Introduction

Introduction
Pediatric stone disease has an increasing incidence. Many
factors like; developmental abnormalities of the genitourinary system
as well as recurrent UTIs and Metabolic abnormalities are contributing
.factors in stone formation in children (Hiro Ishii et al,2015)
Ureteral calculi in children are less frequent than in adults,
representing only about 7% of total urinary calculi, but are usually a
.challenge to the urologist (E.M. Galal et al, 2013)
Factors such as calculus location and size, the degree of
hydronephrosis and pain, and perinephric stranding have been shown
to provide general predictions of the probability and duration of
passage. These characteristics allow the urologist to provide the
patient with a general prediction of the outcomes. In general, stones of
<5 mm have a spontaneous passage rate of 50–95%, especially if they
are in the distal ureter. However, stones of 5–10 mm have a
spontaneous passage rate of 10–50% depending on the portion of the
ureter in which they are located, suggested that the rate of
spontaneous passage of a stone is related to its position in the ureter,
with 75% in the distal, 60% in the middle and 50% in the proximal
ureter. Of children with a stone in the ureter, 25–50% might need a
surgical procedure, for which ureteroscopy is an excellent method.
The physician’s decision for intervention is influenced by many
factors, including the likelihood and time to stone passage, pain,
narcotic requirements and subsequent infection (Ibrahim Mokhless et
.al, 2012)
Historically, the treatment of ureteric calculi in children has been
by open surgical removal followed by prolonged hospital admission;
however, with the advent of shockwave lithotripsy (SWL) in 1980
and other endourological techniques, there has been a significant
change in the management of paediatric stone disease. In 1988,
ureteroscopy (URS) was used for the extraction of lower ureteric
stones in children. Early studies of ureteroscopic treatment of
paediatric stone disease showed good results; however, because of the
fragility of the instruments and lack of experience, the majority of the
stones extracted were located in the mid to distal ureter. Later on,

1
 Introduction

with improvements in the durability and quality of the instruments,

several studies reported stone-free rates (SFRs) ranging from 84 to
.100% after a single ureteroscopic procedure (Hiro Ishii et al, 2015)
Before the development of the holmium laser, there were
significant improvements in ureteroscopes, particularly the creation of
a series of semirigid instruments in 1989. As the experience with the
holmium laser grew, the downsizing of ureteroscopes continued,
culminating in the development of 4.9F/6.5F-tip instruments with an
offset eyepiece. The combination of the smaller ureteroscopes and the
holmium laser has created an ideal system for the treatment of
ureteral stones and has made this a day-care procedure with no
requirement for ureteral dilatation, only minimal anesthesia, and few
postoperative complications (Pawan Gupta, 2007)
The holmium laser fragments stones primarily by a photo
thermal mechanism, Pressure waves created by the laser are
negligible and result in minimal retropulsion of the stone fragments in
comparison with previous laser lithotripters, which fragment stones
through shockwaves rather than direct irradiation of the stone
surface. The fragments created by the holmium laser are smaller
than those resulting from other sources of intracorporeal lithotripsy.
A low-voltage holmium laser is sufficient for intracorporeal
lithotripsy, and low energy, between 0.6 J to 1.2 J, and a frequency of
5 to 15 Hz, generally is used because use of high energy decreases the
safety margin and increases stone retropulsion and fiber damage. It is
safe to use the holmium laser in the ureter when the laser is activated
0.5 to 1 mm from the mucosa (Pawan Gupta, 2007).
Finally, Ureteroscopy (URS) has become a more attractive option
for treating children due to significant improvements in the
miniaturization and durability of endoscopic equipment. In addition
to stone burden and localization, anatomic limitations, patient
factors, and stone characteristics also play important roles in the
.choice of URS treatment (Adanur S. et al, 2014)