Vulnerability to Financial Toxicity From Stone Surgery.

PURPOSE: Financial toxicity has been described in stone formers however little is understood regarding its causes and how it may relate to stone surgery. We therefore aimed to longitudinally describe markers of financial strain in stone formers from the preoperative to postoperative time points. MATERIALS AND METHODS: A prospective cohort study was conducted from January 2022 to April 2023. Patients were enrolled in the waiting area prior to undergoing elective ureteroscopy or percutaneous nephrolithotomy. Participants completed the Commonwealth Fund's Biennial Health Insurance Survey at this time point and at 30 days postop. Items were pre-selected from the survey to capture markers of financial strain due to healthcare costs. RESULTS: One hundred nine participants were enrolled. Participants were a majority white (70%), college educated (62%), and privately ensured (72%). Despite these traditionally protective sociodemographic features, 42% of patients reported some marker of financial strain at the preoperative timepoint. Patients with Medicaid reported even higher financial stress (67%). Furthermore, 46% of patients did not know their deductible amount. Response rate was low at 30 days postop (35%) but suggested some patients were experiencing new financial strains. CONCLUSIONS: This paper shows that a significant proportion of stone patients are already displaying markers of financial strain from healthcare bills even prior to surgery as well as poor understanding of the costs they may incur. This makes them vulnerable to experiencing financial toxicity postoperatively and emphasizes the importance of understanding all contributing factors when developing future strategies to intervene in financial toxicity.

Postoperative Recovery of Quality-of-Life Following Ureteroscopy for Nephrolithiasis: The Impact on Pain Intensity and Interference and the Ability to Participate in Social Roles.

OBJECTIVE: To prospectively capture patient-reported outcomes to assess the recovery profile of ureteroscopy (URS). MATERIALS AND METHODS: Adults undergoing URS for renal/ureteral stones were eligible for inclusion (11/2020-8/2022). Patients prospectively completed PROMIS - Pain Intensity, - Pain Interference, and - Ability to participate in social roles and activities in-person preoperatively (POD 0) and via email on POD 1, 7, 14, and 30. Scores are reported as T-scores (normalized to U.S. population, mean=50) with a change of 5 (0.5 SD) considered clinically significant. RESULTS: One hundred and seventy-eight participants enrolled at POD 0 (POD 1 =87, POD 7 =83, POD 14 =70, POD30 =67). There was a worsening of quality of life from day 0 to day 1 and day 0 to 7. All dimensions then improved with an increase in scores from day 0 to day 14 and day 0 to day 30. On multivariable analysis, the presence of a preoperative ureteral stent (OR 0.14) and use of semirigid URS (OR 0.33) were associated with a reduced odds for severe pain interference at day 1. The use of semirigid URS (OR 0.20) was associated with a reduced odds for severe worsening in the ability to participate in social roles at day 1. CONCLUSION: Ability to participate in social roles declines immediately postoperatively, while pain intensity and interference sharply increase. There is a gradual improvement until POD 30. Findings suggest preoperative stents may influence postoperative recovery. Results offer meaningful insight to assist in counseling and setting expectation for patients postoperatively.

The Patient Voice: Stent Experiences After Ureteroscopy-Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study.

Purpose: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed. Materials and Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS). Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial. Results: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain vs discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n = 12) and far greater impact for participants in the substantial group (n = 8). For patients in the moderate group (n = 19), some daily activities were moderately or substantially affected, whereas other activities were minimally affected. Conclusions: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.

The Endourological Society Inaugural Census Report.

The Endourological Society, the premier urologic society encompassing endourology, robotics, and focal surgery, is composed of a diverse group of >1300 urologists. However, limited information has been collected about society members. Recognizing this need, a survey was initiated to capture data regarding current member practices, as well as help the Society shape the future direction of the organization. Presented herein is the inaugural Endourological Society census report as the beginning of a continued effort for global improvement in the field of endourology. Using a REDCap® database, an email survey was circulated to the membership of the Endourological Society from May through June 2021. Twenty questions were posed, categorizing member data in terms of epidemiology/demographics, practice patterns, member opinions, and future educational preferences. Responses were received from 534 members, representing 40.3% of membership. Data demonstrated that the average age, gender, race, and ethnicity of the typical Society member respondent is a 48-year-old Caucasian male working in the United States, with a mean of 25 years in practice. Retrograde endoscopy and percutaneous nephrolithotomy were identified as the most common practice skills, and 50% of members are involved in robotics. Importantly, the census confirmed that the World Congress of Endourology and Technology remains popular with Society members as a means of educational advancement. To sustain and advance the Society, information is required to understand the career interests and future educational desires of its members. This inaugural census provides crucial data regarding its membership and how the Society can achieve continued success and adjust its focus. Future census efforts will expand on the initial findings and stratify the data to elucidate changes in the needs of the Society as a whole. Circulating an annual census will allow for continued improvements in the field of endourology and, ultimately, better care for urologic patients.

Longitudinal Changes in Quality of Life After Ureteroscopy for Nephrolithiasis.

OBJECTIVE: To assess alterations in health-related quality of life (HRQOL) in patients with nephrolithiasis, given the limited prospective data on patient reported outcomes following surgical intervention with ureteroscopy. METHODS: Adults with either a renal or ureteral calculus who underwent ureteroscopy (URS) were recruited prospectively from 2017-2020. Participants completed the PROMIS-29 profile which measures the dimensions of physical function, fatigue, pain interference, depressive symptoms, anxiety, ability to participate in social roles and activities, and sleep disturbance at enrollment, 1-, 6-, and 12-months. Scores are reported as T-scores (normalized to US-population) and were compared at each time point against the mean for the US-population (50) using one-sample Welch's t'test and between each pairwise time point comparison using a Wilcoxon signed rank test. RESULTS: At enrollment, a total of 69 participants completed the PROMIS-29 survey. As compared to the US-population mean, participants at enrollment had significantly different scores in physical function, fatigue, pain interference, depressive symptoms, anxiety, and sleep disturbance (all P<.05), but not ability to participate in social roles and activities. In pairwise comparisons, improvement was only observed from enrollment to 1-month in pain interference (P<.01) and fatigue (P = .03). However, there was improvement at a longer interval from enrollment to 12-months in all dimensions (pairwise comparisons, all P<.05) except depressive symptoms. CONCLUSION: The PROMIS-29 profile is responsive to changes in HRQOL for patients with nephrolithiasis undergoing URS, with improvement of PROMIS scores up to 12-months. This information can be utilized for patient counseling to guide expectations during the recovery period.

Race/Ethnicity and Insurance's Impact on Delays to Kidney Stone Surgery Scheduling.

OBJECTIVE: To evaluate the association between ethnicity/insurance status and time to kidney stone surgery. METHODS: We retrospectively assessed all patients with evaluation of nephrolithiasis in the emergency room (ED), followed by definitive stone surgery (ureteroscopy/percutaneous nephrolithotomy/ESWL) at our major academic health system consisting of 3 hospitals in a dense, urban center. RESULTS: A total of 682 patients were included. A total of 2.8% (n = 19) were uninsured, 19.3% (n = 132) were enrolled in Medicaid, 23.3% (n = 159) were enrolled in Medicare and 54.5% (n = 372) had commercial insurance. Uninsured patients had a short median time to surgery of only 21 days (IQR 6-49), while Medicare patients had a longer time at 39 days, (IQR 17-64), although these were not significantly different (P =.12). Black race was associated with a higher percentage of uninsured and Medicaid patients (P ≤.001). There was no difference in clinical or patient reported characteristics between the insurance groups (all P >.05) 6.9%, 17.7%, 26.7%, and 48.6% of patients self-identified as Hispanic, Other, Black, and White, respectively. Hispanic patients had the shortest median time to surgery of 28 days (IQR 10-48), while Black patients the longest with a median of 38.5 days (18-72) (P =.007). Clinical variables at presentation including nausea/vomiting, hydronephrosis and sepsis were not statistically significant between the patient groups (all P >.05). CONCLUSION: Our study illustrates persistent delays in surgery scheduling for Black patients regardless of insurance status. This should inform practice patterns for urology providers, highlighting our need to enact institutional safety nets to promote expedient follow up for a vulnerable population.

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS.

BACKGROUND: Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains. METHODS: In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30. RESULTS: The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability. CONCLUSIONS: This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.

Emergency department and hospital revisits after ambulatory surgery for kidney stones: an analysis of the Healthcare Cost and Utilization Project.

Our objective was to identify the rate of revisit to either emergency department (ED) or inpatient (IP) following surgical stone removal in the ambulatory setting, and to identify factors predictive of such revisits. To this end, the AHRQ HCUP ambulatory, IP, and ED databases for NY and FL from 2010 to 2014 were linked. Cases were selected by primary CPT for shock-wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL) with accompanying ICD-9 for nephrolithiasis. Cystoscopy (CYS) was selected as a comparison group. The risk of revisit was explored using multivariate models. The overall unplanned revisit rate following stone removal was 6.4% (4.2% ED and 2.2% IP). The unadjusted revisit rates for SWL, URS, and PNL are 5.9%, 6.8%, and 9.0%, respectively. The adjusted odds of revisit following SWL, URS, and PNL are 1.93, 2.25, and 2.70 times higher, respectively, than cystoscopy. The majority of revisits occurred within the first two weeks of the index procedure, and the most common reasons for revisit were due to pain or infection. Younger age, female sex, lower income, Medicare or Medicaid insurance, a higher number of chronic medical conditions, and hospital-owned surgery centers were all associated with an increased odds of any revisit. The most important conclusions were that ambulatory stone removal has a low rate of post-operative revisits to either the ED or IP, there is a higher risk of revisit following stone removal as compared to urological procedures that involve only the lower urinary tract, and demographic factors appear to have a moderate influence on the odds of revisit.

A Longitudinal Cohort Study of Pain Intensity and Interference After Ureteroscopy for Nephrolithiasis Without Postoperative Opioids.

OBJECTIVE: To better understand the degree and time to resolution of pain in the postoperative period, we captured patient-reported pain intensity and interference prospectively in patients following ureteroscopy for nephrolithiasis. MATERIALS AND METHODS: Adults undergoing ureteroscopy for renal/ureteral stones from 11/2018 to 1/2020 were eligible for inclusion. All received nonopioid postoperative pain control. Patients prospectively completed Patient-Reported Outcome Measurement Information System-Pain Intensity and Patient-Reported Outcome Measurement Information System-Pain Interference instruments preoperatively on postoperative day (POD) 0 and via email on POD 1, 7, and 14. Scores are reported as T-scores (normalized to US population, mean = 50) with changes of 5 (0.5 standard deviation) considered clinically significant. RESULTS: A total of 126 patients completed enrollment at POD 0 (POD 1 = 74, POD 7 = 61, POD 14 = 47). Compared to US means, intensity and interference were significantly different at all time point comparisons (Wilcoxon rank test; all P <.001) except intensity at POD 7 (P = .09) and interference at POD 14 (P = .12). For both, there was a significant difference at each time comparison (repeated measures ANOVA; all P <.05). Increasing age was predictive of lower intensity (Confidence Interval (CI): -0.31 to -0.04; P = .012) and interference (CI: -0.36 to -0.06; P =.01) at POD 1. The presence of a postoperative stent was predictive of higher intensity (CI: 0.68-10.81; P = .03) and interference (CI: 0.61-12.96; P = .03) at POD 7. Increasing age remained a predictor of lower interference at POD 1 on multivariable analysis (CI: -0.46 to -0.01; P = .03). CONCLUSION: Pain intensity and interference are elevated immediately, but intensity normalizes by POD 7, while interference remains elevated until POD 14. Age and indwelling ureteral stent influence both intensity and interference.

Adapting to the Educational Challenges of a Pandemic: Development of a Novel Virtual Urology Subinternship During the Time of COVID-19.

OBJECTIVE: To design, implement, and evaluate learner attitudes of a virtual urologic surgery clinical rotation for medical students. METHODS: Ten senior medical students at the Perelman School of Medicine at the University of Pennsylvania were enrolled. Students were administered a precourse test on their perceived confidence of their urologic knowledge, confidence in identifying urologic conditions, comfort with performing urologic evaluations, and confidence placing consults for urologic issues. Students participated in a 2-week curriculum that included both asynchronous and synchronous content. Asynchronous content included prerecorded lectures, self-paced problem-based learning modules, directed reading and video content, and an online discussion board. Synchronous content included real-time videoconferences covering case discussions, simulated patient presentations, and critical literature reviews. At the conclusion of the course, students were administered the postcourse survey evaluating changes in their ability to identify and understand urologic conditions. RESULTS: The postcourse survey demonstrated this course significantly increases students' scores in: self-perceived urologic knowledge, confidence in naming urologic conditions, comfort with performing urologic evaluations, and confidence placing consults for urologic conditions (P <.05). CONCLUSION: Virtual medical student rotations are scalable and effective at delivering surgical material and can approximate the interpersonal teaching found in clinical learning environments. They may be a useful tool to supplement or augment clinical learning in select situations.

An Analysis of the US News & World Report Methodology for Attribution of Specialty Care in Otolaryngology and Urology.

US News & World Report (USNWR) rankings can assist patients with choosing where to receive their specialty care. USNWR methodology assumes that the specialty caring for hospitalized patients is equivalent to the specialty assigned by administrative coding. We examined the frequency of discordance between USNWR methodology-assigned specialty and the actual specialty care received for 2 surgical specialties, otolaryngology (ENT) and urology (GU). Our analysis included inpatient deaths identified by USNWR coding for these specialties from 2013 to 2017 at a single academic tertiary care center. We found that a minority of patients with deaths attributed by USNWR to these 2 specialties were actually cared for by ENT (6/14; 43%) or GU (3/19; 16%). Only 5 of 14 (36%) and 2 of 19 (11%) deaths were potentially associated with ENT and GU care, respectively. We identified a significant discordance between USNWR-assigned specialty and the actual specialty care received.

Preventing Excess Narcotic Prescriptions in New Robotic Surgery Discharges: The PENN Prospective Cohort Quality Improvement Initiative.

Purpose: To reduce the amount of opioids prescribed at discharge after robotic surgery, we hypothesized that the majority patients do not require opioids for pain control after robotic urologic oncologic procedures. Materials and Methods: This prospective study aimed to reduce opioids prescribed at discharge after robot-assisted radical prostatectomy (RARP), robot-assisted radical nephrectomy (RARN), and robot-assisted partial nephrectomy (RAPN). Before 9/2018, 100% of patients were discharged on varying amounts of oxycodone (range: 75-337.5 oral morphine milligram equivalents [MME]). We implemented a standardized nonopioid analgesia pathway with escalation options (Fig. 1). To assess the safety of our approach, we analyzed pain scores, telephone encounters, and emergency department visits in our cohort. Results: Our cohort (n = 170) consisted of patients undergoing RARP (n = 87), RARN (n = 25), and RAPN (n = 58) between September 2018 and January 2019. Overall, 67.7% were discharged without opioids, 24.4% with 10 pills of tramadol (50 MME), and 8.2% with 10 pills of oxycodone (75 MME). On multivariable analysis, older age (odds ratio: 0.961, 95% confidence interval: 0.923-0.995, p = 0.026) was associated with lower odds of needing opioids at discharge. There was no difference in pain scores at the postoperative outpatient visit (p = 0.66) or postoperative telephone encounters (p = 0.45) between those discharged with and without opioids. Conclusion: The majority of robotic surgery patients do not require opioids upon discharge. Implementation of a simple, standardized nonopioid protocol resulted in a dramatic reduction in the amount of opioids prescribed in our patient population. An escalation protocol allows for a patient-centered approach to reduce narcotic prescribing, although still addressing surgical pain.

National Variation in Opioid Prescription Fills and Long-Term Use in Opioid Naïve Patients after Urological Surgery.

PURPOSE: Prescription opioid use is increasing, leading to increased addiction and mortality. Postoperative care is often the first exposure to opioids of a patient but little data exist on national prescription patterns in urology. We examined post-discharge opioid fills after urological procedures and the association with long-term use. MATERIALS AND METHODS: We identified patients in a private national insurance database who underwent 1 of 15 urological procedures between October 1, 2010 and September 30, 2014. Patients with an opioid fill in the preceding 6 months were excluded from study. Claims for opioids from 30 days before the operation until 7 days after discharge characterized an initial prescription. Factors associated with persistent opioid use (an opioid claim 91 to 180 days after the operation) and chronic opioid use (10 or more refills of a 120-day or greater supply in the year after the operation) were analyzed using multivariable logistic regression. RESULTS: Overall 96,580 patients were included in study, of whom 49,391 (51%) filled an initial opioid prescription. Variation in the initial prescribed amount existed within procedures. Persistent use occurred in 6.2% of patients while chronic use occurred in 0.8%. Increased prescription in patients treated with transurethral prostate resection, vasectomy, female sling surgery, cystoscopy and stent insertion were associated with an increased risk of persistent as well as chronic use. CONCLUSIONS: National variation in opioid prescribing practice exists after urological operations. Patients who fill larger amounts of opioids after certain major and minor urological procedures are at increased risk for long-term opioid use. This provides evidence for procedure specific prescribing guidelines to minimize risk and promote standardization.

Trends in the Setting and Cost of Ambulatory Urological Surgery: An Analysis of 5 States in the Healthcare Cost and Utilization Project.

INTRODUCTION: With the rising costs of health care, surgical procedures have migrated from the inpatient to outpatient setting with more than 60% of urological procedures performed in the ambulatory setting. Ambulatory surgical centers have the potential to reduce costs but may also lead to overutilization. We assessed utilization of ambulatory surgical centers for urological procedures, case mix distribution compared to hospital based outpatient surgery departments and cost implications. METHODS: All outpatient urological procedures were identified from 5 states in the United States (2010 to 2014) using all payer data. Patient demographics, regional data, facility type (ambulatory surgical center vs hospital based outpatient surgery department) and total charges (converted to costs and inflation adjusted to 2014 USD) were determined. Analyses of overall number of procedures, population adjusted rates, annual percent change and adjusted linear regression models were performed. RESULTS: Of more than 37 million surgical procedures 1,842,630 (4.9%) were urological with overall annual percent change +0.97% (+1.09% hospital based outpatient surgery departments vs +0.41% ambulatory surgical centers) and 20.0% performed in ambulatory surgical centers. The proportion performed in ambulatory surgical centers decreased slightly with time (-0.48% per year, p <0.001). Overall costs totaled $4.78 billion, representing 7.6% of all ambulatory surgery (average cost per procedure $2,603.76). All procedures demonstrated reduced costs per case when performed in ambulatory surgical centers (range -$800 to -$1,800). Unadjusted net cost increase per procedure per year was +$147.79 (+$113.98 adjusted). Providers performing the top quartile (Q1) of procedures demonstrated reduced costs. CONCLUSIONS: Ambulatory urological surgery represents 5% of all surgical cases but 7.6% of costs. The rate of procedures is increasing steadily with performance in ambulatory surgical centers outpaced by those in hospital based outpatient surgery departments. The cost of ambulatory urological surgery is rising out of proportion to explanation by inflation, patient factors or case mix.

American Urological Association, American College of Emergency Physicians and American College of Radiology Quality Improvement Summit 2017: Challenges and Opportunities for Stewardship of Urological Imaging.

INTRODUCTION: Since 2014 the AUA (American Urological Association) has convened several Quality Improvement Summits to provide education and promote dialogue around issues of quality improvement and patient safety. The 2017 Summit, Challenges and Opportunities for Stewardship of Urological Imaging, organized in partnership with the American College of Radiology and the American College of Emergency Physicians, highlighted opportunities for collaborative improvement in the value, safety and quality of imaging for patients with urological conditions. METHODS: The Summit was held at AUA headquarters in Linthicum, Maryland on October 21, 2017. Each talk, panel and working group held during the summit highlighted gaps in care being addressed by physician led stewardship initiatives in imaging, in general, as well as multiple specific examples related to prostate cancer and urinary stone disease. RESULTS: Presentations facilitated information exchange on quality efforts between clinicians across disciplines and care settings and served to educate urology practitioners, primary care physicians, and specialists about existing patient centered quality improvement programs. CONCLUSIONS: This exchange serves to accelerate adoption of evidence-based practices and brings together stakeholder organizations to form partnerships that facilitate the further development of research and policy agendas to advance physician led stewardship of advanced imaging across emergency medicine, radiology and urology. In parallel, this meeting established a consortium to develop and disseminate tools for facilitating organizational improvement activities needed to enhance the quality and safety of medical care.

Individual renal unit urine sampling to identify unilateral metabolic defects
.

AIMS: Preventing kidney stone recurrence relies on detecting and modifying urine chemistry abnormalities. The assumption is that an abnormality is due to a global metabolic defect present in both kidneys. However, we hypothesize that clinically significant unilateral defects may exist. We aimed to identify these patients by sampling urine from each renal unit. MATERIALS AND METHODS: Adults undergoing retrograde upper urinary tract surgery were eligible for inclusion. Excluded were patients with a solitary kidney, suspected urothelial malignancy, or urinary tract infection. Following informed consent, all patients proceeded to the operating room. After induction of anesthesia, cystoscopy with ureteral catheterization was performed with urine collected via gravity drainage for 10 minutes. Urine samples with adequate volume were analyzed for chemistry concentrations. A difference greater than the 75th percentile between matched pairs was considered significant. For urine pH, a difference of 0.5 was considered significant. RESULTS: A total of 47 patients were screened for eligibility with only 13 (28%) electing to enroll in the study (26 renal units). All subjects underwent successful bilateral ureteral catheterization with no adverse events observed or later reported. The mean (± SD) urine volume captured from the right and left renal units was 5.0 ± 7.4 cm3 and 6.6 ± 6.4 cm3, respectively. Urine was only captured from paired renal units in 8 participants (8/13; 62%). Of these 8 participants, 5 (5/8; 63%) had at least 1 unilateral metabolic defect. CONCLUSION: Unilateral renal unit urine sampling is safe and feasible. However, captured urine volumes are small and variable, but chemical analysis can still be performed. Unilateral defects in renal electrolyte handling are relatively common, but the clinical implications of these differences are still yet to be determined.
.

Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing.

Routine daily laboratory testing of hospitalized patients reflects a wasteful clinical practice that threatens the value of health care. Choosing Wisely initiatives from numerous professional societies have identified repetitive laboratory testing in the face of clinical stability as low value care. Although laboratory expenditure often represents less than 5% of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60% to 70% of all medical decisions. Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures. Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes. To date, numerous interventions have been deployed across multiple institutions without a standardized approach. Health care professionals and administrative leaders should carefully strategize and optimize efforts to reduce daily laboratory testing. This review presents an evidence-based implementation blueprint to guide teams aimed at improving appropriate routine laboratory testing among hospitalized patients.

Evaluating the Ergonomics of Flexible Ureteroscopy.

INTRODUCTION: To date, the ergonomics of flexible ureteroscopy (URS) have not been well described. We performed a study to assess the biomechanical stresses on urologists performing URS and to investigate the effect of ureteroscope type on these parameters. METHODS: Electromyography (EMG) was used to quantify the activation level of muscle groups involved in URS. Surface EMG electrodes (Delsys, Boston, MA) were placed on the right and left thenar, flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), biceps, triceps, and deltoid. Three endoscopes were studied: single-use digital (Boston Scientific LithoVue), reusable digital (Karl Storz Flex-Xc), and reusable fiber-optic (Karl Storz Flex-X2). Each ureteroscope was used to perform a set sequence of navigation and procedural tasks in a training model. EMG data were processed and normalized to compare the maximum voluntary contractions between muscle groups. Cumulative muscular workload (CMW) and average muscular work per second (AWS) were used for comparative analysis. RESULTS: For navigational tasks, CMW and AWS were greatest for the ECU, followed in descending order by right and left thenar, FCU, biceps, deltoid, and triceps. For procedural tasks, CMW and AWS were greatest for the right thenar, followed in descending order by the left thenar, ECU, FCU, triceps, biceps, and deltoid. During navigational tasks, both LithoVue and Flex-Xc had lower CMWs for every muscle group than Flex-X2 (p < 0.05). LithoVue and Flex-Xc had similar AWS and both were lower than Flex-X2 for the right thenar, ECU, biceps, and deltoid activation (p < 0.05). During procedural tasks, both LithoVue and Flex-Xc had lower CMWs and AWS for right and left thenar, ECU, and biceps than Flex-X2 (p < 0.05). CONCLUSIONS: This study provides the first description of EMG-measured ergonomics of URS. Both the single-use and reusable digital ureteroscopes have similar profiles, and both have significantly better ergonomic metrics than the reusable fiber-optic ureteroscope.