McGee Lauren M, Sack Bryan S, Wan Julian, Kraft Kate H
Department of Urology, Oregon Health & Science University, Portland, OR, USA.
Department of Urology, University of Michigan, Ann Arbor, MI, USA.
J Pediatr Urol. 2021 Dec;17(6):795.e1-795.e6. doi: 10.1016/j.jpurol.2021.08.021. Epub 2021 Sep 4.
Flexible ureteroscopes are not tailored for pediatric ureteral size and may not pass at first attempt into the pediatric ureter. Administration of tamsulosin preoperatively in adults has been shown to facilitate ureteral access sheath placement. Several studies have shown tamsulosin to be safe and effective when utilized for medical expulsive therapy in pediatric patients, but its utility for preoperative ureteral dilation has not been studied to date.
We hypothesized that preoperative tamsulosin reduces failed ureteroscopic access in children.
We conducted a retrospective review of patients aged 0-18 years undergoing flexible ureteroscopy (URS) from 2014 to 2019 at a single institution. Patients were divided into those taking 0.4 mg of tamsulosin daily for at least 1 week prior to surgery and those not taking tamsulosin. The primary outcome was failure to pass a 7.95 Fr flexible ureteroscope on initial attempt, requiring stent placement and staged management. Patients undergoing URS or stent placement within the prior year, requiring semi-rigid URS, or with genitourinary anomalies were excluded.
A total of 49 patients met inclusion criteria. The tamsulosin group (n = 13) and non-tamsulosin group (n = 36) were similar with respect to demographic data. The percentage of prepubertal patients was 53% vs 33% (p = 0.19). The tamsulosin group had lower failed URS (38% vs 61%, p = 0.20). When stratified by age, both prepubertal and postpubertal patients in the tamsulosin group had lower failed URS (43% vs 67%, p = 0.67 and 33% vs 58%, p = 0.38). These clinically significant results suggest initial passage of a flexible ureteroscope is more successful in pediatric patients on preoperative tamsulosin. This study was largely limited by its low power and flaws inherent to its retrospective design.
Our results have implications for prescribing tamsulosin preoperatively to reduce multiple procedures and anesthetics in children. Adequately powered prospective trials are warranted to confirm preoperative tamsulosin reduces failed first-attempt flexible URS in children.
可弯曲输尿管镜并非针对儿童输尿管尺寸设计，首次尝试时可能无法进入儿童输尿管。在成人中，术前服用坦索罗辛已被证明有助于输尿管鞘置入。多项研究表明，坦索罗辛用于儿童患者的药物排石治疗时安全有效，但迄今为止，其在术前输尿管扩张方面的效用尚未得到研究。
我们假设术前使用坦索罗辛可减少儿童输尿管镜检查失败的情况。
我们对2014年至2019年在一家机构接受可弯曲输尿管镜检查（URS）的0至18岁患者进行了回顾性研究。患者分为术前至少1周每天服用0.4毫克坦索罗辛的患者和未服用坦索罗辛的患者。主要结局是首次尝试时无法通过7.95 Fr可弯曲输尿管镜，需要置入支架并进行分期治疗。排除前一年接受过URS或支架置入、需要半刚性URS或有泌尿生殖系统异常的患者。
共有49例患者符合纳入标准。坦索罗辛组（n = 13）和非坦索罗辛组（n = 36）在人口统计学数据方面相似。青春期前患者的比例分别为53%和33%（p = 0.19）。坦索罗辛组URS失败率较低（38%对61%，p = 0.20）。按年龄分层时，坦索罗辛组青春期前和青春期后患者的URS失败率均较低（43%对67%，p = 0.67；33%对58%，p = 0.38）。这些具有临床意义的结果表明，术前使用坦索罗辛的儿童患者首次通过可弯曲输尿管镜更成功。本研究在很大程度上受限于其低效能以及回顾性设计固有的缺陷。
我们的结果对于术前开具坦索罗辛以减少儿童的多次手术和麻醉具有启示意义。有必要进行充分有力的前瞻性试验，以证实术前使用坦索罗辛可降低儿童首次尝试可弯曲URS失败的发生率。
