Pediatric urethroscope versus flexible choledochoscope for removal of distal protein plugs and calculi in choledochal cyst: A prospective cohort study.
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BACKGROUND: Choledochal cyst (CC) is a common congenital biliary malformation that occurs frequently in children. CC is often complicated by protein plugs, calculi, and other debris, predisposing patients to cholangitis, pancreatitis, and other adverse events. Thorough intraoperative removal of obstructive debris is critical for improving postoperative outcomes. At present, intraoperative endoscopy represents the main modality for removing distal obstructions; however, consensus regarding the comparative efficacy of pediatric urethroscope and flexible choledochoscope remains lacking. OBJECTIVE: To compare the clinical efficacy of pediatric urethroscope and flexible choledochoscope in removing distal obstructions in choledochal cysts, to provide evidence for rational selection of clinical therapeutic strategies. METHODS: A single-center prospective cohort study was conducted. A total of 123 pediatric patients with distal obstruction of choledochal cyst admitted to our center from June 2023 to June 2025 were enrolled and alternately allocated into the urethroscope group (62 cases) and the choledochoscope group (61 cases). Distal obstructive debris was removed using pediatric urethroscope and flexible choledochoscope, respectively. Intraoperative parameters, postoperative recovery, complication rates and follow-up outcomes were compared between the two groups. Subgroup analyses were performed according to operative age, cyst type and pancreatobiliary maljunction (PBM) classification. RESULTS: Baseline characteristics, PBM classification and anatomical variations were comparable between the two groups. The complete removal rate of distal obstructions was 100% in both groups, with no significant differences in postoperative hospital stay, drainage tube removal time, or complications such as bile leakage, bleeding and pancreatitis. Compared with the choledochoscope group, the urethroscope group had significantly shorter total operative time [194.5 (153.0, 234.0) min vs. 236.0 (176.0, 307.0) min, P = 0.006], markedly shorter time required for obstruction removal [5.0 (5.0, 7.0) min vs. 15.0 (11.0, 17.0) min, P < 0.001], and fewer total endoscopic insertions [1.0 (1.0, 2.0) vs. 4.0 (3.0, 5.0), P < 0.001]. Subgroup analyses confirmed that these advantages were more prominent in patients aged ≤3 years, those with cystic dilatation, and those with type B PBM. After a median follow-up of 15 months, no significant differences were observed in the rates of anastomotic stenosis, new intrahepatic stone formation or pancreatitis between the two groups. CONCLUSIONS: Both pediatric urethroscope and flexible choledochoscope demonstrate favorable safety profiles and complete clearance efficacy in removing distal obstructions in choledochal cysts. The pediatric urethroscope yields higher procedural efficiency and may be preferred in clinical practice, especially for centers that have recently adopted such procedures. The choice can be flexibly made according to the endoscopic equipment configuration of medical institutions.