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

21 ureteroscopic procedures: 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 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.

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”

All the children underwent : Routine biochemistry 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 .

Routine 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 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

12/21 ( 57% ) - Laser lithotripsy Holmium Laser 5 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 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 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 - 7/13 Metabolic cause - 2/13 UTI - 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

Complications of Uretroscopy: 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

Ureteroscopy in children can be used with equal success 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