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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 44-48

Pediatric ureteroscopy in underprivileged preschool patients: Single-center perspective


1 Department of Surgery; Department of Biochemistry, Faculty of Medicine, University of Gezira, Gezira, Sudan
2 Department of Urology, Gezira Hospital for Renal Disease and Surgery, Gezira, Sudan
3 Department of Surgery, Faculty of Medicine, University of Gezira; Department of Urology, Gezira Hospital for Renal Disease and Surgery, Gezira, Sudan
4 Department of Biochemistry, Faculty of Medicine, University of Gezira, Gezira, Sudan
5 Department of Biochemistry, Faculty of Medicine, University of Gezira, Gezira, Sudan; Department of Basic Medical Sciences, Faculty of Applied Medical Sciences, Albaha University, Saudi Arabia
6 Department of Urology, McGill University Health Centre, Montreal, QC, Canada

Date of Web Publication16-Apr-2018

Correspondence Address:
Sami Mahjoub Taha
Department of Surgery, Faculty of Medicine, University of Gezira, Gezira
Sudan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_105_17

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  Abstract 


Background: The incidence of stone disease in the pediatric age group dramatically increased in developing countries like Sudan. Despite, the challenges in the management of ureteral stone in the aforementioned age group, ureteroscopy (URS), lithotripsy using Holmium Laser (HO) has been reported as standard effective and safe. The aim of this study is to assess the outcome of URS lithotripsy using HO in preschool patients younger than 5 years of age. Materials and Methods: The results of treatment in 42 patients, who had undergone intervention for ureter stones at Gezira Hospital for Renal Disease and Surgery-Sudan, were prospectively evaluated. Miniscopes with an HO were used for lithotripsy. Results: The mean patient's age was 2.5 ± 1.2 years (1–4 years). The success rate was 69.9% after an average follow-up of 16 months (range 10–24). The majority 81% (n = 34) of study cases were presented with ureteric stones, which comprised 52.4% (n = 22) unilateral and 28.6% (n = 12) bilateral. The cases of unilateral and bilateral stricture include 6 and 2 cases, respectively. After the procedure, the ureteric stenting (double J) was used in 81% of the cases. The perioperative complication rate was 31.0%, and the most common complication was a failure of cannulation followed by the false passage. The mortality rate was zero. Conclusion: URS is considered safe and effective method for pediatric ureteric stones. The size of ureteroscope has an important role in the outcome and complications.

Keywords: Gezira Hospital for Renal Disease and Surgery, pediatric ureteroscopy, Sudan, ureteral stone


How to cite this article:
Taha SM, Abdallah AE, Mohammed Ahmed ME, Mansour MO, Ali H, Khalid KE, Ibrahim A. Pediatric ureteroscopy in underprivileged preschool patients: Single-center perspective. Saudi J Health Sci 2018;7:44-8

How to cite this URL:
Taha SM, Abdallah AE, Mohammed Ahmed ME, Mansour MO, Ali H, Khalid KE, Ibrahim A. Pediatric ureteroscopy in underprivileged preschool patients: Single-center perspective. Saudi J Health Sci [serial online] 2018 [cited 2022 Jun 28];7:44-8. Available from: https://www.saudijhealthsci.org/text.asp?2018/7/1/44/230225




  Introduction Top


Endoscopic treatment of stone disease in pediatric patients has developed dramatically during the past 2 decades. The use of ureteroscopy (URS) in the management of ureteric stones in children has challenging role in ureteric stones that not responding to drug expulsive therapy (DET) or failed extracorporeal shock wave lithotripsy (ESWL).[1] It has been stated that the size and the location of the calculus are involved in spontaneous passage of 80% calculi, supporting to this fact, Sandegard [2] determined a 93% and 81% chance of spontaneous passage of stones <4 mm located in the distal ureter and proximal ureter respectively, within 6 weeks of onsets of symptoms. Whereas, stone with larger diameters (4–6 mm) have a 50% chance of spontaneous passage from the proximal or distal ureter. Previous studies indicate that stones with size >6 mm are likely necessitate surgical intervention; nevertheless, the therapeutic options for significant ureteral calculi are diverse despite the progress in technologies.[3],[4]

Urologists gaining sufficient experience with semi-rigid ureteroscopies in interventions on adult patients have led pediatric URS to become more popular. URS is a procedure that can be done more easily in adult and adolescent patients than preschool-aged children are more prone to complications because of the small diameter and fragile structure of the ureter.[5] Nevertheless, several studies reported the feasibility and effectiveness of URS application for the treatment of calculi in children.[6],[7],[8],[9],[10],[11]

We reviewed our experience with URS lithotripsy using Holmium Laser (HO) in preschool children to validate the implementation of this method in the pediatric setting.


  Materials and Methods Top


Patients

This study was conducted at Gezira Hospital for Renal Disease and Surgery (GHRDS) from January 2015 to June 2017 as prospective cohort hospital-based study. Around 42 patients <5 years underwent URS for the management of ureteric stones with the follow-up period ranged from 10 to 24 months. Clinical assessment and diagnosis were done by history, clinical examination and investigations including basic laboratory investigations and imaging in the form of abdominal ultrasound (U/S), intravenous urography (IVU), computed tomography (CT) kidney, and ureter and kidney (KUB) for nonvisualized kidneys in IVU.

The indications of URS were include (1) ureteric stones not responding to DET, (2) stones which were amenable for DET, but there were hydronephrosis and hydroureter, (3) ureteric stones more than 1 cm according to the American urological guidelines, and (4) failure of ESWL. The exclusion criteria include patients more than 5 years presented with other causes, for example, stricture.

Surgical technique

The procedures were carried out by four experienced urologists under general anesthesia, and started with cystoscopy and retrograde introduction of a guide wire in the appropriate ureter. The URS was guided by the wire and flushed with a continuous flow of distilled water using the pressure of the flow of water which is augmented by occluding the sideway opening of the working channel; a process will dilate the ureter. A 7.3 Fr-semirigid miniscope was used for ureteroscopic lithotripsy. The ureteroscope was carefully advanced targeting the ureteric lumen all the time ahead. The procedure was stopped whenever there was any difficulty in advancing the ureteroscope. The stones were disintegrated using HO. The use of ureteral double JJ stent or sometimes short stenting for 48 h with open tip ureteric catheter fixed externally to a Foley's catheter.

Follow-up

Patients were discharged within 24–48 h. The effectiveness of the procedure was assessed based on complete disintegration of the calculi deposit, referred to as stone-free rate (SFR), which is defined as a complete disintegration of the calculi with potential remaining deposits with a diameter up to 2 mm up to 2 weeks after the procedure. The efficacy was based on imaging studies performed postoperatively. On day 1 after the operation, a urinary U/S or a plain abdominal X-ray (KUB), especially for patients with JJ stenting. After 14 days and 3 months, a urinalysis for serum creatinine levels and U/S of the urinary tract were performed in an outpatient clinic. Voiding cystourethrogram is not done routinely, only if there was hydronephrosis on abdominal U/S or recurrent UTI.

Statistical analysis

The results are presented in mean ± standard deviation and percentages. The unpaired t and Chi-square tests used to compare independent variables. P < 0.05 was considered statistically significant. All the analysis was carried out using SPSS (version 20.0, IBM corporation, USA) for Windows.


  Results Top


This study included 42 cases of <5 years who underwent URS and fulfilling the inclusion criteria. The mean of the age was 2.5 ± 1.2 years. The net predominance was in males, with a male to female ratio of 2:1. The mean duration of symptoms was 43.14 ± 47.2 days [Table 1].
Table 1: Baseline characteristics and stone parameters of patients

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Most (52.2%) of the patients from outside Gezira state, and the main presentation symptoms were crying micturition 28.6% (n = 12), followed by loin pain 28.6% (n = 12). The majority (76.2%) of ureteroscopies were elective, and the most common indication of URS was unilateral ureteric stone 52.4% (n = 22), bilateral ureteric stones 28.6% (n = 12), unilateral ureteric stricture 14.3% (n = 6), and bilateral ureteric stricture 4.7% (n = 2) [Table 1].

The lower third of the ureter was the dominant site of the ureteric pathology (stone-stricture) 54.8% followed by the upper and middle third ureters (38.1% and 7.1%, respectively). The preoperative serum creatinine was raised in two cases (2.5–8.1 mg/dl) both of them were presented with bilateral ureteric stones and it became normal postoperatively (0.5–1.1 mg/dl), although the serum creatinine levels dramatically decreases (P = 0.03) postoperatively in all patients [Table 2]. Abdominal U/S was the commonest diagnostic image among the study patients in 85.7% (n = 36), followed by U/S plus CT KUB in 9.5% (n = 4) and U/S plus IVU in 4.5% (n = 2). The ureteric stenting (double J [DJ]) was used in 34 (81%) of study cases, and the overall success rate was 69.9% [Table 2].
Table 2: Perioperative clinical data of patients

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The majority of the cases were presented with ureteric stones which were fragmented completely with ureteric stenting in 57.1%, without stenting in 4.8%, dis-impacted in the kidney plus ESWL in 19.1%, DJ stenting and redo URS only in 9.5% (ureteric strictures) for each [Figure 1].
Figure 1: Outcome of ureteroscopy in patients

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The perioperative complication rate was 30.1% and the comments complication was a failure of cannulation in 28.6% then false passage and urosepsis (4.8% for each). There was no postoperative ureteric stricture, ureteric avulsion nor vesicoureteral reflux [Figure 2], and the mortality rate was zero.
Figure 2: Perioperative complications of ureteroscopy

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  Discussion Top


Technological advances in the design of the ureteroscope have enabled easier access to the kidney and ureters through the urethra, removing stones, and reducing the need for any surgical incision. The study was conducted at GHRDS, most of the patients from nearby states, the main character of those patients was the poverty, and they were not able to pay even for investigations, most of them were supported by the hospital and social nongovernmental organizations. The number of the patients enrolled in the study was 42 cases their age was between 1 and 5 years with mean postoperative hospital stay was 24 h.

The main presentation was crying micturition in those cannot localized the site of the pain, followed by anuria due to bilateral complete obstruction. The most common site of obstruction was the lower third then upper and middle third ureters, and there was a successful redo URS for 4 cases. In contrary to our result, Iqbal et al.[6] found in children <15 years, the stone location-wise in most patients is an upper ureteric stones, followed by mid and distal ureteric stone. Twenty-two (59.5%) children underwent one procedure, while 15 (40.5%) children underwent relook ureteroscopies.[6] We noticed in the current study, distal ureter was the most common site for stones amenable for URS which can be explained by the late presentation due to the poverty and unnecessary DET to cases indicated for URS from the start.

In this study, the success rate was 69.9%, Strohmaier et al.,[12] mentioned endoscopic lithotripsy was initially used for urolithiasis of distal ureter and characterized by SFR efficiency of up to 97%. With the development of technology and staff experience, it started to be used in the treatment of stones located in the other sections of the ureter, with the efficacy of SFR 88%–100% and minimal complications.[13],[14] Other factor like the diameter of the ureteroscope might affect the success rate on top of the site of the stone. There were controversial results relating the URS effectiveness with the rate of success, and owing to our study, the diameter of the ureteroscope used was 7.3 Fr, which was quite similar in diameter to other studies conducted by Tanriverdi et al.,[15] who compared URS interventions performed with an 8-Fr versus 6.9-Fr ureteroscope, nevertheless, they report that the ureteroscope diameter has no effect on success rate. On the other hand, and in agreement with our study, Atar et al.[16] reported URS effectiveness rates as high as 92.6% and 78.6% with 4.5-Fr and 7.5-Fr ureteroscopies, respectively, in treating preschool-age children. Yucel et al.[9] used 7.5 Fr for the URS in patients under 1 year of age, and ureteral access was not achieved in 50% of the patients.

In the current study, the majority of the cases were ureteric stones, and they were fragmented completely and ureteric stenting was in 61.9%. The efficacy and safety of URS in pediatric patients was confirmed by Smaldone et al.[17] where endoscopic treatments were used in 100 children. A complete disintegration of deposits was successful in 91% of them, and only 9% required further surgery. The observations of Minevich et al.[18] performed 71 procedures in children emphasized the safety of the URS procedure. There was no damage to the wall of the ureter reported, while one case of postoperative ureteral stenosis was successfully treated endoscopically.

Miniaturization of the equipment also contributed to reducing the need of dilatation of vesicoureteral orifice and thus the risk of developing iatrogenic vesicoureteral reflux.[16],[17],[18],[19] In the current study, there was no iatrogenic ureteral stricture which was confirmed by the absence of hydroureter or hydronephrosis on abdominal U/S, and this was explained by the use of JJ stent in most of the cases, in addition to the use of HO as intracorporeal lithotripter. Furthermore, there was no postoperative vesicoureteric junction (VUJ) in the micturating cystourethrogram, due to the absence of vesicoureteric dilatation as a part of the procedure.

Despite URS minimally invasive procedure, it may end with some complications such as ureteral perforation, obstruction, avulsion, and gross hematuria. Ureteral perforation is a rare but important complication of URS.[20],[21] In our study, the perforation rate (false passage was 4.8%) generally it takes place during uncontrolled forward pushing of the ureteroscope, or during lithotripsy in addition to the size of ureteroscope and was managed by JJ stent for 6 weeks. Recently, and with the uses of smaller-calibrated ureteroscopies, ureteral perforation rates have fallen below 2%.[21],[22] In cases of perforation, the intervention should be ceased, and the insertion of a DJ stent should be considered the first choice of treatment.[23] If a DJ stent cannot be inserted, percutaneous nephrostomy insertion or open surgical repair may be performed as the last alternative.[24]

Minor complications (e.g., mucosal laceration, mild hematuria, stone migration, renal colic, and urinary system infection with fever) have been commonly reported.[21] In the current study, the most common minor complication was a failure of cannulation (28.6%) followed by infection with fever (4.8%), the high rate of failed cannulation can be explained by to two reasons, the size of ureteroscope and the VUJ dilatation was not part of the procedure.


  Conclusion Top


URS is a good treatment option for pediatric ureteric stones, leading to high SFRs, low complications. The size of ureteroscope has an important role in the outcome and complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kroovand RL, Harrison LH, McCullough DL. Extracorporeal shock wave lithotripsy in childhood. J Urol 1987;138:1106-8.  Back to cited text no. 1
    
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Sandegard E. Prognosis of stone in the ureter. Acta Chir Scand Suppl 1956;219:1-67.  Back to cited text no. 2
    
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Ueno A, Kawamura T, Ogawa A, Takayasu H. Relation of spontaneous passage of ureteral calculi to size. Urology 1977;10:544-6.  Back to cited text no. 3
    
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El-Nahas AR, El-Tabey NA, Eraky I, Shoma AM, El-Hefnawy AS, El-Assmy AM, et al. Semirigid ureteroscopy for ureteral stones: A multivariate analysis of unfavorable results. J Urol 2009;181:1158-62.  Back to cited text no. 5
    
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Iqbal N, Hussain I, Waqar S, Sadaf R, Tashfeen R, Nisa Nabil N, et al. Ureteroscopy for management of ureteric stones in children – A single centre experience. J Coll Physicians Surg Pak 2016;26:984-8.  Back to cited text no. 6
    
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Erkurt B, Caskurlu T, Atis G, Gurbuz C, Arikan O, Pelit ES, et al. Treatment of renal stones with flexible ureteroscopy in preschool age children. Urolithiasis 2014;42:241-5.  Back to cited text no. 7
    
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Resorlu B, Kara C, Resorlu EB, Unsal A. Effectiveness of ultrasonography in the postoperative follow-up of pediatric patients undergoing ureteroscopic stone manipulation. Pediatr Surg Int 2011;27:1337-41.  Back to cited text no. 8
    
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Yucel S, Akin Y, Kol A, Danisman A, Guntekin E. Experience on semirigid ureteroscopy and pneumatic lithotripsy in children at a single center. World J Urol 2011;29:719-23.  Back to cited text no. 9
    
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Cannon GM, Smaldone MC, Wu HY, Bassett JC, Bellinger MF, Docimo SG, et al. Ureteroscopic management of lower-pole stones in a pediatric population. J Endourol 2007;21:1179-82.  Back to cited text no. 11
    
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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.  Back to cited text no. 13
    
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Gecit I, Pirincci N, Günes M, Bilici S, Taken K, Göktas U, et al. Should ureteroscopy be considered as the first choice for proximal ureter stones of children? Eur Rev Med Pharmacol Sci 2013;17:1839-44.  Back to cited text no. 14
    
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Tanriverdi O, Silay MS, Kendirci M, Kadihasanoglu M, Aydin M, Horasanli K, et al. Comparison of ureteroscopic procedures with rigid and semirigid ureteroscopes in pediatric population: Does the caliber of instrument matter? Pediatr Surg Int 2010;26:733-8.  Back to cited text no. 15
    
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Atar M, Sancaktutar AA, Penbegul N, Soylemez H, Bodakci MN, Hatipoglu NK, et al. Comparison of a 4.5 F semi-rigid ureteroscope with a 7.5 F rigid ureteroscope in the treatment of ureteral stones in preschool-age children. Urol Res 2012;40:733-8.  Back to cited text no. 16
    
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Smaldone MC, Cannon GM Jr., Wu HY, Bassett J, Polsky EG, Bellinger MF, et al. Is ureteroscopy first line treatment for pediatric stone disease? J Urol 2007;178:2128-31.  Back to cited text no. 17
    
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Minevich E, Defoor W, Reddy P, Nishinaka K, Wacksman J, Sheldon C, et al. Ureteroscopy is safe and effective in prepubertal children. J Urol 2005;174:276-9.  Back to cited text no. 18
    
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20.
Dogan HS, Onal B, Satar N, Aygun C, Piskin M, Tanriverdi O, et al. Factors affecting complication rates of ureteroscopic lithotripsy in children: Results of multi-institutional retrospective analysis by pediatric stone disease study group of Turkish pediatric urology society. J Urol 2011;186:1035-40.  Back to cited text no. 20
    
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