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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 DilationNo Passive Dilationp-value
N152122
Age (years), median (IQR)14.7 (10.8, 17)15.8 (13.0, 17.5)0.027
Race
White114 (75.5%)84 (68.9%)0.47
Black21 (13.9%)18 (14.8%)
Asian1 (0.7%)2 (1.6%)
Indian1 (0.7%)0 (0.0%)
Other14 (9.3%)18 (14.8%)
Gender
Male69 (45.4%)50 (41.0%)0.54
Female83 (54.6%)72 (59.0%)
Neurogenic Bladder26 (17.1%)23 (18.9%)0.75
ASA Status
19 (5.9%)15 (12.3%)0.13
2102 (67.1%)67 (54.9%)
337 (24.3%)37 (30.3%)
44 (2.6%)3 (2.5%)
Prior ESWL5 (3.3%)3 (2.5%)0.74
Prior PCNL7 (4.6%)10 (8.2%)0.31
Prior URS52 (34.2%)37 (30.3%)0.52
Wheelchair Bound26 (17.1%)23 (18.9%)0.75
Scoliosis14 (9.2%)16 (13.1%)0.33
Indications for Surgery
Pain89 (73.0%)104 (68.4%)0.43
Size of Stone34 (27.9%)52 (34.2%)0.30
UTI19 (15.6%)23 (15.1%)1.00
Hematuria29 (23.8%)42 (27.6%)0.49
Other6 (4.9%)8 (5.3%)1.00
Calyceal Diverticulum7 (5.7%)7 (4.6%)0.78
Nausea/ Vomiting21 (17.2%)37 (24.3%)0.18

Table 2: Outcomes after Ureteroscopy
Passive DilationNo Passive Dilationp-value
N152122
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 Procedure18 (14.8%)19 (12.5%)
Ureteral Access Sheath69 (46.9%)51 (44.3%)0.71
Need for Staged URS35 (23.3%)17 (13.9%)0.063
Intra-Op Stent Placement119 (78.3%)112 (91.8%)0.002
Stent Duration (days), median (IQR)5 (3, 15)5 (3, 13)0.41
30 Day Complication12 (7.9%)27 (22.3%)<0.001
Clavien Grade
Grade I4 (33%)12 (44%)0.50
Grade II8 (67%)12 (44%)
Grade IIIb0 (0%)3 (11%)
Complication Type
Febrile UTI2 (1.3%)5 (4.1%)0.25
Afebrile UTI0 (0.0%)1 (0.8%)0.45
Stent Dislodgement0 (0.0%)2 (1.6%)0.20
Stent Malfunction1 (0.7%)0 (0.0%)1.00
Pain6 (3.9%)14 (11.5%)0.020
Hematuria0 (0.0%)1 (0.8%)0.45
Post-Op Fever4 (2.6%)5 (4.1%)0.52
Other2 (1.3%)7 (5.7%)0.083
Ipsilateral Stone Surgery within 1 year29 (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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