The cost of operating room delays in an endourology center.

INTRODUCTION: This study sought to characterize delays and estimate resulting costs during nephrolithiasis surgery. METHODS: Independent observers documented delays during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures. Fifty index cases over a period of three months was considered sufficient to observe the generalizable trends. Operating room staff, excluding the surgeons, were blinded. Time-related metrics and delays preventing case progression were recorded using a smartphone-accessible data-collection instrument. Delays were categorized as: 1) missing equipment; 2) missing personnel; 3) equipment malfunction; or 4) delay due to case complexity. The first two categories were regarded as preventable and the latter two non-preventable. RESULTS: Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean cumulative delay per case was 3.5±3.2 minutes. Pre-start delays (n=17) were 4.5±3.5 minutes on average while intraoperative delays (n=39) were 3.1±2.9 minutes (p=0.167). Delays were evenly spread among the four categories. Thirty-one (55%) delays were preventable (mean 3.7±3.2 minutes) while 25 (45%) were non-preventable (mean 3.2±3.2 minutes) (p=0.58). This translates to $137 per case in preventable costs. CONCLUSIONS: Preventable operative delays are encountered frequently in nephrolithiasis surgery, translating to significant additional charges and costs. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency in endourological surgeries. Key limitations are the observational nature of the study and sample size.

Low Income and Nonwhite Race are Strongly Associated with Worse Quality of Life in Patients with Nephrolithiasis.

PURPOSE: Kidney stones are a source of significant morbidity which have been shown to negatively impact health related quality of life. We sought to understand the association between health related quality of life, socioeconomic status and race among patients with kidney stones. MATERIALS AND METHODS: Patients with stones at a total of 11 stone centers across the United States completed the WISQOL (Wisconsin Stone Quality of Life questionnaire). The patient ZIP Code™ was used to estimate household income. A mixed effects regression model was constructed for analysis with ZIP Code as the random intercept. RESULTS: A total of 2,057 stone formers completed the WISQOL. Lower income was independently associated with significantly lower health related quality of life (ß = 0.372, p = 0.014), as were nonwhite race (ß = -0.299, p = 0.001), unemployed work status (ß = -0.291, p = 0.008), female gender (ß = -0.204, p <0.001), body mass index greater than 40 kg/m2 (ß = -0.380, p <0.001), 5 or more medical comorbidities (ß = -0.354, p = 0.001), severe recurrent stone formation (ß = -0.146, p = 0.045), enrollment at an acute care visit, or a preoperative or postoperative appointment (ß = -0.548, p <0.001) and recent stone symptoms (ß = -0.892, p <0.001). CONCLUSIONS: Lower income, nonwhite race and unemployed work status were independently associated with lower health related quality of life among patients with kidney stones. While clinical characteristics such as body mass and stone disease severity were also associated with health related quality of life, this study shows that socioeconomic factors are similarly important. Further research to understand the specific mechanisms by which socioeconomic status and race impact health may lend insight into methods to optimize clinical treatment of stone formers and patients with other chronic diseases.

Urolithiasis and Frequent CT Scans: Does Chronic Pain Play a Role?

INTRODUCTION: Urolithiasis is among the top 10 causes of Emergency Department (ED) visits in the United States. Approximately 50% of these patients undergo abdominopelvic CT scan, many more than once. We hypothesized that chronic pain conditions may contribute to frequent CT scans in patients who are evaluated in ED for urolithiasis. METHODS: A retrospective review of patients presenting to our tertiary care and the associated satellite EDs for urolithiasis, during the period 12/2012-05/2013, was performed. Patients with multiple ED visits and two or more abdominopelvic CT scans in any 6-month period were labeled as the frequent CT group. Control group consisted of similar patients who had no more than one CT scan in any 6-month period. Background information, number of CT scans for urolithiasis and other reasons, and the presence of chronic pain (established pain clinic visits, chronic pain medication, known chronic pain syndromes) were captured from charts. Wilcoxon rank-sum test and Fisher's exact test were used to compare variables. Multivariable logistic regression was performed to identify predictors associated with frequent CT scans. RESULTS: We identified 185 patients with frequent CTs and 139 patients in the control arm. Frequent CT scans were independently associated with chronic pain (odds ratio [OR]: 2.67, confidence interval [95% CI]: 1.55, 4.50), age (OR: 0.73, 95% CI: 0.60, 0.89), history of prior urolithiasis (OR: 2.15, 95% CI: 1.11, 4.15), and Medicaid insurance status (OR: 3.94, 95% CI: 1.66, 9.35). CONCLUSION: Chronic pain is a significant contributing factor to frequent CT scans among patients presenting to ED with urolithiasis, leading to increased radiation exposure and healthcare costs.

Endoscopic Valves and Irrigation Devices for Flexible Ureteroscopy: Is There a Difference?

BACKGROUND AND PURPOSE: A variety of ureteroscopic irrigation systems are available, ranging from gravity-driven pressure bags to hand-operated pumps. Endoscopic valves maintain a watertight seal during ureteroscopy (URS) while facilitating passage of instruments. The clinical utility and ergonomics of such devices have not been established. We systematically compare the mechanical properties and usability of select valve devices and hand-operated irrigation systems in an in vitro setting. MATERIALS AND METHODS: In vitro testing of four different endoscopic valves: UroSeal adjustable endoscopic valve (US Urology), adjustable biopsy port seal (Gyrus ACMI), Blue Silicone Seal ACMI CS B612 (Gyrus ACMI), and REF ABP Biopsy Port Seal (ACMI Corporation) was performed. Usability was evaluated via insertion/extraction forces and insertion time for instruments, including a straight tip sensor wire, 0.035″, (Boston Scientific), a laser fiber (Flexiva 200, Boston Scientific), and an Ngage Nitinol Stone Extractor 1.7F (Cook Urological) through a flexible ureteroscope (Olympus URF P5, Olympus). Flow rate, flow time, and user fatigue were tested for two irrigation systems: The single action pumping system (SAP, Boston Scientific) and the Pathfinder Plus (PP, Utah Medical Products). RESULTS: The US needed the shortest time for both wire insertion and basket insertion (P=0.005, and P<0.001, respectively), while the BSS needed the greatest time for laser fiber insertion (P<0.005). The REF ABP needed the greatest force for withdrawal of the Ngage basket, the laser fiber, and the Captura stone grasper through a closed seal, while the US took the least amount of force for both laser fiber withdrawal and insertion via analysis of variance. Leak point pressure assessment demonstrated that the US was leak free at irrigation pressures up to 200 mm Hg, while the ABP, BSS, and the REF ABP devices demonstrated leaks ranging from 30 to 200 mm Hg. The average and peak flow of the SAP were significantly higher than that of the PP. Mean grip strength decreased significantly after operation of the SAP for 10 minutes, while no loss of grip strength was observed after use of the PP. CONCLUSIONS: The US valve has the advantage of facile manipulation of wires and baskets while maintaining a watertight seal, while other devices may be more cost-effective and secure. The PP has the advantage of less operator hand fatigue and ease of use, but the SAPS may allow for greater on-demand pressures. Further studies are needed to evaluate the effect of these irrigation systems on outcomes.

Current practices in percutaneous nephrolithotomy among endourologists.

OBJECTIVE: To characterize current practices of percutaneous nephrolithotomy (PCNL) among endourologists in relation to practice setting, experience, and fellowship training. METHODS: An Internet survey was administered to active Endourological Society members. Responses were grouped based on demographic information pertaining to setting of practice, number of years practiced, and fellowship training in endourology. PCNL technique details were evaluated and compared by each group. Statistical analysis was performed using SPSS. RESULTS: Two hundred ninety-three completed responses of 2000 were received. There was a significant difference in the experience level among respondents (p < 0.001), with a relatively greater proportion being 11-20 years in practice. The majority of respondents were academic urologists (74%), with 18% being within a group-based private practice. Seventy-seven percent of respondents obtained their own access while 19% had access by interventional radiologists. Sixty-two percent were endourology fellowship trained, and fellows were significantly more likely to obtain their own access (82% vs 71%, p=0.022). Eighty-six percent used the prone position to obtain access, 10% used supine, and 4% used lateral decubitus. An antegrade approach was preferred by 68%, while 18.5% used a retrograde, and 12% used a combined approach. Overall, 76% placed a nephrostomy tube for postoperative drainage; a ureteral stent or catheter was placed in 28% or 11% of respondents, respectively, and only 6 respondents (2%) performed a "tubeless" procedure without any drainage. CONCLUSIONS: The majority of Endourological Society members performing PCNLs who responded obtain their own access, and there is a higher proportion of self-obtained access in fellowship-trained endourologists. Prone positioning is predominant, and more than 75% of respondents leave a nephrostomy tube postoperatively, underscoring that the tubeless approach is rare.