Holmium laser ablation of anterior urethral valves: case report.

PURPOSE: To report a novel method for treating anterior urethral valves in children using the holmium:YAG laser. CASE REPORT: A 2-year-old boy presented with symptoms of urinary-outflow obstruction. A micturating cystourethrogram (MCUG) revealed an abrupt narrowing of the penile urethra. At cystourethroscopy, an anterior urethral valve without a diverticulum was visible. This was ablated endoscopically using the Ho:YAG laser. The child voided successfully and was discharged the next day. Repeat MCUG 6 months later revealed a normal-caliber urethra. CONCLUSION: Holmium:YAG laser ablation of anterior valves is a minimally invasive treatment modality that provided a satisfactory result and appears to be very promising.

Ureteric calculi in children: preliminary experience with holmium:YAG laser lithotripsy.

OBJECTIVE: To determine the efficacy and safety of holmium:YAG laser lithotripsy in children with ureteric calculi. PATIENTS AND METHODS: Between 1999 and 2003, 28 ureteroscopic laser procedures were carried out on 26 children (14 boys and 12 girls, mean age 6.5 years) with ureteric calculi. The mean (range) stone size was 1.21 (0.4-2.2) cm. At ureteroscopy the calculi were in the upper ureter in six (23%), mid-ureter in five (19%) and lower ureter in 15 (58%) patients. A rigid 8 F ureteroscope was used and the Ho:YAG laser energy delivered at 0.6-1.4 J and 6-10 Hz. All patients were evaluated after 3 months with intravenous urography to confirm stone clearance and to exclude ureteric stricture formation. RESULTS: The overall stone-free rate was 92% (24 children) after 28 ureteroscopic procedures. Stones were completely cleared in 83%, 80% and 100% of the procedures in the upper, mid- and lower ureters, respectively. In two children the procedure failed; they were salvaged by ureterolithotomy in one and extracorporeal shockwave lithotripsy in the other. During the procedures, a ureteric perforation was caused by several factors, including a technically difficult procedure and higher laser energy. At the mean (range) follow-up of 18 (3-39) months, low grade vesico-ureteric reflux was detected in two children, and there were no ureteric strictures in any. CONCLUSION: Holmium:YAG laser lithotripsy is an efficient and safe treatment for ureteric calculi in children.

Pediatric staghorn calculi: the role of extracorporeal shock wave lithotripsy monotherapy with special reference to ureteral stenting.

PURPOSE: Treatment for staghorn calculi in children represents a unique challenge. We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) monotherapy for the management of staghorn calculi in children with special reference to ureteral stenting. MATERIALS AND METHODS: From June 1992 to January 2001 we treated 42 children 9 months to 12 years old with staghorn stones using the Piezolith 2501 (Richard Wolf GmBH, Knittlingen, Germany) lithotriptor. The initial group of 19 patients underwent ESWL without prophylactic ureteral stenting, while in the latter group of 23 a Double-J (Medical Engineering Corp., New York, New York) ureteral stent was inserted immediately before the first ESWL session. Mean patient age, stone size, number of shock waves and ESWL sessions, hospital stay, stone-free rate and major complications were compared in the 2 groups. RESULTS: Overall 33 children (79%) were stone-free after 3 months. The 2 groups were comparable in regard to patient age, stone size, number of shock waves and ESWL sessions, and stone-free rates. Major complications developed in 21% of the unstented group, whereas none were observed in stented cases. This difference was statistically significant (p = 0.035). Seven post-ESWL auxiliary procedures were required in the unstented group to manage complications. Hospital stay was significantly longer in the unstented compared with the stented group (p = 0.022). At a followup of 9 to 102 months (mean 47) stones recurred in 2 children, who were treated with further ESWL. CONCLUSIONS: ESWL monotherapy was an efficient and safe modality for the treatment of staghorn calculi in children. Stented patients had fewer major complications and a shorter hospital stay. Prophylactic ureteral stenting is advisable before ESWL for staghorn calculi in children.

Paediatric ureteric calculi: efficacy of primary in situ extracorporeal shock wave lithotripsy.

OBJECTIVE: To evaluate the efficacy of primary in situ extracorporeal shockwave lithotripsy (ESWL) for the treatment of ureteric calculi in children. PATIENTS AND METHODS: The Wolf 2500 Piezolith was used to treat 63 children (aged 4 months to 12 years) with 76 ureteric calculi, including 10 children with impacted calculi. The calculi were located in 14 upper, 13 mid and 44 lower ureters, and the stone burden varied from 4 to 17.8 mm (mean 12.6). All children aged < or = 10 years were treated under general anaesthesia; lithotripsy was attempted under intravenous sedation in the older children. RESULTS: At the 3-month follow-up, there was an overall successful outcome in 55 children (87%), which included 12 of 13, eight of nine (89%) and 35 of 41 (85%) of the children with upper, mid and lower ureteric calculi, respectively, and nine of the 10 with impacted calculi. Re-treatment was required in 20 (36%) patients, while auxiliary procedures after ESWL were required in three (6%). The major complications encountered were ureteric obstruction with sepsis in two children, bacteraemia in another and urinary retention due to a urethral stone fragment in a fourth child. CONCLUSIONS: In situ ESWL was an effective treatment modality for ureteric calculi at all levels in children, even when impacted. In the short term, complications were minimal, but the long-term effects need further assessment.

Paediatric ureteroscopy for ureteric calculi: a 4-year experience.

OBJECTIVE: To study the efficacy and safety of ureteroscopy in the management of paediatric ureteric calculi at various levels. PATIENTS AND METHODS: The records of 50 ureteroscopic procedures performed on 43 children (age range 6 months-12 years) for primary ureteric calculi or ureteric fragments after electrohydraulic shockwave lithotripsy (EHWL) were analysed retrospectively. The distribution of the calculi was in nine in the upper upper, seven in the mid and 30 in the lower ureter, with a mean stone burden of 1.26 cm. Ureteroscopy was performed with the 8.5/9.5/11.5 F Wolf ureteroscopes, and EHL was used as the primary method of fragmentation. Intravenous urograms were available in 34 children (79%) and micturating cystography (MCUG) was performed in 23 children (54%) during the follow-up. RESULTS: An overall stone-free status was achieved in 40 children (93%) after performing 47 ureteroscopies (94%). Stones were completely cleared in 78%, 100% and 97% of the procedures in the upper, mid and lower ureters, respectively. In three children the procedure failed and they were salvaged by uretero-lithotomy. During the procedures, an upper ureteric perforation occurred in one patient and a lower perforation in another. MCUG revealed low grade vesico-ureteric reflux in 17% of the patients, but close follow-up showed the reflux to be sterile and clinically insignificant. CONCLUSION: Ureteroscopy was safe and effective for the management of mid and lower ureteric calculi but the results for upper ureteric calculi were marginally inferior. Ureteroscopy must be performed judiciously to minimize ureteric injury in children. The incidence of vesico-ureteric reflux after mechanical dilatation of the intramural ureter was infrequent and clinically insignificant.