PEDIATRIC UROLOGY

Ureteroscopy for pediatric urolithiasis: an evolving first-line therapy
Tan AH, Al-Omar M, Denstedt JD, Razvi H
Division of Urology, Department of Surgery, University of Western Ontario, London, Ontario, Canada
Urology. 2005; 65: 153-6

• Objectives: To present in a retrospective report a contemporary series of patients aged 14 years and younger who were treated for stones with ureteroscopy at our institution from 1991 to 2002. With the improvement and miniaturization of ureteroscopes and ancillary instruments, the endoscopic treatment of renal and ureteral calculi in children has become more feasible.
• Methods: A retrospective chart review was performed of 23 patients aged 14 years and younger who had undergone ureteroscopy for the treatment of ureteral or renal calculi at our institution.
• Results: A total of 27 stones were treated in 23 patients. Of the 27 stones, 18 were in the distal ureter, 5 in the mid ureter, 2 in the proximal ureter, and 2 in the renal pelvis. Ureteral dilation was performed in 4 (17.4%) of the 23 patients. The lithotripsy modalities used were holmium:yttrium-aluminum-garnet laser in 16 (69.6%), electrohydraulic lithotripsy in 3 (13%), a combination of holmium laser and electrohydraulic lithotripsy in 2 (8.7%), and basket extraction alone in 2 (8.7%) of 23 patients. Ureteral stents were placed in 21 (91.3%) of 23 patients. The average operative time was 46.9 minutes (range 15 to 92). In 21 (91.3%) of 23 patients, postoperative imaging was available and revealed that 20 (95.2%) of the 21 patients were rendered stone free. Two patients were lost to follow-up. No intraoperative complications occurred. One patient was treated postoperatively with intravenous antibiotics for transient fever.
• Conclusions: Ureteroscopy is safe and effective in the management of ureteral and renal calculi in children. In our institution, it has emerged as a valid first-line therapy for the treatment of pediatric urolithiasis.
  
  
• Editorial Comment
  The authors make the point that there has been a shift in their clinical practice from shock wave lithotripsy to ureteroscopy for the treatment of stones in children. This shift occurred because of the efficacy and minimal morbidity of ureteroscopy with modern instruments. In particular, small ureteroscopes and holmium: YAG laser lithotripsy have both made major contributions to the approach to these stones.
  I believe that this is a valuable contribution. Although SWL is “non-invasive,” most children will require an anesthetic or at least heavy sedation requiring anesthesia monitoring for the procedure. Newer machines with smaller focal areas and less power mean that fewer children have been stone free after an initial trial of therapy. This has certainly been our experience. At the same time, holmium laser lithotripsy has been highly effective and most patients are stone free shortly after the procedure. This combination has lead to a change in practice pattern in our institution as well. The authors have outlined this change nicely.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA