Original Article Rigid ureteroscopy in children: Our experience Venkat Sripathi, Sujit K. Chowdhary1, Deepak K. Kandpal1, Varun V. Sarode Departments of Pediatric Urology and Pediatric Surgery, Apollo Children’s Hospital, Chennai, Tamil Nadu, 1Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India Address for correspondence: Dr. Sujit K. Chowdhary, Senior Consultant (Pediatric Urology and Pediatric Surgery), Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076, India. E-mail: [email protected]
ABSTRACT Aim: To report our experience of Pediatric ureterorenoscopy for ureteric calculi from two tertiary Pediatric urology centers at Apollo Children’s Hospital, Chennai and Indraprastha Apollo Hospital, New Delhi. Material and methods: All children who presented with symptomatic ureteric stones greater than 6 mm were entered into the study. All children less than 12 months and more than 18 years of age and those who underwent ureterorenoscopy for indications other than the stones were excluded from the study. The children were managed on a fixed investigative and treatment protocol. The data from the Apollo Hospital New Delhi and Apollo Children’s Hospital Chennai was analysed. Results: There were a total of thirty eight children, twenty in Chennai and eighteen in the New Delhi study. The mean age was 10.4 years and 8.5 years and the youngest child was14 months and 24 months in the Chennai and New Delhi group respectively. There was one conversion to open surgery in either group. Pneumatic lithotripter was used in majority of cases and holmium laser in select children. Conclusion: This is the largest Indian series of ureterorenoscopy for ureteric calculi in children. This study over nearly a decade confirms the safety and efficacy of this technique even in young children. In children less than five years, prestenting and delayed ureterorenoscopy allows safe endoscopic treatment of ureteric calculi.
Access this article online Website: www.jiaps.com DOI: 10.4103/0971-9261.136462 Quick Response Code:
KEY WORDS: Pediatric, ureteric stone, ureterorenoscopy
INTRODUCTION Pediatric urolithiasis is relatively rare with an overall incidence of approximately 2-3%.[1] Outside of the endemic areas, ureteric stones form a small proportion of the total stone load. Appropriate management depends on the size and location of the stone, anatomy of the urinary tract as well as the age of the patient. During the last two decades, a whole range of modalities like extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS), percutaneous nephrolithotomy (PCNL), open and laparoscopic surgery has been available for children.[2] Most of these techniques evolved in the
adults and were adapted for children after appropriate modifications. Application of any one or a combination of these modalities in well selected patient can successfully manage stones even in young children. We present the first multicenter experience of ureterorenoscopyin children from India. Data from Apollo Children’s Hospital Chennai and Indraprastha Apollo Hospitals New Delhi has been collated and presented.
PATIENTS AND METHODS The study was based on surgical treatment of ureteric stones in symptomatic children between 2006-2014 in
Cite this article as: Sripathi V, Chowdhary SK, Kandpal DK, Sarode VV. Rigid ureteroscopy in children: Our experience. J Indian Assoc Pediatr Surg 2014;19:138-42. Source of Support: Nil, Conflict of Interest: None declared.
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two Apollo Hospitals- Chennai and New Delhi. We have prospectively enrolled all children with pediatric urolithiasis into a clinical database from 2006 at New Delhi and 2009 onwards at Chennai. All ureteric stones, which were symptomatic and greater than 6 mm were entered in the study protocol. All children less than 12 months and more than 18 years were excluded from the study. They were managed on a fixed protocol and all the investigative, peroperative, postoperative, and follow-up data recorded [Figure 1]. All underwent workup for any underlying metabolic disorder. Ultrasound and plain X-ray KUB were taken on the morning of surgery and a pediatric nephrology consultation was sought. Gentle bowel preparation with mild laxative the night before and a sodium phosphate enema on the day of surgery was done. All the children underwent cystoscopy, retrograde pyelogram, and guide wire placement into the ureter [Figure 2]. The stones were fragmented with either pneumatic lithoclast or laser lithotripsy. Baskets and forceps were never used to physically clear all stones after pulverisation except for removing a few fragments for stone analysis. The retrograde pyelogramis repeated after the procedure to look for any extravasation (indicating ureteral injury). Though the Delhi group did a post procedure DJ stenting in all children, in Chennai when fragmentation was complete DJ stenting was avoided in a few older children. Patients were kept in overhydrated state for first 24 hours to promote clearance of stone fragments. Stents were removed 3 weeks later.
In younger children, particularly less than 5 years and in the initial part of the study when 4.5/6 F URS was not available, all children underwent initial DJ stenting. After one week the ureter and the vesicoureteric junction were found to admit even the large URS with ease. In this way potentially disastrous trauma to the lower ureter was avoided. These children have been closely followed with ultrasound and renal function, no dye studies have been done unless specifically indicated.
RESULTS During 2009-2014, at Apollo Children’s Hospital Chennai, we encountered 20 children who underwent rigid ureterorenoscopy and lithotripsy. The majority were males — 17 in number. Five children were less than 5 years of age, three were 5-10 old, ten were between 10 and 15 years, and three were 16 years old. Of those smaller than 5 years of age, two were infants. Apart from ureteral calculi, the rigid ureteroscope was used during robotic pyelolithotomy and robotic pyeloplasty to remove impacted calyceal calculi and in one child it was used to remove an impacted urethral calculus.
Rigid and semirigid 6/7.5 ureterorenoscope was used in the initial part of the series. With the arrival of the 4.5/6 rigid URS and the flexible URS the larger URS was abandoned. The pneumatic lithotripter or the holmium laser was used as a source of energy for stone fragmentation.
Ureteral calculi were distributed evenly between the right (8) and left (9) sides. The median stone size was 8.3 mm and ranged from 5 mm to a maximum of 14 mm. The pneumatic lithotripter was used in the majority of cases with excellent results. In only three instances of impacted calculi was the holmium laser used — once in the calyces, once in the ureter and once in the urethra. Six children were prestented before URS and lithotripsy was attempted. Three of the six were below two years of age. In two cases open ureterolithotomy was done — in one 11 year old the proximal ureter could not be opacified and the guide wire could not be negotiated.
Figure 1: Non-contrast enhanced CT scan showing 7 mm calculus in left lower ureter Abbreviation: CT Computed tomography
Figure 2: Retrograde pyelogram done before ureterorenoscopy showing filling defect in right lower ureter
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In a 2 year old, the vesicoureteric junction (VUJ) would not allow even the floppy end of a Terumo guide wire. Interestingly in this child after ureterolithotomy even from above a guide wire could not be passed and the child was maintained on a tube nephrostomy for two weeks. The 6/7. 5 ureterorenoscope was used in the early part of the series. From 2012 onwards we had access to the 4/6.5 ureterorenoscope. This allowed much easier ureteral entry even in small children. In no instance was ureteral orifice dilatation attempted nor was an ureteral access sheath used. All children were managed in conjunction with the pediatric nephrologists and were maintained on close follow-up. Five children with ureteric calculi had concomitant renal calculi during the initial evaluation [Tables 1 and 2a]. During the postoperative period, care was taken to note ureteral dilatation on ultrasound (signifying possible vesicoureteric reflux), presence of new calculi or the occurrence of urinary infections. Two children presented with new onset renal calculi necessitating ESWL during follow up. Stone analysis was done in almost all cases but was not noted to be very useful. In Table 1: Comparative table of Indraprastha Apollo, New Delhi and Apollo Children’s Hospital, Chennai Period n M:F Mean age Median stone size Pre-URS stenting Post-URS stenting Conversion to open Recurrence
Apollo, New Delhi
Apollo, Chennai
2006-2014 18 16:2 8.5 years 8.5 mm 5 In all 1 None
2009-2014 20 17:3 10.4 years 8.3 mm 6 16/20 2 Two (renal calculi)
URS: Ureterorenoscopy
almost all children the stone composition was reported as calcium, oxalate and phosphate. At Indraprastha Apollo Hospitals New Delhi, between 2006 and 2014, eighteen children underwent ureterorenoscopy in our unit for symptomatic stones greater than 6 mm. Diagnostic ureterorenoscopyand ancillary procedures i.e, retrieval of migrated stents, strictures, biopsy etc were excluded from the study. The age range was from 2 years to 18 years, mean age was 8.5 years. Six children were younger than 5 years of age. Six were right ureteric, eleven were left ureteric and one was bilateral. Six patients had associated renal calculi with ureteric calculi. The stone size ranged from 6 mm to 15 mm, with a median size of 8.5 mm. Out of 16 ureteric stones, 9 were in the lower ureter, 4 in the mid ureter and 5 in upper ureter. All were symptomatic for more than six weeks. Five children underwent pre ureterorenoscopy DJ stenting, all of whom were less than 5 years of age. Stones were fragmented with pneumatic lithotripsy in 12 children and laser lithotripsy in 3 children. In one child with 11 mm stone in renal pelvis, the flexible URS could not be negotiated beyond the PUJ and the peroperative retrograde pyelogram revealed PUJ obstruction. The child subsequently underwent pyelolithotomy with pyeloplasty. Another 2-year-old child was referred with anuria and acute renal failure for hemodialysis. On investigations he was found to have deranged renal function test and bilateral staghorn calculi obstructing the pelviureteric junction on both sides. The child underwent bilateral DJ stenting and had dramatic recovery from renal failure. He subsequently underwent ESWL and is now 2 years in follow-up and
Table 2a: The Apollo Chennai experience (2009-2014), n = 20 Age/Sex
Site of stone
7F 12 M 16 M 2M 11 M 11 M 10 M 15 M 5F 13 M 5F 11 M
R lower ureter R VUJ L mid ureter R proximal ureter L mid ureter renal L mid ureter Calyces Left VUJ R lower ureter + renal L proximal ureter Left lower ureter + renal L mid ureter
1M 11 M 13 M 13 M 13 M 16 M 10 months 14 months
L mid ureter R staghorn urethral R VUJ Llower ureter+renal R lower ureter R lower ureter R lower ureter+renal
Size/Number 7 mm 6 mm 9.2 mm 6 mm 10 mm 9 mm 10 mm (6 stones) 6 mm 8 mm 8 mm 8 mm 6 mm 8 mm 14 mm 8 mm 5 mm 9 mm 12 mm 8 mm 9 mm
Prestenting
Lithotrite
Post procedure stent
No No No Not able to negotiate VUJ No Yes 8 weeks No No No Yes - stone came out No Unable to opacify proximal ureter Yes 4 weeks No – No No Yes 2wks Yes 8 weeks Yes 8 weeks
Pneumatic Pneumatic Pneumatic Open ureterolithotomy Pneumatic Pneumatic Forceps and removal Pneumatic Pneumatic Nil Pneumatic Open ureterolithotomy
Yes No No Nephrostomy No Yes Yes No Yes
Pneumatic Pneumatic and laser Holmium laser Pneumatic Pneumatic Holmium laser Pneumatic Pneumatic and ESWL
No Yes No Yes Yes Yes Yes Yes
Yes yes
Recurrence
2.5 years later
1.5 years later
ESWL: Extracorporeal shock wave lithotripsy
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free of stones. One 8-year-old boy presented with acute abdominal pain and on investigation was found to have left obstructed ureterocele with multiple calculi in distal ureter. He underwent cystoscopicderoofing of ureterocele and removal of stones. None of the ureteric calculi patients required conversion to open surgery. In those cases in which the ureteric access was difficult prestenting was done and URS was done successfully 2 weeks later. Three patients with coexisting ureteric and renal calculi were managed by post URS ESWL. Those children with renal stones larger than 1 cm required more than one session of shock wave lithotripsy. Out of six patients with renal calculi coexisting with ureteric stones, one underwent pyelolithotomy with pyeloplasty and another required PCNL as the stone load was large. Rest of renal stones with coexisting ureteric stones were managed with ESWL after lithoclast of ureteric stones. All of our patients underwent DJ stenting after ureterorenoscopy [Tables 1 and 2b].
DISCUSSION
In young children both the units prefer prestenting which allows gentle dilatation of ureter and allows access to even a large sized ureteroscope 2 to 4 weeks later. The youngest children managed by Chennai group were 14 months, 12 months, and 10 months old. The youngest child in our experience was 24 months old. All made excellent recovery without any long term sequelae or complications. Van savage et al in their review of distal ureteric calculi in children found that calculi 4 mm or greater in size were unlikely to pass spontaneously and would most likely require surgical intervention.[5] In our studies the median stone sizes were 8.3 mm (Chennai) and 8 mm (Delhi) and were all symptomatic stones. Although, it is believed that stones at VUJ greater than 4 mm will not descend spontaneously through the vesicoureteric junction, there is hardly any doubt that stones larger than 6 mm will ever do so spontaneously and will always need intervention. The stones in between 4 mm and 6 mm in size can have a period of observation with tamsulosine drug therapy.[6]
URS for stones in distal ureter in children was first reported by Ritchey et al in 1988, with stone free rates of 86-100%.[3] Ureterorenoscopy has become the first line treatment for stone disease in children for at least a decade in the western world and our unit.[4]
The pneumatic lithoclast was the energy source used most commonly in both seies with satisfactory results. A combination of pneumatic Lithotripsy and ESWL for concomitant ureteric and renal stones was often used.
The Delhi study was a prospective study and conducted over 7 years, whereas the Chennai study was a retrospective and over the last 4.5 years. The total number of patients in Delhi and Chennai study were 18 and 20, respectively with mean ages of 8.5 and 10.4 years [Table 1, 2a and 2b]. Median stone size, location of stones, need for pre-URS stenting and stone clearance were identical in both studies.
The Delhi group prefer routine post procedure stenting in all as it helps in passage of stone fragments and also prevents colic due to post procedure edema. The Chennai group avoided post procedure stents in five children; however, two of them had severe colic and required readmission. With a DJ stent in place fragments are usually completely eliminated.
Table 2b: The Apollo Delhi experience (2007-2014), n = 18 Age/sex
Site of stone
14 M 5M 7M 9M 2M 17 M 3M 6F 2M 6M 14 M 18 F 6M
Rt mid ureter L lower ureter + bilateral renal L mid ureter + B/L nephrocalcinosis R lower ureter L lower ureter L upper ureter L lower ureter renal L midureter B/L upper ureter, Anuria L lower ureter R lower ureter + renal L midureter R renal + PUJ obstruction
8M 14 M 2M 3M 18 M
L lower ureter ureterocele B/L staghorn, L ureter R lower ureter L upper ureter R lower ureter
Size & no
Pre stenting
Lithotrite
Post procedure stent
Recurrence
8 mm 7 mm 6 mm
No No No
Pneumatic Pneumatic + ESWL Pneumatic
Yes Yes Yes
No No No
7 mm 6 mm 10 mm 9 mm 11 mm 15 mm, 13 mm 11 mm 7 mm, 9 mm 10 mm 11 mm
No Yes No Yes No Yes No No No No
Yes Yes YES Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No
8 mm 8 mm 9 mm 6 mm 8 mm
No No Yes Yes No
Pneumatic Pneumatic Pneumatic Pneumatic + ESWL Laser Pneumatic Laser Pneumatic + ESWL Pneumatic Open pyelolithotomy + pyeloplasty Pneumatic +deroofing pneumatic +B/L PCNL Pneumatic Pneumatic Laser
Yes Yes Yes Yes Yes
No No No No No
ESWL: Extracorporeal shock wave lithotripsy, PCNL: Percutaneous nephrolithotomy
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There are concerns regarding development of vesicoureteric reflux and stricture after ureterorenoscopy for stone removal in children. Schuster et al found in a literature review of 221 ureterorenoscopies in children that only two patients developed stricture and eight had low grade vesicoureteric reflux.[7] To avoid these complications, we do not recommend ureteric orifice dilatation or the use of ureteral access sheath. In young children especially those less than 5 years where ureteric access is difficult we strongly recommend prestenting. Furthermore, repeated passage of instruments across the snugly fitting pediatric VUJ should be avoided to prevent shearing trauma and later development of strictures. Access, availability and skill in different modalities of treatment is absolutely necessary to successfully manage the pediatric calculi. At times the operative plan needs to be changed due to difficult access or abnormal anatomy of the urinary tract. More than one modality or a combination of modalities may be required in any one patient to achieve the therapeutic goal. Complications of ureteroscopy in children can be drastic and serious, and it should not be attempted without adequate experience especially in children younger than five years of age.
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CONCLUSION Ureterorenoscopy for ureteric calculi is the current standard of care procedure in our tertiary referral pediatric urology units for ureteric calculi in infants and children. This procedure is still undergoing evolution with arrival of flexible and smaller calibre scopes. The availability of excellent imaging facilities and energy devices will make it faster and more effective.
REFERENCES 1. Schwarz RD, Dwyer NT. Pediatric kidney stones: Long-term outcomes. Urology 2006;67:812-6. 2. Straub M, Gschwend J, Zorn C. Pediatric urolithiasis: The current surgical management. Pediatr Nephrol 2010;25:1239-44. 3. Ritchey M, Patterson DE, Kelalis PP, Segura JW. A case of pediatricuretero scopiclasertripsy. J Urol 1988;139:1272-4. 4. Tan AH, Al-omar M, Denstedt JD, Razvi H. Ureteroscopy for pediatricurolithiasis: An evolving first line therapy. Urology 2005;65:153-6. 5. Van Savage JG, Palanca LG, Andersen RD, Rao GS, Slaughenhoupt BL. Treatment of distal ureteral stones in children: Similarities to the American urological association guidelines in adults. J Urol 2000;164:1089-93. 6. Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosine in the medical management of juxtavesical ureteral stones. J Urol 2003;170:2202-5. 7. Schuster TG, Russell KY, Bloom DA, Koo HP, Faerber GJ. Ureteroscopy for the treatment of urolithiasis in children. J Urol 2002;167:1813-6.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
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ABSTRACT Aim: To report our experience of Pediatric ureterorenoscopy for ureteric calculi from two tertiary Pediatric urology centers at Apollo Children’s Hospital, Chennai and Indraprastha Apollo Hospital, New Delhi. Material and methods: All children who presented with symptomatic ureteric stones greater than 6 mm were entered into the study. All children less than 12 months and more than 18 years of age and those who underwent ureterorenoscopy for indications other than the stones were excluded from the study. The children were managed on a fixed investigative and treatment protocol. The data from the Apollo Hospital New Delhi and Apollo Children’s Hospital Chennai was analysed. Results: There were a total of thirty eight children, twenty in Chennai and eighteen in the New Delhi study. The mean age was 10.4 years and 8.5 years and the youngest child was14 months and 24 months in the Chennai and New Delhi group respectively. There was one conversion to open surgery in either group. Pneumatic lithotripter was used in majority of cases and holmium laser in select children. Conclusion: This is the largest Indian series of ureterorenoscopy for ureteric calculi in children. This study over nearly a decade confirms the safety and efficacy of this technique even in young children. In children less than five years, prestenting and delayed ureterorenoscopy allows safe endoscopic treatment of ureteric calculi.
Access this article online Website: www.jiaps.com DOI: 10.4103/0971-9261.136462 Quick Response Code:
KEY WORDS: Pediatric, ureteric stone, ureterorenoscopy
INTRODUCTION Pediatric urolithiasis is relatively rare with an overall incidence of approximately 2-3%.[1] Outside of the endemic areas, ureteric stones form a small proportion of the total stone load. Appropriate management depends on the size and location of the stone, anatomy of the urinary tract as well as the age of the patient. During the last two decades, a whole range of modalities like extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS), percutaneous nephrolithotomy (PCNL), open and laparoscopic surgery has been available for children.[2] Most of these techniques evolved in the
adults and were adapted for children after appropriate modifications. Application of any one or a combination of these modalities in well selected patient can successfully manage stones even in young children. We present the first multicenter experience of ureterorenoscopyin children from India. Data from Apollo Children’s Hospital Chennai and Indraprastha Apollo Hospitals New Delhi has been collated and presented.
PATIENTS AND METHODS The study was based on surgical treatment of ureteric stones in symptomatic children between 2006-2014 in
Cite this article as: Sripathi V, Chowdhary SK, Kandpal DK, Sarode VV. Rigid ureteroscopy in children: Our experience. J Indian Assoc Pediatr Surg 2014;19:138-42. Source of Support: Nil, Conflict of Interest: None declared.
138
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two Apollo Hospitals- Chennai and New Delhi. We have prospectively enrolled all children with pediatric urolithiasis into a clinical database from 2006 at New Delhi and 2009 onwards at Chennai. All ureteric stones, which were symptomatic and greater than 6 mm were entered in the study protocol. All children less than 12 months and more than 18 years were excluded from the study. They were managed on a fixed protocol and all the investigative, peroperative, postoperative, and follow-up data recorded [Figure 1]. All underwent workup for any underlying metabolic disorder. Ultrasound and plain X-ray KUB were taken on the morning of surgery and a pediatric nephrology consultation was sought. Gentle bowel preparation with mild laxative the night before and a sodium phosphate enema on the day of surgery was done. All the children underwent cystoscopy, retrograde pyelogram, and guide wire placement into the ureter [Figure 2]. The stones were fragmented with either pneumatic lithoclast or laser lithotripsy. Baskets and forceps were never used to physically clear all stones after pulverisation except for removing a few fragments for stone analysis. The retrograde pyelogramis repeated after the procedure to look for any extravasation (indicating ureteral injury). Though the Delhi group did a post procedure DJ stenting in all children, in Chennai when fragmentation was complete DJ stenting was avoided in a few older children. Patients were kept in overhydrated state for first 24 hours to promote clearance of stone fragments. Stents were removed 3 weeks later.
In younger children, particularly less than 5 years and in the initial part of the study when 4.5/6 F URS was not available, all children underwent initial DJ stenting. After one week the ureter and the vesicoureteric junction were found to admit even the large URS with ease. In this way potentially disastrous trauma to the lower ureter was avoided. These children have been closely followed with ultrasound and renal function, no dye studies have been done unless specifically indicated.
RESULTS During 2009-2014, at Apollo Children’s Hospital Chennai, we encountered 20 children who underwent rigid ureterorenoscopy and lithotripsy. The majority were males — 17 in number. Five children were less than 5 years of age, three were 5-10 old, ten were between 10 and 15 years, and three were 16 years old. Of those smaller than 5 years of age, two were infants. Apart from ureteral calculi, the rigid ureteroscope was used during robotic pyelolithotomy and robotic pyeloplasty to remove impacted calyceal calculi and in one child it was used to remove an impacted urethral calculus.
Rigid and semirigid 6/7.5 ureterorenoscope was used in the initial part of the series. With the arrival of the 4.5/6 rigid URS and the flexible URS the larger URS was abandoned. The pneumatic lithotripter or the holmium laser was used as a source of energy for stone fragmentation.
Ureteral calculi were distributed evenly between the right (8) and left (9) sides. The median stone size was 8.3 mm and ranged from 5 mm to a maximum of 14 mm. The pneumatic lithotripter was used in the majority of cases with excellent results. In only three instances of impacted calculi was the holmium laser used — once in the calyces, once in the ureter and once in the urethra. Six children were prestented before URS and lithotripsy was attempted. Three of the six were below two years of age. In two cases open ureterolithotomy was done — in one 11 year old the proximal ureter could not be opacified and the guide wire could not be negotiated.
Figure 1: Non-contrast enhanced CT scan showing 7 mm calculus in left lower ureter Abbreviation: CT Computed tomography
Figure 2: Retrograde pyelogram done before ureterorenoscopy showing filling defect in right lower ureter
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In a 2 year old, the vesicoureteric junction (VUJ) would not allow even the floppy end of a Terumo guide wire. Interestingly in this child after ureterolithotomy even from above a guide wire could not be passed and the child was maintained on a tube nephrostomy for two weeks. The 6/7. 5 ureterorenoscope was used in the early part of the series. From 2012 onwards we had access to the 4/6.5 ureterorenoscope. This allowed much easier ureteral entry even in small children. In no instance was ureteral orifice dilatation attempted nor was an ureteral access sheath used. All children were managed in conjunction with the pediatric nephrologists and were maintained on close follow-up. Five children with ureteric calculi had concomitant renal calculi during the initial evaluation [Tables 1 and 2a]. During the postoperative period, care was taken to note ureteral dilatation on ultrasound (signifying possible vesicoureteric reflux), presence of new calculi or the occurrence of urinary infections. Two children presented with new onset renal calculi necessitating ESWL during follow up. Stone analysis was done in almost all cases but was not noted to be very useful. In Table 1: Comparative table of Indraprastha Apollo, New Delhi and Apollo Children’s Hospital, Chennai Period n M:F Mean age Median stone size Pre-URS stenting Post-URS stenting Conversion to open Recurrence
Apollo, New Delhi
Apollo, Chennai
2006-2014 18 16:2 8.5 years 8.5 mm 5 In all 1 None
2009-2014 20 17:3 10.4 years 8.3 mm 6 16/20 2 Two (renal calculi)
URS: Ureterorenoscopy
almost all children the stone composition was reported as calcium, oxalate and phosphate. At Indraprastha Apollo Hospitals New Delhi, between 2006 and 2014, eighteen children underwent ureterorenoscopy in our unit for symptomatic stones greater than 6 mm. Diagnostic ureterorenoscopyand ancillary procedures i.e, retrieval of migrated stents, strictures, biopsy etc were excluded from the study. The age range was from 2 years to 18 years, mean age was 8.5 years. Six children were younger than 5 years of age. Six were right ureteric, eleven were left ureteric and one was bilateral. Six patients had associated renal calculi with ureteric calculi. The stone size ranged from 6 mm to 15 mm, with a median size of 8.5 mm. Out of 16 ureteric stones, 9 were in the lower ureter, 4 in the mid ureter and 5 in upper ureter. All were symptomatic for more than six weeks. Five children underwent pre ureterorenoscopy DJ stenting, all of whom were less than 5 years of age. Stones were fragmented with pneumatic lithotripsy in 12 children and laser lithotripsy in 3 children. In one child with 11 mm stone in renal pelvis, the flexible URS could not be negotiated beyond the PUJ and the peroperative retrograde pyelogram revealed PUJ obstruction. The child subsequently underwent pyelolithotomy with pyeloplasty. Another 2-year-old child was referred with anuria and acute renal failure for hemodialysis. On investigations he was found to have deranged renal function test and bilateral staghorn calculi obstructing the pelviureteric junction on both sides. The child underwent bilateral DJ stenting and had dramatic recovery from renal failure. He subsequently underwent ESWL and is now 2 years in follow-up and
Table 2a: The Apollo Chennai experience (2009-2014), n = 20 Age/Sex
Site of stone
7F 12 M 16 M 2M 11 M 11 M 10 M 15 M 5F 13 M 5F 11 M
R lower ureter R VUJ L mid ureter R proximal ureter L mid ureter renal L mid ureter Calyces Left VUJ R lower ureter + renal L proximal ureter Left lower ureter + renal L mid ureter
1M 11 M 13 M 13 M 13 M 16 M 10 months 14 months
L mid ureter R staghorn urethral R VUJ Llower ureter+renal R lower ureter R lower ureter R lower ureter+renal
Size/Number 7 mm 6 mm 9.2 mm 6 mm 10 mm 9 mm 10 mm (6 stones) 6 mm 8 mm 8 mm 8 mm 6 mm 8 mm 14 mm 8 mm 5 mm 9 mm 12 mm 8 mm 9 mm
Prestenting
Lithotrite
Post procedure stent
No No No Not able to negotiate VUJ No Yes 8 weeks No No No Yes - stone came out No Unable to opacify proximal ureter Yes 4 weeks No – No No Yes 2wks Yes 8 weeks Yes 8 weeks
Pneumatic Pneumatic Pneumatic Open ureterolithotomy Pneumatic Pneumatic Forceps and removal Pneumatic Pneumatic Nil Pneumatic Open ureterolithotomy
Yes No No Nephrostomy No Yes Yes No Yes
Pneumatic Pneumatic and laser Holmium laser Pneumatic Pneumatic Holmium laser Pneumatic Pneumatic and ESWL
No Yes No Yes Yes Yes Yes Yes
Yes yes
Recurrence
2.5 years later
1.5 years later
ESWL: Extracorporeal shock wave lithotripsy
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free of stones. One 8-year-old boy presented with acute abdominal pain and on investigation was found to have left obstructed ureterocele with multiple calculi in distal ureter. He underwent cystoscopicderoofing of ureterocele and removal of stones. None of the ureteric calculi patients required conversion to open surgery. In those cases in which the ureteric access was difficult prestenting was done and URS was done successfully 2 weeks later. Three patients with coexisting ureteric and renal calculi were managed by post URS ESWL. Those children with renal stones larger than 1 cm required more than one session of shock wave lithotripsy. Out of six patients with renal calculi coexisting with ureteric stones, one underwent pyelolithotomy with pyeloplasty and another required PCNL as the stone load was large. Rest of renal stones with coexisting ureteric stones were managed with ESWL after lithoclast of ureteric stones. All of our patients underwent DJ stenting after ureterorenoscopy [Tables 1 and 2b].
DISCUSSION
In young children both the units prefer prestenting which allows gentle dilatation of ureter and allows access to even a large sized ureteroscope 2 to 4 weeks later. The youngest children managed by Chennai group were 14 months, 12 months, and 10 months old. The youngest child in our experience was 24 months old. All made excellent recovery without any long term sequelae or complications. Van savage et al in their review of distal ureteric calculi in children found that calculi 4 mm or greater in size were unlikely to pass spontaneously and would most likely require surgical intervention.[5] In our studies the median stone sizes were 8.3 mm (Chennai) and 8 mm (Delhi) and were all symptomatic stones. Although, it is believed that stones at VUJ greater than 4 mm will not descend spontaneously through the vesicoureteric junction, there is hardly any doubt that stones larger than 6 mm will ever do so spontaneously and will always need intervention. The stones in between 4 mm and 6 mm in size can have a period of observation with tamsulosine drug therapy.[6]
URS for stones in distal ureter in children was first reported by Ritchey et al in 1988, with stone free rates of 86-100%.[3] Ureterorenoscopy has become the first line treatment for stone disease in children for at least a decade in the western world and our unit.[4]
The pneumatic lithoclast was the energy source used most commonly in both seies with satisfactory results. A combination of pneumatic Lithotripsy and ESWL for concomitant ureteric and renal stones was often used.
The Delhi study was a prospective study and conducted over 7 years, whereas the Chennai study was a retrospective and over the last 4.5 years. The total number of patients in Delhi and Chennai study were 18 and 20, respectively with mean ages of 8.5 and 10.4 years [Table 1, 2a and 2b]. Median stone size, location of stones, need for pre-URS stenting and stone clearance were identical in both studies.
The Delhi group prefer routine post procedure stenting in all as it helps in passage of stone fragments and also prevents colic due to post procedure edema. The Chennai group avoided post procedure stents in five children; however, two of them had severe colic and required readmission. With a DJ stent in place fragments are usually completely eliminated.
Table 2b: The Apollo Delhi experience (2007-2014), n = 18 Age/sex
Site of stone
14 M 5M 7M 9M 2M 17 M 3M 6F 2M 6M 14 M 18 F 6M
Rt mid ureter L lower ureter + bilateral renal L mid ureter + B/L nephrocalcinosis R lower ureter L lower ureter L upper ureter L lower ureter renal L midureter B/L upper ureter, Anuria L lower ureter R lower ureter + renal L midureter R renal + PUJ obstruction
8M 14 M 2M 3M 18 M
L lower ureter ureterocele B/L staghorn, L ureter R lower ureter L upper ureter R lower ureter
Size & no
Pre stenting
Lithotrite
Post procedure stent
Recurrence
8 mm 7 mm 6 mm
No No No
Pneumatic Pneumatic + ESWL Pneumatic
Yes Yes Yes
No No No
7 mm 6 mm 10 mm 9 mm 11 mm 15 mm, 13 mm 11 mm 7 mm, 9 mm 10 mm 11 mm
No Yes No Yes No Yes No No No No
Yes Yes YES Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No
8 mm 8 mm 9 mm 6 mm 8 mm
No No Yes Yes No
Pneumatic Pneumatic Pneumatic Pneumatic + ESWL Laser Pneumatic Laser Pneumatic + ESWL Pneumatic Open pyelolithotomy + pyeloplasty Pneumatic +deroofing pneumatic +B/L PCNL Pneumatic Pneumatic Laser
Yes Yes Yes Yes Yes
No No No No No
ESWL: Extracorporeal shock wave lithotripsy, PCNL: Percutaneous nephrolithotomy
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
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Sripathi, et al.: Rigid ureteroscopy in children
There are concerns regarding development of vesicoureteric reflux and stricture after ureterorenoscopy for stone removal in children. Schuster et al found in a literature review of 221 ureterorenoscopies in children that only two patients developed stricture and eight had low grade vesicoureteric reflux.[7] To avoid these complications, we do not recommend ureteric orifice dilatation or the use of ureteral access sheath. In young children especially those less than 5 years where ureteric access is difficult we strongly recommend prestenting. Furthermore, repeated passage of instruments across the snugly fitting pediatric VUJ should be avoided to prevent shearing trauma and later development of strictures. Access, availability and skill in different modalities of treatment is absolutely necessary to successfully manage the pediatric calculi. At times the operative plan needs to be changed due to difficult access or abnormal anatomy of the urinary tract. More than one modality or a combination of modalities may be required in any one patient to achieve the therapeutic goal. Complications of ureteroscopy in children can be drastic and serious, and it should not be attempted without adequate experience especially in children younger than five years of age.
142
CONCLUSION Ureterorenoscopy for ureteric calculi is the current standard of care procedure in our tertiary referral pediatric urology units for ureteric calculi in infants and children. This procedure is still undergoing evolution with arrival of flexible and smaller calibre scopes. The availability of excellent imaging facilities and energy devices will make it faster and more effective.
REFERENCES 1. Schwarz RD, Dwyer NT. Pediatric kidney stones: Long-term outcomes. Urology 2006;67:812-6. 2. Straub M, Gschwend J, Zorn C. Pediatric urolithiasis: The current surgical management. Pediatr Nephrol 2010;25:1239-44. 3. Ritchey M, Patterson DE, Kelalis PP, Segura JW. A case of pediatricuretero scopiclasertripsy. J Urol 1988;139:1272-4. 4. Tan AH, Al-omar M, Denstedt JD, Razvi H. Ureteroscopy for pediatricurolithiasis: An evolving first line therapy. Urology 2005;65:153-6. 5. Van Savage JG, Palanca LG, Andersen RD, Rao GS, Slaughenhoupt BL. Treatment of distal ureteral stones in children: Similarities to the American urological association guidelines in adults. J Urol 2000;164:1089-93. 6. Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosine in the medical management of juxtavesical ureteral stones. J Urol 2003;170:2202-5. 7. Schuster TG, Russell KY, Bloom DA, Koo HP, Faerber GJ. Ureteroscopy for the treatment of urolithiasis in children. J Urol 2002;167:1813-6.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
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