The Duration of Stone Disease and the Impact of a Stone Event on Patients' Quality of Life.

Introduction: With a 5-year stone recurrence rate of 30% to 50%, kidney stone formers are subject to significant morbidity that negatively impacts their health-related quality of life (HRQOL). We sought to determine the impact of age at kidney stone onset, duration of stone disease, and kidney stone event (surgery or stone passage) on HRQOL of individual patients by querying the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Patients and Methods: Cross-sectional data were obtained from a total of 2438 kidney stone formers from 14 institutions in North America who completed the WISQOL questionnaire during the period from 2014 to 2019. The 28-question survey has a 1- to 5-point scale for each item (total score range 0-140). Multivariable linear regression models assessed the impact of age at kidney stone onset, duration of stone disease, and time since most recent surgery or stone passage on HRQOL. Results: Of 2438 patients, older age at kidney stone onset and longer duration of disease were both independent predictors of better WISQOL scores (ß = 0.33 points/year; confidence interval [CI] 0.17-0.49; p < 0.001; and ß = 0.50 points/year; CI 0.32-0.68; p < 0.001, respectively). Of 1376 patients who underwent surgery between 2010 and 2019, longer time since most recent surgery was an independent predictor of better WISQOL scores (ß = 2.28 points/year; CI: 1.47-3.10; p = <0.001). Of 1027 patients with spontaneous stone passage occurring between 2010 and 2019, longer time since most recent stone passage was an independent predictor of better WISQOL scores (ß = 1.59 points/year; CI: 0.59-2.59; p = <0.05). Conclusions: Our study demonstrates that older age at onset, longer duration of disease, and longer time since most recent surgery or stone passage were independent predictors of better HRQOL in kidney stone formers. Results of future studies that focus on optimizing stone-related modifiable risk factors to decrease the number of recurrent stone episodes and thus the need for recurrent surgeries will be essential.

Complaint of Testicular Discomfort in Patient with Esophageal Adenocarcinoma.

We report a case of esophageal cancer with solitary metastasis to the testicle in a 71-year-old man. The tumor was picked up on physical exam following new onset complaints of pain and swelling. While most testicular masses in older men are due to lymphoma, this case highlights the need to consider metastatic disease as a source of new symptoms in patients with a recent cancer diagnosis.

Opioids and Kidney Stones.

In recent years, the use of opioids in medical practice has come under significant scrutiny. This, in part, is owing to evidence of overprescription and overuse of opioid medications, as well as the unintended consequences and side effects for patients who take these medications. Here, we review the role of opioids and the responsible use of these medications with respect to kidney stone disease and surgical interventions for kidney stones.

Is Stone-free Status After Surgical Intervention for Kidney Stones Associated With Better Health-related Quality of Life? - A Multicenter Study From the North American Stone Quality of Life Consortium.

OBJECTIVE: To compare the health-related quality of life (HRQOL) of patients with residual fragments after surgical intervention for kidney stones to patients that are stone-free using the disease-specific Wisconsin stone quality of life (WISQOL) questionnaire. Kidney stones contribute to impaired HRQOL, which is increasingly recognized as an important healthcare outcome measurement. MATERIALS AND METHODS: With institutional review board approval, 313 adult patients who underwent surgical intervention for kidney stones at 4 sites completed a WISQOL questionnaire. We retrospectively collected surgical data including presence of residual fragments on post-operative imaging. We calculated standardized WISQOL total and domain scores (0-100), which included items related to social functioning (D1), emotional functioning (D2), stone-related impact (D3), and vitality (D4). Scores were compared between patients with residual fragments to those who were stone-free after surgical intervention. RESULTS: Demographics did not differ between groups, overall mean age 54.6 ± 13.5 and 55.4% female. There was no significant difference in total WISQOL score for patients with residual fragments (n = 124) compared to patients that were stone-free (n = 189), 110.5 ± 27.8 vs 115.4 ± 23.6 respectively, (P = .12). Interestingly, patients with residual fragments who underwent secondary surgery were found to have significantly lower total WISQOL score (88.4 ± 30.1 vs 116.6 ± 25.0, P <.0001). CONCLUSION: Stone-free status after surgical intervention is not associated with better HRQOL when compared with patients whose surgeries left residual fragments. Indeed, further surgical intervention on residual fragments to achieve stone-free status may actually result in worse HRQOL.

Informing the Management of Asymptomatic Nephrolithiasis: Markov Decision Analysis for the 1 cm Renal Stone.

INTRODUCTION: The management of an incidentally discovered, asymptomatic renal stone includes watchful waiting, shock wave lithotripsy, ureteroscopy with basket extraction of fragmented stones (URS-B) or ureteroscopy with laser "dusting" (URS-D). Each intervention has varying stone-free rates, requirements for ureteral stenting, and variable impact on a patient's quality of life. Decision analysis was used to assess the optimal quality adjusted life-years associated with each treatment option. METHODS: A Markov model was constructed to represent potential outcomes for a single 1 cm renal stone after treatment. The cohort was followed for 1-month cycles over 3 years and toll penalties for receiving a stent and undergoing surgery were standardized and incorporated into each subtree. Probabilities, utilities and toll penalties were derived from existing literature or clinical extrapolation when no published data were available. One-way sensitivity analyses were performed to determine threshold probabilities/utilities that may alter preferred options. RESULTS: Watchful waiting was the preferred intervention, preserving 2.82 quality adjusted life-years over 3 years. The remaining options had similar but decreasing quality adjusted life-years: URS-B provided 2.78 quality adjusted life-years; shock wave lithotripsy provided 2.72 quality adjusted life-years, and URS-D provided 2.67 quality adjusted life-years. One-way sensitivity analysis showed that URS-D was preferred when stone-free rates from URS-B dropped below 37%. Shock wave lithotripsy was preferred over URS-B when stone-free rates from URS-B dropped below 62%. As stents became progressively less bothersome, watchful waiting is preferred, followed by URS-B, shock wave lithotripsy and URS-D. CONCLUSIONS: Watchful waiting is the preferred management decision for asymptomatic renal stones. However, these results are sensitive to both actual stone-free rate and individual stent tolerance.

Implications of Erdheim-Chester disease and percutaneous renal access.

Erdheim-Chester disease (ECD) is a rare systemic histiocytosis with urologic manifestations in a majority of affected patients. An important manifestation is a pronounced retroperitoneal fibrosis with reported dense inflammatory rind surrounding the kidneys. We report a case of a patient with large stone burden necessitating percutaneous nephrolithotomy and the implications related to his Erdheim-Chester-related retroperitoneal fibrotic changes. Foreknowledge of these implications may inform perioperative counseling and surgical planning to maximize opportunity for successful outcomes.

Opioid Stewardship in Urology: Quality Improvement Summit 2018.

INTRODUCTION: We summarize the 2018 AUA (American Urological Association) Quality Improvement Summit, Opioid Stewardship in Urology, highlighting appropriate urological opioid use as well as reviewing programs that have been successful in reducing opioid prescribing. The AUA brought together nearly 100 attendees from across the United States, including clinicians who specialize in urology and other specialties, as well as researchers, government officials and others. METHODS: The 2018 AUA Quality Improvement Summit was a 1-day meeting held at AUA headquarters in Linthicum, Maryland. Talks and panels highlighted opioid stewardship programs and emphasized research on the nature and management of postoperative pain. RESULTS: The impact of the opioid epidemic is profound and the contribution of postoperative prescribing is noteworthy (eg 6% of opioid naïve patients demonstrate new persistent use habits after surgery and up to 70% of opioid pills prescribed after surgery go unused). Speakers raised awareness of these facts and detailed opportunities to improve, including prudent prescribing, opioid reclamation, use of nonopioid alternatives, and outreach and education. CONCLUSIONS: The 2018 AUA Quality Improvement Summit provided a platform for urologists to discuss the opioid epidemic and to learn strategies for combatting this issue from multidisciplinary experts. Physician led opioid stewardship and research, facilitated by this Summit, may enhance the quality and safety of medical care and improve the lives of patients, their families and their communities.

The Durability of Active Surveillance in Patients with Asymptomatic Kidney Stones: A Systematic Review.

Introduction: The natural progression of asymptomatic kidney stones remains unclear. Such knowledge may promote value-aligned care for patients and reduce potentially unnecessary procedures. We sought to evaluate the natural history of asymptomatic kidney stones in adults undergoing active surveillance. Materials and Methods: Using themes of "Kidney Stone" and "Active Surveillance," we performed a systematic review by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, Cumulative Index to Nursing and Allied Health Literature, BIOSIS, Scopus, and Web of Science from inception through October 2017-in addition to ClinicalTrials.gov, American Urological Association Annual Meeting abstracts (2014-2017), Google Scholar, and references of included studies and prior reviews. Two blinded reviewers independently extracted data and assessed methodological quality. We qualitatively summarized rates of surgical intervention (primary outcome), spontaneous stone passage, symptom development, and stone growth. We assessed the relationship between surveillance duration and rate of surgical intervention with Pearson's correlation coefficient. Results: Of 7034 unique records, 13 studies met final eligibility criteria. There was substantial variation in reported rates of surgical intervention from 6/85 (7.1%) to 80/301 (26.6%), spontaneous stone passage from 1/32 (3.1%) to 101/347 (29.1%), symptom development from 7/96 (7.3%) to 231/300 (77.0%), and stone growth from 5/96 (5.2%) to 33/50 (66.0%). Mean surveillance duration spanned from 11.3 to 80 months (range 2-180 months). Longer mean duration of surveillance did not correlate with an increase in surgical intervention rate across studies (n = 13, r = 0.01, p = 0.98), and this finding persisted when restricting analysis to observational studies (n = 9, r = 0.12, p = 0.76). Conclusions: Active surveillance appears to be a durable strategy for a majority of patients with asymptomatic kidney stones, as there was no increase in failure of watchful waiting despite increasing duration of surveillance. Higher quality studies are needed to ascertain which patients may benefit most from active surveillance.

Influence of Men's Attitudes toward Health and Health Insurance on Prostate Specific Antigen Screening for the Early Detection of Prostate Cancer.

INTRODUCTION: The majority of guidelines currently recommend shared decision making for men 55 to 69 years old who are considering prostate specific antigen screening, and proceeding based on values and preferences. Qualitative studies have shown that negative attitudes toward physicians, health care and general health can influence decisions to pursue prostate specific antigen screening. We evaluated the impact of men's attitudes toward health and health insurance on prostate specific antigen screening. METHODS: A retrospective secondary data analysis was conducted of men 55 to 69 years old without a history of prostate cancer using 2015 Medical Expenditure Panel Survey data. The relationships between 4 survey statements pertaining to attitudes toward health and health insurance and prostate specific antigen screening in the last 2 years were assessed using multiple logistic regression. RESULTS: The analysis sample consisted of 1,771 men which equated to 20,498,788.2 once weighted, and of these men 63.1% underwent prostate specific antigen screening. Men who agreed 1) they did not need health insurance (OR 0.67, 95% CI 0.47-0.95), 2) health insurance was not worth the money it costs (OR 0.75, 95% CI 0.56-0.99), 3) they were more likely to take risks than the average person (OR 0.73, 95% CI 0.54-0.98) and 4) they could overcome illness without help from a medically trained person (OR 0.55, 95% CI 0.41-0.72) had significantly decreased adjusted odds of undergoing prostate specific antigen screening. CONCLUSIONS: Men with negative attitudes toward health and health insurance have significantly decreased odds of undergoing prostate specific antigen screening. With increased emphasis being placed on patient values, preferences and shared decision making, clinicians should assess for negative attitudes toward health and health insurance and intervene with these men to optimize the delivery of preventive care.

"Allergic-like" reaction risk in patients undergoing non-intravenous contrast urography.

INTRODUCTION: Though widely performed, the safety of non-intravenous contrast (NIVC) urography in patients with documented intravenous, iodinated contrast allergic like reactions (ICA) is unclear. The purpose of this study was to determine the risk of "allergic-like" reaction (ALR) events in patients with ICA undergoing NIVC urography. MATERIALS AND METHODS: Patients undergoing contrast urography at a single institution were identified between 2011-2014. Patient charts were reviewed for documented ICA prior to index surgery, preoperative allergy prophylaxis with steroid or antihistamine, and acute allergic reactions identified by ICD codes within 24 hours of surgery. RESULTS: A total of 2,650 patients were included, 1,325 female (50%). Of these patients, 113 (4.2%) had an ICA. Overall 33% (37/113) of patient received preoperative allergy prophylaxis with a steroid or antihistamine. A potential ALR related ICD-9 code was identified in one patient (0.8%) with a prior IVC ALR without allergy prophylaxis within 24 hours preoperatively undergoing percutaneous nephrolithotomy (PCNL). This event was found to be an associated with a myocardial infarction and lacked ALR sequelae. CONCLUSION: Despite commonly voiced concerns, in this large series of over 2,500 patients, including 113 patients with a prior history of ICA undergoing contrast urography, only one patient was found to have a potential ALR event following PCNL. No patients undergoing a retrograde contrast urography with prior, documented ICA had a NIVC ALR event despite a low rate of pretreatment with corticosteroid or antihistamine.

Conversion from Cystine to Noncystine Stones: Incidence and Associated Factors.

PURPOSE: Patients with cystinuria are often treated with medical alkalization and shock wave lithotripsy, although each treatment is hypothesized to increase the risk of calcium phosphate stones. We performed a multicenter retrospective review to evaluate whether stones of another composition develop in patients with cystinuria and with what frequency. MATERIALS AND METHODS: We retrospectively reviewed the records of a multi-institutional cohort of patients with cystinuria. We assessed medications, stone analyses, 24-hour urinalyses and types of procedures. We compared patients who formed only cystine stones vs those with noncystine stones. RESULTS: We identified 125 patients from a total of 5 institutions who were followed a mean of 5.2 years (range 0 to 26). Stones with noncystine components were submitted by 37 patients (29.6%). Potassium citrate medication was not associated with a noncystine composition (p = 0.1877). Regarding surgical management 18 patients (13%) underwent at least 1 shock wave lithotripsy session (range 0 to 9) and 79 (63%) underwent percutaneous nephrolithotomy at least once (range 0 to 10). When stratified based on pure cystine vs converted stones, the average total number of shock wave lithotripsy and percutaneous nephrolithotomy procedures was higher in the group with cystine and subsequent noncystine stone compositions (0.94 vs 0.10, p <0.0001, and 1.7 vs 1.5, p = 0.0053, respectively). On logistic regression male gender (OR 3.1, p = 0.0280) and the number of shock wave lithotripsy sessions (OR 3.0, p = 0.0170) were associated with an increased likelihood of the development of stones with a noncystine composition. CONCLUSIONS: Stones with noncystine components develop in more than 25% of patients with cystinuria, underscoring the importance of continued stone analysis. In this study prior shock wave lithotripsy was associated with conversion to a noncystine stone composition while urinary alkalization therapy was not associated.

Management of Urinoma Formation After Laparoscopic Cryoablation of Renal Cyst.

Aim: To describe the presentation and management of a urinoma developing as a complication of laparoscopic cryoablation of a Bosniak III renal cyst. Case: A 74-year-old woman presented with acute onset of severe left lower abdominal pain 1 day after a laparoscopic cryoablation of a 3 cm multilobular left cystic renal mass. CT revealed a perinephric fluid collection adjacent to the lower pole of the left kidney with active urinary extravasation seen on retrograde pyelogram, confirming the presence of an urinoma. A retrograde ureteral stent was placed with complete resolution of symptoms and the patient was discharged on the first postoperative day. Follow-up CT scans 2 weeks and 2 months after the procedure showed significant reduction of urinoma size, and retrograde pyelogram 5 months after showed resolution of urinoma. Conclusion: Although often discussed as a possible complication, to our knowledge there are no published case reports in the literature regarding the formation of a urinoma after laparoscopic cryoablation. Furthermore, no data exist on the management of a urinoma after laparoscopic cryoablation. We propose that ureteral stenting is a reasonable approach to the management of this condition.

Incidence and implications of silent hydronephrosis following percutaneous nephrolithotomy
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OBJECTIVE: While routine renal imaging following ureteroscopy for urinary calculi has been recommended to screen for asymptomatic "silent" obstruction, the rate of silent obstruction following percutaneous nephrolithotomy (PCNL) remains poorly defined, and no consensus recommendations exist on routine postoperative imaging. At our institution, we sought to assess the incidence of silent hydronephrosis (SH), as a screen for obstruction, following PCNL. METHODS: The records of all 162 patients who met study inclusion criteria were reviewed. Of this group, 112 patients presented for their scheduled renal ultrasonography 4 - 6 weeks following stent removal to screen for SH. Asymptomatic patients found to have ultrasonographic evidence of hydronephrosis were further analyzed. RESULTS: SH was noted in 16% (18/112) of patients. Two required subsequent ureteroscopic stone extraction (1.8%), one of which also underwent endoureterotomy for a ureteral stricture. Four patients (22%) had stable hydronephrosis and declined functional imaging, 2 patients (11%) had a known partial ureteropelvic junction obstruction and declined intervention. SH resolved spontaneously in 50% (9/18) with a mean time to resolution of 6.3 months. There was no difference in stone complexity based on Guy's stone score between groups, 2.8 (± 0.92) vs. 2.4 (± 1.03), p = 0.34. Although not statistically significant, patients with SH were more likely to have had residual stone fragments postoperatively, 39% (7/18) vs. 19% (18/94), p = 0.067. CONCLUSIONS: SH following, PCNL was identified in 16% of this screened population, with the majority requiring no intervention. However, SH may be attributed to residual stone or stricture, which may have been otherwise unrecognized in up to 2% of patients undergoing PCNL. Consideration should be given for routine postoperative ultrasound to screen for silent obstruction following PCNL.
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From novelty to the every-day: the evolution of ureteroscopy.

Ureteroscopy revolutionized the surgical approach to the upper urinary tract, and is well recognized as a cornerstone of modern urology. Although now commonplace, ureteroscopic equipment and techniques were truly revolutionary. A review of the innovations and innovators that developed ureteroscopic surgery sets the stage for a more thorough understanding of what can be done ureteroscopically, and may additionally better inform what limitations remain. Given that future advancements in urologic therapy will be dependent upon a similar pursuit of paradigm shifting improvements in disease management, an overview of the development of modern ureteroscopy may inspire such change.

Does Omission of Ureteral Stents Increase Risk of Unplanned Return Visit? A Systematic Review and Meta-Analysis.

PURPOSE: Post-ureteroscopy ureteral stent omission remains controversial. Although omission is associated with reduced postoperative discomfort, concern remains for early obstruction. We performed a systematic review and meta-analysis of trials to compare the risk of unplanned visits with vs without a stent following ureteroscopy for nephrolithiasis. MATERIALS AND METHODS: Randomized, controlled trials and observational studies comparing post-ureteroscopic stent omission vs placement and reporting unplanned visits within 30 days were identified via a search of MEDLINE® (1946 to 2015), CENTRAL (Cochrane Central Register of Controlled Trials, 1898 to 2015), Embase® (1947 to 2015), ClinicalTrials.gov (1997 to 2015), AUA (American Urological Association) Annual Meeting abstracts (2011 to 2015) and reference lists of included articles as last updated in October 2015. Two reviewers independently extracted data and assessed methodological quality. ORs, RRs and weighted mean differences were calculated as appropriate for each outcome. RESULTS: Of the initial 1,992 studies 17 in a total of 1,943 participants met inclusion criteria. Unstented patients were significantly more likely to have an unplanned medical visit compared to those who received a post-ureteroscopy stent (OR 1.63, 95% CI 1.15-2.30). Unstented patients had shorter operative time (weighted mean difference -3.19 minutes, 95% CI -5.64--0.74) and were less likely to experience dysuria (RR 0.39, 95% CI 0.25-0.62). They were also less likely to experience postoperative infection (OR 0.89, 95% CI 0.59-1.33) and pain (OR 0.64, 95% CI 0.39-1.05), although these results were not significant. CONCLUSIONS: Stent omission is associated with an increased risk of unplanned medical visits despite reduced symptoms compared to those in stented patients. Patients and physicians should weigh these trade-offs when considering post-ureteroscopy stent placement.

Unplanned Hospital Return for Infection following Ureteroscopy-Can We Identify Modifiable Risk Factors?

PURPOSE: Genitourinary infection after ureteroscopy with laser lithotripsy is a clinically significant event that may lead to expensive and morbid return to the hospital. We evaluate factors associated with infection after ureteroscopy with laser lithotripsy leading to unplanned hospital return. MATERIALS AND METHODS: We performed a retrospective chart review evaluating all ureteroscopy with laser lithotripsy performed at a single academic institution from April 2011 to August 2014. Data were extracted including patient demographics, comorbidities, surgical encounter characteristics, preoperative urine culture status, antibiotic type/duration and compliance with the AUA Best Practice Statement for antibiotic prophylaxis. Bivariate and multivariate analyses were performed to determine factors associated with unplanned return to the hospital. RESULTS: Among 550 patients undergoing ureteroscopy with laser lithotripsy 45% (248) were female with an average age of 56.8 (± 14.8) years. Overall 3.4% (19 patients) had an unplanned return for genitourinary infection, with most (78.9%, 15 of 19) requiring inpatient readmission. Overall compliance with AUA Best Practice Statement for antibiotic prophylaxis was 48.7% (268 of 550). Rates of infection related returns were higher in patients undergoing preoperative stenting (84.2% vs 58.6%, p=0.025), those with an operative time greater than 120 minutes (89.5% vs 32.6% p <0.001) and those for whom there was AUA Best Practice Statement compliance for antibiotic prophylaxis (78.9% vs 47.6%, p=0.007). These factors remained significant on multivariate analysis (p <0.05). CONCLUSIONS: Preoperative stenting and longer operative time were associated with a greater likelihood of serious genitourinary infection after ureteroscopy with laser lithotripsy. These patients may warrant additional antibiotic prophylaxis but further research is needed to answer this question more definitively. Interestingly the AUA Best Practice Statement compliance for antibiotic prophylaxis was also associated with a higher risk of infection, underscoring the need for locally appropriate prophylaxis strategies and further study of optimal prophylaxis regimens.

Keratinized squamous metaplasia of the upper urinary tract resulting in recurrent renal colic.

A 60-year-old female with an extensive history of stone disease and shock wave lithotripsy presents with recurrent and increasingly severe renal colic. Work-up reveals obstruction with translucent debris that is found to be composed of keratin. Her history of chronic irritation of the collecting system has resulted in keratinizing squamous metaplasia (KSM) with hyperkeratosis that has sloughed from the upper urinary tract and has become lodged in the ureter. Because of the worsening of her symptoms on conservative management, the patient elected for a nephrectomy and her symptoms have since resolved. KSM of the renal pelvis is a relatively rare phenomenon and most often presents with irritative symptoms. It is thought to result from chronic irritation of the urothelium. KSM has been found to be coincident with squamous cell cancers of the urinary tract, though clear data implicating KSM as a premalignant lesion is lacking. We present a case of recurrent renal colic secondary to sloughing keratin debris from KSM.

Changes in stone composition over two decades: evaluation of over 10,000 stone analyses.

To examine the changes in stone composition from 1990 to 2010. A retrospective review was performed of all renal and ureteral stones submitted from the state of Massachusetts to a single laboratory (Laboratory for Stone Research, Newton, MA) for the years 1990 and 2010. Stone composition was determined by infrared spectroscopy and/or polarizing microscopy. A total of 11,099 stones were evaluated (56.7% from 1990, 43.3% from 2010). From 1990 to 2010, the percentage of stones from females (i.e., female/male ratio) increased significantly (29.8% in 1990 to 39.1% in 2010, p < 0.001). Among women, from 1990 to 2010, there was a significant increase in stones which were >50% uric acid (7.6-10.2%, p < 0.005) and a significant decrease in struvite stones (7.8-3.0%, p < 0.001). Among women with calcium stones, the % apatite per stone decreased significantly (20.0 vs. 11.7%, p < 0.001). Among men, there were no changes in stones which were majority uric acid (11.7-10.8%, p = 0.2). Among men with calcium stones, the % apatite per stone increased significantly (9.8 vs. 12.5%, p < 0.001). Males also demonstrated a significant increase in both cystine (0.1-0.6%, p < 0.001) and struvite stones (2.8-3.7%, p = 0.02). The epidemiology of stone disease continues to evolve and appears to vary according to gender. While some of these findings may be related to population changes in body mass index and obesity, the etiology of others remains unclear.