URETEROSCOPY IN CHILDREN: IS ROUTINE PRE-OPERATIVE URETERIC STENT INSERTION NECESSARY? Poongkodi Nagappan and Supul Hennayake Department of Paediatric Urology, Royal Manchester Children’s Hospital BACKGROUND The role of pre-operative ureteric stent insertion before flexible and rigid ureteroscopy in children is debatable. Few studies have been published that focus on this issue among children. We aimed to assess the outcome in children who did not have routine pre-operative ureteric stent insertion. MATERIALS & METHODS 165 children (175 renal units) with urolithiasis were managed in our institution over a 11 year period (2002 to 2013). 49 children underwent ureteroscopic procedures. Analysis of prospectively collected data was done. RESULTS Successful ureteric access: We were able to complete the procedure by passing the ureteroscope up to the renal pelvis in 41 of the 46 patients (89.1%) who did not have pre-operative ureteric stent insertion. 15 (32.6%) of patients required ureteric dilatation with tapered ureteric dilator. We failed to advance the ureteroscope in 5 patients (10.8% failure rate). On statistical analysis, there was no significant association between successful ureteric access and the use of pre-operative ureteric stent or ureteral dilator. Immediate complications: One patient developed urinary extravasation requiring post-operative stent insertion and one patient developed post-operative sepsis (4.3% complication rate). Secondary Outcome: Complete stone clearance rates were higher in patients with lower ureteric stones. Patients with renal stones had lower stone clearance rates and were more likely to require repeat procedures. Age: Range Mean Median 2 to 15 years 8.6 years 9 years Gender: Male Female 27 22 Procedure: Flexible ureteroscope Rigid ureteroscope 15 34 OBJECTIVES Primary Outcome Successful ureteric access - defined as the ability to advance the ureteroscope up to the kidney Immediate complications - traumatic or infectious complications such as ureteric or renal pelvis perforation, ureteric avulsion, bleeding and sepsis Secondary Outcome Complete stone clearance - defined as no residual stone fragments seen on post-operative radiograph or ultrasound Need for repeat intervention Ureteroscopy was performed under general anaesthesia in the standard manner. The picture on the right shows the tapered ureteric dilator (Ch 6-12) used in 15 patients to improve access into the ureter. 6 Fr semi-rigid or 6 Fr flexible ureterorenoscopes were used during each procedures. CONCLUSIONS Flexible and rigid ureterorenoscopy in children can be safely performed without routine pre-operative ureteral stent insertion. Our overall success rate in advancing the ureteroscope up to the kidney is 89.1%. The morbidity rates are low (4.3%). Stone Location Stone Size (Mean) Pre-Operative Stent Complete Stone Clearance For Primary Procedure Repeat Intervention Lower ureter (14 patients) 8-15 mm (9.9 mm) No 14 11 (78.6%) 2 Yes - Mid Ureter (2 patients) 10-12 mm (11 mm) 2 (100%) Upper Ureter (3 patients) 6-10 mm (8.7 mm) 1 (50%) 1 Renal (30 patients) 3-22 mm (9.7 mm) 28 16 (57.1%) 13 COMPARISON BETWEEN OUR DATA AND PUBLISHED RESULTS Year Author Number Results Our Series of Patients 49 children with renal and ureteric stones 32.6% required ureteric dilatation 10.8% required stent insertion Stone Clearance Rate 73.7% for ureteric stones 57.1% for renal stones 2014 MA Elgammal et al 42 primary and 24 secondary procedures in children with ureteric stones No Pre-Stenting 73.8% required ureteric dilatation 31% failed to respond to dilatation 59.5% stone clearance rate Pre-Stenting Done 95.8% stone clearance rate Erkurt B et al 65 children 7.7% failed access 83.1% stone clearance rate 2013 PP Lumma 550 adults Stent placement prior to treatment in distal ureter does not improve stone-free rates Corresponding Author: Dr. P. Nagappan, Senior Clinical Fellow in Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, United Kingdom Tel: +44 161 701 1635 Fax: +44 161 701 2630 E-mail: Poongkodi.Nagappan@cmft.nhs.uk