Impact of frailty on perioperative outcomes following percutaneous nephrolithotomy in older persons: evidence from the US Nationwide Inpatient Sample.

To evaluate the impact of frailty on perioperative outcomes of older patients undergoing PCNL, utilizing the US Nationwide Inpatient Sample (NIS) database. Data of hospitalized patients ≥ 60 years who received PCNL were extracted from the 2010 to 2020 NIS database, and included demographics, clinical, and hospital-related information. Patients were assigned to low (< 5), medium (5-15), and high frailty risk (> 15) groups based on the hospital frailty risk score (HFRS). Associations between frailty risk and perioperative outcomes including total hospital cost were determined using population-weighted linear and logistic regression analyses. Data of 30,829 hospitalized patients were analyzed (mean age 72.5 years; 55% male; 78% white). Multivariable analyses revealed that compared to low frailty risk, increased frailty risk was significantly associated with elevated in-hospital mortality (adjusted odds ratio (aOR) = 10.70, 95% confidence interval (CI): 6.38-18.62), higher incidence of unfavorable discharge (aOR = 5.09, 95% CI: 4.43-5.86), prolonged hospital length of stay (LOS; aOR = 7.67, 95% CI: 6.38-9.22), increased transfusion risk (aOR = 8.05, 95% CI: 6.55-9.90), increased total hospital costs (adjusted Beta = 37.61, 95% CI: 36.39-38.83), and greater risk of complications (aOR = 8.52, 95% CI: 7.69-9.45). Frailty is a significant prognostic indicator of adverse perioperative outcomes in older patients undergoing PCNL, underscoring importance of recognizing and managing frailty in older patients.

Comparison of endoscopic versus CT assessment of stone-free status after percutaneous nephrolithotomy (PCNL).

This study is aimed to determine whether postoperative low dose computed tomography (LDCT) imaging is necessary after percutaneous nephrolithotomy (PCNL), or the surgeon's intraoperative assessment of residual fragments (RF) is sufficient and avoidance of postoperative imaging with reduction of radiation exposure can be achieved. Data of all 610 patients who underwent PCNL in prone position in our institution from February 2009 to September 2020 was collected. Parameters such as age, gender, BMI, ASA-Classification, stone related parameters and the surgeon's assessment of stone-free status were analyzed. The LDCT performed postoperatively was compared to the intraoperative assessment of the surgeon regarding RF. The mean age of patients was 52.82 years; the mean BMI was 28.18 kg/m2. In 418 cases, the surgeon made a clear statement about the presence of RF and postoperative LDCT was carried out. The discrepancy between the two methods (surgeon´s assessment vs. LDCT) was significant at p < 0.0001. The sensitivity, specificity, positive and negative predictive value of the surgeon when assessing RF were 24.05%, 99.45%, 98.28% and 50%. Stone free rate (SFR) after primary PCNL was 45.57%. The overall SFR at discharge was 96.23%. Although the surgeon´s assessment of RF was reliable, postoperative LDCT imaging should still be performed if endoscopic stone clearance is suspected due to the high false negative rate and the low negative predictive value. The optimal timing of postoperative imaging following PCNL remains unclear.

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.

Outcomes and Costs Following Mini-percutaneous Nephrolithotomy or Flexible Ureteroscopic Lithotripsy for 1-2-cm Renal Stones: Data From a Prospective, Randomized Clinical Trial.

PURPOSE: We evaluate the outcomes of ureteroscopy vs prone mini-percutaneous nephrolithotomy for 1-2-cm renal stones using a 2-group parallel randomized control trial. MATERIALS AND METHODS: Adult patients presenting with renal stones between 1 and 2 cm were randomized. Exclusion criteria included solitary kidney, multiple stones, and comorbidities precluding prone positioning. Block randomization was performed and was opened to the surgeon the morning of the procedure. Stone-free rate was evaluated by computed tomography 1-30 days postoperatively. Complications, re-treatment rates, and costs were evaluated. RESULTS: A total of 51 mini-percutaneous nephrolithotomy and 50 ureteroscopy patients were included. Baseline demographics were similar. Using a 2-mm cutoff, stone-free rate was higher in the mini-percutaneous nephrolithotomy group (76 vs 46%, P = .0023). The residual stone burden was significantly higher in the ureteroscopy group than the mini-percutaneous nephrolithotomy group (3.6 vs 1.4 mm, P = .0026). Fluoroscopy time was significantly higher in the mini-percutaneous nephrolithotomy group (273 vs 49 seconds, P < .0001). There were no differences in postoperative complications within 30 days, the necessity of a secondary procedure within 30 days, and pre- to postoperative creatinine change (P > .05). Surgical time did not vary significantly (P = .1788). Average length of stay was higher in the mini-percutaneous nephrolithotomy group (P < .0001). Both net revenue and direct costs were higher in mini-percutaneous nephrolithotomy procedures (P < .05), though they offset each other with a nonsignificant operating margin (P = .2541). CONCLUSIONS: In a prospective, randomized, controlled clinical trial using a 2-mm residual stone burden cutoff, mini-percutaneous nephrolithotomy was more likely to render patients stone-free than flexible ureteroscopy. Complications, surgical times, and operating margins did not vary between the approaches.

Infectious Complications, Healthcare Resource Use, and Medical Costs Associated with Delays in Percutaneous Nephrolithotomy Among Patients with Stone Disease and Ureteral Stent Placement.

Purpose: The relationship between ureteral stent duration before percutaneous nephrolithotomy (PCNL) and infectious complications, admissions, imaging, and medical costs was evaluated. Materials and Methods: Patients who underwent PCNL within 6 months of ureteral stent placement were identified from commercial claims, categorized by time to treatment (0-30, 31-60, and >60 days), and followed 1-month post-PCNL. The effect of delayed treatment on inpatient admissions, infectious complications (pyelonephritis/sepsis), and imaging utilization was evaluated with logistic regression. A generalized linear model evaluated the effect of delayed treatment on medical costs. Results: Among 564 patients with PCNL and meeting the inclusion criteria (mean age 50; 55% female; 45% from South), mean (standard deviation) time to surgery was 48.8 (41.8) days. Less than half (44.3%; n = 250) underwent PCNL within 30 days of ureteral stent placement, 27.0% (n = 152) between 31 and 60 days, and 28.7% (n = 162) >60 days. Time to PCNL was significantly associated with inpatient admissions (>60 vs ≤30 days odds ratio [OR] 1.97, 95% confidence interval [CI] 1.29-3.01, p = 0.0016), infectious complications (>60 vs ≤30 days OR 2.43, 95% CI 1.55-3.81, p = 0.0001), imaging utilization (31-60 vs ≤30 days OR 1.56, 95% CI 1.02-2.38, p = 0.0383; >60 vs ≤30 days OR 2.01, 95% CI 1.31-3.06, p = 0.0012), and medical costs (31-60 vs ≤30 days OR 1.27, 95% CI 1.08-1.49, p = 0.0048; >60 vs ≤30 days OR 1.46, 95% CI 1.24-1.71, p < 0.0001). Conclusions: Compared with PCNL within 30 days, patients undergoing PCNL >30 days after ureteral stent placement had increased likelihood of infectious complications, resource use, and medical costs. These results may inform health care resource utilization and PCNL prioritization.

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.

Trends and patterns of initial percutaneous nephrolithotomy and subsequent procedures among commercially-insured US adults with urinary system stone disease: a 10-year population-based study.

PURPOSE: To describe trends and patterns of initial percutaneous nephrolithotomy (PCNL) and subsequent procedures from 2010 to 2019 among commercially-insured US adults with urinary system stone disease (USSD). METHODS: Retrospective study of administrative data from the IBM® MarketScan® Database. Eligible patients were aged 18-64 years and underwent PCNL between 1/1/2010 and 12/31/2019. Measures of interest for analysis of trends and patterns included the setting of initial PCNL (inpatient vs. outpatient), percutaneous access (1 vs. 2-step), and the incidence, time course, and type of subsequent procedures (extracorporeal shockwave lithotripsy [SWL], ureteroscopy [URS], and/or PCNL) performed up-to 3 years after initial PCNL. RESULTS: A total of 8,348 patients met the study eligibility criteria. During the study period, there was a substantial shift in the setting of initial PCNL, from 59.9% being inpatient in 2010 to 85.3% being outpatient by 2019 (P < 0.001). The proportion of 1 vs. 2-step initial PCNL fluctuated over time, with a low of 15.1% in 2016 and a high of 22.0% in 2019 but showed no consistent yearly trend (P = 0.137). The Kaplan-Meier estimated probability of subsequent procedures following initial PCNL was 20% at 30 days, 28% at 90 days, and 50% at 3 years, with slight fluctuations by initial PCNL year. From 2010 to 2019, the proportion of subsequent procedures accounted for by URS increased substantially (from 30.8 to 51.8%), whereas SWL decreased substantially (from 39.5 to 14.7%) (P < 0.001). CONCLUSIONS: From 2010 to 2019, PCNL procedures largely shifted to the outpatient setting. Subsequent procedures after initial PCNL were common, with most occurring within 90 days. URS has become the most commonly-used subsequent procedure type.

Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients.

Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.

Long-term evaluation of outcomes and costs of urolithiasis re-interventions after ureteroscopy, extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy based on German health insurance claims data.

PURPOSE: Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years. METHODS: This retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008-2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models. RESULTS: 54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients. CONCLUSION: This study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.

Comparative assessment of multiple-tract vs single-tract percutaneous nephrolithotomy.

INTRODUCTION: To investigate the efficacy and safety of multi-tract percutaneous nephrolithotomy (PNL) against the benchmark of the single-tract approach. METHODS: A retrospective analysis of 391 consecutive PNL procedures was conducted in our tertiary referral center between April 2016 and March 2020. Clinical outcome parameters such as stone-free rate, operation time, postoperative complications according to Clavien-Dindo, length of hospital stay and time to ipsilateral recurrence resulting in active treatment were assessed. RESULTS: Multi-tract PNL and single-tract PNL were performed in 37 (9%) and 354 (91%) cases respectively. At baseline, compared to single-tract PNL, multi-tract PNL cases were characterized by significantly larger stone burden (2.62 vs 0.97 cm3 , P < .00), lower Hounsfield units (HU) (751 vs 1017 HU, P < .01), a more complex S.T.O.N.E. (size, tract length, obstruction, number of calyces, essence) score (P < .00) and a higher rate of high-risk stone formers (59 vs 19%, P < .00). Analysis of outcome revealed shorter operation time and length of hospital stay for single-tract PNL compared to multi-tract PNL (P < .01). However, the difference in terms of stone-free rates (92% vs 88%), complication rates (43% vs 28%) and time to active retreatment due to ipsilateral recurrence was not statistically significant (P > .05). CONCLUSION: In this retrospective single-center analysis, a multi-tract PNL has been proved to be an efficient and safe expansion of single-tract PNL for large stone burden and complex kidney stone disease. Future prospective research should focus on the procedure's potential effectiveness in reducing the number of interventions until stone-free status in patients with massive stone disease.

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.

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.

Efficacy and Economy of Two-Stage Percutaneous Nephrolithotomy for Complex Renal Calculi.

OBJECTIVES: To evaluate the efficacy and cost effectiveness of two-stage percutaneous nephrolithotomy (PCNL) in complex renal calculus disease. METHODS: The clinical data of 106 patients who underwent two-stage PCNL at the Second Affiliated Hospital of Kunming Medical University from January 2017 to May 2022 were analyzed. In order to select more accurate timing and strategies to reduce costs and surgery risk in two-stage PCNL patients, different parameters were measured-including the preoperative urinary tract infection, intraoperative bleeding, operative time, postoperative stone clearance and treatment costs. Patients were divided into group A and group B according to different timings of two-stage PCNL operation. Group A included patients who underwent two-stage PCNL during their period of hospitalization 5 to 9 days after the one-stage PCNL. Group B comprised patients who were re-hospitalized for two-stage PCNL 29 to 35 days after the one-stage PCNL. RESULTS: There were statistically significant differences in the influence of stone diameter and operation time in intraoperative blood loss of PCNL in 106 patients (p < 0.001). Compared with one-stage PCNL, the intraoperative hemoglobin loss and hematocrit loss means of patients with two-stage PCNL were decreased, the stone diameter mean of was smaller, and the mean operative time was diminished (p < 0.001). There were no significant differences in the hemoglobin loss, hematocrit loss and stone clearance rate means between group A and group B (p > 0.05). The urinary tract infection rate in group A was lower than the one in group B, and the average treatment cost was lower than the one in group B (p = 0.006, p < 0.001, respectively). CONCLUSIONS: Intraoperative bleeding in PCNL is influenced by stone diameter and operative time. Two-stage PCNL displays smaller calculi, shorter operation time and lower intraoperative blood loss than one-stage PCNL. Patients who had no surgical contraindication could undergo two-stage PCNL during the same hospitalization 5 to 9 days after one-stage PCNL to avoid rehospitalization. This approach could reduce the risk of urinary tract infection of indwelling nephrostomy tube and decrease the economic burden of patients.

Cost analysis between mini-percutaneous nephrolithotomy with and without vacuum-assisted access sheath.

PURPOSE: To perform a cost analysis between vacuum-assisted percutaneous nephrolithotomy (vmPCNL) and minimally invasive PCNL (MIP) and explore potential predictors of costs associated with the procedures. METHODS: We analyzed data from 225 patients who underwent vmPCNL or MIP at a single tertiary referral academic center between January 2016 and December 2020. We collected patients' demographics, peri-and postoperative data and detailed expense records. After propensity score matching, 108 (66.7%) vmPCNL and 54 (33.3%) MIP procedures were analyzed. Descriptive statistics assessed differences in clinical and operative parameters. Univariable and multivariable linear regression models tested the association between clinical variables and costs. RESULTS: Operative time (OT) was shorter for vmPCNL, and the use of additional instruments to complete litholapaxy was more frequent in MIP (all p ≤ 0.01). Length of stay (LOS) was longer for MIP patients (p = 0.03) and the stone-free (SF) rate was higher after vmPCNL (p = 0.04). The overall instrumentation cost was higher for vmPCNL (p < 0.001), but total procedural costs were equivalent (p = 0.9). However, the overall cost for the hospitalization was higher for MIP than vmPCNL (p = 0.01). Univariable linear regression revealed that patient's comorbidities, OT, any postoperative complication and LOS were associated with hospitalization costs (all p < 0.001). Multivariable linear regression analysis revealed that LOS and OT were associated with hospitalization costs (all p < 0.001), after accounting for vmPCNL procedure, patients' comorbidities, and complications. CONCLUSION: vmPCNL may represent a valid option due to clinical and economic benefits. Shorter OT, the lower need for disposable equipment and the lower complication rate reduced procedural and hospitalization costs.

Comparación de la costo-efectividad de la nefrolitotomía percutánea y de la nefrolitotomía retrógrada flexible con láser de holmio en pacientes con litiasis renal de 20 a 30 mm en Colombia / Comparison of the Cost-effectiveness of Percutaneous Nephrolithotomy and Flexible Retrograde Holmium Laser Nephrolithotomy in Patients with Kidney Stones of 20 to 30 mm in Colombia

Introducción y Objetivo Con el advenimiento de nuevas tecnologías, vienen controversias respecto al espectro de sus aplicaciones. El costo derivado de estas tecnologías juega un papel muy importante en el momento de la toma de decisiones terapéuticas. Es por esto que consideramos relevante estimar la costo-efectividad de la nefrolitotomía percutánea comparada con la nefrolitotomía retrógrada flexible con láser de holmio en pacientes con litiasis renal de 20 mm a 30 mm en Colombia. Materiales y Métodos Por medio de la construcción de un modelo de árbol de decisión usando el programa Treeage (TreeAge Software, LLC, Williamstown, MA, EE.UU.), se realizó una comparación entre la nefrolitotomía percutánea y la nefrolitotomía retrógrada flexible con láser de holmio en pacientes con litiasis renal de 20 mm a 30 mm. La perspectiva fue la del tercer pagador, y se incluyeron los costos directos. Las cifras fueron expresadas en pesos colombianos de 2018. La mejoría clínica, definida como el paciente libre de cálculos, fue la unidad de resultado. Se hizo una extracción de datos de efectividad y seguridad por medio de una revisión sistemática de la literatura. La razón de costo-efectividad incremental fue calculada. Resultados El modelo final indica que la nefrolitotomía percutánea puede ser considerada como la alternativa más costo-efectiva. Los hallazgos fueron sensibles a la probabilidad de mejoría clínica de la nefrolitotomía percutánea. Conclusión Teniendo en cuenta las variables económicas, los supuestos del modelo y desde la perspectiva del tercer pagador, la nefrolitotomía percutánea para el tratamiento de pacientes con cálculos renales de 20 mm a 30 mm es costo-efectiva en nuestro país. Estos hallazgos fueron sensibles a los costos y a la efectividad de los procedimientos quirúrgicos.

Introduction and Objective The advent of new technologies leads to controversies regarding the spectrum of their applications and their cost. The cost of these technologies plays a very important role when making therapeutic decisions. Therefore, we consider it relevant to estimate the cost-effectiveness of percutaneous nephrolithotomy compared with flexible retrograde holmium laser nephrolithotomy in patients with kidney stones of 20 mm to 30 mm in Colombia. Materials and Methods Through the development of a decision tree model using the Treeage (TreeAge Software, LLC, Williamstown, MA, US) software, we compared percutaneous nephrolithotomy with flexible holmium laser retrograde nephrolithotomy in patients with kidney stones of 20 mm to 30 mm. The perspective was that of the third payer, and all direct costs were included. The figures were expressed in terms of 2018 Colombian pesos. Clinical improvement, which was defined as a stone-free patient, was the outcome unit. We extracted data on effectiveness and safety through a systematic review of the literature. The incremental cost-effectiveness ratio was calculated. Results In terms of cost-effectiveness the final model indicates that percutaneous nephrolithotomy may be considered the best alternative. These findings were sensitive to the probability of clinical improvement of the percutaneous nephrolithotomy. Conclusion Taking into account the economic variables, the assumptions of the model, and through the perspective of the third payer, percutaneous nephrolithotomy for the treatment of patients with kidney stones of 20 mm to 30mm is cost-effective in our country. These findings were sensitive to the costs and effectiveness of the surgical procedures.

Lean: Introduction of a Quality Improvement Concept into Percutaneous Nephrolithotomy to Improve Efficiency while Maintaining Safety / Lean: introducción de un concepto en la nefrolitotomía percutánea para mejorar la eficiencia mientras se mantiene la seguridad

Introduction and objective Standardization of surgical interventions reduces complications and costs and positively impacts intra and postoperative outcomes. Implementation of the lean concept, initially proposed in the auto industry, now becomes an interesting approach in the surgical setting. We want to present the results of how percutaneous nephrolithotripsy (PCNL) in a high-level center can be positively impacted by implementing the lean concept. Methods We evaluated a total of 140 PCNL procedures. Group 1 included all cases operated prior to implementing the lean concept and group 2 was composed of those operated after implementing the lean concept. We looked for all seven sources of waste to identify and modify our practice to improve efficiency and safety. We then collected intraoperative times and compared the ones prior to those after the implementation. Results After implementing the lean concept, with an average of six PCNL cases per day, a comparison was made to an equivalent number of cases prior to the lean implementation (group 1). The average total operative time for PCNL preintervention was 138 (confidence interval [CI]: 79 to 170) minutes and postlean intervention was 71.1 (CI: 43 to 157) minutes. Surgical time (cystoscopy to skin closure) was 36.1 (CI: 25 to 50) minutes prelean and 50 minutes postlean (CI: 23 to 154). For this last one, bilateral procedures were performed. Operative room turnover time was 27.8 (CI: 21 to 38) minutes prelean and 5.67 (CI: 3.5 to 12) minutes postlean. Induction time was 16.5 (CI: 5 to 55) minutes prelean and 5.4 (CI: 3.5 to 7.5) minutes postlean. Conclusion Implementation of the lean concept enables optimization of the surgical procedure, allowing hospitals to reduce costs and standardization.

Introducción y objetivo La estandarización de los procedimientos quirúrgicos reduce complicaciones, costos, y mejora resultados intra y postoperatorios. El concepto lean fue utilizado por primera vez en la industria automotriz. El presente trabajo busca implementar el concepto lean para optimizar el procedimiento de nefrolitotomía percutánea (NLP) en nuestro medio. Métodos Se realizaron 140 procedimientos de nefrolitotomía percutánea, los cuales se dividieron en 2 grupos: uno en el cual se registraron los tiempos intraoperatorios, y el segundo en que se registraron los tiempos luego de la implementación del concepto lean. Resultados Durante el período estudiado, se realizaron 70 procedimientos luego de la implementación del concepto lean, y se logró realizar un promedio de 6 procedimientos por día. Se compararon los tiempos operatorios, y se encontró un tiempo operatorio total promedio de 138 (intervalo de confianza [IC]: 79 a 170) minutos pre-lean, y de 71,1 (IC: 43 a 157) minutos post-lean. El tiempo quirúrgico (cistoscopia a cierre de piel) pre-lean fue de 36,1 (IC: 25 a 50) minutos, y el post-lean fue de 50 (IC: 23 a 154) minutos. Para este último, se trató de procedimientos bilaterales. El cambio de sala fue de 27,8 (IC: 21a 38) minutos pre-lean, y de 5,67 (IC: 3.5 a 12) minutos post-lean. El tiempo de inducción fue de 16.5 (IC: 5 a 55) minutos pre-lean, y de 5.4 (IC: 3.5 a 7.5) minutos post-lean. Conclusiones La implementación del concepto lean permite optimizar el procedimiento, con reducción de costos y estandarización del modelo de atención para cualquier centro asistencial. La movilización de los especialistas en nuestro modelo de atención permite un mayor cubrimiento poblacional de alta calidad.

Cost-effectiveness of Retrograde Intrarenal Surgery, Standard and Mini Percutaneous Nephrolithotomy, and Shock Wave Lithotripsy for the Management of 1-2cm Renal Stones.

OBJECTIVE: To perform a cost-effectiveness evaluation comparing the management options for mid-size (1-2cm) renal stones including percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shockwave lithotripsy (SWL). METHODS: A Markov model was created to compare cost-effectiveness of PCNL, mini-PCNL, RIRS, and SWL for 1-2cm lower pole (index patient 1) and PCNL, RIRS, and SWL for 1-2 cm non-lower pole (index patient 2) renal stones. A literature review provided stone free, complication, retreatment, secondary procedure rates, and quality adjusted life years (QALYs). Medicare costs were used. The incremental cost-effectiveness ratio (ICER) was compared with a willingness-to-pay(WTP) threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS: At 3 years, costs for index patient 1 were $10,290(PCNL), $10,109(mini-PCNL), $5,930(RIRS), and $10,916(SWL). Mini-PCNL resulted in the highest QALYs(2.953) followed by PCNL(2.951), RIRS(2.946), and SWL(2.943). This translated to RIRS being most cost-effective followed by mini-PCNL(ICER $624,075/QALY) and PCNL(ICER $946,464/QALY). SWL was dominated with higher costs and lower effectiveness. For index patient 2, RIRS dominated both PCNL and SWL. For index patient 1: mini-PCNL and PCNL became cost effective if cost ≤$5,940 and ≤$5,390, respectively. SWL became cost-effective with SFR ≥75% or cost ≤$1,236. On probabilistic sensitivity analysis, the most cost-effective strategy was RIRS in 97%, mini-PCNL in 2%, PCNL in 1%, and SWL in 0% of simulations. CONCLUSION: For 1-2cm renal stones, RIRS is most cost-effective. However, mini and standard PCNL could become cost-effective at lower costs, particularly for lower pole stones.

Role of Preoperative Renal Stone Complexity Assessment by Guy's Stone Score as a Predictor of Percutaneous Nephrolithotomy Outcomes.

INTRODUCTION: Various nephrolithometric scoring systems have recently emerged to predict the outcomes of percutaneous nephrolithotomy (PCNL). However, there is no consensus upon an ideal tool. The current study aimed to assess the correlation between Guy's stone score (GSS) and PCNL outcomes. METHOD: This was a hospital-based observational study of 2-year duration. All patients electively undergoing PCNL for renal stones during the study period were included. Based on the imaging findings, the stones were categorized as simple (GSS I & II) and complex (GSS III & IV). The association between GSS and duration of the procedure, the number of percutaneous tracts needed, stone-free rate (SFR), and the severity of complications based on modified Clavien classification and postoperative stay were assessed. RESULTS: Total number of the patients studied were 100 (n = 100), and most of the patients were in the category of GSS II (51%). Post-extrapolation of χ2 to Pearson's test, GSS demonstrated a significant association with duration of surgery, the number of percutaneous tracts needed, the severity of complications, and SFR. CONCLUSIONS: Preoperative assessment of stone complexity by using GSS effectively correlated with SFR as well as other PCNL outcomes. Hence, we recommend utilizing this predictive tool for standardized documentation, preoperative planning, and better patient counseling.

Lessons Learnt (Clinical Outcomes and Cost Savings) from Virtual Stone Clinic and Their Application in the Era Post-COVID-19: Prospective Outcomes over a 6-Year Period from a University Teaching Hospital.

Introduction: We introduced a nurse-led telephone-based virtual stone clinic (VSC) follow-up for the surveillance of patients with asymptomatic renal calculi or those at a high risk of recurrent kidney stone disease (KSD). The aim of this study was to look at the outcomes of VSC and its role in the post-COVID era. Methods: Prospective outcomes audit was done for all patients referred to the VSC for a 6-year period (March 2014-April 2020). VSC is led by specialist stone nurses for on-going surveillance of KSD patients. Results: A total of 290 patients were seen (468 individual appointments; 1.6 ± 1.0 per patient), with a mean age of 57.0 ± 15.8 years (range: 17-92) and a men-women ratio of 3:2. The referral was for surveillance of asymptomatic small renal stones (230, 79.3%); history of recurrent stone disease (45, 15.5%); solitary kidneys (5, 1.7%); cystine stones; young age; and other conditions (10, 3.4%). The mean stone size was 5.0 ± 2.7 mm, followed up with kidney, ureter, and bladder radiograph (225, 77.6%) and ultrasound scan (USS) (65, 22.4%), for median duration of 12 months (range: 3-24 months). At the end, 132 patients (45.6%) remained in VSC, 106 (36.6%) were discharged, 47 (16.2%) returned to face-to-face clinic or treatment, and 5 (1.7%) had emergency admissions. Of 47 patients who returned, 23 (48.9%) developed new symptoms, 21 (44.6%) had stone growth, and 3 defaulted to face-to-face appointment. Thirty-five patients needed surgical intervention (URS-21, SWL-13, and PCNL-1) and 10 were managed conservatively. VSC reduced the cost per clinic appointment from £27.9 to £2 per patient (93% reduction), equating to a total saving of £12,006 for the study period. Conclusion: Nurse-led VSC not only provided a safe follow-up but also allowed to substantially reduce the cost of treatment by allowing patients to be either discharged or return to a face-to-face clinic or surgical intervention if needed. Post-COVID, this model using telemedicine will have a much wider uptake and further help to optimize health care resources.