Published online Mar 9, 2026. doi: 10.5409/wjcp.v15.i1.115147
Revised: November 13, 2025
Accepted: January 5, 2026
Published online: March 9, 2026
Processing time: 148 Days and 15 Hours
Endoscopic ureterolithotripsy (EUL) is a minimally invasive and effective tr
To evaluate the success and safety of EUL in pediatric patients, focusing on lithotripsy technique, stone location, and patient-specific variables.
A retrospective analysis was performed on 250 children treated with EUL from 2015 to 2022. Laser and pneumatic lithotripsy techniques were compared in terms of stone-free rate (SFR), operative duration, and complication rates. Outcomes were also analyzed by stone location and patient age.
The overall SFR was 92.1%, with rates of 94% for distal, 89% for mid-ureteral, and 91% for proximal stones (P = 0.07). Laser lithotripsy showed a slightly higher success rate than pneumatic lithotripsy (P = 0.08) and slightly shorter operative times (P = 0.1). The mean procedure duration was 42.8 ± 16.3 minutes and was longer for proximal stones (P = 0.04). The overall complication rate was 12.4%, with the highest incidence among children aged 4-7 years (P = 0.02). Average hospital stay was 2.3 ± 0.5 days, with no significant intergroup differences.
EUL is a safe and effective treatment for pediatric ureterolithiasis. Laser lithotripsy offers a slightly procedural time advantage, while younger patients are more prone to intraoperative challenges. These findings support EUL as a first-line treatment, with careful planning needed for younger children.
Core Tip: This retrospective study analyzed 250 pediatric cases of semirigid ureterolithotripsy. Both laser and pneumatic lithotripsy demonstrated high stone-free rates and acceptable safety. Laser lithotripsy achieved slightly shorter operative times, while the youngest children had the highest complication rates. These findings highlight the safety and efficacy of endoscopic management of pediatric urolithiasis across all age groups.
- Citation: Khudaybergenov U, Shomarufov A, Abdukarimov O, Nadjimitdinov Y. Efficacy and safety of semirigid ureterolithotripsy in pediatric urolithiasis: Retrospective analysis from a tertiary center. World J Clin Pediatr 2026; 15(1): 115147
- URL: https://www.wjgnet.com/2219-2808/full/v15/i1/115147.htm
- DOI: https://dx.doi.org/10.5409/wjcp.v15.i1.115147
The increasing prevalence of pediatric urolithiasis highlights the growing need for effective and safe treatment options. Factors such as improved diagnostic imaging and rising obesity rates contribute to this trend[1]. Endoscopic ureterolithotripsy (EUL) has emerged as a leading minimally invasive approach for treating ureteral stones in children, offering superior stone-free rates (SFR) and fewer complications compared to traditional methods like extracorporeal shock wave lithotripsy (ESWL)[2].
Laser lithotripsy has further enhanced the precision and effectiveness of EUL, making it the preferred choice for complex cases, such as those involving large or impacted stones[3]. Despite these advancements, the risk of complications during rigid ureteroscopy, including ureteral perforation, stone migration, and bleeding, remains a concern, especially in younger children with narrower ureters and increased tissue fragility[4]. Studies have demonstrated that careful preoperative planning and the use of advanced instrumentation, such as low-profile rigid ureteroscopes, significantly reduce complication rates and improve safety outcomes in this demographic. Moreover, proper training and experience of surgeons play a critical role in minimizing intraoperative challenges and enhancing procedural success[5-7].
This study explores the efficacy and safety of EUL in a pediatric cohort, with a focus on the impact of patient age, stone localization, and technological advancements on clinical outcomes. By analyzing a large case series, the research aims to provide evidence-based insights into optimizing pediatric urolithiasis management.
This retrospective, single-center study analyzed the outcomes of pediatric patients who underwent EUL for ureteral stones.
Inclusion criteria encompassed children aged 4 to 18 years diagnosed with ureteral stones ≥ 5 mm, confirmed via ultrasonography or computed tomography (CT). Exclusion criteria included active urinary tract infections (UTI), congenital urinary tract anomalies, and prior surgical interventions on the ureter.
All patients underwent comprehensive diagnostic evaluations, including kidney ultrasound, fluoroscopy, and CT (in case of radiolucent stones) to confirm stone size and location. In addition, patients underwent complete blood count, urinalysis, and renal function tests to rule out contraindications.
Under general anesthesia, patients were positioned lithotomy-style, and ureteral access was obtained using a semirigid ureteroscope (6/7.5 Fr, Karl Storz) over a hydrophilic guidewire. Stone fragmentation was performed using either a pneumatic lithotripter (Calcusplit®, Karl Storz) or a thulium fiber laser lithotripter (Fiberlase® U1, IRE-Polus), selected based on stone size, density, location, and equipment availability.
Pre-stenting was applied only in a small subset of patients (n = 9), predominantly in younger children, to facilitate ureteral access in cases of narrow ureters or proximal stones. In our center, pre-stenting is not a routine practice because pediatric-size stents are not always readily available, and most procedures can be safely performed using small-caliber semirigid ureteroscopes. Therefore, a separate analysis of pre-stented cases was not conducted due to their limited number.
Laser lithotripsy was favored for larger or denser proximal stones due to its precision and minimal retropulsion, while pneumatic lithotripsy was typically used for smaller, distal stones or when the laser unit was unavailable. Due to limited access to a single laser unit and intermittent technical issues, the choice of method reflected real-world clinical constraints, approximating a quasi-randomized distribution.
Fragments ≥ 4 mm were removed with baskets or forceps; smaller fragments were left for spontaneous passage. Double-J stents were placed selectively in cases of ureteral trauma, edema, or residual fragments. EUL was chosen over ESWL due to institutional preference for active stone removal, limited access to pediatric ESWL devices, and the availability of experienced endourologists.
SFR: SFR was defined as the absence of residual stone fragments on renal ultrasound performed on the day of discharge and confirmed again within 4 weeks postoperatively. In cases with radiolucent stones or unclear ultrasound findings, non-contrast CT was performed. A patient was considered stone-free if no residual fragments ≥ 4 mm were detected.
Stone composition: Stone composition analysis was available for only a few patients, as the service was offered on a voluntary and paid basis. Therefore, it was not included in the analysis.
Operative time: Total duration of the endoscopic procedure, recorded in minutes from scope insertion to scope removal.
Intraoperative complications: Including but not limited to ureteral perforation, mucosal injury, or stone migration.
Early postoperative complications: Such as macroscopic hematuria, UTI, postoperative fever, and need for re-intervention. Preoperative urine cultures were obtained for all patients to rule out existing UTI.
Length of hospitalization: Measured in full days from surgery until discharge. Prolonged hospital stay in the study was influenced by institutional protocols and parental preferences, particularly in younger children.
All statistical analysis was performed using IBM SPSS® Statistics v. 21 and MS Office Excel 2016. Quantitative data, such as stone size and procedure time, were analyzed using descriptive statistics, including mean and SD or median and interquartile range. Distribution normality of studied parameters were assessed using Kolmogorov-Smirnov test. Comparisons between groups (e.g., laser vs pneumatic lithotripsy) utilized student's t-tests for normally distributed data or Mann-Whitney U tests otherwise. Categorical variables, such as complication rates, were analyzed using χ2 or Fisher's exact tests. Statistical significance was set at P < 0.05.
The study included 250 pediatric patients, with an average age of 9.8 ± 4.1 years. Among them, 135 (54%) were boys and 115 (46%) were girls. Stones were more frequently observed in the left ureter (58.4%, 146 patients) compared to the right (41.6%, 104 patients). Patients were grouped by stone location, revealing that 76 cases (30.4%) involved the distal ureter, 70 (28%) involved the mid-ureter, and 104 (41.6%) involved the proximal ureter. Table 1 outlines the demographic and clinical features of the cohort, alongside key surgical outcomes. Further analysis categorized patients by stone size and anatomical location (Table 2).
| Parameter | Value |
| Mean age (years) | 9.8 ± 4.1 |
| Gender | |
| Boys | 135 (54) |
| Girls | 115 (46) |
| Stone location | |
| Distal ureter | 76 (30.4) |
| Mid-ureter | 70 (28) |
| Proximal ureter | 104 (41.6) |
| Mean stone size (mm) | 10.2 ± 0.1 |
| Fragmentation method | |
| Laser lithotripsy | 145 (58) |
| Pneumatic lithotripsy | 105 (42) |
| Stone-free rate (%) | 92 |
| Complication rate | 31 (12.4) |
| Average surgery duration (minutes) | 42.8 ± 16.3 |
| Laser lithotripsy | 40.5 ± 18.5 |
| Pneumatic lithotripsy | 45.1 ± 11.3 |
| Stent placement rate | 30 (12) |
| Mean hospital stay (days) | 2.3 ± 0.5 |
The average duration of the procedure was 42.8 ± 16.3 minutes (range: 20-90 minutes). Pneumatic lithotripsy was employed in 42% of cases (105 patients), while laser lithotripsy was utilized in 58% (145 patients). Ureteral stents were placed postoperatively in 13 patients (5.2%), primarily to address ureteral injury or significant edema.
A single EUL session achieved a SFR of 92%, with residual fragments (< 4 mm) in 12 patients resolved via medical expulsive therapy (MET) within 10-12 days. The SFRs were 94% for distal stones, 89% for mid-ureteral stones, and 91% for proximal stones, highlighting the high efficacy of EUL regardless of stone location.
Further analysis categorized patients by stone location to determine if anatomical differences influenced treatment outcomes. SFRs were highest for distal stones (94%) but were not significantly different across locations (P > 0.05). Proximal stones had the longest operative times (44.5 ± 12.3 minutes), longer (but not significantly) than distal stones (41.0 ± 10.9 minutes, P > 0.05). Other parameters, including complication rates and hospital stay, did not show significant differences across stone locations. These findings suggest that stone location does not substantially impact success rates but may affect operative time (Table 3).
| Parameter | Proximal (n = 104) | Mid-ureter (n = 70) | Distal (n = 76) | P (ANOVA) | P (Tukey post hoc) |
| Stone size (mm) | 10.2 ± 1.3 | 9.2 ± 1.3 | 10.6 ± 1.2 | 0.03 | Mid vs distal (P < 0.05) |
| Stone-free rate (%) | 91 | 89 | 94 | 0.07 | - |
| Operative time (minutes) | 44.5 ± 12.3 | 42.1 ± 11.8 | 41.0 ± 10.9 | 0.10 | - |
| Complication rate (%) | 10.5 | 11.3 | 9.2 | 0.74 | - |
| Hospital stay (days) | 2.4 ± 0.5 | 2.3 ± 0.5 | 2.2 ± 0.4 | 0.20 | - |
When comparing both techniques the overall SFR was similar, with laser lithotripsy achieving 92.4% and pneumatic lithotripsy 91.4% (P > 0.05). However, laser lithotripsy was associated with a slightly shorter operative time (40.5 ± 18.5 minutes vs 45.1 ± 11.3 minutes, P > 0.05). The complication rates were comparable between the two techniques (10.3% vs 15.2%, P > 0.05). Patients treated with laser lithotripsy had a slightly longer hospital stay (2.4 ± 0.6 days vs 2.2 ± 0.4 days, P < 0.05), likely reflecting the more controlled and precise fragmentation process (Table 4).
| Parameter | Laser lithotripsy (n = 145) | Pneumatic lithotripsy (n = 105) | P value |
| Stone-free rate (%) | 92.4 | 91.4 | 0.08 |
| Operative time (minutes) | 40.5 ± 18.5 | 45.1 ± 11.3 | 0.10 |
| Complication rate | 10.3% (15/145) | 15.2% (16/105) | 0.25 |
| Hospital stay (days) | 2.4 ± 0.6 | 2.2 ± 0.4 | 0.20 |
Both techniques demonstrated high efficacy with SFRs above 90%. Laser lithotripsy required a slightly longer operative time but resulted in similar complication rates.
Patients were divided into four age groups: 4-7 years (n = 19), 8-10 years (n = 40), 11-14 years (n = 75), and 15-18 years (n = 116). The overall SFR increased with age, but the difference was not statistically significant (P > 0.05). However, operative time, complication rate, and hospital stay significantly differed among age groups (P < 0.05, ANOVA).
The youngest patients (4-7 years) had the longest operative time (49.3 ± 12.5 minutes) and highest complication rate (15.5%), reflecting the anatomical challenges of EUL in smaller children. In contrast, older children (15-18 years) had the shortest operative time (39.5 ± 8.7 minutes), lowest complication rate (5.7%), and fastest recovery (hospital stay: 2.0 ± 0.4 days).
Post hoc analysis (Tukey’s HSD) confirmed that these differences were most pronounced between the 4-7 years and 15-18 years’ groups, with significant differences in operative time, complication rates, and hospital stay (Table 5).
| Parameter | 4-7 years (n = 19) | 8-10 years (n = 40) | 11-14 years (n = 75) | 15-18 years (n = 116) | P (ANOVA) | P (Tukey post hoc) |
| Stone-free rate (%) | 89 | 91 | 94 | 96 | 0.12 | - |
| Operative time (minutes) | 49.3 ± 12.5 | 45.8 ± 10.2 | 41.2 ± 9.8 | 39.5 ± 8.7 | 0.03 | 4-7 vs 15-18 (P < 0.05) |
| Complication rate (%) | 15.5 | 12.0 | 8.0 | 5.7 | 0.02 | 4-7 vs 11-14, 15-18 (P < 0.05) |
| Hospital stay (days) | 2.6 ± 0.7 | 2.4 ± 0.5 | 2.2 ± 0.5 | 2.0 ± 0.4 | 0.04 | 4-7 vs 15-18 (P < 0.05) |
SFRs were similar across age groups (P > 0.05). Younger children (4-7 years) had significantly longer operative times, more complications, and longer hospital stays. Older children (15-18 years) had the shortest operative times and lowest complication rates. ANOVA confirmed significant differences in operative time, complication rates, and hospital stay (P < 0.05).
Intraoperative complications occurred in 12.4% of cases (31/250) and are further detailed in Table 6.
| Complication | 4-7 years (n = 19) | 8-10 years (n = 40) | 11-14 years (n = 75) | 15-18 years (n = 116) | Total |
| Intraoperative events (n = 11) | |||||
| Stone migration | 1 (0.4) | 1 (0.4) | 1 (0.4) | – | 3 (1.2) |
| Retrograde access failure | 2 (0.8) | – | – | – | 2 (0.8) |
| Bleeding | 1 (0.4) | – | – | – | 1 (0.4) |
| Ureteral perforation | 1 (0.4) | – | 1 (0.4) | 1 (0.4) | 3 (1.2) |
| Conversion to open surgery | 1 (0.4) | – | – | – | 1 (0.4) |
| Mucosal injury | 1 (0.4) | – | – | – | 1 (0.4) |
| Subtotal intraoperative | 7 (2.8) | 1 (0.4) | 2 (0.8) | 1 (0.4) | 11 (4.4) |
| Postoperative events (n = 20) | |||||
| Residual fragments ≥ 5 mm (ESWL performed) | 7 (2.8) | 4 (1.6) | 5 (2.0) | 4 (1.6) | 20 (8.0) |
| Total complications | 14 (5.6) | 5 (2.0) | 7 (2.8) | 5 (2.0) | 31 (12.4) |
In 8% of cases (20/250) clinically significant residual fragments were detected 2-4 weeks after surgery when MET was ineffective; these patients underwent auxiliary ESWL. Stone migration to the renal collecting system occurred in 2.0% (5/250) and required additional percutaneous intervention. Retrograde access failure was observed in two cases (0.8%), both in younger children (4-7 years). A single conversion to open surgery (0.4%) was required in a 4-year-old patient due to an unrecognized distal ureterovesical junction stricture identified intraoperatively.
All postoperative re-interventions were classified according to the Clavien-Dindo system (Table 7). ESWL procedures were performed under sedation (Grade IIIa). Ureteral reimplantation was performed under general anesthesia (Grade IIIb). No Grade IV-V events occurred.
| Clavien-Dindo grade | Event | n (%) | Anesthesia/management |
| IIIa | ESWL for residual fragments | 20 (8.0) | Sedation/ataralgesia |
| IIIb | Ureteral reimplantation (open conversion) | 1 (0.4) | General anesthesia |
| Total | 21 (8.4) |
The study demonstrated that EUL is a highly effective method for managing pediatric ureteral stones, achieving a SFR of 92% with minimal complication risks. These findings are consistent with earlier studies that have highlighted the superiority of EUL over ESWL, particularly for larger or impacted stones[2,8,9].
The advancements in endoscopic equipment, including miniaturized ureteroscopes and high-performance lithotripters such as holmium: YAG lasers, have significantly contributed to improved clinical outcomes. These innovations allow for greater precision, reduced operation times, and enhanced safety, as demonstrated in this and other studies[10-12].
Laser lithotripsy demonstrated significant advantages in this study, particularly in terms of precision, reduced risk of stone migration, and safety in younger children[3,5,13,14]. Compared to pneumatic lithotripsy, laser technology enabled more controlled fragmentation, reducing ureteral trauma and secondary interventions. Although laser lithotripsy showed slightly longer operative times in our cohort, this likely reflects the need for precise fragmentation into fine particles to minimize residual stones. The requirement for careful adjustment of power and frequency may also contribute to the duration. Nonetheless, this trade-off appears beneficial. Notably, a recent meta-analysis demonstrated that thulium fiber laser offers faster ablation, shorter operative time, and lower retropulsion than holmium: YAG, supporting its superior efficiency in ureteroscopic lithotripsy[14]. Another prospective randomized clinical trial demonstrated that Thulium Fibre Laser offers superior SFRs, shorter operative times, and fewer intraoperative complications compared to Holmium: YAG laser in ureteroscopic lithotripsy, highlighting its potential advantages in clinical practice[15]. These findings suggest that laser lithotripsy, especially TFL offers a safer and more effective approach, particularly for proximal stones and cases requiring precise fragmentation to optimize stone clearance.
Stone location also influenced procedural outcomes, with a slightly lower SFR observed for proximal stones (91%) compared to distal stones (94%). This is consistent with findings from prior research, which highlights the technical challenges associated with accessing and fragmenting stones in the proximal ureter[4,11]. A systematic review by Ishii et al[16] demonstrated that FURSL is a safe and effective treatment for pediatric renal calculi, achieving a mean SFR of 85.5% with a low complication rate (12.4%) which is consistent with our data. Another study of 385 cases of holmium laser ureterolithotripsy reported an SFR of 87.8%, noting that factors such as stone impaction and hydronephrosis had a greater impact on treatment success than anatomical location[7]. These results suggest that while ureteroscopic lithotripsy may be highly effective across all ureteral locations, other patient-specific factors may play a more significant role in determining success rates.
Despite its high safety profile, intraoperative complications such as ureteral perforation and stone migration were observed in 12.4% of cases. Similar complication rates have been reported in other studies, where the use of flexible guidewires and improved visualization tools was shown to reduce risks[16,17]. In our study, ureteral stents were selectively placed in cases of significant edema or mucosal injury, further minimizing complications.
The impact of age was another important factor in our findings. Younger children (ages 4-7) experienced higher complication rates due to narrower ureters and increased ureteral elasticity. These challenges necessitate tailored approaches to minimize risks, as noted in other studies on pediatric urolithiasis[13,18,19]. Our results contradict those of other authors. Scarpa et al[20] in their study with 7 children younger than 10 years demonstrated no complications after laser (pulsed dye laser Pulsolith) and pneumatic (ballistic lithotripter Lithoclast) ureterolithotripsy. Such results may be connected with a very small sample size.
This study has several limitations. Its retrospective and single-center design limits causal inference and generalizability. Long-term follow-up on recurrence and delayed complications was unavailable. Stone size was measured by length only, without volumetric analysis, and stone composition data were limited due to the optional, paid nature of the service. Multivariate analysis was not performed, as the study was observational and aimed to describe clinical outcomes rather than identify independent predictors. Additionally, the choice between laser and pneumatic lithotripsy was not randomized but based on clinical factors such as stone size, density, and location. Also, as pre-stenting was performed in only nine patients to facilitate ureteral access in narrow ureters or proximal stones, no separate subgroup analysis was conducted. Therefore, results should be interpreted cautiously, and further prospective, randomized studies are needed for definitive comparisons.
EUL is a safe and effective treatment for pediatric ureteral stones, with the highest success in distal locations. While laser and pneumatic lithotripsy showed similar efficacy, laser offered slightly shorter operative times. Younger children (< 7 years) faced more procedural challenges, underscoring the need for careful planning. EUL remains a reliable minimally invasive option, and further multicenter studies with long-term follow-up are warranted to optimize outcomes and technique.
The authors express their sincere gratitude to the administration of the Republican Specialized Scientific and Practical Medical Center of Urology for providing institutional support and the opportunity to conduct this study.
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