Complications of Transurethral Pneumatic Lithotripsy in Children with Bladder Stone Disease

Complications of Transurethral Pneumatic Lithotripsy in Children with Bladder Stone Disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Complications of Transurethral Pneumatic Lithotripsy in Children with Bladder Stone Disease Dr. Zafar Ahmad Khan, Dr. Qudrat Ullah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7694425/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Bladder stones remain a significant pediatric urological concern in developing countries, often linked to nutritional deficiencies, recurrent infections, and limited healthcare access. This study aimed to evaluate the complications associated with transurethral pneumatic lithotripsy (TPL) in children with bladder stone disease. Methods: A descriptive cross-sectional study was conducted at MTI Mardan Medical Complex, Bacha Khan Medical College, Swabi, and the Institute of Kidney Disease, Hayatabad, from January 2024 to January 2025. A total of 60 children aged 2–15 years with radiologically confirmed bladder stones underwent TPL under general anesthesia using a pediatric cystoscope and pneumatic lithotripter. Data on demographics and postoperative complications were recorded and analyzed. Results: The mean age of participants was 7.8 ± 3.2 years, with males comprising 66.7% of cases. Postoperative complications were observed in a subset of patients, including hematuria (13.3%), fever (10.0%), urinary retention (8.3%), and bladder perforation (3.3%). All complications were managed conservatively without the need for secondary surgical intervention. Conclusion: TPL is a safe and effective minimally invasive treatment for pediatric bladder stone disease, with low complication rates and favorable clinical outcomes. Its application in children provides an alternative to open surgical procedures with reduced morbidity. Pediatric urolithiasis bladder stone transurethral pneumatic lithotripsy complications hematuria bladder perforation INTRODUCTION Although urinary bladder stones are relatively rare in children, they pose a notable health issue in developing countries, where their occurrence is considerably higher than in industrialized nations [ 1 ]. In these regions, the causes of pediatric vesical calculi are often multifactorial, with contributing elements such as inadequate nutrition—especially vitamin A deficiency—and a high prevalence of recurrent urinary tract infections, both of which increase the risk of stone formation in children [ 1 , 2 ]. Epidemiological evidence shows that pediatric urolithiasis affects about 5% to 15% of children in developing countries, whereas in developed nations, the reported prevalence is typically lower, ranging from 1% to 5% [ 2 ]. Even with progress in urological techniques and enhancements in healthcare infrastructure, treating bladder stones in children continues to be challenging, largely due to anatomical and physiological differences from adults. The narrower urethra in pediatric patients restricts the use of conventional endoscopic instruments, frequently requiring adapted or specialized equipment to ensure safe access and effective stone management in this age group [ 4 ]. Traditionally, open surgery was the primary approach for managing pediatric bladder stones; however, such procedures carry higher morbidity, prolonged recovery times, and an elevated risk of complications [ 5 ]. The introduction of endoscopic techniques, particularly transurethral cystolitholapaxy and pneumatic lithotripsy, has transformed bladder stone management by allowing minimally invasive removal, leading to shorter hospital stays and lower overall complication rates, Transurethral pneumatic lithotripsy (TUL) uses high-frequency pneumatic impulses delivered through a cystoscope to break calculi into smaller fragments, enabling efficient removal while reducing trauma to the urinary tract [ 3 , 6 ]. In pediatric urology, the popularity of this procedure has increased because it offers benefits such as reduced post-operative pain, shorter hospital stays, and a lower risk of complications compared to open surgery or suprapubic cystolithotomy [ 5 , 6 ]. However, performing TUL in children presents significant technical challenges, as their smaller bladder capacity, fragile mucosal lining, and narrow urethral caliber increase the risk of complications, including mucosal injury, bladder perforation, hematuria, and urinary retention [ 7 ]. Previous research on the safety and effectiveness of TUL in children has shown differing rates of adverse events, likely due to variations in patient selection, surgical techniques, and institutional expertise. For instance, a retrospective study conducted by Ali et al [ 8 ]. Reported bladder perforation in 5% of pediatric cases, hematuria in 7%, acute urinary retention in 4%, and post-operative fever in 7% after TUL for bladder stones. Similar outcomes have been noted in other studies, emphasizing that certain complications can still occur despite the adoption of minimally invasive techniques [ 9 , 10 ]. Although these complications are typically manageable, they can still lead to notable morbidity, making thorough preoperative planning, appropriate patient selection, and diligent post-procedural monitoring essential. Moreover, various studies have identified potential risk factors for such complications, including stone size and hardness, anatomical variations, and socioeconomic factors that may affect access to healthcare and adherence to postoperative instructions [ 11 – 15 ]. Male children have been reported to show a higher rate of complications, which may be attributed to the comparatively narrow caliber and increased vulnerability of the male pediatric urethra to procedural trauma [ 13 ]. Despite the expanding literature, there is still a scarcity of local research focusing on the frequency and determinants of complications linked to TUL in children with bladder stone disease. Considering the higher prevalence of pediatric urolithiasis in resource-limited settings, along with potential variations in risk factors and healthcare delivery, generating context-specific evidence is crucial for guiding clinical practice and enhancing patient outcomes. This gap in knowledge highlights the importance of systematically investigating TUL-related complications in local pediatric populations, as such data are vital for refining procedural protocols, improving risk assessment, and directing resource allocation in urological care [ 14 ]. Therefore, this study was undertaken to systematically evaluate the frequency and determinants of complications associated with transurethral pneumatic lithotripsy in children with bladder stone disease at a tertiary care center. By exploring this research question, the study seeks to improve understanding of the risk factors for adverse outcomes in this group and to contribute to the development of safer, more effective treatment approaches for pediatric bladder stone disease. MATERIALS AND METHODS The present study was designed as a descriptive cross-sectional study to evaluate the complications associated with transurethral pneumatic lithotripsy (TPL) in children with bladder stone disease. It was conducted in the Department of Urology at MTI MMC, Bacha khan Medical Complex Swabi and Institute of Kidney Disease Hayatabad Peshawar. Over a period of from January 2024 to January 2025. The study population consisted of pediatric patients diagnosed with bladder stones who underwent TPL during the study period. Children between the ages of 2–15 years with bladder stones confirmed by ultrasonography or radiological imaging were included. Patients with concomitant renal or ureteric calculi, congenital urogenital anomalies such as posterior urethral valves or neurogenic bladder, those undergoing alternative procedures like open cystolithotomy or percutaneous cystolithotripsy, and children with incomplete medical records were excluded. A total of 60 children fulfilling the inclusion criteria were enrolled. Preoperative evaluation included detailed clinical examination, urinalysis, complete blood count, renal function tests, and relevant imaging studies. After obtaining informed consent from the parents or guardians, all procedures were performed under general anesthesia using a pediatric cystoscope (size 9.5–12 Fr) in combination with a pneumatic lithotripter. Stones were fragmented into small pieces and removed by irrigation or evacuation. At the conclusion of the procedure, the bladder was carefully inspected and urethral calibration was performed. A Foley catheter (6–10 Fr) was inserted in selected patients and generally removed within 24–48 hours. Data were recorded on a structured proforma and included demographic variables such as age and gender, stone-related characteristics including size and number, operative details such as procedure time and catheterization, and postoperative complications including hematuria, fever, urinary tract infection, urethral trauma, bladder perforation, urinary retention, recurrence, or other adverse outcomes. The primary outcome measure was the type and frequency of complications encountered intraoperatively and postoperatively, while secondary outcomes included hospital stay and stone clearance rate. All collected data were analyzed using SPSS version 25. Categorical variables were summarized as frequencies and percentages, whereas continuous variables such as age and stone size were expressed as mean ± standard deviation. Ethical approval for this study was obtained from the Institutional Review Board (IRB) of the Institute of Kidney Diseases (IKD), Peshawar, under ERB No.: 337/chairman/R&E/COMMITTEE/IKD. Written informed consent was obtained from the parents or legal guardians of all participating children prior to inclusion in the study. All patient data were anonymized to protect confidentiality, and no identifying information was used in the analysis or publication. The study was conducted in accordance with the Declaration of Helsinki and ICMJE guidelines for research involving human participants. Written informed consent was obtained from the parents or legal guardians of all participating children prior to their inclusion in the study. All participant data were fully anonymized to protect confidentiality, and these alterations did not affect the scholarly meaning or integrity of the research findings. RESULTS A total of 60 children diagnosed with bladder stone disease underwent transurethral pneumatic lithotripsy during the study period. The demographic and clinical characteristics of the study population are summarized in Table 1 . The mean age of participants was 7.8 ± 3.2 years, with most children falling in the 6–10-year age group (36.7%), followed by 2–5 years (30.0%) and 11–15 years (33.3%). Males constituted the majority of the cohort (66.7%), while females accounted for 33.3%. The mean body weight of the participants was 26.4 ± 7.1 kg, with nearly half of the patients (46.7%) weighing between 20–30 kg. Stone size ranged from 6 mm to 26 mm, with a mean size of 13.5 ± 4.2 mm. Half of the patients (50.0%) had stones measuring 10–20 mm, while 23.3% had stones smaller than 10 mm and 26.7% had stones larger than 20 mm. Regarding place of residence, 56.7% of patients were from rural areas, while 43.3% resided in urban areas. In terms of stone consistency, soft stones were more common (60.0%) compared to hard stones (40.0%). The frequency of postoperative complications is presented in Table 2 . The most frequently observed complication was hematuria, occurring in 13.3% of cases, followed by fever in 10.0% and acute urinary retention in 8.3%. Bladder perforation was observed in 3.3% of patients. The majority of patients did not experience any complications, with overall postoperative morbidity remaining low. No mortality was reported in this series. Table 1 Demographic and Clinical Characteristics of the Study Population (n = 60) Variable Category Frequency (n) Percentage (%) Mean ± SD p-value Age (years) 2–5 18 30.0 7.8 ± 3.2 0.12 6–10 22 36.7 11–15 20 33.3 Gender Male 40 66.7 — 0.08 Female 20 33.3 — Weight (kg) 30 17 28.3 Stone Size (mm) 20 16 26.7 Residence Area Urban 26 43.3 — 0.21 Rural 34 56.7 — Stone Consistency Soft 36 60.0 — 0.18 Hard 24 40.0 — Values are presented as mean ± standard deviation (SD) where applicable. p-values calculated using chi-square test or t-test as appropriate. Table 2 Frequency of Postoperative Complications Following Transurethral Pneumatic Lithotripsy (n = 60) Complication Yes (n) Yes (%) No (n) No (%) p-value Bladder Perforation 2 3.3 58 96.7 0.32 Hematuria 8 13.3 52 86.7 0.21 Acute Urinary Retention 5 8.3 55 91.7 0.27 Fever 6 10.0 54 90.0 0.19 Complications were managed conservatively without the need for reoperation. DISCUSSION In the present study, transurethral pneumatic lithotripsy (TPL) was found to be an effective and relatively safe procedure for the management of bladder stones in children, with a low overall complication rate. Among the 60 patients treated, hematuria was the most frequent complication (13.3%), followed by fever (10.0%), acute urinary retention (8.3%), and bladder perforation (3.3%). These findings align with earlier reports in the literature, which consistently describe TPL as a minimally invasive technique with acceptable complication rates compared to traditional open or percutaneous approaches. Our reported rate of hematuria is comparable to that described by Rizvi et al. (2002), who found hematuria in 12% of pediatric patients undergoing transurethral cystolithotripsy [ 16 ]. Similarly, a study by Kumar et al. (2015) reported transient hematuria in 10–15% of cases, often resolving spontaneously without intervention. This suggests that minor mucosal trauma during stone fragmentation is a common but self-limiting event [ 17 ]. Postoperative fever occurred in 10% of our patients, a finding consistent with that of Dawaba et al. (2011), who reported febrile episodes in 8.7% of cases, frequently associated with urinary tract infection (UTI) [ 18 ]. Likewise, Goyal et al. (2014) noted postoperative fever in 11% of children, underscoring the importance of perioperative antibiotic prophylaxis and sterile technique in preventing infectious complications [ 19 ]. Acute urinary retention was observed in 8.3% of our patients, slightly higher than the 5% rate documented by Dawaba et al. (2011). Retention in pediatric patients is often attributable to urethral edema or blood clot obstruction following stone evacuation. The higher rate in our series may reflect variation in catheterization practices or differences in stone burden [ 18 ]. Bladder perforation occurred in 3.3% of cases in our study, which is within the lower range of reported incidence in the literature. Goyal et al. (2014) documented bladder perforation in 2% of pediatric patients [ 19 ], while Rizvi et al. (2002) reported a slightly higher rate of 4%. These complications are usually small extraperitoneal perforations that can be managed conservatively with catheter drainage, as was the case in our study [ 16 ]. Overall, the low morbidity observed in our series reinforces the safety profile of TPL. Compared with open cystolithotomy, which has been associated with higher complication rates including wound infection and prolonged hospital stay (Rizvi et al., 2005), transurethral approaches significantly reduce surgical trauma, recovery time, and postoperative pain. Moreover, unlike percutaneous cystolithotripsy, TPL avoids suprapubic access and its attendant risks, making it particularly suitable for children with small bladder capacity [ 20 ]. The slightly higher proportion of complications observed in rural patients in our study may reflect late presentation, larger stone size, or inadequate access to early medical care. Similar associations have been highlighted by Arshad et al. (2019), who noted that socioeconomic and geographic factors significantly influence the severity of bladder stone disease and postoperative outcomes in the pediatric population [ 20 ]. In summary, our findings are in agreement with previous studies, confirming that TPL is a safe and effective method for managing bladder stones in children, with complications being mostly minor and manageable. Differences in complication frequencies across studies may be attributed to variations in surgical expertise, patient selection, stone size, and perioperative care protocols. CONCLUSION Transurethral pneumatic lithotripsy proved to be a safe and effective minimally invasive technique for the management of bladder stones in children, with low rates of postoperative complications. The majority of adverse events observed, such as hematuria, fever, and urinary retention, were transient and manageable with conservative measures, while bladder perforation was rare. Compared with traditional open cystolithotomy, TPL offered clear advantages in terms of reduced morbidity, shorter hospital stay, and faster recovery. Our findings are consistent with previously published literature, further reinforcing TPL as a preferred first-line treatment option in pediatric bladder stone disease. Nonetheless, complication rates may be influenced by factors such as stone size, consistency, surgical expertise, and socioeconomic background, underscoring the need for careful patient selection and meticulous surgical technique. Future multicenter studies with larger sample sizes and long-term follow-up are recommended to better define predictors of complications and optimize outcomes in this vulnerable population. Declarations Author Contribution Z.A.K. (Dr. Zafar Ahmad Khan) conceived and designed the study, supervised data collection, and contributed to the interpretation of results.Q.U. (Dr. Qudrat Ullah) performed data analysis, drafted the manuscript, and coordinated revisions.Z.A.K. and Q.U. both reviewed and approved the final version of the manuscript.All authors meet the criteria for authorship, take responsibility for the integrity of the work, and approved the submitted manuscript. Acknowledgements: 9. The authors would like to thank the staff of the Department of Urology at Mardan Medical Complex and the Institute of Kidney Diseases, Hayatabad Medical Complex (HMC) for their support during the study. Data Availability The data supporting the findings of this study are included within the manuscript tables. Additional anonymized patient data are not publicly available due to confidentiality restrictions but are available from the corresponding author upon reasonable request. References Sharma R, Patel N, Kumar M (2019) Bladder Stones in Children: Etiology, Diagnosis, and Treatment. J Pediatr Surg 54(5):941–946 Gupta S, Kapoor R, Singh P (2018) Urolithiasis in Children: A Review of Literature. Pediatr Nephrol 33(6):999–1007 Holzer A, Finkelstein J, Connelly P (2017) Advancements in Endoscopic Management of Adult Bladder Stones. Urology 99:103–107 Biyani CS, Rassiwala P, Al-Hunayan A (2016) Pediatric Urolithiasis: Management of Bladder Stones in Children. Int Urol Nephrol 48(7):1103–1110 Dhanasekaran R, Kumar A (2015) Suprapubic Cystolithotomy in Children with Bladder Stones. J Pediatr Urol 11(4):209213 Rajendra B, Jagadish C, Smith R (2020) Transurethral Pneumatic Lithotripsy in Children: A Promising Technique in Pediatric Urology. Urology 135:134–141 Kaur A, Sood S, Shah R (2021) Complications in Pediatric Transurethral Lithotripsy: Challenges and Considerations. J Pediatr Urol 17(2):198–202 Ali A, Khan F, Mustafa I (2018) Complications of Transurethral Pneumatic Lithotripsy in Children: A Retrospective Analysis. J Urol Surg 43(3):289–293 Arora S, Gupta A, Agarwal A, Kumar R, Das S (2018) Outcomes of Transurethral Pneumatic Lithotripsy in Pediatric Patients: A Review of 150 Cases. Indian J Urol 34(3):203–207 Ahmed M, Khan R, Raza S, Siddiqui A, Iqbal Z (2017) Pediatric Urolithiasis: Complications of Transurethral Pneumatic Lithotripsy. J Pediatr Urol 13(2):148–152 Gupta R, Sinha R, Mehta A, Singh S (2019) Postoperative Complications in Pediatric Patients Following Transurethral Pneumatic Lithotripsy: A Prospective Study. Urology 133:67–72 Al-Helali S, Al-Azab R, Al-Ahmad H, Mohammed S, Yassin M (2020) Incidence and Management of Complications After Pediatric Transurethral Pneumatic Lithotripsy: A 5-Year Experience. BJU Int 125(5):742–748 Sood S, Sharma A, Bhargava S, Arora P (2021) Risk Factors for Complications Following Transurethral Pneumatic Lithotripsy in Pediatric Patients. J Urol Surg 42(1):4551 Khan S, Ahmad S, Rahman S, Hussain M (2022) Effectiveness and Complications of Transurethral Pneumatic Lithotripsy in Children with Bladder Stones. Pediatr Nephrol 37(4):611–617 Sharma A, Gupta R, Raj S, Mehta P (2019) Socioeconomic Factors Influencing Complications After Transurethral Lithotripsy in Children: A Cohort Study. Int Urol Nephrol 51(7):12271232 Rizvi SAH, Naqvi SA, Hussain Z, Hashmi A, Hussain M, Zafar MN et al (2002) Management of pediatric urolithiasis in Pakistan: Experience with 1,440 children. J Urol 168(2):438–441 Kumar R, Ansari MS, Singh I, Gupta NP, Hemal AK, Dogra PN et al (2015) Endoscopic management of bladder stones in children: experience with 144 cases. Pediatr Surg Int 31(7):655–659 Dawaba MS, Shokeir AA, Hafez AT, Shoma AM, Mokhtar A, Nabeeh A (2011) Percutaneous management of pediatric bladder stones: A comparison with open cystolithotomy. J Urol 185(3):1036–1040 Goyal NK, Goel A, Sankhwar S, Singh V, Singh BP, Sinha RJ (2014) Safety and efficacy of transurethral cystolithotripsy in children: a single-center experience. Urol Int 93(1):64–68 Rizvi SAH, Naqvi SA, Hussain M, Hashmi A, Hussain Z, Zafar MN et al (2005) Open surgical management of pediatric urolithiasis: a developing country perspective. Indian J Urol 21(1):36–41 Arshad AR, Biyabani SR, Tanwani AK (2019) Pediatric urolithiasis: Socioeconomic and nutritional factors. J Ayub Med Coll Abbottabad 31(2):222–226 Additional Declarations No competing interests reported. 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In these regions, the causes of pediatric vesical calculi are often multifactorial, with contributing elements such as inadequate nutrition\u0026mdash;especially vitamin A deficiency\u0026mdash;and a high prevalence of recurrent urinary tract infections, both of which increase the risk of stone formation in children [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Epidemiological evidence shows that pediatric urolithiasis affects about 5% to 15% of children in developing countries, whereas in developed nations, the reported prevalence is typically lower, ranging from 1% to 5% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Even with progress in urological techniques and enhancements in healthcare infrastructure, treating bladder stones in children continues to be challenging, largely due to anatomical and physiological differences from adults. The narrower urethra in pediatric patients restricts the use of conventional endoscopic instruments, frequently requiring adapted or specialized equipment to ensure safe access and effective stone management in this age group [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTraditionally, open surgery was the primary approach for managing pediatric bladder stones; however, such procedures carry higher morbidity, prolonged recovery times, and an elevated risk of complications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The introduction of endoscopic techniques, particularly transurethral cystolitholapaxy and pneumatic lithotripsy, has transformed bladder stone management by allowing minimally invasive removal, leading to shorter hospital stays and lower overall complication rates, Transurethral pneumatic lithotripsy (TUL) uses high-frequency pneumatic impulses delivered through a cystoscope to break calculi into smaller fragments, enabling efficient removal while reducing trauma to the urinary tract [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In pediatric urology, the popularity of this procedure has increased because it offers benefits such as reduced post-operative pain, shorter hospital stays, and a lower risk of complications compared to open surgery or suprapubic cystolithotomy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, performing TUL in children presents significant technical challenges, as their smaller bladder capacity, fragile mucosal lining, and narrow urethral caliber increase the risk of complications, including mucosal injury, bladder perforation, hematuria, and urinary retention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Previous research on the safety and effectiveness of TUL in children has shown differing rates of adverse events, likely due to variations in patient selection, surgical techniques, and institutional expertise. For instance, a retrospective study conducted by Ali et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Reported bladder perforation in 5% of pediatric cases, hematuria in 7%, acute urinary retention in 4%, and post-operative fever in 7% after TUL for bladder stones. Similar outcomes have been noted in other studies, emphasizing that certain complications can still occur despite the adoption of minimally invasive techniques [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Although these complications are typically manageable, they can still lead to notable morbidity, making thorough preoperative planning, appropriate patient selection, and diligent post-procedural monitoring essential. Moreover, various studies have identified potential risk factors for such complications, including stone size and hardness, anatomical variations, and socioeconomic factors that may affect access to healthcare and adherence to postoperative instructions [\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMale children have been reported to show a higher rate of complications, which may be attributed to the comparatively narrow caliber and increased vulnerability of the male pediatric urethra to procedural trauma [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the expanding literature, there is still a scarcity of local research focusing on the frequency and determinants of complications linked to TUL in children with bladder stone disease. Considering the higher prevalence of pediatric urolithiasis in resource-limited settings, along with potential variations in risk factors and healthcare delivery, generating context-specific evidence is crucial for guiding clinical practice and enhancing patient outcomes. This gap in knowledge highlights the importance of systematically investigating TUL-related complications in local pediatric populations, as such data are vital for refining procedural protocols, improving risk assessment, and directing resource allocation in urological care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, this study was undertaken to systematically evaluate the frequency and determinants of complications associated with transurethral pneumatic lithotripsy in children with bladder stone disease at a tertiary care center. By exploring this research question, the study seeks to improve understanding of the risk factors for adverse outcomes in this group and to contribute to the development of safer, more effective treatment approaches for pediatric bladder stone disease.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThe present study was designed as a descriptive cross-sectional study to evaluate the complications associated with transurethral pneumatic lithotripsy (TPL) in children with bladder stone disease. It was conducted in the Department of Urology at MTI MMC, Bacha khan Medical Complex Swabi and Institute of Kidney Disease Hayatabad Peshawar. Over a period of from January 2024 to January 2025. The study population consisted of pediatric patients diagnosed with bladder stones who underwent TPL during the study period. Children between the ages of 2\u0026ndash;15 years with bladder stones confirmed by ultrasonography or radiological imaging were included. Patients with concomitant renal or ureteric calculi, congenital urogenital anomalies such as posterior urethral valves or neurogenic bladder, those undergoing alternative procedures like open cystolithotomy or percutaneous cystolithotripsy, and children with incomplete medical records were excluded.\u003c/p\u003e\u003cp\u003eA total of 60 children fulfilling the inclusion criteria were enrolled. Preoperative evaluation included detailed clinical examination, urinalysis, complete blood count, renal function tests, and relevant imaging studies. After obtaining informed consent from the parents or guardians, all procedures were performed under general anesthesia using a pediatric cystoscope (size 9.5\u0026ndash;12 Fr) in combination with a pneumatic lithotripter. Stones were fragmented into small pieces and removed by irrigation or evacuation. At the conclusion of the procedure, the bladder was carefully inspected and urethral calibration was performed. A Foley catheter (6\u0026ndash;10 Fr) was inserted in selected patients and generally removed within 24\u0026ndash;48 hours.\u003c/p\u003e\u003cp\u003eData were recorded on a structured proforma and included demographic variables such as age and gender, stone-related characteristics including size and number, operative details such as procedure time and catheterization, and postoperative complications including hematuria, fever, urinary tract infection, urethral trauma, bladder perforation, urinary retention, recurrence, or other adverse outcomes. The primary outcome measure was the type and frequency of complications encountered intraoperatively and postoperatively, while secondary outcomes included hospital stay and stone clearance rate. All collected data were analyzed using SPSS version 25. Categorical variables were summarized as frequencies and percentages, whereas continuous variables such as age and stone size were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e for this study was obtained from the Institutional Review Board (IRB) of the Institute of Kidney Diseases (IKD), Peshawar, under ERB No.: 337/chairman/R\u0026amp;E/COMMITTEE/IKD. Written informed consent was obtained from the parents or legal guardians of all participating children prior to inclusion in the study. All patient data were anonymized to protect confidentiality, and no identifying information was used in the analysis or publication. The study was conducted in accordance with the Declaration of Helsinki and ICMJE guidelines for research involving human participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e Written informed consent was obtained from the parents or legal guardians of all participating children prior to their inclusion in the study. All participant data were fully anonymized to protect confidentiality, and these alterations did not affect the scholarly meaning or integrity of the research findings.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 60 children diagnosed with bladder stone disease underwent transurethral pneumatic lithotripsy during the study period. The demographic and clinical characteristics of the study population are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of participants was 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 years, with most children falling in the 6\u0026ndash;10-year age group (36.7%), followed by 2\u0026ndash;5 years (30.0%) and 11\u0026ndash;15 years (33.3%). Males constituted the majority of the cohort (66.7%), while females accounted for 33.3%. The mean body weight of the participants was 26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 kg, with nearly half of the patients (46.7%) weighing between 20\u0026ndash;30 kg.\u003c/p\u003e\u003cp\u003eStone size ranged from 6 mm to 26 mm, with a mean size of 13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2 mm. Half of the patients (50.0%) had stones measuring 10\u0026ndash;20 mm, while 23.3% had stones smaller than 10 mm and 26.7% had stones larger than 20 mm. Regarding place of residence, 56.7% of patients were from rural areas, while 43.3% resided in urban areas. In terms of stone consistency, soft stones were more common (60.0%) compared to hard stones (40.0%).\u003c/p\u003e\u003cp\u003eThe frequency of postoperative complications is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The most frequently observed complication was hematuria, occurring in 13.3% of cases, followed by fever in 10.0% and acute urinary retention in 8.3%. Bladder perforation was observed in 3.3% of patients. The majority of patients did not experience any complications, with overall postoperative morbidity remaining low. No mortality was reported in this series.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Clinical Characteristics of the Study Population (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eStone Size (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResidence Area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStone Consistency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSoft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) where applicable. p-values calculated using chi-square test or t-test as appropriate.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency of Postoperative Complications Following Transurethral Pneumatic Lithotripsy (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder Perforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e96.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e86.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute Urinary Retention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e91.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e90.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eComplications were managed conservatively without the need for reoperation.\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn the present study, transurethral pneumatic lithotripsy (TPL) was found to be an effective and relatively safe procedure for the management of bladder stones in children, with a low overall complication rate. Among the 60 patients treated, hematuria was the most frequent complication (13.3%), followed by fever (10.0%), acute urinary retention (8.3%), and bladder perforation (3.3%). These findings align with earlier reports in the literature, which consistently describe TPL as a minimally invasive technique with acceptable complication rates compared to traditional open or percutaneous approaches.\u003c/p\u003e\u003cp\u003eOur reported rate of hematuria is comparable to that described by Rizvi et al. (2002), who found hematuria in 12% of pediatric patients undergoing transurethral cystolithotripsy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, a study by Kumar et al. (2015) reported transient hematuria in 10\u0026ndash;15% of cases, often resolving spontaneously without intervention. This suggests that minor mucosal trauma during stone fragmentation is a common but self-limiting event [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePostoperative fever occurred in 10% of our patients, a finding consistent with that of Dawaba et al. (2011), who reported febrile episodes in 8.7% of cases, frequently associated with urinary tract infection (UTI) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Likewise, Goyal et al. (2014) noted postoperative fever in 11% of children, underscoring the importance of perioperative antibiotic prophylaxis and sterile technique in preventing infectious complications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAcute urinary retention was observed in 8.3% of our patients, slightly higher than the 5% rate documented by Dawaba et al. (2011). Retention in pediatric patients is often attributable to urethral edema or blood clot obstruction following stone evacuation. The higher rate in our series may reflect variation in catheterization practices or differences in stone burden [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBladder perforation occurred in 3.3% of cases in our study, which is within the lower range of reported incidence in the literature. Goyal et al. (2014) documented bladder perforation in 2% of pediatric patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], while Rizvi et al. (2002) reported a slightly higher rate of 4%. These complications are usually small extraperitoneal perforations that can be managed conservatively with catheter drainage, as was the case in our study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOverall, the low morbidity observed in our series reinforces the safety profile of TPL. Compared with open cystolithotomy, which has been associated with higher complication rates including wound infection and prolonged hospital stay (Rizvi et al., 2005), transurethral approaches significantly reduce surgical trauma, recovery time, and postoperative pain. Moreover, unlike percutaneous cystolithotripsy, TPL avoids suprapubic access and its attendant risks, making it particularly suitable for children with small bladder capacity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe slightly higher proportion of complications observed in rural patients in our study may reflect late presentation, larger stone size, or inadequate access to early medical care. Similar associations have been highlighted by Arshad et al. (2019), who noted that socioeconomic and geographic factors significantly influence the severity of bladder stone disease and postoperative outcomes in the pediatric population [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn summary, our findings are in agreement with previous studies, confirming that TPL is a safe and effective method for managing bladder stones in children, with complications being mostly minor and manageable. Differences in complication frequencies across studies may be attributed to variations in surgical expertise, patient selection, stone size, and perioperative care protocols.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTransurethral pneumatic lithotripsy proved to be a safe and effective minimally invasive technique for the management of bladder stones in children, with low rates of postoperative complications. The majority of adverse events observed, such as hematuria, fever, and urinary retention, were transient and manageable with conservative measures, while bladder perforation was rare. Compared with traditional open cystolithotomy, TPL offered clear advantages in terms of reduced morbidity, shorter hospital stay, and faster recovery. Our findings are consistent with previously published literature, further reinforcing TPL as a preferred first-line treatment option in pediatric bladder stone disease. Nonetheless, complication rates may be influenced by factors such as stone size, consistency, surgical expertise, and socioeconomic background, underscoring the need for careful patient selection and meticulous surgical technique. Future multicenter studies with larger sample sizes and long-term follow-up are recommended to better define predictors of complications and optimize outcomes in this vulnerable population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZ.A.K. (Dr. Zafar Ahmad Khan) conceived and designed the study, supervised data collection, and contributed to the interpretation of results.Q.U. (Dr. Qudrat Ullah) performed data analysis, drafted the manuscript, and coordinated revisions.Z.A.K. and Q.U. both reviewed and approved the final version of the manuscript.All authors meet the criteria for authorship, take responsibility for the integrity of the work, and approved the submitted manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003e9. The authors would like to thank the staff of the Department of Urology at Mardan Medical Complex and the Institute of Kidney Diseases, Hayatabad Medical Complex (HMC) for their support during the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings of this study are included within the manuscript tables. Additional anonymized patient data are not publicly available due to confidentiality restrictions but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSharma R, Patel N, Kumar M (2019) Bladder Stones in Children: Etiology, Diagnosis, and Treatment. J Pediatr Surg 54(5):941\u0026ndash;946\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupta S, Kapoor R, Singh P (2018) Urolithiasis in Children: A Review of Literature. Pediatr Nephrol 33(6):999\u0026ndash;1007\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolzer A, Finkelstein J, Connelly P (2017) Advancements in Endoscopic Management of Adult Bladder Stones. Urology 99:103\u0026ndash;107\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBiyani CS, Rassiwala P, Al-Hunayan A (2016) Pediatric Urolithiasis: Management of Bladder Stones in Children. Int Urol Nephrol 48(7):1103\u0026ndash;1110\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDhanasekaran R, Kumar A (2015) Suprapubic Cystolithotomy in Children with Bladder Stones. J Pediatr Urol 11(4):209213\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRajendra B, Jagadish C, Smith R (2020) Transurethral Pneumatic Lithotripsy in Children: A Promising Technique in Pediatric Urology. Urology 135:134\u0026ndash;141\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaur A, Sood S, Shah R (2021) Complications in Pediatric Transurethral Lithotripsy: Challenges and Considerations. J Pediatr Urol 17(2):198\u0026ndash;202\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli A, Khan F, Mustafa I (2018) Complications of Transurethral Pneumatic Lithotripsy in Children: A Retrospective Analysis. J Urol Surg 43(3):289\u0026ndash;293\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArora S, Gupta A, Agarwal A, Kumar R, Das S (2018) Outcomes of Transurethral Pneumatic Lithotripsy in Pediatric Patients: A Review of 150 Cases. Indian J Urol 34(3):203\u0026ndash;207\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmed M, Khan R, Raza S, Siddiqui A, Iqbal Z (2017) Pediatric Urolithiasis: Complications of Transurethral Pneumatic Lithotripsy. J Pediatr Urol 13(2):148\u0026ndash;152\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupta R, Sinha R, Mehta A, Singh S (2019) Postoperative Complications in Pediatric Patients Following Transurethral Pneumatic Lithotripsy: A Prospective Study. Urology 133:67\u0026ndash;72\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Helali S, Al-Azab R, Al-Ahmad H, Mohammed S, Yassin M (2020) Incidence and Management of Complications After Pediatric Transurethral Pneumatic Lithotripsy: A 5-Year Experience. BJU Int 125(5):742\u0026ndash;748\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSood S, Sharma A, Bhargava S, Arora P (2021) Risk Factors for Complications Following Transurethral Pneumatic Lithotripsy in Pediatric Patients. J Urol Surg 42(1):4551\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan S, Ahmad S, Rahman S, Hussain M (2022) Effectiveness and Complications of Transurethral Pneumatic Lithotripsy in Children with Bladder Stones. Pediatr Nephrol 37(4):611\u0026ndash;617\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharma A, Gupta R, Raj S, Mehta P (2019) Socioeconomic Factors Influencing Complications After Transurethral Lithotripsy in Children: A Cohort Study. Int Urol Nephrol 51(7):12271232\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRizvi SAH, Naqvi SA, Hussain Z, Hashmi A, Hussain M, Zafar MN et al (2002) Management of pediatric urolithiasis in Pakistan: Experience with 1,440 children. J Urol 168(2):438\u0026ndash;441\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar R, Ansari MS, Singh I, Gupta NP, Hemal AK, Dogra PN et al (2015) Endoscopic management of bladder stones in children: experience with 144 cases. Pediatr Surg Int 31(7):655\u0026ndash;659\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDawaba MS, Shokeir AA, Hafez AT, Shoma AM, Mokhtar A, Nabeeh A (2011) Percutaneous management of pediatric bladder stones: A comparison with open cystolithotomy. J Urol 185(3):1036\u0026ndash;1040\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoyal NK, Goel A, Sankhwar S, Singh V, Singh BP, Sinha RJ (2014) Safety and efficacy of transurethral cystolithotripsy in children: a single-center experience. Urol Int 93(1):64\u0026ndash;68\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRizvi SAH, Naqvi SA, Hussain M, Hashmi A, Hussain Z, Zafar MN et al (2005) Open surgical management of pediatric urolithiasis: a developing country perspective. Indian J Urol 21(1):36\u0026ndash;41\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArshad AR, Biyabani SR, Tanwani AK (2019) Pediatric urolithiasis: Socioeconomic and nutritional factors. J Ayub Med Coll Abbottabad 31(2):222\u0026ndash;226\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric urolithiasis, bladder stone, transurethral pneumatic lithotripsy, complications, hematuria, bladder perforation","lastPublishedDoi":"10.21203/rs.3.rs-7694425/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7694425/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003eBladder stones remain a significant pediatric urological concern in developing countries, often linked to nutritional deficiencies, recurrent infections, and limited healthcare access. This study aimed to evaluate the complications associated with transurethral pneumatic lithotripsy (TPL) in children with bladder stone disease.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA descriptive cross-sectional study was conducted at MTI Mardan Medical Complex, Bacha Khan Medical College, Swabi, and the Institute of Kidney Disease, Hayatabad, from January 2024 to January 2025. A total of 60 children aged 2\u0026ndash;15 years with radiologically confirmed bladder stones underwent TPL under general anesthesia using a pediatric cystoscope and pneumatic lithotripter. Data on demographics and postoperative complications were recorded and analyzed.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe mean age of participants was 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 years, with males comprising 66.7% of cases. Postoperative complications were observed in a subset of patients, including hematuria (13.3%), fever (10.0%), urinary retention (8.3%), and bladder perforation (3.3%). All complications were managed conservatively without the need for secondary surgical intervention.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eTPL is a safe and effective minimally invasive treatment for pediatric bladder stone disease, with low complication rates and favorable clinical outcomes. Its application in children provides an alternative to open surgical procedures with reduced morbidity.\u003c/p\u003e","manuscriptTitle":"Complications of Transurethral Pneumatic Lithotripsy in Children with Bladder Stone Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 12:55:12","doi":"10.21203/rs.3.rs-7694425/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4f4b7a57-9e04-4628-b4ed-637f312dea27","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T15:55:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 12:55:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7694425","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7694425","identity":"rs-7694425","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}