Passive ureteral dilation with pre-ureteroscopy stenting results in decreased complication rate in pediatric stone removal
Christopher J. Long, MD, Trudy Kawal, MD, Jason Van Batavia, MD, Dana A. Weiss, MD, Aseem R. Shukla, MD, Arun K. Srinivasan, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
BACKGROUND: Ureteroscopy (URS) is the standard of care for surgical management of pediatric stone disease. Safe scope passage can be limited in the pediatric population due to small ureteral caliber necessitating either passive (double J stent placement) or active (coaxial vs. balloon dilation) ureteral dilation. Little is known about patient risk factors for post-URS complication development. We hypothesized that pediatric URS may be safely performed even in complex clinical scenarios with a large stone burden and neurogenic bladder, and that passive ureteral dilation is commonly required prior to successful pediatric URS.
METHODS: Consecutive pediatric patients (≤ 18 years of age) undergoing URS at our institution from January 2004-April 2016 were retrospectively analyzed. Demographic information was obtained as was stone location and size, medical history, and previous stone management. Decision to stage the URS was based upon surgeon assessment of the degree of scope passage resistance. Complications were assessed throughout the entire inclusion period and were stratified according to the Clavien-Dindo criteria. Exclusion criteria included stone management by alternative surgical approaches and age >18 years.
RESULTS: A total of 306 patients underwent 401 procedures during the inclusion period. Our overall complication rate was 57/401 (14%) (Table 1). Of our complications, 7/57 (12%) were Clavien 3-4. No deaths occurred in the cohort. The majority of complications were non-surgical in nature, classified as Clavien 1-2 in 50/57 (88%) patients. Subsequent multivariate analysis revealed age >15 and non-white ethnicity as a risk factor for complication development while pre-URS ureteral stenting decreased the risk (Table 2). Our pre-URS stent rate was 287/401 (72%). Stone location within the renal pelvis vs the ureter did not increase pre-URS stent rate (28.5% vs 35.8%, NS) (Table 3). Median age in the stented group was significantly younger 13.3 vs. 14.7 years (p<0.05). Patients with a neurogenic bladder were less likely to require pre-URS stent insertion. Pre-URS stent rates were no different based on ethnicity, gender, stone size, or rate of congenital anomalies.
CONCLUSIONS: Although pre-URS ureteral stenting is safe and resulted in decreased risk of post-surgical complication development, these benefits must be weighed against additional anesthetic exposures. Younger patients were more likely to require a staged URS with ureteral stent placement. A history of a neurogenic bladder was associated with a decreased need for ureteral stenting.
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