Ureteroscopy in pediatric patients with spinal abnormalities

Is There Still a Place for Percutaneous Nephrolithotomy in Current Times?

Background: Percutaneous nephrolithotomy (PCNL) and its miniaturized modifications are usually considered the standard surgical options for large (>20 mm) staghorn and infected stones. Moreover, PCNL is a viable alternative to retrograde intrarenal surgery (RIRS) for smaller stones (<20 mm) in the presence of anatomical malformations or inaccessible lower pole stones. However, due to the advancements in laser and scope technology, RIRS is expanding its indications with the potential benefits of lower complications and a shorter hospital stay. Methods: A literature search using the PUBMED database from inception to June 2022 was performed to explore the current role of PCNL in endourology. The analysis involved a narrative synthesis. Results: PCNL confirmed its role in the treatment of large and complex stones; moreover, miniaturized PCNL has become more competitive, gaining space among classic indications of flexible ureteroscopy. Conclusions: considering all the evaluated subgroups, we can conclude that PCNL is an old fascinating procedure and is here to stay.

Retrograde intrarenal surgery for impacted upper ureteral stone in a patient with advanced lumbar scoliosis and lower-extremity development defect: a case report

BACKGROUND

Today, retrograde intrarenal surgery is the most preferred and very successful treatment method for upper ureteral stones that do not spontaneously pass and/or do not benefit from extracorporeal wave lithotripsy. However, perioperative complications are more common in retrograde intrarenal surgery if the stone in the ureter is impacted. Moreover, urosepsis and renal dysfunction are detected more frequently in patients with impacted stones. Impacted stones, which are a risky stone group even in patients with normal vertebral anatomy, are a more challenging situation in patients with advanced vertebral scoliosis. It is difficult to achieve an operating position in these patients. In addition, the ureteral tracing is altered, curved, and tortuous, making it more difficult for the endoscope to advance through the ureter.

CASE PRESENTATION

In this case report, we present a 23-year-old Caucasian male patient with right concavity and severe scoliosis, lower-extremity developmental disorder, and urosepsis. To treat the urosepsis picture, first percutaneous nephrostomy drainage was provided and the urine was sterilized with appropriate antibiotics according to the culture/antibiogram. Then, we performed ureterolithotripsy with a flexureterorenoscope. Finally, we see that flexible ureterorenoscopic lithotripsy to the upper ureteral stone with impacted stones, which is a very challenging operation even in patients with normal vertebrae, could be successfully performed in our patient with advanced scoliosis deformity.

CONCLUSION

High stone-free and low complication rates can be obtained with flexible ureterorenoscopic retrograde intrarenal surgery in medium-sized impacted upper ureteral stones in patients with advanced scoliosis.

Evaluation and Long-term Management of Neurogenic Bladder in Spinal Dysraphism

Spinal dysraphism, which includes conditions such as myelomeningocele and sacral agenesis, is one of the most common causes of congenital lower urinary tract dysfunction. Early evaluation of the neurogenic bladder serves to minimize renal damage, and the main goals of management include preserving renal function, achieving acceptable continence, and optimizing quality of life. The survival of patients with such conditions has improved to greater than 80% reaching adulthood, owing to advances in diagnostic and therapeutic modalities. The result is a real, and unfortunately often unmet, need for successful transitional care in this complex patient population. Clinicians must be able to identify the unique challenges encountered by patients with neurogenic bladder as they shift through different stages of their life.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Retrograde intrarenal surgery by flexible ureteroscope in patients with spinal deformities

OBJECTIVE

To present our experience with retrograde intrarenal surgery (RIRS) for managing renal stones in patients with spinal deformities.

DESIGN

We retrospectively reviewed the records of patients.

METHODS

We retrospectively reviewed the records of seven patients with congenital scoliosis (n = 5), spina bifida (n = 2) who had undergone RIRS for renal stones. Stone-free status was determined by CT 30 days after the procedure and was defined as the absence of stones in the kidney or residual fragments ≤1 mm.

RESULTS

Mean patient age was 27 years (18-45 years), and mean stone size was 176 mm (143-340 mm). The average operative time was 38 minutes (25-53 minutes), and postoperative hospital stay was 1 day (1-2 days). A stone-free status was obtained in six (85.7 %) patients, and one patient was considered to have treatment failure. This patient was managed by a repeat RIRS. A Double-J stent was placed at the end of the procedure in all (100 %) patients. No severe complications, either from anesthesia or the surgical procedure, were observed, and no blood transfusion was reported.

CONCLUSIONS

The good clearance rate with a low incidence of complications shown by the present study has demonstrated that RIRS is a safe and effective procedure for renal stones in patients with spinal deformities.

Ureteroscopy for treatment of upper urinary tract stones in children: technical considerations

The incidence of pediatric urolithiasis is increasing. While many smaller stones may pass spontaneously, surgical therapy is sometimes warranted. Surgical options include shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and open surgery. Ureteroscopy represents a minimally invasive approach, and it is increasingly being used to treat pediatric upper tract calculi. Ureteroscopy is performed under anesthesia and fluoroscopic guidance, with basket extraction or lithotripsy of the calculi. Technical considerations include active or passive ureteral dilatation, the use of ureteral access sheaths for larger stone burdens, and post-operative stent placement. The current pediatric literature suggests high success rates (equal to or surpassing shock wave lithotripsy) and low complication rates. However, concerns remain regarding feasibility in patients with variant anatomies and risk due to intra-operative radiation exposure.

Children with spinal abnormalities have an increased health burden from upper tract urolithiasis

OBJECTIVE

To examine the epidemiology and health care burden of upper tract urolithiasis in children with spinal abnormalities using a large, national database. Children with spinal dysraphism are predisposed to urolithiasis for many reasons, including immobility, bacteriuria, and urinary stasis. No large epidemiologic studies exist regarding stones in this specific group. Isolated spinal curvature may lead to hypercalciuria from immobility; however, urolithiasis rates are unknown.

METHODS

We extracted data from the Pediatric Health Information Systems database over an 8-year period. Hospitals reporting inpatient visits, emergency room visits, and ambulatory surgery visits were included. Using International Classification of Diseases, Ninth Revision codes and Current Procedural Terminology codes, we identified children with upper tract urolithiasis, spinal dysraphism, and spinal curvature. Data regarding demographics, prevalence, surgical procedures, costs related to stone procedures were extracted.

RESULTS

A total of 11,987 patients had urolithiasis. Prevalence of stones in patients with normal spines was 0.24% compared with 1.40% and 4.03% among children with spinal curvature and spinal dysraphism, respectively (P<.001). Children with spinal curvature and spinal dysraphism were more likely to have multiple procedures for stones than those without spinal abnormalities (25% vs 25.7% vs 13.1%, P<.001). Costs per patient were significantly higher for children with spinal abnormalities compared with those with normal spines.

CONCLUSION

Children with spinal curvature and spinal dysraphism have a much greater rate of upper tract urolithiasis, resulting in more procedures and related costs. Urolithiasis represents a significant, chronic health burden for children with spinal abnormalities. Screening and preventive care may reduce the impact of urolithiasis in these patients.