Avaliação da depuração de litíase ureteral até 7 mm em pacientes com cateter duplo-J / Assessment of ureteral lithiasis clearance up to 7 mm in patients with double-J catheter

A prevalência da nefrolitíase está em torno de 1-15% com estimativa crescente, sendo a ureterolítíase comum nos atendimentos de urgência. Custos elevados estão associados ao manejo da ureterolitíase em proporções que chegam ultrapassar 5 bilhões de dólares nos EUA. A cateterização com duplo-J por pielonefrite obstrutiva pode, em alguns casos, ser a única intervenção necessária. O objetivo foi analisar o impacto da retirada de cateteres duplo-J em pacientes com pielonefrite obstrutiva por ureterolitíase menor ou igual a 7 mm, sem intervenção cirúrgica prévia. Foi realizado um estudo clínico prospectivo, no período de Outubro de 2021 a Abril de 2023 em um hospital terciário da cidade de São Paulo. O estudo incluiu pacientes sem manipulação endourológica prévia, submetido à passagem de cateter duplo-J por pielonefrite obstrutiva secundária à ureterolitíase menor ou igual a 7mm. O cateter foi retirado a partir de 21 dias do evento inicial, e tomografia computadorizada foi realizada 14 dias após a extração do cateter. Durante o período, 36 pacientes foram incluídos no estudo, sendo 19 homens, e 61,1% com topografia em ureter distal. Desses, 29 pacientes (80,5%) apresentaram depuração do cálculo na tomografia de controle, apenas 7 (19,5%) desses pacientes foram submetidos ao retratamento. O diâmetro médio dos cálculos no grupo de pacientes que depuraram foi de 4,9mm (variação de 3 a 7 mm), com tempo médio de permanência do cateter de 39,5 dias. Em relação ao grupo que necessitou de retratamento, o diâmetro médio foi de 5,2 mm (variação de 4 a 7 mm), com tempo de permanência de 52,1 dias. Pacientes com ureterolitíase não infecciosa podem, inicialmente, serem tratados clinicamente. No tratamento da pielonefrite obstrutiva a utilização do cateter ureteral pode ser uma ferramenta única, devido à elevada depuração e incidência mínima de complicações, reduzindo a morbidade e os custos aos serviços de saúde. Palavras-chave: Ureterolitíase. Pielonefrite. Cateter duplo-J.

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.

Small ruminant urinary obstruction: decision trees for treatment.

Urolithiasis is the most common cause of urinary tract disease in small ruminants and has significant economic and production impacts worldwide. Urolithiasis is multifactorial in origin and generally begins with the formation of cystoliths followed by urethral obstruction. The condition is most common in males. Clinical signs are variable depending on the severity of the obstruction. Uroliths can be calcium, struvite, or silicate based; however, struvite and amorphous magnesium calcium phosphate are the most common urolith types observed in small ruminants. Although urethral process (vermiform appendage) amputation is widely considered the first line of treatment, reobstruction is common within the first 36 hours. Surgical interventions such as temporary tube cystostomy, perineal urethrostomy (PU), modified proximal perineal urethrostomy, vesico-preputial anastomosis (VPA), and urinary bladder marsupialization (BM) are reported to carry an improved prognosis for long-term survival. PU carries a lower proportion of long-term success (> 12-month survival time) when compared with VPA and BM. Stoma stricture and urine scald are the most commonly observed surgical complications. Currently, the literature provides minimal direction for clinician decision-making in managing these cases while accounting for patient history, client financial ability, composition of calculi, and potential treatment complications. Small ruminant urinary obstructions are challenging and complicated conditions to treat, due to their multifactorial etiology, ruminant urogenital anatomy, and the variety of imperfect treatment options available. The purpose of this article this article is to provide veterinary practitioners with decision trees to guide management and treatment of urolithiasis in small ruminants.

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.

Disposable Ureteroscopes in Urology: Current State and Future Prospects.

Ureteroscopy is the most common surgical modality for stone treatment. Reusable flexible ureteroscopes are delicate instruments that require expensive maintenance and repairs. Multiple single use ureteroscopes have been developed recently to combat the expensive and time-intensive sterilization and repair of ureteroscopes. Although multiple studies have looked at different aspects of reusable and single use ureteroscopes, there is significant heterogeneity in performance measures and cost between the 2 categories, and neither has a clear advantage. Both can be used successfully, and individual and institution level factors should be considered when deciding which ureteroscope to use.

Demographic and Socioeconomic Factors Associated with Urinary Stone Disease Management in a Large Urban US Population.

OBJECTIVE: To determine the influence of socioeconomic parameters on urinary stone surgeries. METHODS: A retrospective cohort study analyzed patients undergoing urolithiasis surgery in our community network hospital in North Carolina from 2005-2018. RESULTS: Of 7731 patients, 2160 (28%), 5,174 (67%), and 397 (5%) underwent SWL, URS, and PCNL, respectively. A higher proportion of Whites underwent URS (67%) and SWL (74%) than PCNL (56%); whereas a larger percentage of Blacks underwent PCNL (24%) than URS (20%) and SWL (15%) groups (P <.001). Private insurance payers were greater in the SWL (95%) group than URS (80%) and PCNL (81%) (P <.001). The distribution of median income was significantly different amongst the 3 surgeries with higher income classes overutilizing SWL and underutilizing PCNL compared to lower income classes (P <.001). In linear regression modeling, the proportion of SWL in a postal code was positively associated with median income (R2=0.55, P <.001); URS and PCNL were negatively associated with median income (R2=0.40, P <.001 and R2=0.41, P <.001, respectively). On multivariate logistic regression modeling, Blacks were significantly more likely to undergo PCNL than Whites (aOR 1.32, 95% CI 1.01-1.74 P <.050). Private insurance payers were more likely to undergo SWL (aOR 11.0, 95% CI 7.26-16.8, P <.0001) than public insurance payers. Patients in higher median income brackets are significantly less likely to undergo PCNL than those in the <$40,000 income bracket (P <.0001). CONCLUSION: Our study suggests that socioeconomic status impacts urolithiasis surgical management, underscoring disparity recognition importance in endourologic care and ensuring appropriate surgical care regardless of socioeconomic status.

Low Urologist Density Predicts High-Cost Surgical Treatment of Stone Disease.

Introduction and Objectives: Lack of access to urologic specialists is approaching crisis levels as the number of urologists is decreasing, while the demand for urologic care is increasing. The financial implications of this have not been explored. The objective of this study is to examine the impact of access and other patient factors on cost to treat urolithiasis. We hypothesized that markers of poor access would associate with higher costs of surgical encounters for patients presenting with urolithiasis. Methods: A retrospective review of prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) from September 2015 to July 2018 was conducted to investigate characteristics of surgical patients treated for urinary stone disease. Univariate analysis was performed using the Welch two-sample t-test. Multivariate analysis was performed using logistic regression. Statistical analysis was performed in R version 3.5. Results: When taking into account age, delayed presentation, procedure type, stone size >20 mm, American Society of Anesthesiologists (ASA) code, gender, race, income, distance, urologist density, body mass index, diabetes, infection, education, language, insurance, and stone complexity, patients undergoing percutaneous nephrolithotomy procedure (p < 0.001; odds ratio [OR] 12.9, confidence interval [CI] 4.05-48.5), urologist density in the bottom quartile (p = 0.014; OR 4.66, CI 1.40-16.9), diabetes (p = 0.018; OR 4.38, CI 1.32-15.6), and infection (p = 0.007; OR 4.51, CI 1.55-14.0) were the only variables statistically significant for association with top quartile of total cost. Conclusions: Surgical encounter costs are largely dictated by patient clinical factors, but low regional urologist density appears to independently predicted for high-cost stone surgery. Increasing patients' access to a urologist may prove to be financially beneficial in the longitudinal reduction in health care costs for stone disease.

Switching to Single-use Flexible Ureteroscopes for Stones Management: Financial Impact and Solutions to Reduce the Cost Over a 5-Year Period.

OBJECTIVES: To assess the financial impact of switching to single-use ureteroscopes (sURS) in urolithiasis management for a hospital, over a 5-year period, and to identify possible solutions to contain or reduce it. METHODS: A Budget Impact (BI) model was designed for a public hospital performing around 200 ureteroscopies or extracorporeal shockwave lithotripsies per year. The BI was estimated as the difference between financial balances (between costs and revenues) of 2 environments (with and without sURS). The population was defined as adults treated for urolithiasis. The BI model was based on assumptions about the expected progression in the incidence of urolithiasis, and the expected change in clinical practices due to the availability of sURS. We considered the costs and revenues of hospital stays, the purchase price of sURS and the costs of digital or fiberoptic reusable ureteroscopes (rURS). Univariate and multivariate sensitivity analyses were performed. RESULTS: The cumulative 5-year financial impact of switching completely to sURS was €807,824 and €649,677 in comparison with fiberoptic and digital rURS respectively. This impact could be reduced by half or more if the health-care facility were to adopt different solutions, including negotiating the purchase price of sURS, developing outpatient activity and reducing production costs for ureteroscopy procedures. CONCLUSION: The BI model gives decision-makers a more accurate picture of the financial impact of switching to sURS and highlights ways to reduce the expected additional cost.

European Association of Urology Section of Urolithiasis (EULIS) Consensus Statement on Simulation, Training, and Assessment in Urolithiasis.

BACKGROUND: Simulation-based training offers an acceptable adjunct to the traditional mentor-apprentice model in helping trainees to traverse the early stages of the learning curve for ureteroscopy and percutaneous renal surgery. In addition, nontechnical skills are increasingly important in preventing adverse events in the operating room, and simulation-based training can be used for training in such skills. Incorporation of simulation into formalised, standardised, and validated curricula offers an applicable method for training residents. OBJECTIVE: To develop a curriculum for urolithiasis procedures incorporating technical and nontechnical skills training for implementation across Europe. DESIGN, SETTING, AND PARTICIPANTS: An international panel of experts from EULIS, EUREP, ESU and ESUT was consulted in five stages. The study incorporated a mix of qualitative and quantitative data for collection and analysis. Responses were drawn out in (1) an opinion survey and (2) a curriculum development survey, which were discussed in (3) a focus group meeting. Group responses from this meeting were analysed for themes, which were discussed at (4) a focus group meeting, where consensus was reached among the group. Data analysis and integration at this stage were used to draft the curriculum. RESULTS AND LIMITATIONS: All group meetings were transcribed from the focus group discussion. Eight themes were generated, into which all data were categorised. These were: need for a training curriculum; curriculum objectives; curriculum structure; curriculum content; teaching platforms and tools; assessment and certification; validation and implementation; and global integration of the curriculum. A curriculum, including recommended simulators for use, was subsequently proposed. CONCLUSIONS: We propose a comprehensive curriculum for training in urolithiasis. Additional planning is required for full validation and implementation before it can be used to train residents. PATIENT SUMMARY: Stone disease accounts for a major proportion of surgical interventions worldwide. We describe a consensus guideline for effective training of stone surgeons.

The Evolving Role of Retrograde Intrarenal Surgery in the Treatment of Urolithiasis.

CONTEXT: Retrograde intrarenal surgery has gained substantial popularity worldwide thanks to continuous improvements in technology and techniques, and is now considered one of the first-line treatment options for active removal of renal stones. OBJECTIVE: To provide a comprehensive synthesis of the main evidences in literature on the current management of kidney stones by means of retrograde intrarenal surgery (RIRS). EVIDENCE ACQUISITION: A review of literature has been conducted using search string "retrograde intrarenal surgery OR flexible ureteroscop* OR ureterorenoscop*", without any language restriction; PubMed, Embase, and Scopus databases were searched in November 2016. Exclusion criteria involved manuscripts dealing with paediatric patients, and RIRS for proximal ureteric stones and for upper tract urothelial tumours. Fifty-seven papers were finally included in the analysis. EVIDENCE SYNTHESIS: Technological progress focuses on the miniaturisation of disposables and scopes, as well as on the increase of durability and improvement of the quality of image provided by these instruments. The technique has been in continuous development following the progress in technology. Currently, the main target of RIRS are renal stones 1-2cm in size, even though tertiary centres are pushing the boundaries to the treatment of larger stones. Nomograms predicting surgical outcomes and improving preoperative surgical planning have been developed. RIRS has been shown to be safe and effective in patients with specific conditions such as bleeding diathesis, anatomical malformation, or pregnancy. Cost effectiveness of the approach is still a matter of controversy when compared with other treatment modalities. CONCLUSIONS: RIRS is a well-established procedure under constant evolution with advances in technique and technology. It has gained worldwide popularity due to its minimal invasiveness and satisfactory outcomes. Future developments are needed to increase its cost effectiveness and extend its use to a wider range of indications. PATIENT SUMMARY: In this collaborative review, we have summarised the best evidence in literature with respect to current management of renal stones by means of retrograde intrarenal surgery (RIRS) with flexible ureteroscopy. RIRS has been shown to be a safe and effective treatment modality in a wide spectrum of clinical scenarios; technology and technique are continuously evolving to further push boundaries of its indications and efficacy.

Comparison of cost of care for tethered versus non-tethered ureteric stents in the management of uncomplicated upper urinary tract stones.

BACKGROUND: Many surgeons use a stent after ureteroscopic lithotripsy (URSL). For short-term stenting purposes, a surgeon has the choice of either a tethered or a non-tethered stent. Stents may be associated with complications that entail an additional cost to their use. There is a paucity of data on the direct healthcare cost of using stent type after either primary or secondary URSL. METHODS: We retrospectively reviewed medical records for patients who underwent URSL for uncomplicated urolithiasis between January 2013 and December 2013 at two tertiary referral hospitals. Costs data was sourced from the costing department with complete data available for 134 patients. The overall medical care cost was estimated by computing the cost of surgery, stent-related emergency department presentations, re-admissions and stent removal. RESULTS: A total of 113 patients had tethered stents and 21 had non-tethered stents, with similar age and gender composition between the two groups and complications rates. The mean cost of URSL and stent placement was A$3071.7 ± A$906.8 versus A$3423.8 ± A$808.4 (P = 0.049), mean cost of managing complications was A$309.4 ± A$1744.8 versus A$31.3 ± A$98.9 (P = 0.096), mean cost of out-patient clinic stent removal was A$222.5 ± A$60 versus A$1013.6 ± A$75.4 (P < 0.001) for endoscopic stent removal, overall mean cost of care was A$3603.6 ± A$1896.7 versus A$4468.1 ± A$820.8 (P = 0.042) for tethered and non-tethered stents, respectively. CONCLUSION: It is cheaper to use a tethered ureteric stent compared with non-tethered stents for short-term stenting after uncomplicated URSL, with a mean cost saving of A$864.5.

Geographical variation in the management of urolithiasis in Australia.

BACKGROUND: To examine any geographical variation in the management of urolithiasis amongst the Australian states and territories. METHODS: Retrospective study with data obtained from the Medicare Australia database, the Royal Australasian College of Surgeons and the Urological Society of Australia and New Zealand. RESULTS: Minimally invasive stone treatment with shock wave lithotripsy (SWL) and ureteroscopy (URS) accounted for the majority of stone treatments in Australia (98%). Variation of stone treatment modalities exists amongst the Australian states and territories with an inverse relationship between the use of SWL and URS. We compared Western Australia (WA) and Queensland (QLD) which have a comparable geographical area. SWL accounts for 1% and 22% of stone treatments in WA and QLD, respectively. In WA, urologists are concentrated in two cities with no SWL available in the private sector. In QLD, urologists are distributed in 11 cities with SWL available in both the public and private sector. The three largest states or territories by geographical area - the Northern Territory, WA and QLD - have stone treatment rates of 1:1337, 1:1110 and 1:2432 per capita of privately insured patients, respectively. In comparison, smaller Australian states/territories such as Tasmania and Victoria have stone treatment rates of 1:619 and 1:765 per capita of privately insured patients, respectively. CONCLUSION: The distribution of urologists and treatment modalities available in each state or territory appear to play a contributory role in choice of treatment modality. In addition, inequality to stone treatment access exists in geographically large Australian states/territories.

Benefits and risks of ureteral access sheaths for retrograde renal access.

PURPOSE OF REVIEW: Ureteral access sheath (UAS) became increasingly popular worldwide. However, the safety of its routine use remains controversial. The aim of the current revision is to provide a systematic review on the benefits and disadvantages of the UAS. RECENT FINDINGS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Two reviewers independently searched the literature, finally identifying 20 articles valuable for this review. The use of UAS demonstrated several advantages to facilitate retrograde intrarenal access, lower intrarenal pressure, protect the ureter, protect the scope, and expedite stone extraction. Despite this, there is also some evidence that UAS use may be associated with acute ureteral injury and long-term complications, apparently related to maneuvers for UAS insertion and mucosal or deeper layers of injury and ischemia. Furthermore, there are still pending questions on the possible increase in stone-free rates, and decrease in operative time and costs. SUMMARY: Although the use of UAS is associated with some risk and limiting factors, it appears from this systematic review that its use is common and safe for the retrograde intrarenal access. Therefore, UAS is highly recommended for the treatment of upper tract disease by means of retrograde intrarenal surgery.

Contemporary Trends in the Ambulatory Surgical Treatment of Urolithiasis: Population-Based Analysis.

PURPOSE: To describe the utilization of shockwave lithotripsy (SWL) and ureteroscopy (URS) in ambulatory surgery centers, as well as to identify patient-specific factors predictive of one procedure over the other. PATIENTS AND METHODS: We evaluated the current trends in the use of SWL and URS in the ambulatory settings over a 5-year period in the state of California using the State of California Office of Statewide Health Planning and Development (OSHPD) database. RESULTS: We identified 113,447 ambulatory kidney stone surgical procedures including 64,632 SWL (57%) and 48,815 URS (43%) treatments in the OSHPD database between 2005 and 2010. The total annual ambulatory stone surgeries increased from 17,831 cases in 2005 to 18,933 cases in 2010 (P<0.001). Between 2005 and 2010, the use of URS increased significantly from 6978 (39%) cases in 2005 to 9259 (49%) cases in 2010 (P<0.0012), whereas the use of SWL decreased from 10,853 (61%) cases in 2005 to 9674 (51%) cases in 2010 (P=0.0012). In multivariate analysis, age ≥ 75 years (P<0.001), hypertension (P=0.025), and obesity (P<0.001) all increased odds of undergoing URS. In addition, men (P=0.013) and non-Medicaid patients (P<0.001) were more likely to undergo URS. CONCLUSIONS: The use of URS increased significantly in the state of California among patients undergoing urinary stone surgical procedures in the ambulatory setting, while the use of SWL decreased between 2005 and 2010. Possible explanations for these trends include improved URS stone-free rates, improved cost-effectiveness of URS, and enhanced technology leading to increased use of URS over SWL.

Contemporary Trends of Inpatient Surgical Management of Stone Disease: National Analysis in an Economic Growth Scenario.

PURPOSE: To assess trends in urologic surgical management of upper tract urolithiasis in Brazil over the past 15 years. MATERIALS AND METHODS: The Public Health System of Brazil (SUS) provides health coverage to 47% to 74% of the population. SUS has a longitudinal hospital inpatient database (SIH/SUS). Hospital discharges between January 1,1998 and December 31, 2012 were abstracted from the SIH/SUS. All inpatient hospitalizations for patients of any age with a primary/secondary diagnosis code of N20.x (calculus of kidney or ureter) were abstracted (ICD-9/10). All urolithiasis-related procedure codes were analyzed. The absolute number of procedures/year and the proportion among all techniques were analyzed for Brazil and also separately for the five distinguished regions of the country. Prevalence trends over the studied period were quantified by the estimated annual percent change (EAPC) using the least squares linear regression methodology. Significance was set at P<0.05. RESULTS: The number of surgical interventions for stone disease increased significantly from 10080 to 24713 (+145%; EAPC=1008.1; P<0.001). The most common surgical modalities in 1998 were nephrectomy (n=2918; 29%), ureterolithotomy (n=2361; 23%), and pyelolithotomy (n=1771; 18%). In 2012, ureteroscopy (URS) was the most commonly performed procedure (n=8725; 35%), followed by ureterolithotomy (n=5822; 24%), and nephrectomy (n=3466; 14%). Between 1998 and 2012, percutaneous nephrolithotomy had the highest significant relative increase (+791.8%; EAPC=0.6%; P<0.001), followed by URS (+607%; EAPC=1.78%; P<0.001). Pyelolithotomy showed the most significant decrease (-47.5%; EAPC = -0.91%; P<0.001). All five regions presented a significant positive increase in the EAPC (P<0.001). CONCLUSION: Trends of stone disease surgical management in the public health system of Brazil follow worldwide tendencies toward less invasive treatment modalities.

The effect of repair costs on the profitability of a ureteroscopy program.

BACKGROUND AND PURPOSE: Ureteroscopy (URS) is a common treatment for patients with stone disease. One of the disadvantages of this approach is the great capital expense associated with the purchase and repair of endoscopic equipment. In some cases, these costs can outpace revenues and lead to an unprofitable and unsustainable enterprise. We sought to characterize the profitability of our URS program when accounting for endoscope maintenance and repair costs. MATERIALS AND METHODS: We identified all URS cases performed at a single hospital during fiscal year 2013 (FY2013). Charges, collection rates, and fixed and variable costs including annual equipment repair costs were obtained. The net margin and break-even point of URS were derived on a per-case basis. RESULTS: For 190 cases performed in FY2013, total endoscope repair costs totaled $115,000, resulting in an average repair cost of $605 per case. The vast majority of cases (94.2%) were conducted in the outpatient setting, which generated a net margin of $659 per case, while inpatient cases yielded a net loss of $455. URS was ultimately associated with a net positive margin approaching $600 per case. On break-even analysis, URS remained profitable until repair costs reached $1200 per case. CONCLUSIONS: Based on these findings, an established URS program can sustain profitability even with large equipment repair costs. Nonetheless, our findings serve to emphasize the importance of controlling costs, particularly in the current setting of decreasing reimbursement. A multifaceted approach, based on improving endoscope durability and exploring digital and disposable platforms, will be critical in maintaining the sustainability of URS.

Stone specialist, cancer surgeon, or both? Optimizing the endourology fellowship training model.

BACKGROUND: The traditional endourology fellowship model includes advanced training in minimally invasive surgery (MIS) for both benign disease/kidney stones and oncology. We have anecdotally observed, however, that many former endourology fellows subspecialize within their practices. Recently the fellowship paradigm, accredited by the Endourological Society (EUS), has been modified to allow for emphasis on benign disease/kidney stones or laparoscopy/robotic surgery, which is heavily weighted toward oncology. In this study, we sought to assess the practice patterns of former endourology fellows to evaluate various fellowship models. METHODS: Email addresses for 320 of the 327 endourology fellowship graduates between 2001 and 2010 identified by the EUS were obtained. These were cross-referenced with the American Urological Association (AUA) member database to maximize the yield of valid addresses. A 20-question electronic survey (SurveyMonkey Inc., Palo Alto, CA) was sent to this group. Eleven addresses were invalid and 24 recipients opted out of the survey. RESULTS: Responses were received from 121 of 285 former fellows with active email addresses who did not opt out of the survey (42.5%). Of these respondents, 86% completed fellowships in North America and 71% completed 1-year fellowships. Among respondents in academic practice (46%), 44% reported a "mixed" benign and oncology-based practice, compared to 68% of nonacademic practitioners (P=0.009). Among academic practitioners, 33% practice predominantly MIS for benign disease, and 24% practice predominantly MIS for oncology, versus 23.1% (P=0.3) and 9% (P=0.04), respectively, of nonacademic practitioners. Most fellows had stability of clinical interests (benign v malignant disease) before and after their fellowship. CONCLUSION: Fellowship-trained endourologists who work in an academic setting are more likely to have a subspecialized practice. A subset of private practice endourologists also have focused practices in benign disease. While the traditional fellowship model will be useful for some graduates, subspecialized tracks may improve the efficiency of the training model.

Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis.

PURPOSE: The use of medical expulsive therapy to hasten stone passage potentially decreases expenditures around episodes of renal colic. However, these efficiency gains may be mitigated if patients treated with medical expulsive therapy have frequent health care encounters due to pain while waiting for the stones to pass. MATERIALS AND METHODS: Using claims data (2002 to 2006) we identified adult men with acute renal colic. We compared 6-week payments as well as frequency of hospitalization and emergency department revisits associated with an initial course of medical expulsive therapy with those for early endoscopic stone removal. To account for unmeasured confounding we performed an instrumental variable analysis, exploiting variation in recommended treatments based on the day of the week that a patient's first emergency department visit occurred. RESULTS: Overall 1,835 and 4,397 men underwent medical expulsive therapy or early endoscopic stone removal, respectively. Although minimal differences existed between men with respect to the day of the week of emergency department presentation, weekend encounters were strongly associated with receiving medical expulsive therapy (p <0.001). Two-stage least squares regression revealed 6-week payments to be tenfold lower for men on medical expulsive therapy who were candidates for either treatment (p <0.001). While there was no difference in frequency of hospitalization, these men were more likely to have a repeat emergency department visit compared to those who underwent endoscopic stone removal (68.8% vs 39.6%, respectively, p = 0.025). CONCLUSIONS: Findings on medical expulsive therapy are mixed, with lower 6-week payments but more frequent repeat emergency department visits. These data inform patients who are candidates for medical expulsive therapy or endoscopic stone removal when making decisions about their care.

Ureteroscopia flexible: experiencia inicial / Flexible ureteroscopy: experience in 13 patients

Background: Flexible ureteroscopy is an increasingly used diagnostic and therapeutic tool for the upper urinary tract. Aim: To report our experience with flexible ureteroscopy. Material and Methods: Analysis of 13 procedures performed to seven males and 6 women aged 30 to 72 years. Results: The indications for flexible ureteroscopy were urinary lithiasis in six patients, a filling defect found in a CAT scan in five, proximal displacement of a double J catheter in one patient and unilateral hematuria in one patient. Lithiasis was managed with extracorporeal lithotripsy using a Holmium laser. Biopsies were obtained from the sites with filling defects; the catheter was extracted using a Dormia basket. In the patient with hematuria, a hemangioma was found and managed with laser excision. No complications were registered. Conclusions: Flexible ureteroscopy is safe and effective.

Introducción: El gran desarrollo tecnológico de los últimos años ha permitido un impresionante avance en la endourologia. Debido a esto, la ureteroscopia flexible ha ganado cada vez más espacio, tanto como método diagnóstico y terapéutico, en la patología de la vía urinaria alta. Presentamos nuestra experiencia inicial en ureteroscopia flexible. Material y Métodos: Entre marzo y noviembre de 2009 realizamos 13 ureteroscopias flexibles, analizándose en todos los casos las variables demográficas y perioperatorias. Se describe además la técnica quirúrgica. Resultados: Realizamos un total de 13 ureteroscopias flexibles en 7 hombres y 6 mujeres, con una edad promedio de 55 años. Respecto a la indicación del procedimiento, en 6 casos esta fue producto de un cuadro de litiasis urinaria, en 5 casos debido a un defecto de llene en la tomografía axial computada (TC), en 1 paciente debido al desplazamiento proximal de un catéter Doble-J y en 1 paciente producto de una hematuria unilateral. El manejo de las litiasis se realizó mediante litotricia intracorpórea con láser Holmium. En los defectos de llene, se realizaron biopsias del sitio del defecto. El catéter Doble-J fue extraído con Dormia. Finalmente, en el paciente con hematuria se evidenció la presencia de un hemangioma, el que fue manejado con láser. No se registraron complicaciones. Discusión: El desarrollo de los ureteroscopios flexibles ha permitido ampliar el uso de la ureteroscopia tanto en lo diagnóstico como en lo terapéutico. Las complicaciones son cada vez menos frecuentes, convirtiéndolo en un procedimiento seguro y eficaz para el manejo de la patología de la vía urinaria alta.