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.

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.

Single Session Bilateral Vs Staged Bilateral Ureteroscopy for Nephrolithiasis: An Assessment of Safety and Efficacy.

OBJECTIVE: To compare outcomes of patients undergoing single session bilateral ureteroscopy (SSBU) to those undergoing planned staged ureteroscopy (URS) for bilateral nephrolithiasis. While SSBU has the advantage of 1 anesthetic procedure, some may pursue a staged approach due to the potential higher risk of complications and patient discomfort with 2 ureteral stents. METHODS: We retrospectively identified patients undergoing SSBU and planned staged URS for nephrolithiasis between December 2007 and December 2014. Preoperative characteristics, intraoperative techniques, and postoperative outcomes were compared. Stone burden was calculated as cumulative stone diameter. Residual stone fragments were defined as any stone visible on postoperative imaging. RESULTS: Sixty-three patients underwent SSBU and 37 underwent planned staged URS. Both cohorts had a relatively large cumulative stone burden (30.9 mm vs 32.4 mm, P = .71). Total operative time was significantly longer for planned staged URS (139 vs 86 minutes, P <.0001). There were no significant differences in complications or emergency room visits between the 2 cohorts despite bilateral ureteral stents being placed in the majority of the SSBU cohort (73%). There were no differences in stone-free rates or the need for additional procedures. CONCLUSION: SSBU is safe and effective with overall shorter operative times and similar stone-free rates compared to planned staged URS. Bilateral ureteral stent placement did not increase the rate of unplanned emergency visits. For patients with bilateral nephrolithiasis, urologists should strongly consider SSBU to limit anesthetic exposure, overall operative time, and health care costs.

Race- and Sex-related Differences in Nephrolithiasis Risk Among Blacks and Whites in the Southern Community Cohort Study.

OBJECTIVE: To investigate race-sex associations with risk among whites and blacks in the southeastern United States. The relationship between race, sex, and kidney stone risk is poorly understood. METHODS: Participants were 42,136 black and white adults enrolled in the Southern Community Cohort Study between 2002 and 2009, with no history of kidney stones and receiving Medicare or Medicaid services. Incident kidney stone diagnoses through December 2014 were determined via linkage with Centers for Medicare and Medicaid Services research files. Hazard ratios (HRs) for associations with race and sex were computed from multivariable Cox proportional hazards models adjusting for baseline characteristics, comorbid diseases, and dietary intakes. RESULTS: During 116,931 and 270,917 person-years of follow-up for whites and blacks, respectively, age-adjusted incidence rates (95% confidence interval [CI]) were 5.98 (4.73-7.23) and 4.50 (3.86-5.14) per 1000 person-years for white men and women, respectively, while corresponding rates among blacks were 2.19 (1.71-2.67) and 2.47 (2.19-2.75) per 1000 person-years. Risk was higher among whites compared to blacks (HR = 2.23, 95% CI 1.97-2.53). Male sex was significantly associated with risk among whites (HR = 1.45, 95% CI 1.20-1.75), but not among blacks (HR = 0.90, 95% CI 0.75-1.07). Formal tests of interaction by race and sex were statistically significant for all models (P = .01 for fully adjusted model). CONCLUSION: The association of incident kidney stones with sex differs between whites and blacks. White men have the highest risk, while no difference in risk is observed between black men and women.