The effect of preoperative tamsulosin on pediatric ureteroscopic access: A multi-institutional experience
Kayla M. Meyer, BS1, Kwesi Asantey, MD2, Jonathan S. Ellison, MD3, Aditya Jadcherla, BS2, Adam Ostergar, MD4, Erica J. Traxel, MD5, Alethea Paradis, MS4, Joel Vetter, PhD4, Douglas W. Storm, MD, FAAP6, Erik S. Davis, BS6, Lauren McGee, MD7, Kate H. Kraft, MD, MHPE8.
1University of Michigan Medical School, Ann Arbor, MI, USA, 2Medical College of Wisconsin, Milwaukee, WI, USA, 3Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA, 4Washington University School of Medicine, St. Louis, MO, USA, 5Division of Urologic Surgery, Washington University, St. Louis, MO, USA, 6Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA, 7Department of Urology, Oregon Health & Science University, Portland, OR, USA, 8Department of Urology, Michigan Medicine, Ann Arbor, MI, USA.
BACKGROUND: An increased rate of pediatric nephrolithiasis has led to advances in the surgical and medical management of pediatric stone disease. Flexible ureteroscopy (URS) is the most common surgical intervention for urolithiasis in children. One limitation of pediatric URS is the inability to access the ureter on the first attempt, a situation particularly challenging in younger children owing to the smaller pediatric ureterovesical junction (UVJ). Tamsulosin has been shown to improve success rates of instrumentation in the adult ureter. Single institution studies on ureteral access in children following tamsulosin show trends towards a benefit, however the efficacy of this medication to facilitate ureteral access remains unclear. The goal of this retrospective study is to evaluate the effect of tamsulosin in children undergoing URS. We hypothesize that tamsulosin will improve the ability to access the pediatric ureter with a flexible ureteroscope.
Methods: We conducted a multi-institutional retrospective review of pediatric patients aged 0-17 years who underwent URS for the treatment of nephrolithiasis from January 2013 to March 2022. Patients were excluded if they had undergone previous URS or ureteral stent placement within the prior year, underwent semi-rigid URS, or had a known genitourinary abnormality. Study exposure was defined as 0.4 mg tamsulosin prescribed to be taken daily for at least one week prior to surgery. The primary outcome was failure to pass a flexible ureteroscope on initial surgical attempt. Treatment-stratified summary statistics were reported as medians and interquartile ranges or counts and frequencies for continuous and categorical measures, respectively. Between-treatment assessments were made using Wilcoxon rank sum and Fisher’s exact tests.
Results: We identified 336 patients. Patient demographics and stone characteristics are included in Table 1. Table 2 compares the URS outcomes between the two cohorts.
Table 1
| No Tamsulosin N = 224 | Tamsulosin N = 112 | p-value | ||
| Age (years) | 10 (8, 14) | 15 (12, 16) | <0.0001 | |
| Height (cm) | 137 (116, 158) | 160 (150, 165) | <0.0001 | |
| Weight (kg) | 35.9 (21.6, 52.3) | 53.8 (42.2, 68.0) | <0.0001 | |
| BMI | 18.4 (16.0, 22.3) | 21.0 (18.1, 24.8) | <0.0001 | |
| Gender | Male | 48 (43%) | 96 (43%) | >0.9999 |
| Female | 128 (57%) | 64 (57%) | ||
| Race | Other | 27 (12%) | 15 (13%) | 0.7289 |
| White | 197 (88%) | 97 (87%) | ||
| Surgery Laterality | Left | 94 (42%) | 40 (36%) | 0.1098 |
| Right | 112 (50%) | 68 (61%) | ||
| Bilateral | 18 (8%) | 4 (3%) | ||
| Largest Stone Size (mm) | 7 (4, 8) | 5 (4, 7) | 0.1143 | |
| Stone Location | Left Renal Collecting System | 73 (33%) | 37 (33%) | >0.9999 |
| Right Renal Collecting System | 79 (36%) | 45 (40%) | 0.4025 | |
| Left Ureter | 54 (24%) | 29 (26%) | 0.7886 | |
| Right Ureter | 54 (24%) | 45 (40%) | 0.0034 | |
Table 2
| No Tamsulosin N = 224 | Tamsulosin N = 112 | p-value | |
| Successful at gaining access with ureteroscope into the ureter | 180 (81%) | 102 (92%) | 0.0141 |
| Use of ureteral dilation during the procedure | 139 (64%) | 72 (64%) | >0.9999 |
| Stent placed afterthe procedure | 180 (81%) | 86 (77%) | 0.3155 |
Conclusions: Our results suggest that at least one week of preoperative tamsulosin facilitates passage of the flexible ureteroscope across the UVJ in the pediatric population. Tamsulosin exposure did not reduce the need for ureteral dilation or the rate of stent placement after URS. This multi-institutional study expands on prior research that demonstrated fewer failures of initial passage of a flexible ureteroscope into the pediatric ureter in patients prescribed preoperative tamsulosin. These results have significant clinical implications, with the potential to minimize surgical complications, reduce multiple procedures and spare children from repeat anesthetic exposures. Limitations of this study include those inherent to a retrospective design. There remains a need for prospective trials to more adequately evaluate the role of preoperative tamsulosin for ureteroscopy in children.
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