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.Peter’s Hospital )
LONDON, UK.

2. 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

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

4. PHYSICAL CHARCTERISTICS.
Age - 13 months to 14 year
Weight - 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 a
pur pose built 13F Ureteroscope

5. 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

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.

7. 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”

8. 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

9. 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

10. 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 .

11. 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

12. 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 “

13. 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

14. 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

15. 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.

16. 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.

17. Mean 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 year
Children can pass fairly big calculi spontaneously

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

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

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

21. 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

22. 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

23. 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

24. COMPLEX URETEROSCOPIES
Case 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

25. 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

26. COMPLEX URETEROSCOPIES
Case ( 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 weeks
Ureterogram at stent removal - normal calibre ureter
Primary Oxaluria suitable for combined Liver &
Kidney Transplant

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

28. 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