Ureteroscopy for Stone Disease in Pediatric Patients with Neurogenic Bladder
Aznive Aghababian, BS, Katherine Fischer, MD, Yashaswi Parikh, BS, Sami Shaikh, BS, Curran Uppaluri, MD, Sonam Saxena, BS, Sahar Eftekharzadeh, MD, MPH, Karl Godlewski, MD, John Weaver, MD, Sameer Mittal, MD, Aseem Shukla, MD, Christopher Long, MD, Arun Srinivasan, MD.
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Introduction: Ureteroscopy (URS) for urolithiasis in pediatric patients may be particularly challenging for patients with other co-morbidities and those at increased risk for stone formation and recurrence. Patients with neurogenic bladders (NGB) and/or non-ambulatory are reported to have higher rates of additional comorbidities, an increased risk of developing urolithiasis, and higher rates of infections and post-operative complications. Our aim was to report our outcomes of URS for stone disease in pediatric patients with NGB and/or non-ambulatory status and compare these to outcomes in patients without these co-morbidities. Methods: An IRB-approved prospective single institutional registry was used to retrospectively identify all patients under 18 years of age who underwent URS for stone disease between July 2012 and July 2021, excluding bladder stones. We categorized patients in two groups: patient with NGB and/or wheelchair bound versus all other patients (controls). Baseline demographics, pre-operative radiologic imaging, intra-operative details, and post-operative outcomes including 30-day complications were aggregated and compared between the two groups. Results: 275 URS in 198 patients were performed during the study period, and 49 (18%) of these were performed on patients with NGB or who were non-ambulatory [Table 1]. On pre-operative imaging, patients with NGB had a significantly higher number of stones (3 vs 2, p=0.003) and larger total stone burden than those without NGB (15 mm vs 9mm, p=0.009). Compared to patients without NGB, patients with NGB had a significantly longer length of procedure (86 vs 60 minutes, p=0.002), increased need for staged procedures, increased length of stay (1 vs 0 days, p<0.001), and increased use of pre-operative course of antibiotics (<0.001). There was no difference in need for passive dilation, stent placement, or other intra-operative parameters. Post-operatively, there was no statistical difference in the incidence of 30 days complications between the two groups, however there was a higher incidence of febrile UTIs (8.2% vs 1.3%, p=0.021) in patients with NGB and a lower incidence of pain related complications (0 % vs 9.3%, p=0.032). Within a year of surgery, patients with NGB had a higher incidence of requiring ipsilateral URS for recurrent stone diseaseConclusion: Our results show that URS for urolithiasis can be done safely and effectively in pediatric patients who are non-ambulatory and/or have neurogenic bladders. The increased risk of infectious complications within 30 days of surgery warrants careful pre-operative and post-operative antibiotic care plan for this patient population.
| Table 1: demographics, intra-operative and post-operative outcomes for patients with and without neurogenic bladder and/or non-ambulatory status undergoing URS | |||
| Neurogenic Bladder/ Non-Ambulatory | Controls | p-value | |
| 49 | 227 | ||
| Age (years), median (IQR) | 14.83 (12.4, 16.6) | 15.63 (10.9, 17.4) | 0.71 |
| Race | <0.001 | ||
| White | 21 (42.9%) | 179 (79.2%) | |
| Black | 17 (34.7%) | 22 (9.7%) | |
| Asian | 0 (0.0%) | 3 (1.3%) | |
| Indian | 0 (0.0%) | 1 (0.4%) | |
| Other | 11 (22.4%) | 21 (9.3%) | |
| Gender | <0.001 | ||
| Male | 36 (73.5%) | 83 (36.6%) | |
| Female | 13 (26.5%) | 144 (63.4%) | |
| Total Stone Burden, median (IQR) | 15 (8, 20) | 9 (6, 14) | 0.009 |
| Total # Stones, median (IQR) | 3 (2, 10) | 2 (1, 4) | 0.003 |
| Procedure Length (mins), median (IQR) | 86 (48, 136) | 60 (43, 86) | 0.002 |
| Passive Dilation | 24 (49.0%) | 123 (54.2%) | 0.53 |
| Access Sheath Used | 29 (59.2%) | 91 (42.3%) | 0.039 |
| Need for Staged Procedure | 17 (34.7%) | 35 (15.6%) | 0.004 |
| Length of Stay (Days), median (IQR) | 1 (0, 3) | 0 (0, 0) | <0.001 |
| Pre-Op Urine Culture | 26 (53.1%) | 79 (34.8%) | 0.023 |
| Pre-Op Antibiotics | 16 (33.3%) | 17 (8.5%) | <0.001 |
| Stent on a String | 28 (68.3%) | 139 (73.2%) | 0.57 |
| 30-day Complication | 9 (18.4%) | 31 (13.8%) | 0.38 |
| Clavien Grade | 0.002 | ||
| Grade I | 0 (0%) | 17 (55%) | |
| Grade II | 9 (100%) | 11 (35%) | |
| Grade IIIb | 0 (0%) | 3 (10%) | |
| Complication Type | |||
| Febrile UTI | 4 (8.2%) | 3 (1.3%) | 0.021 |
| Afebrile UTI | 1 (2.0%) | 0 (0.0%) | 0.18 |
| Stent Malfunction | 1 (2.0%) | 0 (0.0%) | 0.18 |
| Stent Dislodgement | 0 (0.0%) | 2 (0.9%) | 1.00 |
| Pain | 0 (0.0%) | 21 (9.3%) | 0.032 |
| Hematuria | 1 (2.0%) | 0 (0.0%) | 0.18 |
| Post-Op Fever | 4 (8.2%) | 5 (2.2%) | 0.056 |
| Other | 2 (4.1%) | 7 (3.1%) | 0.66 |
| Ipsilateral Stone Surgery within 1 year | 18 (36.7%) | 43 (18.9%) | 0.012 |
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