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PEDIATRIC
UROLOGY
Ureteroscopy
In Children: Is There a Need for Ureteral Dilation and Postoperative Stenting?
Herndon CD, Viamonte L, Joseph DB
Section of Pediatric Urology, Division of Urology, Department of Surgery,
University of Alabama at Birmingham, USA
J Pediatr Urol. 2006; 2: 290-3
- Introduction:
Ureteroscopic
stone manipulation and extraction is the standard of care for distal
stone disease in the adult population. Recently, with refinements in
instrumentation, these standards have been applied in pediatrics. Here,
we investigate the role of ureteral dilation and the need for postoperative
stenting after ureteroscopy.
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Materials and Methods:
Twenty-nine children (21 male, eight female) with a mean age of 11.0
(2.5–17.5) years underwent 34 ureteroscopic procedures (21 right,
13 left) to address ureteral stones in 27 (23 distal, 3 mid and 1 proximal),
surveillance of the upper tract in six and a retained stent in one.
Active ureteral dilation was not required in any of these patients.
A Wolff 4.5-F or 6.5-F tapered semi-rigid ureteroscope was passed alongside
a previously placed guidewire to access the upper collecting system.
Proximal ureteral surveillance was performed after completion of the
procedure; all but two patients had a diagnostic ureterogram. Four patients
had preoperative placement of a JJ stent. Postoperative stents were
placed in six patients, two had stents placed preoperatively for infection
associated with either autonomic dysreflexia or stone impaction, two
for extravasation or perforation, one for edema and one for subsequent
ESWL.
-
Results: Mean
follow up after ureteroscopy was 16.2 (0.3–48) months. Of the
27 procedures for stone disease, 15 (55%) stones required laser litholipaxy
and 12 (45%) were managed with stone basket extraction. The overall
re-treatment rate for stone disease was 4%. Diagnostic ureteroscopy
was normal in six procedures. None of the procedures managed without
a post-ureteroscopy stent required subsequent intervention.
-
Conclusion:
Ureteroscopy is a safe, effective method to manage ureteral stones.
Refinements in instrumentation allow its application to the pediatric
population. Ureteroscopy including laser lithotripsy can be performed
without ureteral dilation or postoperative stenting.
- Editorial
Comment
This article reviews a four-year consecutive series of ureteroscopies
performed in children under the age of 18. Thirty-four ureteroscopic
procedures were performed, 27 for renal stones, 6 for upper tract surveillance
and 1 to remove a retained ureteral stent. All procedures were done
under general anesthesia utilizing a guide wire, followed by a 4.5F
or 6.5F tapered semi-rigid ureteroscope without the use of ureteral
dilatation or a sheath. Twelve patients had stone basket extraction,
while the remaining stone patients required Holmium: YAG laser and/or
electrohydraulic litholapaxy with a retreatment rate of only 4%. Seventy-nine
percent of the patients were managed as outpatients. Twenty-one percent
were inpatients due to pre-operative pain or infections or a planned
secondary procedure. The 23 (79%) patients who were managed as outpatients
did not have a ureteral stent after the procedure. Two complications
occurred. One was a small amount of extravasation from the perforation
of the tip of a stone basket. The second had perforation migration and
then impacted distal ureteral stone. The authors conclude that ureteroscopy
in children is safe without ureteral dilatation and postoperative stenting.
Technology continues to bring improvements to pediatric urologic stone
management. It has allowed for ureteral surgery that previously was
not thought possible. This study shows a very low complication rate
and a low stent usage rate demonstrating that with the refinements in
the technology ureteral stone disease can be treated very similarly
in children as is currently done for adult patients.
Dr.
Brent W. Snow
University of Utah Health Sci Ctr
Division of Urology
Salt Lake City, Utah, USA |