EXPERIENCE WITH URETEROSCOPY IN CHILDREN DR.SUNIL SHROFF, MS, D.Urol (Lond.), FRCS (UK),

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EXPERIENCE WITH URETEROSCOPY IN CHILDREN
DR. SUNIL SHROFF, MS, FRCS ( UK), D.UROL (LOND),
LECTURER IN UROLOGY RENAL TRANSPLANTATION
, INSTITUTE OF UROLOGY NEPHROLOGY, ( In
association with St.Peters Hospital ) LONDON, UK.
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TECHNOLOGICAL INNOVATIONS

• 6F to 8Fr Semi-Rigid Ureteroscope
• Better modalities to fragment calculi
• Variety of Accessories

INCREASING EXPERIENCE WITH URETEROSCOPIES IN
ADULTS
Hampton Young performed 1sr Ureteroscopy in
1929
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NO. TYPE OF URETEROSCOPY

• 15 children underwent 21 Ureteroscopic
  procedures
• 19 Retrograde (Semi -Rigid Urs Flex. Urs )
• 2 Antegrade (Flex. Urs)
• ( PERIOD - 1989 - 1994 )

Hampton Young used paediatric cystoscope for
ureteroscopy in child with PUV
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PHYSICAL CHARCTERISTICS

• Age - 13 months to 14 year
• Weight - Mean 35.9 kgs (range from 7 to 70 Kgs).
• Height - Mean 127.2 CMS (range from 70 to 162
  cms)
• Lyon and his associates were the first to develop
  a
• pur pose built 13F Ureteroscope

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CAUSE FOR URETEROSCOPY

• 21 ureteroscopic procedures
• 18 were for stone disease
• 2 for haematuria of unknown origin
• 1 for removal of a migrated stent
• In 1979 Goodman used paediatric cystoscope (11F)
  for 3 adult ureteroscopy

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• Dilatation of Ureteric orifice was required only
  in 1/21 Ureteroscopic procedure
• ( Dilatation for Retrograde 9.5 Fr Flexible
  Ureteroscope )

Newer semi-rigid tapered ureteroscope with tip
diameter of 7.2 Fr two 3F 2F channel
dilatation of ureteric orifice unnecessary.

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NUMBER OF URETEROSCOPIES

• 10/13 Children with stone Disease required SINGLE
  ureteroscopy
• 3/13 Children with Stone Disease required NINE
  ureteroscopies

Ureteroscopy in children was considered dangerous
because of the size mismatch - small ureter big
scope
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INVESTIGATIONS

• All the children underwent
• Routine biochemistry
• Urine-culture
• Full metabolic screen for stone disease
• KUB -X-ray US

Metabolic screen in all children with stone ds
essential
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TECHNIQUE OF URETEROSCOPY

• All the procedures were performed under GENERAL
  anaesthesia
• Muscle paralysis for stones in the LUMBAR ureter
• Technique of ureteroscopy in children similar to
  ADULTS

With 9 to 13 Fr Ureteroscope Dilatation required
in majority
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FLEXIBLE URETEROSCOPE

• Haematuria of Unknown Origin -
• Flexible 9.5F ureteroscope used retrogradely (
  To inspect URETER CALYCES of kidney)
• For Re-implanted ureter - antegrade approach
  through 12F Nephrostomy for lower third stone
• FLEXIBLE URETEROSCOPE USEFUL SCOPE FOR
  ANTEGRADE URETEROSCOPY
• .

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TECHNIQUE OF URETEROSCOPY...

• Routine prophylactic antibiotics Gentamicin -
  one dose
• ( appropriate to the body wt.)
• All the procedures viewed on video camera rather
  than directly through the eyepiece
• Fluoroscopic monitoring was made available
• Video camera helped to perfect upper endoscopic
  procedures IMPROVED OVERALL RESULTS

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TECHNIQUE OF URETEROSCOPY...

• Ureteroscope rotated hence guidewire faces
  superio-laterally
• Ureteric meatus Opens up due to stretching of
  Orifice.
• Once Intramural Ureter entered the Ureteroscope
  Rotated back in alignment with ureter
• THE ABOVE TECHNIQUE CALLED SHOE-HORN TECHNIQUE

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TECHNIQUE OF URETEROSCOPY...( TO AVOID
MORBIDITY )

• Height of saline irrigation bag kept between 40
  60 cms
• Ureteroscope never advanced if resistance
  encountered or if vision poor
• The gentlest touch used to advance the
  ureteroscope through the ureteric lumen
• When kinking of ureter encountered guidewire
  advanced to straighten ureter
• Pressure on abdominal wall ( over iliac vessels)
  helps straightens curvature to line of ureter

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Site of Calculus

• 14/21 (66) - Lower - third
• 3/21(14) - Middle - third
• 4/21 (20) - Upper - third
• ( 21 Calculi cleared in 18 children )
• In situ ESWL quite effective for upper ureteric
  VUJ calculus

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FRAGMENTATION / RETRIEVAL TECHNIQUE

• 12/21 ( 57 ) - Laser lithotripsy
• Holmium Laser 5
• Pulsed Dye Laser 7
• 4/21 ( 19 ) - EHL Lithoclast
• 5/21 ( 24 ) - Simple Basketing

Pulsed Dye laser safe for ureteric wall.
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FRAGMENTATION / RETRIEVAL TECHNIQUE..

• Stones fragmented into several small extractable
  pieces
• Most of fragments extracted using 3Fr Segura
  basket ( with its plastic sheath removed)
• A stent was avoided whenever possible

First clinical trials of Pulsed dye laser for
lasertripsy at St.Peter's Hospital, U.K.
Massachusett's General Hospital, USA.
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Mean Size of the stone - 12.9 x 6.6 mm (Range
5 x 2 mm to 35 x 10 mm)Hospital stay - 1 to 6
days Mean - 1.46 days Follow up - 3/12 to 3
yearsMean - 1 year
Children can pass fairly big calculi spontaneously
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ANAESTHESIA
Anaesthesia Time varied from 40 minutes to 120
minutes ( Mean - 68.8 minutes )
For upper uretric calculi G.A. helps to control
respiration during fragmentation
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CAUSE OF STONE DISEASE

• No known cause - 7/13
• Metabolic cause - 2/13
• UTI - 4/13

Incidence of Stone Ds in UK Children - 2 per
million Adults - 2 per thousand
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RESULTS

• No Access failures - using Antegrade / Retrograde
  miniaturised ureteroscopes all stones accessed

Ureteroscopy in girls relatively easier than boys
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RESULTS

• 10/13 children with stone disease stone free
  with one ureteroscopy
• 3/13 children - complex problems Required 9
  ureteroscopies for stone disease

Double J stents has helped to undertake multiple
upper endoscopic procedures with ease
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• RESULTS
• Complications of Uretroscopy
• 1 stricture at the site of stone impaction
• 1 retention of urine due to a stone fragment in
  the posterior urethra
• 1 haematuria
• 1 migrated stent requiring ureteroscopy

Holmium laser has potential of ureteric damage
stricture
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SATISFACTORY RESULT

• 14 year old boy
• 4 stones - 2 Upper- third / 2 Lower -third
• One ureteroscopy to clear stones using Holmium
  laser
• JJ stent left

Children with adult body mass proportions
ureteroscopy no different from adults
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COMPLEX URETEROSCOPIES

• Case 1 - 14 year old Girl
• Impacted stone 20 x10 mm - Upper third ureter /
  2nd stone - 5 x 8 mm lower pole(L) kidney
• Ureteroscopy / fragmentation of stone JJ Stent
• Over 6 weeks failed to pass fragments
• PCNL / antegrade flexible ureteroscope to clear
  ureteric lower pole stone

Double J stent sometimes prevents stone fragments
from pssing out
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COMPLEX URETEROSCOPIES

• CASE - 2
• 6 year old girl with Primary Hyperoxaluria
• Stone obstructing her middle third ureter
• 1st ureteroscopy cleared the ureter - Holmium
  laser used for fragmentation

Primary Oxaluria - Kidney Transplantation results
not satisfactory
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COMPLEX URETEROSCOPIES

• Case - 2 ( Primary hyperoxaluria )
• 2nd stone dropped from kidney. Repeat Urs -
  stricture at site of previous stone
• The stone fragmented using Holmium laser 4.8
  F JJ stent left for 6 - weeks
• Ureterogram at stent removal - normal calibre
  ureter

Primary Oxaluria suitable for combined Liver
Kidney Transplant
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• Children with adult body mass proportions
  ureteroscopy no different from adults
• This was true in 4/14 children who underwent
  ureteroscopy in present review

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• Conclusion
• Ureteroscopy in children can
• be used with equal success
• as in adults to treat calculus
• disease in experienced hands

Laser lithotripsy using 200 micron sized tip of
quartz fibre made minitaturisation of
ureteroscope feasable