Ureteroscopy for stone disease in pediatric patients with neurogenic bladder: A single institution case-control study

Introduction

Ureteroscopy (URS) for urolithiasis in pediatric patients may be particularly challenging for patients with co-morbidities that increase the risk for stone formation and recurrence. Patients with neurogenic bladders (NGB) and/or patients that are non-ambulatory are reported to have higher rates of additional comorbidities and a particularly increased risk of developing urolithiasis, and higher rates of infections and post-operative complications.

Objective

To report outcomes of URS for stone disease in pediatric patients with NGB and/or non-ambulatory status and compare these outcomes to patients without these co-morbidities.

Methods

An IRB-approved prospective single institutional registry was used to retrospectively identify all patients under 18 years of age who underwent URS for stone disease between July 2012 and July 2021, excluding bladder stones. Patients were categorized in two groups: patient with NGB with or without non-ambulatory status versus all other patients (control). Baseline demographics, pre-operative radiologic imaging, intra-operative details, and post-operative outcomes including 30-day complications were aggregated and compared between the two groups.

Results

275 URS in 198 patients were performed during the study period, and 49 (18 %) of these were performed on patients with NGB. Pre-operative imaging showed significantly higher number of stones (3 vs 2, p = 0.003) and larger total stone burden in patients with NGB than those without NGB (15 mm vs 9 mm, p = 0.009). Patients with NGB had a significantly longer length of procedure (86 vs 60 min, p = 0.002), increased need for staged procedures, increased length of stay (1 vs 0 days, p < 0.001), and increased use of an extended duration of antibiotics prior to the procedure (<0.001). There was no difference in need for passive dilation, stent placement, or other intra-operative parameters. There was no statistical difference in the incidence of 30-day complications between the two groups post-operatively. However, there was a higher incidence of febrile UTIs (8.2 % vs 1.3 %, p = 0.021) in patients with NGB and a lower incidence of pain related complications (0 % vs 9.3 %, p = 0.032). Patients with NGB had a higher incidence of requiring ipsilateral URS for recurrent stone disease within a year of surgery (34.6 % vs 18.9 %, p = 0.01).

Conclusion

The results show that URS for urolithiasis can be done safely and effectively in pediatric patients with neurogenic bladders. The increased risk of infectious complications within 30 days of surgery warrants careful pre- and post-operative antibiotic care plan for this patient population.

Summary table 1. Post-operative outcomes for patients with and without neurogenic bladder undergoing URS.

Empty Cell	Neurogenic Bladder	Control	p-value
49	226
Length of Stay (Days), median (IQR)	1 (0, 3)	0 (0, 0)	<0.001
30-day Complication	9 (18.4 %)	35 (15.5 %)	0.667
Clavien Dindo Classification			0.002
Grade I	0 (0 %)	21 (60.0 %)
Grade II	9 (100 %)	11 (31.4 %)
Grade IIIb	0 (0 %)	3 (8.6 %)
Complication Type
Febrile UTI	4 (8.2 %)	3 (1.3 %)	0.021
Afebrile UTI	1 (2.0 %)	0 (0.0 %)	0.18
Stent Malfunction	1 (2.0 %)	0 (0.0 %)	0.18
Stent Dislodgement	0 (0.0 %)	2 (0.9 %)	1.00
Pain	0 (0.0 %)	25 (11.1 %)	0.011
Hematuria	1 (2.0 %)	0 (0.0 %)	0.18
Post-Op Fever	4 (8.2 %)	5 (2.2 %)	0.056
Other	2 (4.1 %)	7 (3.1 %)	0.66
Stone Free Rate (SFR)	63 %	68 %	0.465
Ipsilateral Stone Surgery within 1 year	18 (36.7 %)	43 (18.9 %)	0.012