Passive Dilation in Pediatric Patients Undergoing Ureteroscopy for Stone Disease: a Single-Institutional Cohort
Aznive Aghababian, BS, Katherine Fischer, MD, Sami Shaikh, BS, Yashaswi Parikh, BS, Curran Uppaluri, MD, Sonam Saxena, BS, Karl Godlewski, MD, Sahar Eftekharzadeh, MD, MPH, John Weaver, MD, Sameer Mittal, MD, MSc, Aseem Shukla, MD, Christopher Long, MD, Arun Srinivasan, MD.
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Introduction: Ureteroscopy (URS) for surgical management of pediatric stone disease has become common practice. When initial passage of the ureteroscope is not feasible, pre-stenting the ureter is commonly done to allow for passive dilation of the ureter. However, the role of pre-stenting in pediatric ureteroscopy and its influence on outcomes are not well studied. We hypothesize that passive dilation in pediatrics with pre-stenting is safe, effective, and may decrease the risk of post-operative complications.
Methods: An IRB-approved single institutional registry was used to retrospectively identify all patients ≤18 years old undergoing URS for stone disease between July 2012 to July 2021. Patients were categorized into two groups based on whether passive dilation was utilized. Baseline demographics, co-morbidities, pre-operative radiologic findings, intra-operative details, and post-operative outcomes including 30-day complications and incidence of subsequent procedures were aggregated. Association of passive dilation with 30-day complications was evaluated with univariate and multivariate logistic regression.
Results: We identified 274 URS procedures (198 patients) during the study period: 152 (55.5%) URS with passive dilation and 122 (44.5%) without passive dilation. The median age at surgery was significantly younger for the passive dilation group: 14.7 years (IQR: 10.8, 17) versus 15.8 years (IQR: 13, 17.5) for the no passive dilation group (p=0.027). The median duration of the pre-URS stent when passive dilation was employed was 21.5 days (IQR: 15, 35). There was no statistical difference noted between the groups in patient weight, presence of neurogenic bladder, ASA status, total stone burden noted in pre-operative imaging, indications for URS, need for staged URS nor length of procedure. Patients undergoing passive dilation had a significantly lower incidence of 30-day post-operative complications compared to patients undergoing URS without passive dilation (7.9% vs 22.3%, p<0.001) particularly complications related to post-operative pain (3.9% vs 11.5%, p=0.02). When controlling for age, gender and intra-operative stent placement on multivariate regression, passive dilation by pre-stenting was associated with a lower risk of post-operative complications (OR 0.34, 95% CI 0.16 – 0.71, p=0.005).
Conclusions: Our results demonstrate that passive dilation by pre-stenting in pediatric patients undergoing ureteroscopy is safe and efficacious and lowers incidence of 30-day complications, particularly those related to pain, post-operatively. This benefit should be balanced with risks of second procedure and anesthesia that pre-stenting adds to decide best course for individual patients.
| Table 1: Pre-operative demographics for patients undergoing URS for stone disease | |||
| Passive Dilation | No Passive Dilation | p-value | |
| N | 152 | 122 | |
| Age (years), median (IQR) | 14.7 (10.8, 17) | 15.8 (13.0, 17.5) | 0.027 |
| Race | |||
| White | 114 (75.5%) | 84 (68.9%) | 0.47 |
| Black | 21 (13.9%) | 18 (14.8%) | |
| Asian | 1 (0.7%) | 2 (1.6%) | |
| Indian | 1 (0.7%) | 0 (0.0%) | |
| Other | 14 (9.3%) | 18 (14.8%) | |
| Gender | |||
| Male | 69 (45.4%) | 50 (41.0%) | 0.54 |
| Female | 83 (54.6%) | 72 (59.0%) | |
| Neurogenic Bladder | 26 (17.1%) | 23 (18.9%) | 0.75 |
| ASA Status | |||
| 1 | 9 (5.9%) | 15 (12.3%) | 0.13 |
| 2 | 102 (67.1%) | 67 (54.9%) | |
| 3 | 37 (24.3%) | 37 (30.3%) | |
| 4 | 4 (2.6%) | 3 (2.5%) | |
| Prior ESWL | 5 (3.3%) | 3 (2.5%) | 0.74 |
| Prior PCNL | 7 (4.6%) | 10 (8.2%) | 0.31 |
| Prior URS | 52 (34.2%) | 37 (30.3%) | 0.52 |
| Wheelchair Bound | 26 (17.1%) | 23 (18.9%) | 0.75 |
| Scoliosis | 14 (9.2%) | 16 (13.1%) | 0.33 |
| Indications for Surgery | |||
| Pain | 89 (73.0%) | 104 (68.4%) | 0.43 |
| Size of Stone | 34 (27.9%) | 52 (34.2%) | 0.30 |
| UTI | 19 (15.6%) | 23 (15.1%) | 1.00 |
| Hematuria | 29 (23.8%) | 42 (27.6%) | 0.49 |
| Other | 6 (4.9%) | 8 (5.3%) | 1.00 |
| Calyceal Diverticulum | 7 (5.7%) | 7 (4.6%) | 0.78 |
| Nausea/ Vomiting | 21 (17.2%) | 37 (24.3%) | 0.18 |
| Table 2: Outcomes after Ureteroscopy | |||
| Passive Dilation | No Passive Dilation | p-value | |
| N | 152 | 122 | |
| Procedure Length (mins), median (IQR) | 64.5 (45, 90.5) | 60.5 (42, 92) | 0.50 |
| Weight (kg) at surgery, median (IQR) | 50.4 (38.3, 64.1) | 48.1 (29.4, 58.5) | 0.087 |
| Bilateral Procedure | 18 (14.8%) | 19 (12.5%) | |
| Ureteral Access Sheath | 69 (46.9%) | 51 (44.3%) | 0.71 |
| Need for Staged URS | 35 (23.3%) | 17 (13.9%) | 0.063 |
| Intra-Op Stent Placement | 119 (78.3%) | 112 (91.8%) | 0.002 |
| Stent Duration (days), median (IQR) | 5 (3, 15) | 5 (3, 13) | 0.41 |
| 30 Day Complication | 12 (7.9%) | 27 (22.3%) | <0.001 |
| Clavien Grade | |||
| Grade I | 4 (33%) | 12 (44%) | 0.50 |
| Grade II | 8 (67%) | 12 (44%) | |
| Grade IIIb | 0 (0%) | 3 (11%) | |
| Complication Type | |||
| Febrile UTI | 2 (1.3%) | 5 (4.1%) | 0.25 |
| Afebrile UTI | 0 (0.0%) | 1 (0.8%) | 0.45 |
| Stent Dislodgement | 0 (0.0%) | 2 (1.6%) | 0.20 |
| Stent Malfunction | 1 (0.7%) | 0 (0.0%) | 1.00 |
| Pain | 6 (3.9%) | 14 (11.5%) | 0.020 |
| Hematuria | 0 (0.0%) | 1 (0.8%) | 0.45 |
| Post-Op Fever | 4 (2.6%) | 5 (4.1%) | 0.52 |
| Other | 2 (1.3%) | 7 (5.7%) | 0.083 |
| Ipsilateral Stone Surgery within 1 year | 29 (19.1%) | 32 (26.2%) | 0.19 |
| Time to Repeat Intervention (Days), median (IQR) | 96 (44, 193) | 41.5 (15.5, 89) | 0.031 |
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