Ultrasound Guided Ureteroscopy in Children: Safety and Success
Jeffrey C. Morrison, MD, Kassa Darge, MD, Christopher J. Long, MD, Arun K. Srinivasan, MD MRCS.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Background: Incidence of pediatric nephrolithiasis has been increasing in recent years. Ureteroscopy is the most common surgical intervention, for which fluoroscopy is traditionally used for intraoperative guidance. Children with nephrolithiasis are at increased risk of secondary effects from ionizing radiation in their lifetime due to their risk of stone recurrence and need for repeated procedures, longer life expectancy, high cellular mitotic rate, and close proximity of the operative field to the gonads. Ultrasound guided ureteroscopy has potential to provide a radiation-free, safe and effective approach to stone management in children. We present the first case series demonstrating the safety and success of ultrasound guided ureteroscopy in pediatric nephrolithiasis patients.
METHODS: With IRB approval, a review of consecutive patients that underwent ultrasound guided ureteroscopy at our institution was performed. We collected data on demographics, procedures performed, stone size, operative time, outcomes, and complications.
RESULTS: Eight patients underwent nine ultrasound guided ureteroscopic procedures for nephrolithiasis. One patient had to be pre-stented and subsequently had ureteroscopy and stone extraction. Real time ultrasound guidance was used for guidewire placement, followed by double lumen catheter, second wire access, access sheath, and ureteroscope. All instruments were followed in both bladder and renal ends for confirmation of position. Stones were removed via ultrasound guidance from various locations including lower pole calyx, proximal ureter, and from a calyceal diverticulum. In one patient, ultrasound was used to perform a ureteral balloon dilation of uretero-vesical junction and one patient had ultrasound guided access and dilation of calcyeal diverticulum. Stents were placed under ultrasound guidance. Fluoroscopy was used in the initial six procedures to verify stent location at the end of the procedure during the learning phase of the ultrasound technique. Patient characteristics and outcomes are summarized in Table 1 and 2.
CONCLUSIONS: Ultrasound guided ureteroscopy can be safely and effectively used in pediatric patients to successfully treat urolithiasis with significant reduction or complete elimination of ionizing radiation.
|Table 1. Patient characteristics and operative outcomes|
|Gender (female %)||67%|
|Age (years) – Median (Range)||13 (3-22)|
|BMI (kg/m2) – Median (Range)||20.6 (13.7-30.1)|
|Stone size (mm) – Median (Range)||6 (4-10)|
|Operative time (mins) – Median (Range)||66 (43-94)|
|Table 2. Procedural details and outcomes|
|Patient||Ultrasound Guided Procedure||Operative Time (min)||Outcome||Complications|
|Patient 1||Ureteroscopy||61||Basket extraction of upper and lower pole stones||none|
|Patient 2||Ureteroscopy||89||Laser lithotripsy of mid pole stones||none|
|Patient 3||Ureteroscopy||65||Identification of lower pole Randall’s plaque||Additional pain control (Clavien I)|
|Patient 4A||Cystoscopy, attempted ureteroscopy, pre-stent placement||44||Failed ureteroscopy, pre-stenting was done||none|
|Patient 4B||Ureteroscopy||71||Basket extraction of proximal ureteral stone||none|
|Patient 5||Ureteroscopy||83||Basket extraction of mid pole stone||Additional pain control (Clavien I)|
|Patient 6||Ureteroscopy||43||Laser lithotripsy and basket extraction of lower pole stone||none|
|Patient 7||Cystoscopy, Balloon dilation of ureter, attempted ureteroscopy, stent placement||65||Ureteral balloon dilation of UVJ and pre-stent placement||none|
|Patient 8||Ureteroscopy, laser calycostomy, Stone extraction||94||Calyceal diverticulum-laser calycostomy, removal of stones and stent placement into diverticulum||none|
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