol Clin North Am 1997;

24(1):173–184 3 Rizvi SA, Sultan S, Ijaz H, et al. Open surgical management of

4

5

6

7

8

pediatric urolithiasis: A developing country perspective. Indian J Urol 2010;26(4):573–576 Rizvi SA, Naqvi SA, Hussain Z, et al. Management of pediatric urolithiasis in Pakistan: experience with 1,440 children. J Urol 2003;169(2):634–637 da Cunha Lima JP, Duarte RJ, Cristofani LM, Srougi M. Extracorporeal shock wave lithotripsy in children: Results and short-term complications. Int J Urol 2007;14(8):684–688 Basiri A, Zare S, Shakhssalim N, Hosseini Moghaddam SM. Ureteral calculi in children: what is best as a minimally invasive modality? Urol J 2008;5(2):67–73 Wadhwa P, Aron M, Seth A, Dogra PN, Hemal AK, Gupta NP. Pediatric shockwave lithotripsy: size matters!. J Endourol 2007; 21(2):141–144 Aldridge RD, Aldridge RC, Aldridge LM. Anesthesia for pediatric lithotripsy. Paediatr Anaesth 2006;16(3):236–241

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Laparoscopic Ureterolithotomy in Children: With and Without Stent

Srivastava et al.

9 Aksoy Y, Özbey I, Atmaca AF, Polat O. Extracorporeal shock wave

17 Lopes Neto AC, Korkes F, Silva JL II, et al. Prospective randomized

lithotripsy in children: experience using a mpl-9000 lithotriptor. World J Urol 2004;22(2):115–119 Picramenos D, Deliveliotis C, Alexopoulou K, Makrichoritis C, Kostakopoulos A, Dimopoulos C. Extracorporeal shock wave lithotripsy for renal stones in children. Urol Int 1996;56(2): 86–89 Turunc T, Kuzgunbay B, Gul U, et al. Factors affecting the success of ureteroscopy in management of ureteral stone diseases in children. J Endourol 2010;24(8):1273–1277 Hill DE, Segura JW, Patterson DE, Kramer SA. Ureteroscopy in children. J Urol 1990;144(2 Pt 2):481–483, discussion 492–493 Thomas R, Ortenberg J, Lee BR, Harmon EP. Safety and efficacy of pediatric ureteroscopy for management of calculous disease. J Urol 1993;149(5):1082–1084 Zargooshi J. Open stone surgery in children: is it justified in the era of minimally invasive therapies? BJU Int 2001;88(9):928–931 Fragoso AC, Valla JS, Steyaert H, Arnaud P, Esposito C, EstevãoCosta J. Minimal access surgery in the management of pediatric urolithiasis. J Pediatr Urol 2009;5(1):42–46 Ko YH, Kang SG, Park JY, et al. Laparoscopic ureterolithotomy as a primary modality for large proximal ureteral calculi: comparison to rigid ureteroscopic pneumatic lithotripsy. J Laparoendosc Adv Surg Tech A 2011;21(1):7–13

study of treatment of large proximal ureteral stones: extracorporeal shock wave lithotripsy versus ureterolithotripsy versus laparoscopy. J Urol 2012;187(1):164–168 Agrawal V, Bajaj J, Acharya H, Chanchalani R, Raina VK, Sharma D. Laparoscopic management of pediatric renal and ureteric stones. J Pediatr Urol 2013;9(2):230–233 Gaur DD, Trivedi S, Prabhudesai MR, Madhusudhana HR, Gopichand M. Laparoscopic ureterolithotomy: technical considerations and long-term follow-up. BJU Int 2002;89(4):339–343 Demirci D, Gülmez I, Ekmekçioğlu O, Karacagil M. Retroperitoneoscopic ureterolithotomy for the treatment of ureteral calculi. Urol Int 2004;73(3):234–237 Hammady H, Gamal W, Zaki M, Hussein M, Abuzaeid A. Evaluation of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy for upper ureteral stone: randomized controlled study. J Endourol 2011;25(5):825–830 Abolyosr A. Laparoscopic transperitoneal ureterolithotomy for recurrent lower-ureteral stones previously treated with open ureterolithotomy: initial experience in 11 cases. J Endourol 2007;21(5):525–529 Lee RS, Passerotti CC, Cendron M, Estrada CR, Borer JG, Peters CA. Early results of robot assisted laparoscopic lithotomy in adolescents. J Urol 2007;177(6):2306–2309, discussion 2309–2310

10

11

12 13

14 15

16

18

19

20

21

22

23

European Journal of Pediatric Surgery

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Laparoscopic Ureterolithotomy in Children: With and Without Stent

Laparoscopic Ureterolithotomy in Children: With and Without Stent - Initial Tertiary Care Center Experience with More Than 1-Year Follow-Up.

Background The purpose of our study was to assess the safety and feasibility of transperitoneal laparoscopic ureterolithotomy (LU) in children with ur...
566B Sizes 1 Downloads 11 Views