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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.

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Presentation on theme: "EXPERIENCE WITH URETEROSCOPY IN CHILDREN DR. SUNIL SHROFF, MS, FRCS ( UK), D.UROL (LOND), LECTURER IN UROLOGY & RENAL TRANSPLANTATION, INSTITUTE OF UROLOGY."— Presentation transcript:

1 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.

2 TECHNOLOGICAL INNOVATIONS 6F to 8Fr Semi-Rigid Ureteroscope 6F to 8Fr Semi-Rigid Ureteroscope Better modalities to fragment calculi Better modalities to fragment calculi Variety of Accessories Variety of Accessories INCREASING EXPERIENCE WITH URETEROSCOPIES IN ADULTS Hampton Young performed 1sr Ureteroscopy in 1929

3 15 children underwent 21 Ureteroscopic procedures l 19 Retrograde (Semi -Rigid Urs & Flex. Urs ) l 2 Antegrade (Flex. Urs) ( PERIOD ) Hampton Young used paediatric cystoscope for ureteroscopy in child with PUV NO. & TYPE OF URETEROSCOPY

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

5 21 ureteroscopic procedures: 21 ureteroscopic procedures: l 18 were for stone disease l 2 for haematuria of unknown origin l 1 for removal of a migrated stent In 1979 Goodman used paediatric cystoscope (11F) for 3 adult ureteroscopy CAUSE FOR URETEROSCOPY

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

7 l 10/13 Children with stone Disease required SINGLE ureteroscopy l 3/13 Children with Stone Disease required NINE ureteroscopies NUMBER OF URETEROSCOPIES Ureteroscopy in children was considered dangerous because of the size mismatch - small ureter big scope

8 All the children underwent : l Routine biochemistry l Urine-culture l Full metabolic screen for stone disease l KUB -X-ray & US INVESTIGATIONS: Metabolic screen in all children with stone ds essential

9 l All the procedures were performed under GENERAL anaesthesia l Muscle paralysis for stones in the LUMBAR ureter l Technique of ureteroscopy in children similar to ADULTS TECHNIQUE OF URETEROSCOPY With 9 to 13 Fr Ureteroscope Dilatation required in majority

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

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

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

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

14 14/21 (66%)- Lower - third 3/21(14%)- Middle - 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 Site of Calculus:

15 12/21 ( 57% ) - Laser lithotripsy Holmium Laser5 Pulsed Dye Laser 7 4/21 ( 19% )- EHL & Lithoclast 5/21( 24% )- Simple Basketing FRAGMENTATION / RETRIEVAL TECHNIQUE: Pulsed Dye laser safe for ureteric wall.

16 FRAGMENTATION / RETRIEVAL TECHNIQUE…….. l Stones fragmented into several small extractable pieces l Most of fragments extracted using 3Fr Segura basket ( with its plastic sheath removed) l 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.

17 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 year Children can pass fairly big calculi spontaneously

18 Anaesthesia Time varied from 40 minutes to 120 minutes ( Mean minutes ) ANAESTHESIA For upper uretric calculi G.A. helps to control respiration during fragmentation

19 No known cause - 7/13 Metabolic cause - 2/13 UTI - 4/13 CAUSE OF STONE DISEASE Incidence of Stone Ds in UK : Children - 2 per million Adults - 2 per thousand

20 No Access failures - using Antegrade / Retrograde & miniaturised ureteroscopes all stones accessed RESULTS Ureteroscopy in girls relatively easier than boys

21 RESULTS l 10/13 children with stone disease stone free with one ureteroscopy l 3/13 children - complex problems Required 9 ureteroscopies for stone disease Double J stents has helped to undertake multiple upper endoscopic procedures with ease

22 RESULTS Complications of Uretroscopy: l 1 stricture at the site of stone impaction l 1 retention of urine due to a stone fragment in the posterior urethra l 1 haematuria l 1 migrated stent requiring ureteroscopy Holmium laser has potential of ureteric damage & stricture

23 SATISFACTORY RESULT 14 year old boy 14 year old boy l 4 stones - 2 Upper- third / 2 Lower - third l One ureteroscopy to clear stones using Holmium laser l JJ stent left Children with adult body mass proportions ureteroscopy no different from adults

24 COMPLEX URETEROSCOPIES Case year old Girl Case year old Girl l Impacted stone 20 x10 mm - Upper third ureter / 2nd stone - 5 x 8 mm lower pole(L) kidney l Ureteroscopy / fragmentation of stone & JJ Stent l Over 6 weeks failed to pass fragments l PCNL / antegrade flexible ureteroscope to clear ureteric & lower pole stone Double J stent sometimes prevents stone fragments from pssing out

25 COMPLEX URETEROSCOPIES CASE - 2 CASE year old girl with Primary Hyperoxaluria 6 year old girl with Primary Hyperoxaluria l Stone obstructing her middle third ureter l 1st ureteroscopy cleared the ureter - Holmium laser used for fragmentation Primary Oxaluria - Kidney Transplantation results not satisfactory

26 COMPLEX URETEROSCOPIES Case - 2 ( Primary hyperoxaluria ) l 2nd stone dropped from kidney. Repeat Urs - stricture at site of previous stone l The stone fragmented using Holmium laser & 4.8 F JJ stent left for 6 - weeks l Ureterogram at stent removal - normal calibre ureter Primary Oxaluria suitable for combined Liver & Kidney Transplant

27 l Children with adult body mass proportions ureteroscopy no different from adults l This was true in 4/14 children who underwent ureteroscopy in present review

28 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


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