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required ureteral stent placement, thereby eliminating the need for additional anesthesia in 60% of the patient cohort. Although personally I choose not to actively dilate the ure- teral orifice due to the proven association with postoperative complications, including ureterovesical stricture, the au- thors observed the ability to decrease the number of anes- thetic procedures by active dilation. Also, the introduction of smaller ureteroscopes has en- hanced the ability of the pediatric endoscopist to treat upper urinary tract calculi in retrograde fashion. Traditionally flexible ureteroscopy has been the preferred technique to evaluate and treat proximal to the iliac vessels. We have previously reported the safety, advantages and high success rate (83%) of retrograde proximal rigid ureteroscopy and pyeloscopy for proximal ureteral and renal pelvis calculi as well as diagnostic ureteropyeloscopy in prepubertal children (reference 12 in article). Although rigid ureteroscopes have obvious limitations compared to flexible ureteroscopes to treat upper tract stones, I tend to use the former endoscopes when possible. The current authors used a 6.9Fr flexible ureteroscope in a relatively large number of children unable to successfully undergo the initial procedure, presumably due to ureteral anatomy. An option that the authors do not discuss in the article is the use of a wire, which usually allows the anatomy to be more clearly delineated, providing guidance and passage of the ureteroscope. The authors should be acknowledged for further advancing retrograde ureteroscopy in the upper urinary tract in children. Jeffrey S. Palmer Center for Pediatric Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, Ohio REPLY BY AUTHORS Our technique includes a safety wire and a working wire to delineate anatomy and facilitate passage of the uretero- scope. We believe our results show that dilating the ureteral orifice is a safe and effective means of accessing the upper urinary tract in prepubertal children, facilitating high stone-free rates with flexible ureteroscopy. Although there continues to be concern that active dilation of the pediatric ureteral orifice will cause stricture, to date we have encoun- tered only 1 ureteral stricture in a prepubertal patient who had a stent placed before ureteroscopy (reference 1 in arti- cle). PRIOR URETERAL STENT PLACEMENT AND UPPER URINARY TRACT ACCESS 1864
Transcript of Reply by Authors
required ureteral stent placement, thereby eliminating theneed for additional anesthesia in 60% of the patient cohort.Although personally I choose not to actively dilate the ure-teral orifice due to the proven association with postoperativecomplications, including ureterovesical stricture, the au-thors observed the ability to decrease the number of anes-thetic procedures by active dilation.
Also, the introduction of smaller ureteroscopes has en-hanced the ability of the pediatric endoscopist to treat upperurinary tract calculi in retrograde fashion. Traditionallyflexible ureteroscopy has been the preferred technique toevaluate and treat proximal to the iliac vessels. We havepreviously reported the safety, advantages and high successrate (83%) of retrograde proximal rigid ureteroscopy andpyeloscopy for proximal ureteral and renal pelvis calculi aswell as diagnostic ureteropyeloscopy in prepubertal children(reference 12 in article). Although rigid ureteroscopes haveobvious limitations compared to flexible ureteroscopes totreat upper tract stones, I tend to use the former endoscopeswhen possible. The current authors used a 6.9Fr flexibleureteroscope in a relatively large number of children unableto successfully undergo the initial procedure, presumablydue to ureteral anatomy. An option that the authors do notdiscuss in the article is the use of a wire, which usually
allows the anatomy to be more clearly delineated, providingguidance and passage of the ureteroscope. The authorsshould be acknowledged for further advancing retrogradeureteroscopy in the upper urinary tract in children.
Jeffrey S. PalmerCenter for Pediatric Urology
Glickman Urological and Kidney InstituteCleveland ClinicCleveland, Ohio
REPLY BY AUTHORS
Our technique includes a safety wire and a working wire todelineate anatomy and facilitate passage of the uretero-scope. We believe our results show that dilating the ureteralorifice is a safe and effective means of accessing the upperurinary tract in prepubertal children, facilitating highstone-free rates with flexible ureteroscopy. Although therecontinues to be concern that active dilation of the pediatricureteral orifice will cause stricture, to date we have encoun-tered only 1 ureteral stricture in a prepubertal patient whohad a stent placed before ureteroscopy (reference 1 in arti-cle).
PRIOR URETERAL STENT PLACEMENT AND UPPER URINARY TRACT ACCESS1864
