Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location.

BACKGROUND: The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates. PURPOSE: To identify predictors of revisits among patients with ureteral calculi in the ED. DESIGN, SETTING, AND PARTICIPANTS: Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit. RESULTS: Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021). CONCLUSIONS: Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

Ovarian torsion masquerading as a ureteral stone.

BACKGROUND: Abdominal pain is the most common complaint within the emergency department (ED) and has many varied etiologies. Some of these conditions can be medical emergencies, including ovarian torsion. While representing just 3% of gynecologic emergencies, ovarian torsion should be considered in all females presenting to the ED with abdominal or pelvic complaints. CASE: A 38-year-old G5P5 female with a past medical history significant for ureterolithiasis presented to a freestanding ED with abdominal pain, nausea, and vomiting. She developed sudden onset of right sided abdominal pain radiating to her right flank upon awakening. The initial differential diagnosis was for ureterolithiasis or appendicitis. Her complete blood count (CBC) was normal, and testing for pregnancy, infection, and hematuria was negative. Computed topography (CT) imaging of the abdomen and pelvis revealed a 9 cm adnexal mass, consistent with a possible dermoid cyst. A pelvic ultrasound was ordered which showed a possible ovarian torsion. She was transferred to a tertiary care hospital where she had a laparoscopy with right-sided oophorectomy and salpingectomy performed. DISCUSSION: This patient presented with abdominal pain, nausea, and vomiting and was first suspected to have ureterolithiasis or appendicitis. She was found to have an ovarian torsion with a dermoid cyst, which resulted in the loss of her ovary and fallopian tube. This case demonstrates the importance of including gynecologic emergencies in the differential on all female patients presenting with abdominal pain.

[Retrograde Ureteroscopic Lithotripsy with Ureteral Access Sheath Via Cutaneous Ureterostomy after Urinary Diversion : A Case Report].

A 65-year-old man presented with a history of rectal cancer 20 years prior that led to the development of a cutaneous ureterostomy and a colostomy. Subsequently, the patient was diagnosed with acute complicated pyelonephritis due to a right ureteral stone. After the placement of a single J ureteral stent in the right ureter for therapeutic management, the patient was referred to our institution for treatment of the right ureteral stone. An abdominal computed tomography (CT) revealed an 11×8 mm stone in the upper right ureter. A 10/12 Fr ureteral access sheath was inserted through the cutaneous ureterostomy and retrograde ureteroscopic lithotripsy was performed. Although a febrile urinary tract infection appeared postoperatively, the patient was discharged on the sixth postoperative day. At postoperative 1-month, CT showed no residual stones and no hydronephrosis. The use of a ureteral access sheath in performing retrograde ureteroscopic lithotripsy effectively managed the ureteral stone with cutaneous ureterostomy.

Ureteral Wall Thickness Is an Effective Predictor of Ureteral Stone Impaction and Management Outcomes: A Systematic Review and Meta-analysis.

PURPOSE: Ureteral stone impaction is associated with unfavorable endourological outcomes; however, reliable predictors of stone impaction are limited. We aimed to assess the performance of ureteral wall thickness on noncontrast computed tomography as a predictor of ureteral stone impaction and failure rates of spontaneous stone passage, shock wave lithotripsy, and retrograde guidewire and stent passage. MATERIALS AND METHODS: This study was completed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A search was conducted in April 2022 for all adult, human, and English language studies investigating ureteral wall thickness using PROSPERO, OVID Medline, OVID EMBASE, Wiley Cochrane Library, Proquest Dissertations & Theses Global, and SCOPUS. A systematic review and meta-analysis using random effects model was conducted. Risk of bias was assessed using the MINORS (Methodological Index for Non-randomized Studies) score. RESULTS: Fourteen studies with a pooled population of 2,987 patients were included for quantitative analysis, and 34 studies were included in our qualitative review. Meta-analysis findings suggest that a thinner ureteral wall thickness is associated with more favorable subgroup stone outcomes. Thinner ureteral wall thickness suggests a lack of stone impaction and was associated with improved rates of spontaneous stone passage, successful retrograde guidewire and stent placement, and improved shock wave lithotripsy outcomes. Studies lack a standardized ureteral wall thickness measurement protocol. CONCLUSIONS: Ureteral wall thickness is a noninvasive measure that predicts ureteral stone impaction, and thin measurements are predictive of successful outcomes. Variability in measurement methods confirms that a standardized ureteral wall thickness protocol is needed, and the clinical utility of ureteral wall thickness is yet to be determined.

Is low-dose tadalafil better than tamsulosin? A randomized controlled trial in shockwave lithotripsy for solitary upper tract calculi.

OBJECTIVE: To ascertain whether low-dose tadalafil (5 mg) is more efficient than tamsulosin (0.4 mg) in facilitating calculus expulsion in those receiving extracorporeal shockwave lithotripsy for solitary upper urinary tract calculi. PATIENTS AND METHODS: This was a triple-blinded, prospective, superiority, randomized controlled, single-centre trial. A total of 250 patients with solitary renal or ureteric calculus measuring 6-24 mm were randomized (1:1) to receive either 0.4 mg tamsulosin or 5 mg tadalafil daily for 30 days or until calculus clearance, whichever was earlier. RESULTS: There was no difference in the primary outcome, namely, calculus expulsion rate at 30 days (tamsulosin vs tadalafil, n (%) 99 [81.1%] vs 98 [80.3%] respectively, 95% confidence interval = 0.8% [-9.0, 10.7], P = 0.874). Similarly, a lack of difference was also noted in the secondary outcome, number of days to expulsion (tamsulosin vs tadalafil, geometric mean [SD] 13.59 [2.39] vs 13.74 [2.39] respectively, P = 0.928). Four patients discontinued the drug due to adverse drug reactions in the tadalafil group. CONCLUSIONS: Low-dose tadalafil is not superior to tamsulosin in improving calculus expulsion when used as an adjunct to shockwave lithotripsy. In this study, we also noted that tadalafil was less tolerated.

Clinical and time-related predictors of sepsis in patients with obstructive uropathy due to ureteral stones in the emergency setting.

PURPOSE: Well-defined clinical predictors of sepsis after upper tract drainage for obstructive uropathy due to ureteral stones are needed. We aim to determine whether sepsis after decompression of the upper urinary tract may be predicted by clinical and time-related factors, specifically delay time from symptom onset to hospital presentation (StH) and from hospital presentation to surgical decompression (HtD). METHODS: In this single-center retrospective study, data from 196 consecutive patients presenting to the emergency department for obstructive uropathy due to ureteral stones and submitted to surgical decompression were evaluated. Postoperative sepsis was defined as an acute increase in ≥ 2 SOFA points and documented blood or urine cultures. RESULTS: Median StH and HtD were 24 (6-48) and 17 (10-30) hours, respectively. Thirty-three (16.8%) patients developed sepsis. Septic patients were more frequently female (75.8% vs. 37.4%, p < 0.001), had higher preoperative max body temperature (p < 0.001), white blood cells (WBC) count (p < 0.01), C-reactive protein (CRP) values (p < 0.001) and larger stone diameter (7.2 vs. 6 mm, p = 0.02). StH and HtD did not differ according to sepsis status. Time for WBC normalization and CRP halving were longer for septic patients (all p < 0.02). At multivariable logistic regression analysis, max body temperature ≥ 38 °C (OR 21.5; p < 0.001), female gender (OR 3.6; p = 0.02) and higher CRP (OR 1.1; p < 0.001) were independently associated with sepsis status. CONCLUSION: Clinical and laboratory parameters are associated with an increased risk of sepsis after decompression. StH and HtD timing are not associated with higher sepsis rates. In selected patients, urinary decompression could be delayed or primary ureteroscopy could be considered.

Evaluation of the efficacy of ureteroscopic lithotripsy for proximal impacted ureter stones based on a new scoring standard: a bicentric matched-pair analysis.

OBJECTIVE: To evaluate the clinical efficacy of ureteroscopic lithotripsy (URSL) in the treatment of proximal impacted ureter stones (PIUS) based on a new scoring standard in two medical centers. METHODS: The data of 45 patients with Complicated PIUS (total stone score ≥ 3) and 350 with Simple PIUS (total stone score < 3) who underwent URSL were collected in this retrospective study between January 2015 and June 2022. The definition and scoring standards for preoperative high-risk factors associated with stones included whether the diameter of the stone was > 2 cm, stone density was > 1000 HU, there was a history of lithotripsy, the degree of hydronephrosis was greater than moderate, and there was an infection. Scores for stones were then assigned (yes = 1, no = 0), and the Complicated stone case was defined as a total stone score ≥ 3; the Simple stone case was defined as a total stone score < 3. During the same period, 45 patients were selected from the patients with Simple stone cases as the control group, matched at a 1:1 ratio to index Complicated stone cases with regard to age, sex, and BMI. Perioperative data were compared between the two groups. RESULTS: All 90 operations were successfully completed. Compared to the Simple cases group, the surgical duration of the Complicated group was significantly longer (59.69 ± 28.06 min vs. 73.46 ± 27.12 min, p < 0.05), and stone-free rate (SFR) was significantly lower (88.89 vs. 68.9%, p < 0.05). There was a significant difference in complication rate between the two groups regarding Clavien grade I, II, or III complications (20.0% in Complicated cases group vs. 8.9% in Simple cases group, p = 0.037). As for the length of the hospital stay and the total treatment cost, the two groups have no difference. CONCLUSION: For Simple stone cases, URSL had a better SFR and higher surgical efficacy, whereas complicated stone cases had a high complication rate and long operation time. Thus, we suggest that URSL is the preferred choice for Simple stone cases rather than complicated stone cases.

Comparative study between antegrade flexible ureteroscopy and reterograde intrarenal surgery in the management of impacted upper ureteric stones 1.5 cm or larger.

OBJECTIVE: To prospectively investigate the safety and efficacy of antegrade flexible ureteroscopy (FURS) with the following criteria (supine, ultrasonic guided puncture through lower calyx with 14 fr tract, tubeless) versus retrograde intrarenal surgery (RIRS) in the management of large impacted upper ureteric stones ≥ 1.5 cm. PATIENTS AND METHODS: This study recruited 61 patients with single large impacted upper ureteric stone of ≥ 1.5 cm. The patients were randomly allocated to two groups. Group A, included 31 patients who treated by antegrade FURS, all patients were put in supine modified galadako Valdivia position and the renal access is reached by ultrasonic guided puncture through the lower calyx with dilatation upto 14 fr to insert ureteric access sheath and all cases were tubless with JJ stent insertion. Group B, included 30 patients who were treated by RIRS with JJ stent insertion. Stone fragmentation was done by holmium laser in both group. RESULTS: Group A was significantly associated with higher proportion of SFR (90.3%) compared to Group B (70%) (p = 0.046). Group B was significantly associated with shorter operative time and fluoroscopy time in comparison with Group A (p < 0.001). No significant differences were found between studied groups regarding bleeding (p = 0.238). Urosepsis showed significantly higher proportion associated with retrograde approach when compared to antegrade approach (p = 0.024). CONCLUSION: This study showed that antegrade FURS is safe and more effective than RIRS for the management of large impacted upper ureteric stones ≥ 1.5 cm.

Value of preoperative ureteral wall thickness in prediction of impaction of ureteric stones stratified by size in laser ureteroscopic lithotripsy.

OBJECTIVES: To evaluate the role of preoperative UWT in the prediction of impaction of ureteral stones stratified according to stone size in ureteroscopic laser lithotripsy. PATIENT AND METHODS: This study included 154 patients submitted to URSL for ureteral stones. Radiological data comprised the presence of hydronephrosis, anteroposterior pelvic diameter (PAPD), proximal ureteric diameter (PUD), and maximum UWT at the stone site. Collected stone characteristics were stone size, side, number, site, and density. RESULTS: The study included 154 patients subjected to URSL. They comprised 74 patients (48.1%) with impacted stones and 80 (51.9%) with non-impacted stones. Patients were stratified into those with stone size ≤ 10 mm and others with stone size > 10 mm. In the former group, we found that stone impaction was significantly associated with higher PAPD, PUD, and UWT. In patients with stone size > 10 mm, stone impaction was related to higher UWT, more stone number, and higher frequency of stones located in the lower ureter. ROC curve analysis revealed good power of UWT in discrimination of stone impaction in all patients [AUC (95% CI) 0.65 (0.55-0.74)] at a cut-off of 3.8 mm, in patients with stone size ≤ 10 mm [AUC (95% CI) 0.76 (0.61-0.91)] at a cut-off of 4.1 mm and in patients with stone size > 10 mm [AUC (95% CI) 0.72 (0.62-0.83)] at a cut-off of 3.0 mm. CONCLUSIONS: Stratifying ureteric stones according to size would render UWT a more practical and clinically-oriented approach for the preoperative prediction of stone impaction.

Application of tip-bendable ureteral access sheath in flexible ureteroscopic lithotripsy: an initial experience of 224 cases.

INTRODUCTION: During the last decades, the advent of flexible ureteroscopic lithotripsy has revolutionized the management of upper urinary tract stones. We designed a patented tip-bendable ureteral access sheath to facilitate stone clearance. Our current study reported our initial experience of 224 cases. MATERIALS AND METHODS: The study is a descriptive, retrospective analysis. The initial 224 cases, operated consecutively by one surgeon during 16 months, were reviewed. The novel tip-bendable ureteral access sheath was applied in the procedure. Demographics, laboratory tests, and peri- and postoperative findings (operation duration, stone-free rate (SFR), utilization of flexible instruments and complications) were analyzed. RESUTLS: The median age of the patients was 56 years and the mean stones size was 2.3 ± 1.3 cm. There were 63 cases of upper ureteral stone, 93cases of renal stone and 68 cases of ureteral-renal stones. The mean operative time was 69.2 ± 65.2 min. The immediate stone-free rate was 76.8% and the 1 month post-operative stone-free rate was 97.3%. Most cases(95.5%)were success in single session. Two patient experienced post-operative fever. There was no unplanned readmission. The frequency of post-operative complications was estimated at 0.89% (Clavien I). CONCLUSION: Flexible ureteroscopic lithotripsy with tip-bendable ureteral access sheath is a safe and effective procedure, which can achieve excellent stone clearance.

A comparative study of flexible ureteroscopic lithotripsy for upper urinary tract stones in patients with prior urosepsis following emergency drainage via retrograde ureteral stent or percutaneous nephrostomy.

BACKGROUND: Patients with urosepsis associated with upper urinary tract stones require further stone management after emergency drainage. OBJECTIVE: To evaluate the safety and efficacy of elective flexible ureteroscopic lithotripsy (F-URSL) for upper urinary tract stones in patients with prior urosepsis who have undergone emergency drainage using retrograde ureteral stent(RUS) or percutaneous nephrostomy (PCN). METHOD: Between January 2017 and December 2021, clinical data were collected for 102 patients who underwent elective F-URSL following emergency drainage for urosepsis caused by upper ureteral or renal stones. The patients were categorized into two groups based on the drainage method used: the RUS group and the PCN group. The collected data included patient demographics, stone parameters, infection recovery after emergency drainage, and clinical outcomes post F-URSL. Subsequently, the data underwent statistical analysis. RESULTS: A total of 102 patients were included in the statistical analysis, with 58 (56.86%) in the RUS group and 44 (43.14%) in the PCN group. Among the patients, 84 (82.35%) were female and 18 (17.65%) were male, with an average age of 59.36 years. Positive urine cultures were observed in 71 (69.61%) patients. Successful drainage was achieved in all patients in both groups, and there were no significant differences in the time required for normalization of white blood cell count (WBC) and body temperature following drainage. Additionally, all patients underwent F-URSL successfully, and no statistically significant differences were observed between the two groups in terms of operative time, stone-free rates, postoperative fever, and postoperative hospital stay. CONCLUSION: Both RUS and PCN have been established as effective approaches for managing urosepsis caused by upper urinary tract stones. Furthermore, the impact of these two drainage methods on the subsequent management of stones through elective F-URSL has shown consistent outcomes.

CT Use Reduction In Ostensive Ureteral Stone (CURIOUS).

INTRODUCTION: Computed tomography (CT) is performed in over 90% of patients diagnosed with ureteral stones, but only 10% of patients presenting to the emergency department (ED) with acute flank pain are hospitalized for a clinically important stone or non-stone diagnosis. Hydronephrosis can be accurately detected using point-of-care ultrasound and is a key predictor of ureteral stone and risk of subsequent complications. The absence of hydronephrosis is insufficient to exclude a stone. We created a sensitive clinical decision rule to predict clinically important ureteral stones. We hypothesized that this rule could identify patients at low risk for this outcome. METHODS: We conducted a retrospective cohort study in a random sample of 4000 adults who presented to one of 21 Kaiser Permanente Northern California EDs and underwent a CT for suspected ureteral stone from 1/1/2016 to 12/31/2020. The primary outcome was clinically important stone, defined as stone resulting in hospitalization or urologic procedure within 60 days. We used recursive partition analysis to generate a clinical decision rule predicting the outcome. We estimated the C-statistic (area under the curve), plotted the receiver operating characteristic (ROC) curve for the model, and calculated sensitivity, specificity, and predictive values of the model based on a risk threshold of 2%. RESULTS: Among 4000 patients, 354 (8.9%) had a clinically important stone. Our partition model resulted in four terminal nodes with risks ranging from 0.4% to 21.8%. The area under the ROC curve was 0.81 (95% CI 0.80, 0.83). Using a 2% risk cut point, a clinical decision tree including hydronephrosis, hematuria, and a history of prior stones predicted complicated stones with sensitivity 95.5% (95% CI 92.8%-97.4%), specificity 59.9% (95% CI 58.3%-61.5%), positive predictive value 18.8% (95% CI 18.1%-19.5%), and negative predictive value 99.3% (95% CI 98.8%-99.6%). CONCLUSIONS: Application of this clinical decision rule to imaging decisions would have led to 63% fewer CT scans with a miss rate of 0.4%. A limitation was the application of our decision rule only to patients who underwent CT for suspected ureteral stone. Thus, this rule would not apply to patients who were thought to have ureteral colic but did not receive a CT because ultrasound or history were sufficient for diagnosis. These results could inform future prospective validation studies.

Clinical and postoperative characteristics of stentless ureteroscopy patients: a prospective analysis from ReSKU.

INTRODUCTION: To evaluate the clinical characteristics as well as the postoperative course of urolithiasis patients undergoing a ureteroscopy (URS) without stent placement. MATERIALS AND METHODS: This was a prospective case cohort study utilizing data collected in the Registry for Stones of the Kidney and Ureter (ReSKU) from a single institution between October 2015 and December 2020. We identified all consecutive patients undergoing URS for stone disease and analyzed data encompassing demographics, medical history, intra and postoperative characteristics, including complications and postoperative symptoms. Univariate and multivariate logistic regression analyses were performed based on the presence or absence of an indwelling ureteral stent. RESULTS: A total of 470 patients were included for analysis, 92 patients in the stentless group (19.5%). Factors associated with stentless ureteroscopy were a lower stone burden (p < 0.001), the pre-existence of a ureteral stent (37.4% vs. 27.9% p = 0.011), absence of an access sheath (14.6% vs. 69.5% p < 0.001), and a shorter operative time (31 vs. 58 min p < 0.001). Postoperative gross hematuria and lower urinary tract symptoms (LUTS) were reported less frequently in stentless patients (p = 0.02, p = 0.01, respectively). There was no difference in postoperative complications between both groups (15.2% vs. 12.0%, p = 0.385). On multivariate analysis, the risk of postoperative complications was associated with obesity, stone burden ≥ 1 cm, and positive preoperative urine culture. There was no patient who required emergent stent placement in the stentless group. CONCLUSION: Our data show that, in well selected patients, omitting ureteral stent placement after URS can decrease postoperative gross hematuria and LUTS without increasing postoperative complications.

Optimal Dwelling Time for Ureteral Stents Placed for Passive Dilation after Impassable Ureteroscopy.

INTRODUCTION: The aim of the study was to determine the correlation between the dwelling time for a ureteral stent placed for passive dilation after impassable ureteroscopy and success and complications. METHODS: A retrospective evaluation was made of patients who underwent stent placement after impassable ureteroscopy and a repeat ureteroscopy due to kidney stones. A total of 161 patients were included in the study between 2015 and 2022. Demographic, clinical, preoperative, and perioperative data were collected. Logistic regression analyses were performed on the data showing a significant difference in the univariate analyses performed to determine the predictive factors of ureteroscopy after the stent dwelling period in terms of stone-free status and perioperative complications. RESULTS: Stone-free status was achieved in 110 (68.3%) of 161 patients, and perioperative complications were observed in 41 (25.4%). Factors that affected the stone-free status were determined as the dwelling time and the S-ReSC score, while factors affecting perioperative complications were the stent dwelling time and the operation time. The stone-free rates were observed to increase from 46.4% in the first 2 weeks to 72.9% after the 2nd week, an increase of 1.5-fold. Perioperative complications were determined at the rate of 17.5% during the first 5 weeks and increased 2.1-fold to 37.5% after the 5th week. CONCLUSION: It can be recommended that great care is taken during the stent dwelling period and ureteroscopy should be performed within 5 weeks (14-35 days) but no earlier than 2 weeks, so as not to affect the success of the procedure.

Differences in management of pregnant women with obstructing infected ureteral stones: A population-based analysis.

OBJECTIVES: Obstructing ureteral stones complicated by urinary tract infection are urologic emergencies that require prompt decompression. We explore the association of pregnancy with rates of and delays in decompression in a cohort of women of reproductive age. METHODS: Using the National Inpatient Sample from 2010 to 2015, a cross-sectional, descriptive analysis of women of reproductive age (15 to 44 years old) diagnosed with obstructing ureteral stones and urinary tract infection was performed and stratified by pregnancy status. Survey-weighted regression models were used to assess the association of pregnancy on decompression, delays in decompression, and hospital length of stay. Additional exploratory analyses on the association of timing and type of decompression with maternal-fetal outcomes were performed. RESULTS: A weighted total of 38 783 hospitalizations were identified, with 6.1% of admissions occurring in pregnant women. On multivariable regression, pregnant women with obstructing ureteral stones and urinary tract infection were 38% less likely of undergoing decompression (adjusted OR: 0.62; p < 0.001) compared with nonpregnant women. Among those decompressed, pregnant women had greater odds of delayed decompression (adjusted OR: 2.28; p < 0.001) and longer length of stay (adjusted IRR: 1.11; p = 0.007). Delayed decompression among pregnant women was associated with increased rates of C-section, early or threatened labor, fetal distress, and umbilical cord complications. CONCLUSIONS: Overall, pregnant women had reduced odds of decompression, as well as increased odds of delayed decompression, when compared with nonpregnant women of reproductive age. Delays in decompression among pregnant women were also associated with increased maternal and fetal complications.

The role of serum and urinary markers in predicting obstructing ureteral stones and reducing unjustified non-contrast computerized tomographic scans in emergency departments.

INTRODUCTION: The reported yield of non-contrast computed tomography (NCCT) in assessing flank pain and obstructive urolithiasis (OU) in emergency departments (EDs) is only ~ 50%. We investigated the potential capability of serum and urinary markers to predict OU and improve the yield of NCCT in EDs. METHODS: All consecutive ED patients with acute flank pain suggestive of OU and assessed by NCCT between December 2019 and February 2020 were enrolled. Serum white blood cells (WBC), C-reactive protein (CRP) and creatinine (Cr) levels, and urine dipstick results were analyzed for association with OU, and unjustified NCCT scan rates were calculated. RESULTS: NCCTs diagnosed OU in 108 of the 200 study patients (54%). The median WBC, CRP, and Cr values were 9,100/µL, 4.3 mg/L, and 1 mg/dL, respectively. Using ROC curves, WBC = 10,000/µL and Cr = 0.95 mg/dl were the most accurate thresholds to predict OU. Only WBC ≥ 10,000/µL (OR = 3.7, 95% CI 1.6-8.3, p = 0.002) and Cr ≥ 0.95 mg/dl (OR = 5, 95% CI 2.3-11, p < 0.001) were associated with OU. Positive predictive value and specificity for detecting OU among patients with combined WBC ≥ 10,000 and Cr ≥ 0.95 were 83% and 89%, respectively. Patients negative to the serum markers criteria underwent significantly more unjustified NCCTs (p = 0.03). The negative predictive value of the serum criteria for justified NCCT scanning was 81%. CONCLUSIONS: WBC and Cr may be valuable serum markers in predicting OU among patients presenting to EDs with acute flank pain. They may potentially reduce the number of unjustified NCCT scans in the ED setting.

[A Study of Factors Affecting Febrile Urinary Tract Infection Following Ureterorenoscopic Lithotripsy].

Febrile urinary tract infection (f-UTI) is a common complication after ureterorenoscopic lithotripsy (URSL) but is sometimes lethal. In this article, we analyzed the factors of post URSL f-UTI. We retrospectively evaluated the association between the development of f-UTI and patients, stones, and perioperative factors in 695 cases in which URSL was performed at our institution from September 2015 to 2018. Seventy-six of the 695 patients (10.9%) had postoperative f-UTI. Elderly (p＝0.013), female (p＝0.02), and hypertension (p＝0.001) patients had significantly higher rates of f-UTI. Renal stone (p＝0.001) cases showed significantly higher rates of f-UTI. Preoperative urine positive culture (p＝0.045), preoperative f-UTI (p＜0.001), URSL procedure using flexible ureteroscopy (p＝0.048), non-stone-free (p＝0.006), long operation time (p＝0.011), preoperative urinary stent insertion due to preoperative f-UTI (p＜0.001), were factors associated with post-operative f-UTI. Multivariate analysis revealed that hypertension (OR＝2.08, p＝0.008) and preoperative f-UTI (OR＝3.739, p＝0.033) were independent factors of postoperative f-UTI. Patients with hypertension or preoperative f-UTI should be managed more carefully during the perioperative period, suspecting that they are more likely to develop postoperative f-UTI.

[A Study of Retrograde Ureteroscopic Lithotripsy with Ureteral Access Sheath for Urinary Calculus After Ileal Conduit Construction].

We retrospectively evaluated the safety and effectiveness of retrograde ureteroscopy via ileal conduit construction. Between January 2014 and December 2021, 5 patients (8 procedures) with ileal conduit construction received retrograde ureteroscopic lithotripsy with a 11/13 Fr ureteral access sheath. At postoperative 1 month, a plain computed tomography (CT) and kidney, ureter, and bladder X-ray (KUB) were performed to assess stone fragmentation and hydronephrosis. According to postoperative imaging, stone-free was defined as residual fragments of 4 mm or less on KUB and 2 mm or less on CT. The mean stone size was 11 mm (6-13 mm). The mean stone volume was 1. 51 ml (0.33-2.56 ml). The mean operative time was 91 min (60-133 min). SFR was 100% on KUB and 87.5% on CT. One procedure (12.5%) resulted in a postoperative fever greater than 38.5℃. There were no complications of grade III or higher according to the modified Clavien-Dindo classification. No exacerbation of hydronephrosis was observed on CT. Retrograde ureteroscopy with a ureteral access sheath was found to be effective for urolithiasis in patients with ileal conduit.

[Safety and efficiency of retrograde intrarenal surgery without X-ray guidance].

INTRODUCTION: The main stages of flexible ureteroscopy in patients with renal stones are usually performed under X-ray guidance. Long-term exposure of ionizing radiation can have negative effects on the patients with nephrolithiasis and the operating team. AIM: To study the results of retrograde intrarenal surgery (RIRS) without fluoroscopic guidance. MATERIALS AND METHODS: The results of flexible ureteroscopy (fURS) without X-ray-guidance in 76 patients were analyzed. There were 46 (53.3%) men and 30 (46.7%) women. The average age was 50.4+/-14.6 years. All patients underwent laboratory tests and non-contrast-enhanced computed tomography to determine the size and density of the stone. In all cases, preoperative ureteral stenting was performed. The average stone size was 10.5+/-4.2 mm. First, ureteroscopy with a rigid endoscope was done to assess the ureter and determine the depth of the introducing ureteral access sheath. After removing the ureteroscope along the guidewire, a ureteral access sheath was put at this distance. An inspection of the collecting system and laser fragmentation of kidney stones were performed using a flexible ureteroscope. In 64 (84.2%) patients, a 4.7 Ch stent was put at the end of the procedure, while in the remaining 12 (15.8%) patients, a ureteral catheter was left for 1-2 days. The operation time, stone-free rate, and the number of intra- and postoperative complications were studied. RESULTS: All fURS were successful and performed without X-ray guidance. The average operation time was 42.5+/-8.0 minutes. After the first session, stone-free rate was 92.1% (70/76). In 6 (7.9%) cases, residual stones were found, which were completely removed after the second session. Intraoperative complications, namely perforation of the upper calyx by the distal end of the ureteral access sheath, were observed in 2 (2.6%) patients, which did not require any additional interventions. Postoperative complications occurred in 10 (13.2%) patients, including fever in 6 (7.9%) and hematuria in 4 (5.3%) cases. There were no serious complications, such as ureteral perforation or sepsis, and no blood transfusion was performed. CONCLUSION: Flexible ureteroscopy with laser lithotripsy can be performed safely and effectively without X-ray guidance.

Construction of a novel rabbit model of ureteral calculi implanted with flowable resin.

BACKGROUND: The purpose of this study was to characterize the pathophysiological changes of hydronephrosis caused by ureteral calculi obstruction in a new rabbit ureteral calculi model by implanting flowable resin. METHODS: Forty New Zealand rabbits were randomly divided into two groups: the calculi group and the sham control group. In the calculi group (n = 20), rabbits were operated at left lower abdomen and the left ureter was exposed. Then flowable resin (flowable restorative dental materials) was injected into the left ureter using a 0.45 mm diameter intravenous infusion needle. Then light-cured for 40 s by means of a dental curing light to form calculi. In the sham control group, normal saline was injected into the ureter. Rabbits underwent X-ray and routine blood and urine tests preoperatively, as well as X-ray, CT, dissection, HE staining and routine blood and urine tests on 1, 3, 5 and 7 days postoperatively. Stone formation was assessed by X-ray and unenhanced CT scan after surgery. The pathophysiological changes were evaluated through dissection, HE staining and routine blood and urine tests. RESULTS: Ureteral calculi models were successfully constructed in 17 rabbits. In calculi group, high-density shadows were observed in the left lower abdomen on postoperative day 1st, 3rd, 5th and 7th by X-ray and CT scan. Dissection found obstruction formation of the left ureters, dilatation of the renal pelvis and upper ureter during 7 days after surgery. The renal long-diameters of the left ureters increased only on the 1st postoperative day. HE staining found ureteral and kidney damage after surgery. In calculi group and sham group,the serum creatinine, urea nitrogen, white blood cells and urine red blood cells were raised at day 1 after surgery. However, the indicators returned to normal at day 3, 5, and 7. CONCLUSIONS: This is a stable, less complicated operation and cost-effective ureteral calculi model by implanting flowable resin. And this novel model may allow us to further understand the pathophysiology changes caused by ureteral calculi obstruction.