EXPERIENCE WITH EXPERIENCE WITH URETEROSCOPY IN CHILDREN”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.Peter’s Hospital )

LONDON, UK.

TECHNOLOGICALTECHNOLOGICAL INNOVATIONSINNOVATIONS

• 6F to 8Fr Semi-Rigid 6F to 8Fr Semi-Rigid UreteroscopeUreteroscope• Better modalities to fragment Better modalities to fragment calculicalculi• Variety of AccessoriesVariety of Accessories

INCREASING EXPERIENCE WITH INCREASING EXPERIENCE WITH URETEROSCOPIES IN ADULTSURETEROSCOPIES IN ADULTS

Hampton Young performed 1sr Ureteroscopy in 1929

15 children underwent 21 15 children underwent 21 Ureteroscopic proceduresUreteroscopic procedures

19 Retrograde (Semi -Rigid Urs 19 Retrograde (Semi -Rigid Urs & Flex. Urs )& Flex. Urs )

2 Antegrade (Flex. Urs)2 Antegrade (Flex. Urs)( PERIOD - 1989 - 1994 )( PERIOD - 1989 - 1994 )

Hampton Young used paediatric cystoscope for ureteroscopy in child with PUV

NO. & TYPE OF URETEROSCOPYNO. & TYPE OF URETEROSCOPY

.. Age - 13 months to 14 yearAge - 13 months to 14 year WeightWeight - - Mean 35.9 kgs (range from 7 to 70 Kgs).Mean 35.9 kgs (range from 7 to 70 Kgs). Height - Height - Mean 127.2 CMS (range from 70 to 162 Mean 127.2 CMS (range from 70 to 162

cmscms))

Lyon and his associates were the first to develop a pur pose built 13F Ureteroscope

PHYSICAL CHARCTERISTICS

21 ureteroscopic procedures:21 ureteroscopic procedures: 18 were for stone disease18 were for stone disease 2 for haematuria of unknown origin 2 for haematuria of unknown origin

1 for removal of a migrated stent1 for removal of a migrated stent

In 1979 Goodman used paediatric cystoscope (11F) for 3 adult ureteroscopy

CAUSE FOR URETEROSCOPY

Dilatation of Ureteric orifice was Dilatation of Ureteric orifice was required only in 1/21 required only in 1/21 Ureteroscopic procedureUreteroscopic procedure

( Dilatation for Retrograde 9.5 Fr ( Dilatation for Retrograde 9.5 Fr

Flexible UreteroscopeFlexible Ureteroscope ) )

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

10/13 Children with stone Disease 10/13 Children with stone Disease required SINGLE ureteroscopy required SINGLE ureteroscopy

3/13 Children with Stone Disease 3/13 Children with Stone Disease required NINE ureteroscopiesrequired NINE ureteroscopies

NUMBER OF URETEROSCOPIES

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

All the children underwent :All the children underwent : Routine biochemistry Routine biochemistry Urine-cultureUrine-culture Full metabolic screen for stone Full metabolic screen for stone

diseasedisease

KUB -X-ray & USKUB -X-ray & US

INVESTIGATIONS:

Metabolic screen in all children with stone ds essential

All the procedures were performed under All the procedures were performed under GENERAL anaesthesia GENERAL anaesthesia

Muscle paralysis for stones in the Muscle paralysis for stones in the LUMBAR ureterLUMBAR ureter

Technique of ureteroscopy in children Technique of ureteroscopy in children similar to ADULTSsimilar to ADULTS

TECHNIQUE OF URETEROSCOPYTECHNIQUE OF URETEROSCOPY

With 9 to 13 Fr Ureteroscope Dilatation required in majority

FLEXIBLE URETEROSCOPEFLEXIBLE URETEROSCOPE

Haematuria of Unknown Origin -Haematuria of Unknown Origin -

Flexible 9.5F ureteroscope used retrogradely ( Flexible 9.5F ureteroscope used retrogradely ( To inspect URETER & CALYCES of kidney)To inspect URETER & CALYCES of kidney)

For Re-implanted ureter - antegrade For Re-implanted ureter - antegrade approach through 12F Nephrostomy for approach through 12F Nephrostomy for lower third stonelower third stone

FLEXIBLE URETEROSCOPE USEFUL SCOPE FOR ANTEGRADE FLEXIBLE URETEROSCOPE USEFUL SCOPE FOR ANTEGRADE URETEROSCOPYURETEROSCOPY

..

Routine prophylactic antibiotics Routine prophylactic antibiotics Gentamicin - one doseGentamicin - one dose

( appropriate to the body wt.)( appropriate to the body wt.) All the procedures viewed on video All the procedures viewed on video

camera rather than directly through the camera rather than directly through the eyepieceeyepiece

Fluoroscopic monitoring was made Fluoroscopic monitoring was made availableavailable

Video camera helped to perfect upper endoscopic procedures Video camera helped to perfect upper endoscopic procedures & IMPROVED OVERALL RESULTS& IMPROVED OVERALL RESULTS

TECHNIQUE OF URETEROSCOPY………...TECHNIQUE OF URETEROSCOPY………...

TECHNIQUE OF URETEROSCOPY………...TECHNIQUE OF URETEROSCOPY………...

Ureteroscope rotated hence guidewire Ureteroscope rotated hence guidewire faces superio-laterallyfaces superio-laterally

Ureteric meatus Opens up due to Ureteric meatus Opens up due to stretching of Orifice.stretching of Orifice.

Once Intramural Ureter entered the Once Intramural Ureter entered the Ureteroscope Rotated back in Ureteroscope Rotated back in alignment with ureter alignment with ureter

THE ABOVE TECHNIQUE CALLED THE ABOVE TECHNIQUE CALLED “SHOE-HORN TECHNIQUE“SHOE-HORN TECHNIQUE “ “

TECHNIQUE OF URETEROSCOPY………...TECHNIQUE OF URETEROSCOPY………...( TO AVOID MORBIDITY )( TO AVOID MORBIDITY )

Height of saline irrigation bag kept between 40 Height of saline irrigation bag kept between 40 & 60 cms& 60 cms

Ureteroscope never advanced if resistance Ureteroscope never advanced if resistance encountered or if vision poor encountered or if vision poor

The gentlest touch used to advance the The gentlest touch used to advance the ureteroscope through the ureteric lumen ureteroscope through the ureteric lumen

When kinking of ureter encountered guidewire When kinking of ureter encountered guidewire advanced to straighten ureter advanced to straighten ureter

Pressure on abdominal wall ( over iliac vessels) helps Pressure on abdominal wall ( over iliac vessels) helps straightens curvature to line of ureterstraightens curvature to line of ureter

14/21 (66%)14/21 (66%) - - Lower - third Lower - third

3/21(14%)3/21(14%) -- Middle - third Middle - third

4/214/21 (20%)(20%) - - Upper - thirdUpper - third

( 21 Calculi cleared in 18 children )( 21 Calculi cleared in 18 children )

In situ ESWL quite effective for upper ureteric & VUJ In situ ESWL quite effective for upper ureteric & VUJ calculuscalculus

Site of Site of Calculus:Calculus:

12/21 ( 57% ) - Laser lithotripsy12/21 ( 57% ) - Laser lithotripsyHolmium LaserHolmium Laser 5 5 Pulsed Dye Laser Pulsed Dye Laser 77

4/21 ( 19% )4/21 ( 19% ) - EHL & Lithoclast - EHL & Lithoclast

5/215/21 ( 24% )( 24% ) - Simple Basketing- Simple Basketing

FRAGMENTATION / RETRIEVAL FRAGMENTATION / RETRIEVAL TECHNIQUE:TECHNIQUE:

Pulsed Dye laser safe for ureteric wall.

FRAGMENTATION / RETRIEVAL FRAGMENTATION / RETRIEVAL TECHNIQUE……..TECHNIQUE……..

Stones fragmented into several small Stones fragmented into several small extractable pieces extractable pieces

Most of fragments extracted using 3Fr Most of fragments extracted using 3Fr Segura basket ( with its plastic sheath Segura basket ( with its plastic sheath removed) removed)

A stent was avoided whenever possibleA 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.

Mean Size of the stone - Mean Size of the stone - 12.9 x 6.6 mm 12.9 x 6.6 mm

(Range 5 x 2 mm to 35 x 10 mm) (Range 5 x 2 mm to 35 x 10 mm)

Hospital stay - 1 to 6 days Hospital stay - 1 to 6 days Mean - 1.46 daysMean - 1.46 days

Follow up - 3/12 to 3 yearsFollow up - 3/12 to 3 years

Mean - 1 yearMean - 1 yearChildren can pass fairly big calculi spontaneously

Anaesthesia Time varied from Anaesthesia Time varied from 40 minutes to 120 minutes40 minutes to 120 minutes

( Mean - 68.8 minutes( Mean - 68.8 minutes ) )

ANAESTHESIAANAESTHESIA

For upper uretric calculi G.A. helps to control respiration during fragmentation

NoNo known cause - known cause - 7/13 7/13

Metabolic cause -Metabolic cause - 2/13 2/13

UTI UTI - - 4/134/13

CAUSECAUSE OF STONEOF STONE DISEASEDISEASE

Incidence of Stone Ds in UKIncidence of Stone Ds in UK : :

Children - 2 per million Adults - 2 per thousandChildren - 2 per million Adults - 2 per thousand

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

RESULTSRESULTS

Ureteroscopy in girls relatively easier than boysUreteroscopy in girls relatively easier than boys

RESULTSRESULTS

10/13 children with stone disease 10/13 children with stone disease stone free with one ureteroscopystone free with one ureteroscopy

3/13 children - complex problems 3/13 children - complex problems Required 9 ureteroscopies for stone Required 9 ureteroscopies for stone diseasedisease

Double J stents has helped to undertake multiple upper endoscopic procedures with ease

RESULTSRESULTS

Complications of Uretroscopy: Complications of Uretroscopy:

1 stricture at the site of stone impaction 1 stricture at the site of stone impaction 1 retention of urine due to a stone fragment in 1 retention of urine due to a stone fragment in

the posterior urethra the posterior urethra 1 haematuria 1 haematuria 1 migrated stent requiring ureteroscopy1 migrated stent requiring ureteroscopy

Holmium laser has potential of ureteric damage & stricture

SATISFACTORY RESULTSATISFACTORY RESULT

14 year old boy 14 year old boy 4 stones - 2 Upper- third / 2 Lower -4 stones - 2 Upper- third / 2 Lower -

thirdthird One ureteroscopy to clear stones One ureteroscopy to clear stones

using Holmium laserusing Holmium laser JJ stent leftJJ stent left

Children with adult body mass proportions Children with adult body mass proportions ureteroscopy no different from adultsureteroscopy no different from adults

COMPLEX URETEROSCOPIESCOMPLEX URETEROSCOPIES

Case 1 - 14 year old GirlCase 1 - 14 year old Girl

Impacted stone 20 x10 mm - Upper third ureter / Impacted stone 20 x10 mm - Upper third ureter / 2nd stone - 5 x 8 mm lower pole(L) kidney2nd stone - 5 x 8 mm lower pole(L) kidney

Ureteroscopy / fragmentation of stone & JJ StentUreteroscopy / fragmentation of stone & JJ Stent Over 6 weeks failed to pass fragmentsOver 6 weeks failed to pass fragments PCNL / antegrade flexible ureteroscope to clear PCNL / antegrade flexible ureteroscope to clear

ureteric & lower pole stone ureteric & lower pole stone

Double J stent sometimes prevents stone fragments from pssing out

COMPLEX URETEROSCOPIESCOMPLEX URETEROSCOPIES

CASE - 2 CASE - 2

6 year old girl with Primary Hyperoxaluria6 year old girl with Primary Hyperoxaluria

Stone obstructing her middle third ureterStone obstructing her middle third ureter

1st ureteroscopy cleared the ureter - 1st ureteroscopy cleared the ureter - Holmium laser used for fragmentationHolmium laser used for fragmentation

Primary Oxaluria - Kidney Transplantation results not satisfactory

COMPLEX URETEROSCOPIESCOMPLEX URETEROSCOPIES

Case - 2 ( Primary hyperoxaluria )Case - 2 ( Primary hyperoxaluria )

2nd stone dropped from kidney. Repeat 2nd stone dropped from kidney. Repeat Urs - stricture at site of previous stoneUrs - stricture at site of previous stone

The stone fragmented using Holmium The stone fragmented using Holmium laser & 4.8 F JJ stent left for 6 - weekslaser & 4.8 F JJ stent left for 6 - weeks

Ureterogram at stent removal - normal Ureterogram at stent removal - normal calibre uretercalibre ureter

Primary Oxaluria suitable for combined Liver & Kidney Transplant

Children with adult body mass proportions ureteroscopy no Children with adult body mass proportions ureteroscopy no different from adultsdifferent from adults

This was true in 4/14 children who This was true in 4/14 children who underwent ureteroscopy in present underwent ureteroscopy in present reviewreview

Conclusion: Conclusion:

Ureteroscopy in children can Ureteroscopy in children can

be used with equal success be used with equal success

as in adults to treat calculusas in adults to treat calculus

disease in experienced handsdisease in experienced hands

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