The effect and safety assessment of monitoring ethanol concentration in exhaled breath combined with intelligent control of renal pelvic pressure on the absorption of perfusion fluid during flexible ureteroscopic lithotripsy.

PURPOSE: Previously, we designed a ureteral access sheath with the capability of renal pelvic pressure (RPP) measurement and a medical perfusion and aspiration platform, allowing for the intelligent control of RPP. However, the effect of different RPP levels on perfusion fluid absorption remains unclear. This randomized controlled trial aimed to investigate the effects of exhaled ethanol concentration monitoring and intelligent pressure control on perfusion fluid absorption during flexible ureteroscopic lithotripsy. METHODS: Eighty patients scheduled for flexible ureteroscopic lithotripsy were randomly divided into four groups. In groups A, B, and C, the RPPs were set at 0, - 5, and - 10 mmHg, respectively. Group D was regarded as the controls with unfixed RPP. Isotonic saline containing 1% ethanol was used as the irrigation fluid, with an average irrigation flow rate of 100 mL/min. The primary outcome of this study was the absorption of perfusion fluid that was calculated based on the exhaled ethanol concentration. The secondary outcomes included duration of operation and amounts of perfusion fluid used. Postoperative complications, pre- and postoperative renal function, infection markers, and blood gas analysis were also recorded for safety assessment. RESULTS: In all, 76 patients were involved in this study, whose demographic characteristics and preoperative conditions were comparable among groups. Under the same perfusion flow rate, the groups with fixed RPP exhibited reduced absorption of perfusion fluid, duration of operation, and perfusion volume. In particular, the lowest values were observed in group C (RPP = - 10 mmHg). In contrast to the unfixed RPP group, no considerable difference were observed in levels of BUN, Scr, WBC, CRP, and blood gas values among the fixed RPP groups. Moreover, postoperative complications showed no significant difference among groups. CONCLUSION: In flexible ureteroscopic lithotripsy, the groups with fixed RPP had less absorption of perfusion fluid and perfusion volume, shorter duration of surgery, and higher safety than the unfixed group.

Impact of the implementation of Identification-Situation-Background-Assessment-Recommendation (ISBAR) tool to improve quality and safety measure in a lithotripsy and endourological unit.

INTRODUCTION: A lack of professional communication and collaboration may be one of the main causes of medication errors. The objective was to evaluate the results of the implementation of ISBAR as a communication and safety tool in a Lithotripsy and Endourologic Unit of a tertiary public hospital. METHODS: A total of 457 patients were included in a retrospective study from 2014 to 2019. Patients were divided into two groups: group A (357 patients) in which an endourological procedure was performed before march of 2018 (without the implementation of ISBAR tool) and Group B (100 patients) with the implementation of ISBAR tool. The inclusion criteria were patients accepted for surgical intervention by anaesthesiology Department and operated in the period of the study. The variables analysed included number of procedures, global, intraoperative and postoperative complications rate, urinary infection or sepsis, NPR (FMEA), percentage of suspended surgical patients and hospital stay. RESULTS: The postoperative complications showed no significant differences between groups, but a trend to diminishing was seen in the complication in the group B. The sepsis reduced its incidence and it was close to significant difference. The operative time was shorter in group B 119,11min (114,63-123,59) vs 115,11min (109,63-121,67) p = 0,3. The reduction in the main postoperative complication (sepsis) explained the lower hospital stay for group B. The severe adverse events detected were reduced completely. CONCLUSIONS: ISBAR tool was an effective patient safety tool improving quality care. To provide safe patient care and improving quality is indispensable an effective communication flow.

Assessment of single-probe dual-energy lithotripters in percutaneous nephrolithotomy: a systematic review and meta-analysis of preclinical and clinical studies.

PURPOSE: To evaluate the safety and efficacy of single-probe dual-energy (SPDE) lithotripters in patients undergoing percutaneous nephrolithotripsy (PCNL) through a systematic review and meta-analysis. METHODS: We searched PubMed, Cochrane Library, Scopus and Embase databases until July 2022 for any preclinical or clinical studies, exploring the safety and efficacy of different SPDE lithotripters in patients undergoing PCNL. We performed a meta-analysis to compare stone-free rate, bleeding, or other complications and mean operative time between SPDE lithotripters and other lithotripters (PROSPERO: CRD42021285631). RESULTS: We included 16 studies (six preclinical, seven observational and three randomized with 625 participants) in the systematic review and four in the meta-analysis. Preclinical studies suggest that SPDE lithotripters are safe and effective for the management of renal stones. Among clinical studies, four studies assessed Trilogy with no comparative arm, two compared Trilogy or ShockPulse with a dual-probe dual-energy lithotripter, two compared Trilogy with a laser, one compared ShockPulse with a pneumatic lithotripter, and one directly compared Trilogy with ShockPulse. Comparing SPDE lithotripters to other lithotripters, no significant differences were demonstrated in stone free rate (OR 1.13, 95% CI 0.53-2.38, I2 = 0%), postoperative blood transfusion (OR 1.33, 95% CI 0.34-5.19, I2 = 0%), embolization (OR 0.45, 95% CI 0.02-12.06), operative time (WMD: 2.82 min, 95% CI -7.31-12.95, I2 = 78%) and postoperative complications based on the Clavien-Dindo classification. CONCLUSIONS: SPDE lithotripters represent a promising treatment modality for patients requiring PCNL. Despite the initial encouraging findings of preclinical and isolated clinical studies, it seems that Trilogy or ShockPulse provide similar efficiency compared to older generation devices.

Ureteral Strictures Following Ureteroscopy for Kidney Stone Disease: A Population-based Assessment.

PURPOSE: As the prevalence of urolithiasis increases and ureteroscopy is used more frequently, the risks of uncommon complications such as ureteral stricture may become more notable. Our objective is to assess the rate and associated risk factors of ureteral stricture formation in patients undergoing ureteroscopy. MATERIALS AND METHODS: Utilizing the IBM MarketScan research database, we evaluated data from 2008 to 2019 and compared ureteral stricture rates and their management following ureteroscopy to subjects who had shock wave lithotripsy. Shock wave lithotripsy was used as a comparison group to represent the rate of stricture from stone disease alone. A third group of those having both shock wave lithotripsy and ureteroscopy was included. Patients and secondary procedures were identified using Current Procedural Terminology, and International Classification of Diseases-9 and -10 codes. RESULTS: A total of 329,776 patients received ureteroscopy, shock wave lithotripsy, or shock wave lithotripsy+ureteroscopy between 2008 and 2019. Stricture developed in 2.9% of patients after ureteroscopy, 1.5% after shock wave lithotripsy, and 2.6% after shock wave lithotripsy+ureteroscopy. In the multivariable model, rates of stricture were 1.7-fold higher after ureteroscopy vs shock wave lithotripsy (OR:1.71, 95% CI 1.62-1.81). Preoperative hydronephrosis, age, prior stones/intervention, and concurrent kidney and ureteral stones were associated with increased risk of stricture. Of those with strictures incurred after ureteroscopy, 35% required drainage, 21% had endoscopic intervention, 4.8% required reconstructive surgery, and 1.7% underwent nephrectomy. CONCLUSIONS: Ureteral stricture rate after ureteroscopy of nearly 3% was higher than expected and approximately twice the rate attributable to stone disease alone. Factors associated with the stone as well as instrumentation were found to be risk factors. The morbidity of stricture disease following ureteroscopy was significant.

Shockwave lithotripsy compared with ureteroscopic stone treatment for adults with ureteric stones: the TISU non-inferiority RCT.

BACKGROUND: Urinary stone disease affects 2-3% of the general population. Ureteric stones are associated with severe pain and can have a significant impact on a patient's quality of life. Most ureteric stones are expected to pass spontaneously with supportive care; however, between one-fifth and one-third of patients require an active intervention. The two standard interventions are shockwave lithotripsy and ureteroscopic stone treatment. Both treatments are effective, but they differ in terms of invasiveness, anaesthetic requirement, treatment setting, number of procedures, complications, patient-reported outcomes and cost. There is uncertainty around which is the more clinically effective and cost-effective treatment. OBJECTIVES: To determine if shockwave lithotripsy is clinically effective and cost-effective compared with ureteroscopic stone treatment in adults with ureteric stones who are judged to require active intervention. DESIGN: A pragmatic, multicentre, non-inferiority, randomised controlled trial of shockwave lithotripsy as a first-line treatment option compared with primary ureteroscopic stone treatment for ureteric stones. SETTING: Urology departments in 25 NHS hospitals in the UK. PARTICIPANTS: Adults aged ≥ 16 years presenting with a single ureteric stone in any segment of the ureter, confirmed by computerised tomography, who were able to undergo either shockwave lithotripsy or ureteroscopic stone treatment and to complete trial procedures. INTERVENTION: Eligible participants were randomised 1 : 1 to shockwave lithotripsy (up to two sessions) or ureteroscopic stone treatment. MAIN OUTCOME MEASURES: The primary clinical outcome measure was resolution of the stone episode (stone clearance), which was operationally defined as 'no further intervention required to facilitate stone clearance' up to 6 months from randomisation. This was determined from 8-week and 6-month case report forms and any additional hospital visit case report form that was completed by research staff. The primary economic outcome measure was the incremental cost per quality-adjusted life-year gained at 6 months from randomisation. We estimated costs from NHS resources and calculated quality-adjusted life-years from participant completion of the EuroQol-5 Dimensions, three-level version, at baseline, pre intervention, 1 week post intervention and 8 weeks and 6 months post randomisation. RESULTS: In the shockwave lithotripsy arm, 67 out of 302 (22.2%) participants needed further treatment. In the ureteroscopic stone treatment arm, 31 out of 302 (10.3%) participants needed further treatment. The absolute risk difference was 11.4% (95% confidence interval 5.0% to 17.8%); the upper bound of the 95% confidence interval ruled out the prespecified margin of non-inferiority (which was 20%). The mean quality-adjusted life-year difference (shockwave lithotripsy vs. ureteroscopic stone treatment) was -0.021 (95% confidence interval 0.033 to -0.010) and the mean cost difference was -£809 (95% confidence interval -£1061 to -£551). The probability that shockwave lithotripsy is cost-effective is 79% at a threshold of society's willingness to pay for a quality-adjusted life-year of £30,000. The CEAC is derived from the joint distribution of incremental costs and incremental effects. Most of the results fall in the south-west quadrant of the cost effectiveness plane as SWL always costs less but is less effective. LIMITATIONS: A limitation of the trial was low return and completion rates of patient questionnaires. The study was initially powered for 500 patients in each arm; however, the total number of patients recruited was only 307 and 306 patients in the ureteroscopic stone treatment and shockwave lithotripsy arms, respectively. CONCLUSIONS: Patients receiving shockwave lithotripsy needed more further interventions than those receiving primary ureteroscopic retrieval, although the overall costs for those receiving the shockwave treatment were lower. The absolute risk difference between the two clinical pathways (11.4%) was lower than expected and at a level that is acceptable to clinicians and patients. The shockwave lithotripsy pathway is more cost-effective in an NHS setting, but results in lower quality of life. FUTURE WORK: (1) The generic health-related quality-of-life tools used in this study do not fully capture the impact of the various treatment pathways on patients. A condition-specific health-related quality-of-life tool should be developed. (2) Reporting of ureteric stone trials would benefit from agreement on a core outcome set that would ensure that future trials are easier to compare. TRIAL REGISTRATION: This trial is registered as ISRCTN92289221. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 19. See the NIHR Journals Library website for further project information.

Approximately 1 in 20 people suffers from kidney stones that pass down the urine drainage tube (ureter) into the urinary bladder and cause episodes of severe pain (ureteric colic). People with ureteric colic attend hospital for pain relief and diagnosis. Although most stones smaller than 10 mm eventually reach the bladder and are passed during urination, some get stuck and have to be removed using telescopic surgery (called ureteroscopic stone treatment) or shockwave therapy (called shockwave lithotripsy). Ureteroscopic stone treatment involves passing a telescope-containing instrument through the bladder and into the ureter to fragment and/or remove the stone. This is usually carried out under general anaesthetic as a day case. For shockwave lithotripsy, the patient lies flat on a couch and the apparatus underneath them generates shockwaves that pass through the skin to the ureter and break the stones into smaller fragments, which can be passed naturally in the urine. This involves using X-ray or ultrasound to locate the stone, but can be carried out on an outpatient basis and without general anaesthetic. Telescopic surgery is known to be more successful at removing stones after just one treatment, but it requires more time in hospital and has a higher risk of complications than shockwave lithotripsy (however, shockwave lithotripsy may require more than one session of treatment). Our study, the Therapeutic Interventions for Stones of the Ureter trial, was designed to establish if treatment for ureteric colic should start with telescopic surgery or shockwave therapy. Over 600 NHS patients took part and they were split into two groups. Each patient had an equal chance of their treatment starting with either telescopic surgery or shockwave lithotripsy, which was decided by a computer program (via random allocation). We counted how many patients in each group had further procedures to remove their stone. We found that telescopic surgery was 11% more effective overall, with an associated slightly better quality of life (10 more healthy days over the 6-month period), but was more expensive in an NHS setting. The finding of a lack of any significant additional clinical benefit leads to the conclusion that the more cost-effective treatment pathway is shockwave lithotripsy with telescopic surgery used only in those patients in whom shockwave lithotripsy is unsuccessful.

Outcomes and costs of ureteroscopy, extracorporeal shockwave lithotripsy, and percutaneous nephrolithotomy for the treatment of urolithiasis: an analysis based on health insurance claims data in Germany.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term health and economic outcomes based on claims data are rare. Our aim was to analyze URS, SWL, and PCNL regarding complications within 30 days, re-intervention, healthcare costs, and sick leave days within 12 months, and to investigate inpatient and outpatient SWL treatment as the latter was introduced in Germany in 2011. METHODS: This retrospective cohort study based on German health insurance claims data included 164,203 urolithiasis cases in 2008-2016. We investigated the number of complications within 30 days, as well as time to re-intervention, number of sick leave days and hospital and ambulatory health care costs within a 12-month follow-up period. We applied negative binomial, Cox proportional hazard, gamma and two-part models and adjusted for patient variables. RESULTS: Compared to URS cases, SWL and PCNL had fewer 30-day complications, time to re-intervention within 12 months was decreased for SWL and PCNL, SWL and PCNL were correlated with a higher number of sick leave days, and SWL and particularly PCNL were associated with higher costs. SWL outpatients had fewer complications, re-interventions and lower costs than inpatients. This study was limited by the available information in claims data. CONCLUSION: URS cases showed benefits in terms of fewer re-interventions, fewer sick leave days, and lower healthcare costs. Only regarding complications, SWL was superior. This emphasizes URS as the most frequent treatment choice. Furthermore, SWL outpatients showed less costs, fewer complications, and re-interventions than inpatients.

Use of ultra-low dose computed tomography versus abdominal plain film for assessment of stone-free rates after shock-wave lithotripsy: implications on emergency room visits, surgical procedures, and cost-effectiveness.

The aims of this investigation were: (1) to compare residual stone-fragment (RSF) detection rates of ultra-low dose computed tomography (ULD-CT) and abdominal plain film (KUB) in urolithiasis patients undergoing shock-wave lithotripsy (SWL), and (2) to evaluate the downstream sequelae of utilizing these two disparate imaging pathways of differing diagnostic fidelity. A retrospective chart-review of patients undergoing SWL at two high-volume surgical centers was undertaken (2013-2016). RSF diagnostic rates of ULD-CT and KUB were assessed, and the impact of imaging modality used on subsequent emergency room (ER) visits, unplanned procedures, and cost-effectiveness was investigated. Adjusted analyses examined association between imaging modality used and outcomes, and Markov decision-tree analysis was performed to identify a cost advantageous scenario for ULD-CT over KUB. Of 417 patients studied, 57 (13.7%) underwent ULD-CT while the remaining 360 underwent KUB. The RSF rates were 36.8% and 22.8% in the ULD-CT and KUB groups, respectively (p = 0.019). A 5.6% and 18% of the patients deemed stone-free on ULD-CT and KUB, respectively, returned to the ER (p = 0.040). Similarly, 2.8% and 15.1% needed an unplanned surgery (p = 0.027). These findings were confirmed on multivariable analyses, Odds ratios CT-ULD versus KUB: 0.19 and 0.10, respectively, p < 0.05. With regards to cost-effectiveness, at low ULD-CT charges, the ULD-CT follow-up pathway was economically more favorable, but with increasing ULD-CT charges, the KUB follow-up pathway superseded. ULD-CT seems to provide a more 'true' estimate of stone-free status, and in consequence mitigates unwanted emergency and operating room visits by reducing untimely stent removals and false patient reassurances. Further, at low ULD-CT costs, it may also be economically more favorable.

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.

Analysis of the efficacy of holmium laser and pneumatic ballistic in the treatment of impacted ureteral calculi.

To explore the safety and effectiveness of ureteroscopic holmium laser lithotripsy (UHLL) and ureteroscopic pneumatic lithotripsy (UPL) in the treatment of impacted ureteral calculi (IUC).Clinical data of 280 patients in our hospital from April 2016 to May 2019 were retrospectively collected and analyzed, including 136 cases of UHLL group and 144 cases of UPL group. The general clinical data, operation time, intraoperative bleeding volume, hospital stay, stone-free rate (SFR), and surgical complications were collected and analyzed in 2 group.Compared with UPL group, the operation time of UHLL group was significantly reduced (27.25 ±â€Š8.39 vs 34.32 ±â€Š10.57, P < .05), but the hospitalization cost was significantly increased (9.25 ±â€Š0.75 vs 8.24 ±â€Š0.51, P < .05). In terms of total SFR, the UHLL group was significantly higher than the UPL group (93.38% vs 83.33%, P = .011). For proximal IUC, compared with the UPL group, the SFR of the UHLL group was significantly increased (88.33% vs 70.31%, P = 0.005). For distal IUC, there was no significant difference in SFR (97.37% vs 93.75%, P = .638) between the UHLL group and UPL group. There were no significant differences in the complications of local mucosal injury, hematuria, febrile urinary tract infection, ureteral perforation, and urinary sepsis in the 2 groups (P > .05). However, the UHLL group was significantly lower in stone residual rate than the UPL group (6.61% vs 16.67%, P = .001).This study found that UHLL and UPL are safe and effective in the treatment of IUC, but UHLL has the advantages of shorter operation time and high SFR in the treatment of IUC.

Novel prediction scoring system for simple assessment of stone-free status after flexible ureteroscopy lithotripsy: T.O.HO. score.

OBJECTIVES: To develop a novel simple quantitative scoring model for predicting stone-free status after a flexible ureteroscopy lithotripsy procedure by standardizing the complexity of ureteral stone characteristics. METHODS: We retrospectively reviewed 586 patients with renal or ureteral stones who underwent flexible ureteroscopy lithotripsy at Abiko Toho Hospital, Chiba, Japan, from 2015 to 2018. Multivariate regression was applied to examine the relationship between preoperative descriptors and stone-free status, and a nomogram was developed using significant predictors. Next, the individual components of the nomogram were assigned points to form a simple scoring system. The predictive performance of this new scoring system was compared with the STONE score at optimal cut-off values using receiver operating characteristic curve and area under the curve analyses. RESULTS: Multivariate logistic regression findings showed that factors associated with stone-free status were length, Hounsfield unit and stone location. A nomogram prediction model was developed with an area under the curve value of 0.845, then consequently used to develop a new simple score system termed the T.O.HO. score consisting of three stone characteristics: (T)allness (1-5 points), (O)ccupied lesion (1-3 points) and (HO)unsfield units evaluation (1-3 points). The T.O.HO. score was significantly higher in stone remaining (7.66) than stone-free (5.27; P < 0.001) cases. The area under the curve for the T.O.HO. score was 0.833 at an optimal cut-off value of 7, whereas that for the STONE score was 0.683 at an optimal cut-off value of 9, showing the superiority of this new scoring system. CONCLUSION: The T.O.HO. score is a useful tool for predicting stone-free status in patients who have undergone a flexible ureteroscopy lithotripsy procedure.

TISU: Extracorporeal shockwave lithotripsy, as first treatment option, compared with direct progression to ureteroscopic treatment, for ureteric stones: study protocol for a randomised controlled trial.

BACKGROUND: Urinary stone disease is very common with an estimated prevalence among the general population of 2-3%. Ureteric stones are associated with severe pain as they pass through the urinary tract and have significant impact on patients' quality of life due to the detrimental effect on their ability to work and need for hospitalisation. Most ureteric stones can be expected to pass spontaneously with supportive care. However, between one-fifth and one-third of cases require an intervention. The two standard active intervention options are extracorporeal shockwave lithotripsy (ESWL) and ureteroscopic stone retrieval. ESWL and ureteroscopy are effective in terms of stone clearance; however, they differ in terms of invasiveness, anaesthetic requirement, treatment setting, complications, patient-reported outcomes (e.g. pain after intervention, time off work) and cost. There is uncertainty around which is the most clinically effective in terms of stone clearance and the true cost to the NHS and to society (in terms of impact on patient-reported health and economic burden). The aim of this trial is to determine whether, in adults with ureteric stones, judged to require active intervention, ESWL is not inferior and is more cost-effective compared to ureteroscopic treatment as the initial management option. METHODS: The TISU study is a pragmatic multicentre non-inferiority randomised controlled trial of ESWL as the first treatment option compared with direct progression to ureteroscopic treatment for ureteric stones. Patients aged over 16 years with a ureteric stone confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) will be randomised to either ESWL or ureteroscopy. The primary clinical outcome is resolution of the stone episode (no further intervention required to facilitate stone clearance) up to six months from randomisation. The primary economic outcome is the incremental cost per quality-adjusted life years (QALYs) gained at six months from randomisation. DISCUSSION: Determining whether ESWL is not inferior clinically and is cost-effective compared to ureteroscopic treatment as the initial management in adults with ureteric stones who are judged to require active treatment is relevant not only to patients and clinicians but also to healthcare providers, both in the UK and globally. TRIAL REGISTRATION: ISRCTN registry, ISRCTN92289221 . Registered on 21 February 2013.

Evaluation of perioperative prophylaxis with fosfomycin tromethamine in ureteroscopic stone removal: an investigator-driven prospective, multicenter, randomized, controlled study.

PURPOSE: To compare efficacy, safety, and cost-effectiveness of fosfomycin tromethamine with other standard-of-care antibiotics in patients undergoing ureteroscopic lithotripsy. METHODS: This study was a prospective, multicenter, randomized, controlled trial. Eligible patients scheduled for ureteroscopic lithotripsy were randomly assigned to receive either fosfomycin (fosfomycin group, N = 101 patients) or standard-of-care antibiotic therapy as prophylaxis (control group, N = 115 patients). The incidence of infectious complications and adverse events was analyzed between the two groups, as well as the cost-benefit analysis. RESULTS: The incidence of infections following lithotripsy was 3.0% in the fosfomycin group and 6.1% in the control group (p > 0.05). Only asymptomatic bacteriuria was reported in fosfomycin group. In the control group was reported asymptomatic bacteriuria (3.5%), fever (0.9%), bacteremia (0.9%), and genitourinary infection (0.9%). The rate of adverse events was very low, with no adverse event reported in the fosfomycin group and only one in the control group (forearm phlebitis). The average cost per patient of antibiotic therapy with fosfomycin was 151.45 ± 8.62 yuan (22.7 ± 1.3 USD), significantly lower compared to the average cost per patient of antibiotics used in the control group 305.10 ± 245.95 yuan (45.7 ± 36.9 USD; p < 0.001). CONCLUSIONS: Two oral doses of 3 g fosfomycin tromethamine showed good efficacy and safety and low cost in perioperative prophylaxis of infections following ureteroscopic stone removal.

Assessment of electrocardiographic parameters in adult patients undergoing extracorporeal shockwave lithotripsy.

OBJECTIVE: Extracorporeal shock wave lithotripsy (ESWL) is a safe and effective treatment for urinary tract calculi. While serious side effects are rare, transient cardiac arrhythmias may occur. New electrocardiographic (ECG) parameters, such as P wave dispersion (PWD), QT dispersion (QTd), T peak to T end (Tp-e) interval, Tp-e interval/QT ratio, and Tp-e interval/corrected QT ratio have been defined to help predict atrial and ventricular arrhythmias. However, effect of ESWL on these ECG parameters has not been previously investigated. The present study was an examination of the effect of ESWL on ECG parameters. METHODS: Total of 40 consecutive patients who underwent ESWL were prospectively enrolled in the study. Pre-procedure ECG parameters were compared with post-procedure ECG parameters. RESULTS: PWD values were significantly longer on post-procedure ECG compared with pre-procedure ECG (p=0.017). Corrected QT duration and QTd were significantly longer on postprocedure ECG compared with pre-procedure ECG (p=0.046 and p=0.008, respectively). In addition, Tp-e interval, Tp-e interval/QT ratio, and Tp-e interval/QTc ratio were significantly longer post procedure (p=0.035, p=0.045, and p=0.022, respectively). In univariate correlation analysis, duration of procedure was significantly correlated with post-procedure PWD, QTc, and QTD values. CONCLUSION: Clinical use of ECG parameters may be helpful in monitoring of patients receiving ungated ESWL in order to detect cardiac dysrhythmia.

Assessment of the SonixGPS system for its application in real-time ultrasonography navigation-guided percutaneous nephrolithotomy for the treatment of complex kidney stones.

SonixGPS is a novel real-time ultrasonography navigation technology, which has been demonstrated to promote accuracy of puncture in surgical operations. The aim of this study is to evaluate its application in guiding the puncture during percutaneous nephrolithotomy (PCNL). We retrospectively reviewed our experience in treating a total of 74 patients with complex kidney stones with PCNL, in which puncture in 37 cases were guided by SonixGPS system, while the other 37 by conventional ultrasound. The effectiveness of operation was evaluated in terms of stone clearance rate, operation time, time to successful puncture, number of attempts for successful puncture and hospital stay. The safety of operation was examined by evaluating postoperative complications. Our retrospective review showed that although there were no significant differences in stone clearance rates between the groups, SonixGPS guidance resulted in more puncture accuracy with shorter puncture time and higher successful puncture rate. Under the help of SonixGPS, most patients (92 %) had no or just mild complications, compared to that (73 %) in conventional ultrasound group. Post-operative decrease of hemoglobin in SonixGPS group was 13.79 (7-33) mg/dl, significantly lower than that 20.97 (8-41) mg/dl in conventional ultrasound group. Our experience demonstrates that SonixGPS is superior to conventional ultrasound in guiding the puncture in PCNL for the treatment of complex kidney stone.

Clinical efficacy, safety, and costs of percutaneous occlusive balloon catheter-assisted ureteroscopic lithotripsy for large impacted proximal ureteral calculi: a prospective, randomized study.

PURPOSE: To evaluate the clinical efficacy, safety, and costs of percutaneous occlusive balloon catheter-assisted ureteroscopic lithotripsy (POBC-URSL) for large impacted proximal ureteral calculi. PATIENTS AND METHODS: 156 patients with impacted proximal ureteral stones ≥1.5 cm in size were randomized to ureteroscopic lithotripsy (URSL), POBC-URSL, and percutaneous nephrolithotomy (PNL) group between May 2010 and May 2013. For URSL, the calculi were disintegrated with the assistance of anti-retropulsion devices. POBC-URSL was performed with the assistance of an 8F percutaneous occlusive balloon catheter. PNL was finished with the combination of an ultrasonic and a pneumatic lithotripter. A flexible ureteroscope and a 200 µm laser fiber were used to achieve stone-free status to a large extent for each group. Variables studied were mean operative time, auxiliary procedure, postoperative hospital stay, operation-related complications, stone clearance rate, and treatment costs. RESULTS: The mean lithotripsy time for POBC-URSL was shorter than URSL, but longer than PNL (42.6±8.9 minutes vs 66.7±15.3 minutes vs 28.1±6.3 minutes, p=0.014). The auxiliary procedure rate and postoperative fever rate for POBC-URSL were significantly lower than URSL and comparable to PNL (p<0.01, p=0.034). POBC-URSL was superior to URSL with regard to the stone clearance rate at 3 days postoperatively, and as good as PNL (98.1% vs 75.0% vs 96.2%, p<0.01). The postoperative hospital stay and hematuria rate were lower in POBC-URSL group than PNL group and similar to URSL group (p=0.016, p<0.01). The treatment costs were lowest in POBC-URSL group ($1205.0±$113.9 vs $1731.7±$208.1 vs $2446.4±$166.4, p=0.004). CONCLUSIONS: For large impacted proximal ureteral calculi, POBC-URSL was associated with a higher stone clearance rate, fewer complications and costs. POBC-URSL combined the advantages of URSL and PNL.

Antiretropulsion devices.

PURPOSE OF REVIEW: Stone migration during the treatment of ureteral stones can prove frustrating and increases both healthcare cost and patient morbidity. Antiretropulsion devices have been engineered to prevent stone migration. RECENT FINDINGS: Improvements in antiretropulsion devices allow for efficient prevention of stone migration during ureteroscopic lithotripsy with minimal adverse effects or complications. Multiple devices are now available each with advantages and disadvantages. New devices are currently engineered to prevent stone migration and maintain ureteral access. Antiretropulsion devices appear to be cost-effective to prevent stone migration during intracorporeal lithotripsy. SUMMARY: Antiretropulsion devices have been safely and effectively used during ureteroscopic procedures. These tools increase stone-free rates, decrease morbidity and new studies have demonstrated their cost-effectiveness.

Evaluation of the LithoGold LG-380 lithotripter: in vitro acoustic characterization and assessment of renal injury in the pig model.

PURPOSE: Conduct a laboratory evaluation of a novel low-pressure, broad focal zone electrohydraulic lithotripter (TRT LG-380). METHODS: Mapping of the acoustic field of the LG-380, along with a Dornier HM3, a Storz Modulith SLX, and a XiXin CS2012 (XX-ES) lithotripter was performed using a fiberoptic hydrophone. A pig model was used to assess renal response to 3000 shockwaves (SW) administered by a multistep power ramping protocol at 60 SW/min, and when animals were treated at the maximum power setting at 120 SW/min. Injury to the kidney was assessed by quantitation of lesion size and routine measures of renal function. RESULTS: SW amplitudes for the LG-380 ranged from (P(+)/P(-)) 7/-1.8 MPa at PL-1 to 21/-4 MPa at PL-11 while focal width measured ~20 mm, wider than the HM3 (8 mm), SLX (2.6 mm), or XX-ES (18 mm). For the LG-380, there was gradual narrowing of the focal width to ~10 mm after 5000 SWs, but this had negligible effect on breakage of model stones, because stones positioned at the periphery of the focal volume (10 mm off-axis) broke nearly as well as stones at the target point. Kidney injury measured less than 0.1% FRV (functional renal volume) for pigs treated using a gradual power ramping protocol at 60 SW/min and when SWs were delivered at maximum power at 120 SW/min. CONCLUSIONS: The LG-380 exhibits the acoustic characteristics of a low-pressure, wide focal zone lithotripter and has the broadest focal width of any lithotripter yet reported. Although there was a gradual narrowing of focal width as the electrode aged, the efficiency of stone breakage was not affected. Because injury to the kidney was minimal when treatment followed either the recommended slow SW-rate multistep ramping protocol or when all SWs were delivered at fast SW-rate using maximum power, this appears to be a relatively safe lithotripter.

Shock wave lithotripsy versus ureteroscopy for ureteral calculi: a prospective assessment of patient-reported outcomes.

OBJECTIVE: To compare patient-reported outcomes (PROs) with objective outcomes after shock wave lithotripsy (SWL) and ureteroscopic surgery (URS) for ureteral calculi (UC). METHODS: We prospectively evaluated 160 consecutive patients who underwent SWL (n = 65) or URS (n = 95) for a single radiopaque UC ranging from 4 to 15 mm. For patients who underwent URS, a 6-Fr double-J stent was routinely placed for 2 weeks after surgery. To examine PRO, we used a self-administered nonvalidated questionnaire evaluating overall satisfaction and PRO in four domains (pain, hematuria, voiding symptom, and time to return to routine activity) and willingness to undergo the treatment procedure again. Propensity-score matching analysis was performed to adjust for potential confounding by discrepancy of pretreatment parameters between groups. Stone-free rates (SFRs) and complications were also compared. RESULTS: SFRs after the first, second, and third sessions of SWL were 61.5, 81.0, and 93.5%, respectively. SFR after URS was 100%, which was significantly better than SFRs for third-session SWL (p = 0.023). Complications were comparable. By propensity-score matching analysis, overall satisfaction was similar between groups, whereas PRO for voiding symptom and time to return to routine activity were significantly better in the SWL group (all p < 0.05). The two groups were not different in willingness to undergo the same procedure again. CONCLUSIONS: Despite significantly higher SFR after URS for UC, overall patient satisfaction was comparable after SWL and URS, meanwhile PRO of the SWL group was better than URS for voiding symptom and time to return to routine activity. In addition of objective treatment outcomes, PROs should be considered in counseling treatment methods for UC.

Prevalence and management of complications of ureteroscopy: a seven-year experience with introduction of a new maneuver to prevent ureteral avulsion.

PURPOSE: To evaluate the prevalence and type of rigid ureteroscopy complications and suggest a new method for ureteral avulsion prevention. MATERIALS AND METHODS: Between March 2002 and March 2009, we retrospectively evaluated 2955 patients who had undergone diagnostic or therapeutic ureteroscopy for asymptomatic hematuria, migrated ureteral stent, or transurethral lithotripsy. They were enrolled from four hospitals in Ahvaz, Iran. RESULTS: Complications were encountered in 241 (8%) patients, including transient hematuria (4.2%), mucosal erosion (1.4%), stone migration (1.3%), ureteral perforation (1.2%), and fever and/or sepsis (1.0%). Ureteral avulsion occurred in 6 (0.2%) patients. Mostly, complications were managed conservatively, using ureteral stenting. Ureteral avulsions were managed using a new technique. CONCLUSION: In our series, the complication rate is comparable with the literature. A new technique was used in case of ureteroscope entrapment in the ureter, to lessen the occurrence of ureteral avulsion.