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Title: Ureteroscopic lithotripsy for ureteral stones in children using holmium: yag laser energy: results of a multicentric survey.
Author: Esposito C, Masieri L, Bagnara V, Tokar B, Golebiewski A, Escolino M.
Journal: J Pediatr Urol; 2019 Aug; 15(4):391.e1-391.e7. PubMed ID: 31182399.
Abstract:
BACKGROUND: Holmium:YAG (Ho:YAG) laser lithotripsy has broadened the indications for ureteroscopic stone managements in adults, but few evidence are currently available in the pediatric population. OBJECTIVE: This article aimed to assess the outcome of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral stones in different locations in children. STUDY DESIGN: The medical records of 149 patients (71 boys and 78 girls; median age 9.2 years) treated with Ho:YAG laser ureteroscopic lithotripsy in five international pediatric urology units over the last 5 years were retrospectively reviewed. Exclusion criteria included patients with renal calculi and/or with a history of ipsilateral stricture, renal failure, active urinary tract infection, or coagulation disorder. RESULTS: Stones were treated with dusting technique in all cases. The median stone size was 10.3 mm (range 5-17). Stones were located in the distal ureter in 77 cases (51.7%), in the middle ureter in 23 cases (15.4%), and in the proximal ureter in 49 cases (32.9%). The median operative time was 29.8 min (range 20-95). Intra-operative complications included five bleedings (3.3%) and seven stone retropulsions (4.7%). Overall stone-free rate was 97.3%. Overall postoperative complications rate was 4.0% and included two cases of stent migration (1.3%) (Clavien II) and four residual stone fragments (2.7%) that were successfully treated using the same technique (Clavien IIIb). On multivariate analysis, re-operation rate was significantly dependent on the proximal stone location and presence of residual fragments >2 mm (P = 0.001). DISCUSSION: This study is one of the largest pediatric series among those published until now. The study series reported a shorter operative time, a higher success rate, and a lower postoperative complications rate compared with previous series. A limitation of this study is that stone-free rates may be somewhat inaccurate using ultrasonography and plain X-ray compared with computed tomography (CT); the study's 97.3% success rate may be overestimated because no CT scan was done postoperatively to check the stone-free rate. Other limitations of this article include its retrospective nature, the multi-institutional participation, and the heterogeneous patient collective. CONCLUSION: The Ho:YAG laser ureteroscopic lithotripsy seems to be an excellent first-line treatment for children with ureteral stones, independently from primary location and size. However, patients with proximal ureteral stones and residual fragments >2 mm reported a higher risk to require a secondary procedure to become stone-free. Combination of techniques as well as appropriate endourologic tools are key points for the success of the procedure regardless of stones' size and location.

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