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Flexible and Navigable Suction Access Sheaths in the Medically Complex Pediatric Population
Grady Arnzen, MD1, Zachary Melchiode, MD1, Christopher Roth, MD2.
1Louisiana State University Health Sciences Center, New Orleans, LA, USA, 2Manning Family Children's Hospital, New Orleans, LA, USA.
Background: Children with neurological disorders experience immobility, high incidences of struvite and calcium phosphate stones, and positioning difficulties caused by limb contractures or vertebral abnormalities. Struvite stones carry a higher recurrence risk if incompletely treated and are associated with CKD progression. Percutaneous nephrolithotomy (PCNL) is traditionally considered first-line for larger struvite stones but carries increased hospital length of stay and major complications versus ureteroscopy (URS), with patient positioning posing further challenges in the complex neurogenic pediatric population.The adoption of flexible and navigable suction access sheaths (FANS-URS) has greatly expanded in adult urology, with over 91% of surveyed urologists now utilizing this technology. Recent pediatric studies demonstrate that FANS-URS is safe in children with stone-free rates comparable to suction mini-PCNL. Despite these findings, society guidelines for FANS-URS indications are sparse for adults and nonexistent for the pediatric population. We seek to demonstrate the usability of FANS-URS and advocate for its wider adoption within the neurogenic pediatric population.Methods: Our index patient initially presented as a 14-year-old female with VACTERL anomalies, including spina bifida with Chiari Type 2 malformation, severe scoliosis, and paraplegia with lower limb contractures. Urologic history includes a congenital solitary right kidney and neurogenic bladder managed with a Mitrofanoff catheterizable channel. Upper tract surveillance at age 16 identified two non-obstructing stones of 1-1.5cm diameter (HU 500-900), treated via URS due to family preference against PCNL. The stones were revealed to be innumerable 1-2mm gravel-like fragments, proving difficult to basket-extract. Final stone analysis demonstrated calcium oxalate and struvite composition, and the family elected for surveillance of the residual fragments. At age 19, a CT scan revealed right-sided ‘staghorn patterned’ calculi extending into the proximal ureter, an average density of 500 HU, and chronic moderate hydroureteronephrosis. FANS-URS was selected given the patient's solitary kidney, severe scoliosis, limb contractures, and family preference against PCNL.Results: The chronically dilated ureter accommodated an 11F/13F, 40cm suction access sheath (ClearPetra, KARL STORZ). A 270µm Holmium:YAG laser fiber was used. Irrigation infusion pressure was set at 250mmHg with sheath suction at 100mmHg to promote optimal passive and active suction without pelvicalyceal collapse. A 9F flexible ureteroscope was used, yielding a scope-to-sheath ratio of 0.81. Despite this ratio being slightly above the optimal range for stone evacuation, approximately 80% of stone burden was cleared at the initial operation, with repeat FANS-URS successfully clearing the remainder. Endoscopic findings included an increased size of the innumerable stone fragments with two visually distinct components to each stone. Final stone analysis confirmed struvite plus calcium oxalate composition. There were no complications following either procedure. Cumulative operative time was approximately 260 minutes. Follow-up ultrasound demonstrated improvement in hydroureteronephrosis with no residual stone burden.Conclusion: FANS-URS achieves stone-free rates comparable to mini-PCNL while reducing the morbidity associated with percutaneous approaches. Our case demonstrates FANS-URS's low barrier to adoption and particular benefit for complex pediatric stone-formers where percutaneous approaches are challenging. Pediatric urologists now have a unique opportunity to offer young, complex stone-formers a less invasive treatment of comparable efficacy.
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