Presentation on theme: "EXPERIENCE WITH URETEROSCOPY IN CHILDREN”"— Presentation transcript:
1EXPERIENCE 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.
2TECHNOLOGICAL INNOVATIONS 6F to 8Fr Semi-Rigid UreteroscopeBetter modalities to fragment calculiVariety of AccessoriesINCREASING EXPERIENCE WITH URETEROSCOPIES IN ADULTSHampton Young performed 1sr Ureteroscopy in 1929
3NO. & TYPE OF URETEROSCOPY 15 children underwent 21 Ureteroscopic procedures19 Retrograde (Semi -Rigid Urs & Flex. Urs )2 Antegrade (Flex. Urs)( PERIOD )Hampton Young used paediatric cystoscope forureteroscopy in child with PUV
4PHYSICAL CHARCTERISTICS .Age - 13 months to 14 yearWeight - Mean 35.9 kgs (range from 7 to 70 Kgs).Height - Mean CMS (range from 70 to 162 cms)Lyon and his associates were the first to develop apur pose built 13F Ureteroscope
521 ureteroscopic procedures: CAUSE FOR URETEROSCOPY21 ureteroscopic procedures:18 were for stone disease2 for haematuria of unknown origin1 for removal of a migrated stentIn 1979 Goodman used paediatric cystoscope (11F) for 3 adult ureteroscopy
6( Dilatation for Retrograde 9.5 Fr Flexible Ureteroscope ) 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.
7NUMBER OF URETEROSCOPIES 10/13 Children with stone Disease required SINGLE ureteroscopy3/13 Children with Stone Disease required NINE ureteroscopiesUreteroscopy in children was considered dangerous because of the size mismatch - “small ureter big scope”
8All the children underwent : Routine biochemistry INVESTIGATIONS:All the children underwent :Routine biochemistryUrine-cultureFull metabolic screen for stone diseaseKUB -X-ray & USMetabolic screen in all children with stone ds essential
9TECHNIQUE OF URETEROSCOPY All the procedures were performed under GENERAL anaesthesiaMuscle paralysis for stones in the LUMBAR ureterTechnique of ureteroscopy in children similar to ADULTSWith 9 to 13 Fr Ureteroscope Dilatation required in majority
10FLEXIBLE 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 stoneFLEXIBLE URETEROSCOPE USEFUL SCOPE FOR ANTEGRADE URETEROSCOPY.
11Routine prophylactic antibiotics Gentamicin - one dose 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 eyepieceFluoroscopic monitoring was made availableVideo camera helped to perfect upper endoscopic procedures & IMPROVED OVERALL RESULTS
12TECHNIQUE OF URETEROSCOPY………... Ureteroscope rotated hence guidewire faces superio-laterallyUreteric meatus Opens up due to stretching of Orifice.Once Intramural Ureter entered the Ureteroscope Rotated back in alignment with ureterTHE ABOVE TECHNIQUE CALLED “SHOE-HORN TECHNIQUE “
13TECHNIQUE OF URETEROSCOPY………... ( TO AVOID MORBIDITY ) Height of saline irrigation bag kept between 40 & 60 cmsUreteroscope never advanced if resistance encountered or if vision poorThe gentlest touch used to advance the ureteroscope through the ureteric lumenWhen kinking of ureter encountered guidewire advanced to straighten ureterPressure on abdominal wall ( over iliac vessels) helps straightens curvature to line of ureter
14Site of Calculus: 14/21 (66%) - Lower - third 3/21(14%) - Middle - third4/21 (20%) - Upper - third( 21 Calculi cleared in 18 children )In situ ESWL quite effective for upper ureteric & VUJ calculus
16FRAGMENTATION / RETRIEVAL TECHNIQUE…….. Stones fragmented into several small extractable piecesMost of fragments extracted using 3Fr Segura basket ( with its plastic sheath removed)A stent was avoided whenever possibleFirst clinical trials of Pulsed dye laser for lasertripsy atSt.Peter's Hospital, U.K. & Massachusett's General Hospital, USA.
17Mean Size of the stone - 12. 9 x 6 Mean Size of the stone x 6.6 mm (Range 5 x 2 mm to 35 x 10 mm) Hospital stay - 1 to 6 days Mean days Follow up - 3/12 to 3 years Mean - 1 yearChildren can pass fairly big calculi spontaneously
18Anaesthesia Time varied from 40 minutes to 120 minutes ( Mean minutes )For upper uretric calculi G.A. helps to control respirationduring fragmentation
19CAUSE OF STONE DISEASE No known cause - 7/13 Metabolic cause - 2/13 UTI /13Incidence of Stone Ds in UK :Children - 2 per million Adults - 2 per thousand
20RESULTSNo Access failures - using Antegrade / Retrograde & miniaturised ureteroscopes all stones accessedUreteroscopy in girls relatively easier than boys
21RESULTS10/13 children with stone disease stone free with one ureteroscopy3/13 children - complex problems Required 9 ureteroscopies for stone diseaseDouble J stents has helped to undertake multipleupper endoscopic procedures with ease
22Complications of Uretroscopy: RESULTSComplications of Uretroscopy:1 stricture at the site of stone impaction1 retention of urine due to a stone fragment in the posterior urethra1 haematuria1 migrated stent requiring ureteroscopyHolmium laser has potential of ureteric damage & stricture
23SATISFACTORY RESULT 14 year old boy 4 stones - 2 Upper- third / 2 Lower -thirdOne ureteroscopy to clear stones using Holmium laserJJ stent leftChildren with adult body mass proportions ureteroscopy no different from adults
24COMPLEX URETEROSCOPIES Case year old GirlImpacted stone 20 x10 mm - Upper third ureter / 2nd stone - 5 x 8 mm lower pole(L) kidneyUreteroscopy / fragmentation of stone & JJ StentOver 6 weeks failed to pass fragmentsPCNL / antegrade flexible ureteroscope to clear ureteric & lower pole stoneDouble J stent sometimes prevents stone fragments frompssing out
25COMPLEX URETEROSCOPIES CASE - 26 year old girl with Primary HyperoxaluriaStone obstructing her middle third ureter1st ureteroscopy cleared the ureter - Holmium laser used for fragmentationPrimary Oxaluria - Kidney Transplantation resultsnot satisfactory
26COMPLEX URETEROSCOPIES Case ( Primary hyperoxaluria )2nd stone dropped from kidney. Repeat Urs - stricture at site of previous stoneThe stone fragmented using Holmium laser & 4.8 F JJ stent left for weeksUreterogram at stent removal - normal calibre ureterPrimary Oxaluria suitable for combined Liver &Kidney Transplant
27Children with adult body mass proportions ureteroscopy no different from adults This was true in 4/14 children who underwent ureteroscopy in present review
28Ureteroscopy in children can be used with equal success Conclusion:Ureteroscopy in children canbe used with equal successas in adults to treat calculusdisease in experienced handsLaser lithotripsy using 200 micron sized tip of quartz fibremade minitaturisation of ureteroscope feasable