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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.Peter’s Hospital )
LONDON, UK.
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
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
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
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
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.
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”
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
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
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
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
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 “
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
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
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.
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.
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 years
Mean - 1 year
Children can pass fairly big calculi spontaneously
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
CAUSE OF STONE DISEASE
No known cause Metabolic cause UTI
-
7/13
2/13
4/13
Incidence of Stone Ds in UK :
Children - 2 per million Adults - 2 per thousand
RESULTS
No Access failures - using
Antegrade / Retrograde &
miniaturised ureteroscopes all
stones accessed
Ureteroscopy in girls relatively easier than boys
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
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
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
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
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
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

Children with adult body mass proportions ureteroscopy no
different from adults

This was true in 4/14 children who
underwent ureteroscopy in present
review
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
1/--страниц
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