Journal Archives - Volume 13
Prenatal therapy for Lower Urinary Tract Obstruction (LUTO) continues to evolve. Initial procedures that involved open fetal surgery techniques have been replaced by percutaneous approaches, including fetal cystoscopy. Although the fetal outcomes have improved and maternal morbidity has decreased after the introduction of less invasive procedures, the overall outcomes after in utero treatment for LUTO remain poor. In this chapter the authors have reviewed the limitations of ultrasound-guided percutaneous vesicoamniotic shunts for the treatment of PUV and the current evidence to support the use of fetal cystoscopy in the diagnosis and treatment of this condition.
The importance of investigating metabolic risk factors, such as hypercalciuria, is becoming evident as these are a leading cause for pediatric stone disease world-wide. The data to support the safety and efficacy of treatments, such as shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy, continue to emerge. This chapter evaluates these aspects of pediatric stone disease, as well as summarize some of the literature to date on endoscopic treatment.
Pediatric ureteropyeloscopy has been facilitated by the continuous miniaturization of ureteroscopes and their accessory instruments. Small caliber endoscopes with improved optics allow safe and effective ureteroscopy in the pediatric upper urinary tract for a variety of disorders, including stricture disease, essential hematuria, and stone disease. Pediatric ureteroscopy follows many of the same tenants as adult ureteroscopy, with the goal of attaining atraumatic access to the ureter and calyceal system. In general, pre-stenting the ureter facilitates passive dilation and leads to less traumatic endoscopy. In select circumstances, dilation of the distal ureter under direct vision or with a balloon dilator may be employed when the distal ureter is tight. Ureteral access sheaths are rarely used in young, small children, but may be used more liberally in adolescent children with large stones. The majority of the literature on pediatric ureteroscopy is for the treatment of pediatric stone disease. In these series, excellent stone free rates of 90-95% may be achieved. With proper technique, major complications, such as ureteral perforation are rarely encountered. Minor complications, such as gross hematuria and pyelonephritis are similar to adults, and occur with a reported rate of 1 to 5%.
The incidence, risk factors and the composition of stones dictate the management of pediatric stone disease. Ureteroscopy has proven to be an important tool in the treatment of upper urinary tract urolithiasis in children. It is less invasive than PCNL and has an almost equivalent effectiveness to that of ESWL, with reported stone free rates between 76 and 100%. This chapter will focus on ureteroscopy as an important tool in the armamentarium against ureteric and renal stones.
In children, a dorsal lumbotomy approach provides excellent posterior access to the kidney. Less subcutaneous fat, a thinner muscular abdominal wall and proximity of the kidney to the lumbodorsal fascia (LDF) make this approach more attractive in children than in adolescents or adults. Exposure is obtained via a muscle-sparing approach, which decreases post-operative pain and permits rapid recovery. Eventual cosmesis can be excellent if the initial incision is made to follow skin tension lines. In pediatric patients, dorsal lumbotomy is a practical option in cases of pyeloplasty, open renal biopsy, removal of pelvic or upper ureteric stones and simple nephrectomy for atrophy or multicystic dysplasia. Infants and young children routinely go home within 12-24 hours after dorsal lumbotomy. In older children, the stay may be up to 24-48 hours and the authors underscore, that, this is equal whether these patients undergo laparoscopic repair or an open repair via dorsal lumbotomy.
Robotic surgery enables a revolutionary advance for pediatric urological reconstruction providing a great benefit for patients and surgeons. Although further outcome studies and prospective randomized comparison studies with open surgery or conventional laparoscopic surgery may be needed, pediatric robotic pyeloplasty can be considered a safe and effective alternative minimally invasive approach to UPJO. In this chapter the authors have outlined the advantages which robotic surgery offers in terms of precision, ease in suturing, three-dimensional visualization & decreases in the learning curve, especially, with respect to overcoming many impediments of conventional laparoscopic pyeloplasty.
Shock Wave Lithotripsy has been proved to be efficient and safe in all age groups. The basic principle of this treatment is the disintegration of stones by external shock waves. Its efficiency depends on the ability of the urinary system to expel the fragments out of the body. It has been shown that the pediatric ureter is at least as efficient as the adult ureter in transporting stone fragments. Shock wave lithotripsy is still an excellent treatment for small and medium size renal and ureteral stones, even in the era of modern pediatric scopes. In this chapter the authors have described its simplicity & efficiency to operate with minimal morbidity.
Percutaneous nephrolithotomy (PCNL) was first applied to the pediatric population in the 1980’s using adult-size instruments, primarily in cases of shock wave lithotripsy (SWL) failure. Although there is still concern for potential renal damage in developing kidneys, initial investigations have demonstrated the safety and efficacy of PCNL in children. Operative techniques are similar to those utilized in adult patients but considerations specific to pediatric populations must be addressed. Modifications in technique including “mini-perc” access have reduced post operative morbidity in select children without an appreciable difference in stone clearance rates. Accumulating experience and technological improvements including miniaturization of endoscopes and advances in energy fragmentation sources has facilitated stone free rates comparable to adult populations, making open surgery for large upper tract calculi in children obsolete. This article provides a comprehensive review of the percutaneous management of pediatric stone disease, focusing on recent advances in technique and resulting stone clearance outcomes.
At the children center of excellence in Tehran, endoscopic endoureterotomy and endoscopic endoureterotomy and injection of bulking agents (BA) have allowed most children with obstructive megaureter, including: primary obstructive megaureter (POMU) and primary obstructive refluxing megaureter (PORM) to avoid conventional open surgery that is associated with significant postoperative pain, long hospital stay, prolonged convalescence and remaining unsightly scars. We review the outcome of endoscopic treatment in 47 patients with POMU and 18 patients with PORM. With a mean follow-up of 39 months in the POMU group and 30 months in the POMU group no leakage, ureteral-orifice obstruction, or reflux was observed. The postoperative success rate was 90% in the POMU group and 85% in the PORM group. Our results proved that pediatric urologists could manage obstructive megaureters in a minimally invasive approach, even in extreme cases, before converting to more invasive procedures. The high success rate with no need to taper or plicate the lower ureter and the short hospital stay could be reasons to consider these methods as a valid option for the treatment of megaureter.
Though vesicoscopic ureteral reimplantation is a technically challenging procedure to learn, after the learning curve, success rates are equivalent to open repair. Vesicoscopic ureteral reimplantation is a minimally invasive procedure for the definitive repair of primary reflux. Analgesic requirement is lesser compared to open reimplantation. In this chapter the authors share their experience of 150 cases performed by this procedure and emphasize, that, vesicoscopic reimplantation should be considered as an option especially if cosmesis is a concern.
First published by Lurz in 1956, the posterior lumbotomy is a simple approach to the kidney & upper ureter. Pyeloplasty and upper ureteric stones can be treated advantageously using this approach. The ease of performing the procedure makes it easy to display the anatomical regions involved: The lumbodorsal region is delineated by three bony structures, i.e. the iliac crest, the 12th rib and the spinal processes. Between these three structures are the sacrospinalis and the quadratus lumborum muscle. The teaching and learning curve is, thus, short. It provides limited exposure but it is good enough for the planned procedure. The ‘step by step’ description is provided in this chapter.