1. 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
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