Quick Sequential Organ Failure Assessment Score Is a Better Predictor of Septic Shock After Percutaneous Nephrolithotomy: A Secondary Analysis of Two Multicenter Prospective Trials.

Introduction: Recent retrospective literature suggests that the quick sequential organ failure assessment (qSOFA) scoring tool is a potentially superior tool over use of the systemic inflammatory response syndrome (SIRS) criteria to predict septic shock after percutaneous nephrolithotomy (PCNL) surgery. Here we examine use of qSOFA and SIRS to predict septic shock within data series collected prospectively on PCNL patients as part of a greater study of infectious complications. Materials and Methods: We performed a secondary analysis of two prospective multicenter studies including PCNL patients across nine institutions. Clinical signs informing SIRS and qSOFA scores were collected no later than postoperative day 1. The primary outcome was sensitivity and specificity of SIRS and qSOFA (high-risk score of greater-or-equal to two points) in predicting admission to the intensive care unit (ICU) for vasopressor support. Results: A total of 218 cases at 9 institutions were analyzed. One patient required vasopressor support in the ICU. The sensitivity/specificity was 100%/72.4% (McNemar's test p < 0.001) for SIRS and was 100%/90.8% (McNemar's test p < 0.001) for qSOFA. Conclusion: Although positive predictive value for both qSOFA and SIRS in prediction of post-PCNL septic shock is low, prospectively collected data demonstrate use of qSOFA may offer greater specificity than SIRS criteria when predicting post-PCNL septic shock.

Economic burden of complicated ureteral stent removal in patients with kidney stone disease in the USA.

Aim: To examine the medical costs of simple versus complicated ureteral stent removal. Materials & methods: We included adults with kidney stones undergoing simple or complicated cystoscopy-based stent removal (CBSR) post ureteroscopy from the 2014 to 2018 Merative™ MarketScan® Commercial Database. The medical costs of patients with complicated and simple CBSR were compared. Results: Among 16,682 patients, 2.8% had complicated CBSR. Medical costs for patients with complicated CBSR were higher than for simple CBSR ($2182 [USD] vs $1162; p < 0.0001). Increased stenting time, increased age, southern US geography and encrusted stent diagnoses were significantly associated with complicated CBSR. Conclusion: Complicated ureteral stent removal doubled the medical costs associated with CBSR. Ureteral stents with anti-encrustation qualities may reduce the need for complicated CBSR and associated costs.

Cost-Effectiveness of 90-day Single-use Flexible Cystoscope Trial: Single Center Micro-Costing Analysis and User Satisfaction.

OBJECTIVE: To evaluate cost-effectiveness and user satisfaction of a single-use flexible cystoscope at a tertiary care center we conducted a 90-day trial. Single-use flexible cystoscope advancements have introduced alternative options to reusable scopes. However, there is a paucity of cost-effectiveness and provider satisfaction studies examining the implementation of a hospital-based transition to single-use cystoscopes. METHODS: Following institutional device-approval we initiated a 90-day trial period (November 1, 2020-January 29, 2021) where all flexible, transurethral, and percutaneous, urologic care was provided with a disposable AMBU aScope. We performed a micro-costing analysis examining payor per case cost of the reusable flexible cystoscope (including servicing and processing) to the disposable units. Provider surveys assessed visual quality, deflection, ease of working channel and overall satisfaction on a 10-point Likert scale. RESULTS: Over the 90-day period, we encountered 84 cases (78 operative, 5 inpatient, 1 emergency department) where flexible cystoscopy was required. One disposable flexible cystoscope was successfully used in 78 of 84 (93%) cases. Of the 6 failures, 2 were due to an inability to access a disposable scope/monitor. Per use cost of the reusable flexible cystoscope at our center was $272.41 versus $185.00 for the single use. Extrapolating our average case volume and conservative failure rate (3 single use failures/month, requiring reusable), transitioning to predominately single use scopes results in $39,142.84 annual cost savings. CONCLUSIONS: This single center 90-day trial of disposable flexible cystoscopy identified per-use costs to be less when a single-use flexible cystoscope was utilized at a high-volume tertiary care center.

The Economic Burden of Cystoscopy-Based Ureteral Stent Removal in the United States: An Analysis of Nearly 30,000 Patients.

INTRODUCTION: Ureteral stents are commonly placed after ureteroscopy. We examined the rate of cystoscopy-based stent removal (CBSR) following ureteroscopy for stone disease and its economic burden in the United States. METHODS: Adults undergoing ureteroscopy and stenting (index surgery) for stone disease between 2014 and 2018 were identified using the IBM® MarketScan® Commercial Database. Patients were categorized as those with CBSR or without CBSR within 6 months post-index surgery. Rate and location of CBSR were assessed. To estimate the economic burden of CBSR, medical costs (2019 U.S. dollars) paid by insurers were calculated at 6 months post-index surgery. A generalized linear model examined the association of CBSR with total costs adjusting for patient characteristics. RESULTS: Among 29,535 patients meeting the inclusion criteria, 56.5% had CBSR within 6 months. Median time to CBSR was 9 days; 70% of patients with CBSR had their stent removed in the office. Medical costs for CBSR patients were significantly higher than those for nonCBSR patients ($7,808 vs $6,231; p <0.0001). The difference was driven by the cost of CBSR ($1,132 vs $0; p <0.0001) and health care utilization for stone disease ($2,464 vs $2,121; p <0.0001). CBSR was associated with a 17% increase in medical costs compared to nonCBSR (OR: 1.17; 95% CI 3.03, 3.46). CONCLUSIONS: Over 50% of patients had CBSR within 6 months following ureteroscopy. Medical costs for patients undergoing CBSR were significantly higher and driven by the cost of CBSR and resource utilization for stone disease. Ureteral stents that avoid CBSR can lower medical costs to the health care system.

Ambulatory Percutaneous Nephrolithotomy May Be Cost-Effective Compared to Standard Percutaneous Nephrolithotomy.

Background: Coronavirus disease 2019 (COVID-19) changed the practice of medicine in America. During the March 2020 lockdown, elective cases were canceled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing aPCNL against standard PCNL (sPCNL). Materials and Methods: Ninty-eight patients underwent PCNL at Indiana University Methodist Hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of emergency department (ED) visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included cost analysis and stone-free rates (SFRs). Propensity score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results: Ninety-eight patients underwent PCNL during the study period (sPCNL = 75 and aPCNL = 23). After propensity score matching, 42 patients were available for comparison (sPCNL = 19 and aPCNL = 23). We found no difference in 30-day ED visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327 ± 442 per case. SFRs were higher for aPCNL compared with sPCNL. Conclusions: aPCNL appears safe to perform and does not have a higher rate of ED visits or readmissions compared with sPCNL. aPCNL may also be cost-effective compared with sPCNL.

Comparison of cost-effectiveness and postoperative outcomes following integration of a stiff shaft glidewire into percutaneous nephrolithotripsy.

AIMS: To analyze the cost effectiveness of integrating a stiff shaft glidewire (SSGW) in percutaneous nephrolithotripsy (PCNL) relative to standard technique (ST). This is prudent because healthcare providers are experiencing increased pressure to improve procedure-related cost containment. METHODS: ST for PCNL at our institution involves a hydrophilic glidewire during initial percutaneous access and then two new stiff shaft wires. The SSGW is a hydrophilic wire used for initial access and the remainder of the procedure. We collected operating room (OR) costs for all primary, unilateral PCNL cases over a 5-month period during which ST for PCNL was used at a single institution with a single surgeon and compared with a 6-month period during which a SSGW was used. Mean costs for each period were then compared along with stone-free rates and complications. RESULTS: We included 17 total cases in the ST group and 22 in the SSGW group. The average operating room supply cost for the ST group was $1937.32 and $1559.39 in the SSGW group. The net difference of $377.93 represents a nearly 20% decrease in cost. This difference was statistically significant (p = 0.031). There was no difference in postoperative stone-free rates (82.4% versus 86.4%, p = 1.0, respectively) or complications (23.5% versus 13.6%, p = 0.677, respectively) between ST and SSGW groups. CONCLUSION: Transitioning to a SSGW has reduced OR supply cost by reducing the number of supplies required. The change in wire did not affect stone-free rates or complications.

Opioid Free Ureteroscopy: What is the True Failure Rate?

OBJECTIVE: To determine the true failure rate of opioid free ureteroscopy (OF-URS) and rates of new-persistent opioid use utilizing a national prescription drug monitoring program. MATERIAL AND METHODS: We identified 239 patients utilizing our retrospective stone database who underwent OF-URS from Februrary 2018-March 2020. In Feb 2018, we initiated a OF-URS pathway (diclofenac, tamsulosin, acetaminophen, pyridium and oxybutynin). Patients who had a contraindication to NSAIDs were excluded from primary analyses. A prescription drug monitoring program was then utilized to determine the number of patients who failed OF-URS (defined as receipt of an opioid within 31 days of surgery) as well as rates of new-persistent opioid use (defined as receipt of opioid 91-180 days after surgery). All statistical analyses were performed using SAS 9.4. Tests were 2-sided and statistical significance was set at P<0.05. RESULTS: We found a OF-URS failure rate of 16.6% and 14.0% in the total and opioid naïve cohorts, respectively. Rates of new-persistent opioid use were 0.9% and 1.2%, respectively (lower than published expected rate of ~6% after URS with postoperative opioids). 91% of patients obtained opioid from alternative sources. Uni/multivariate analyses were performed for both cohorts. In the total cohort, benzodiazepine users had a lower risk of OF-URS failure on multivariate analysis. No variables were associated with OF-URS failure in the opioid naïve cohort. CONCLUSION: The true failure rate of OF-URS is higher than previously thought at 16.6% and 14.0%. However, efforts to reduce opioid prescriptions with OF-URS pathways have successfully reduced new-persistent opioid use.

Determining the true burden of kidney stone disease.

The incidence and prevalence of kidney stones have increased over the past four decades. However, the diagnosis of 'kidney stone' can range from an incidental asymptomatic finding of limited clinical significance to multiple painful episodes of ureteral obstruction with eventual kidney failure. Some general strategies may be useful to prevent the recurrence of kidney stones. In particular, greater attention to kidney stone classification, approaches to assessing the risk of recurrence and individualized prevention strategies may improve the clinical care of stone formers. Although there have been some advances in approaches to predicting the recurrence of kidney stones, notable challenges remain. Studies of kidney stone prevalence, incidence and recurrence have reported inconsistent findings, in part because of the lack of a standardized stone classification system. A kidney stone classification system based on practical and clinically useful measures of stone disease may help to improve both the study and clinical care of stone formers. Any future kidney stone classification system should be aimed at distinguishing asymptomatic from symptomatic stones, clinically diagnosed symptomatic stone episodes from self-reported symptomatic stone episodes, symptomatic stone episodes that are confirmed from those that are suspected, symptomatic recurrence from radiographic recurrence (that is, with radiographic evidence of a new stone, stone growth or stone disappearance from presumed passage) and determine stone composition based on mutually exclusive categories.

Critical Assessment of Single-Use Ureteroscopes in an In Vivo Porcine Model.

METHODS: A female pig was placed under general anesthesia and positioned supine, and retrograde access to the renal collecting system was obtained. The LithoVue (Boston Scientific) and Uscope (Pusen Medical) were evaluated by three experienced surgeons, and each surgeon started with a new scope. The following parameters were compared between each ureteroscope: time for navigation to upper and lower pole calyces with and without implements (1.9 F basket, 200 µm laser fiber, and 365 µm laser fiber for upper only) in the working channel and subjective evaluations of maneuverability, irrigant flow through the scope, lever force, ergonomics, and scope optics. RESULTS: Navigation to the lower pole calyx was significantly faster with LithoVue compared to Uscope when the working channel was empty (24.3 vs. 49.4 seconds, p < 0.01) and with a 200 µm fiber (63.6 vs. 94.4 seconds, p=0.04), but not with the 1.9 F basket. Navigation to the upper pole calyx was similar for all categories except faster with LithoVue containing the 365 µm fiber (67.1 vs. 99.7 seconds, p=0.02). Subjective assessments of scope maneuverability to upper and lower pole calyces when the scope was empty and with implements favored LithoVue in all categories, as did assessments of irrigant flow, illumination, image quality, and field of view. Both scopes had similar scores of lever force and ergonomics. CONCLUSIONS: In an in vivo porcine model, the type of single-use ureteroscope employed affected the navigation times and subjective assessments of maneuverability and visualization. In all cases, LithoVue provided either equivalent or superior metrics than Uscope. Further clinical studies are necessary to determine the implications of these findings.

A Decision Analysis of Observation vs Immediate Reintervention for Asymptomatic Residual Fragments Less than 4 mm Following Ureteroscopic Lithotripsy.

INTRODUCTION: We performed a decision analysis model of the cost-effectiveness of observation vs intervention for asymptomatic residual fragments less than 4 mm in diameter following ureteroscopic holmium laser lithotripsy. METHODS: Outcomes data from a retrospective analysis evaluating the natural history, complications and reintervention rates of asymptomatic residual stone fragments performed by the EDGE (Endourology Disease Group for Excellence) Research Consortium were used. A decision analysis model was constructed to compare the cost-effectiveness of initial observation of residual fragments to immediate intervention. Cost of observation included emergency room visits, hospitalizations and reinterventions. The cost analysis model extended to 3 years to account for delayed reintervention rates for fragments less than 4 mm. Costs of emergency department visits, readmissions and reinterventions were calculated based on published figures from the literature. RESULTS: Decision analysis modeling demonstrated that when comparing initial observation to immediate reintervention, the cost was $2,183 vs $4,424. The difference in cost was largely driven by the fact that over 3 years, approximately 55% of all patients remained asymptomatic and did not incur additional costs. This represents an approximate annual per patient savings of $747, and $2,241 over 3 years when observation is selected over immediate reintervention. CONCLUSIONS: Our decision analysis model demonstrates superior cost-effectiveness for observation over immediate reintervention for asymptomatic residual stones less than 4 mm following ureteroscopic lithotripsy. Based on these findings careful stratification and selection of patients may enable surgeons to improve cost-effectiveness of managing small, asymptomatic residual fragments following ureteroscopic lithotripsy.

A Survey of Morcellator Preference and Cost Comparison of the Lumenis VersaCut and Wolf Piranha Morcellators.

OBJECTIVE: To evaluate operating room (OR) costs associated with the 2 available morcellators in the United States in a matched cohort and to determine benign prostatic hyperplasia surgeon's morcellator preference. MATERIALS AND METHODS: Patients from 2013, the last year our institution exclusively used the VersaCut device, were matched 1:1 with the most recent patient cohort, utilizing the Wolf Piranha morcellator. Cost of morcellation including the expense of OR time and disposable instrument costs were calculated. A survey to the Endourological Society e-mail listserv was sent to determine morcellator preference. RESULTS: We identified 142 patients who underwent holmium laser enucleation of the prostate in 2013. When compared with the VersaCut group, morcellation efficiency (4.4 vs 7.0 g/min, P <.01) and expense of OR time ($1420.80 vs $992.21, P <.005) both favored the Piranha morcellator system even when the costs of disposable instruments were factored into the analysis ($1338.81 vs $1637.50, P <.05). A total of 126 urologists responded to the survey. Of these, 56 (44.5%) perform transurethral prostate enucleations, which included 48 (86%) holmium. More endourologists use the VersaCut (n = 33, 59%) than the Piranha (n = 24, 43%) morcellator. Qualities that impacted the preference of morcellator included the preferred device is safer, faster, easier to use, reusable, and less expensive. CONCLUSION: We identified a significant improved efficiency and improved cost savings utilizing the Piranha morcellator even when controlling for disposable costs. Of the endourologists who responded to the survey, less than half perform transurethral enucleation. Morcellator preference is largely based on safety, efficiency, and ease of use, whereas cost and reusablility were of lesser importance.

Multi-institutional assessment of ureteroscopic laser papillotomy for chronic flank pain associated with papillary calcifications.

PURPOSE: We evaluated the long-term safety, efficacy and durability of ureteroscopic laser papillotomy for chronic flank pain associated with renal papillary calcifications. MATERIALS AND METHODS: We reviewed the medical records of all patients who underwent ureteroscopic laser papillotomy in the absence of free urinary calculi at our institutions from 1998 through 2008. Success was defined as patient report of significant pain relief. The duration of response was considered the time from papillotomy to repeat papillotomy in the same renal unit, patient report of recurrent pain or final followup. RESULTS: Ureteroscopic Ho:YAG laser papillotomy was done a total of 176 times in 65 patients, including 147 unilateral and 29 bilateral procedures. Of the patients 39 underwent multiple procedures (2 to 12). Symptomatic followup was available in 50 patients (146 procedures) during a mean of 38 months. Significantly less pain was reported after 121 procedures (83%). The mean duration of response per procedure was 26 months and 30 patients (60%) had a mean remission duration of greater than 1 year. Postoperatively hospital admission was required after 14 procedures (8%). There was no significant change in the mean estimated glomerular filtration rate during a mean 41.3-month followup. Seven of the 65 patients (11%) had hypertension before papillotomy. In 3 of the 49 patients (6.1%) with adequate followup new hypertension developed during a mean of 38 months. CONCLUSIONS: Ureteroscopic laser papillotomy is safe and effective. In patients with papillary calcifications and characteristic chronic, noncolicky pain this procedure provides significant, moderately durable symptom relief.