Evidence-based guidelines in lower urinary tract symptoms secondary to benign prostatic hyperplasia and variation in care.

PURPOSE OF REVIEW: Guidelines have been developed to assist physicians in the diagnosis and management of patients with lower urinary tract symptoms. These guidelines vary in the level of evidence used and the strength of their recommendations. With variations in guidelines, multiple variations in clinical practice may also been seen. RECENT FINDINGS: Although examinations of physician compliance with benign prostatic hyperplasia (BPH) guidelines date back to the 1980s, researchers have become more interested in closer examination of guideline compliance. Furthermore, guidelines themselves are becoming more robust documents, with the American Urological Association and European Association of Urology guidelines updated in 2014 and 2015, respectively. This review examines both the evidence base behind these BPH guidelines and the variations in clinical care related to the guidelines. SUMMARY: Despite over 40 years of study, variations continue to occur in the work up and treatment of men with BPH. With the proliferation of medications and surgical procedures available for symptomatic lower urinary tract symptoms (LUTS) due to BPH, we will continue to see this variation in care. Our current guidelines can help mitigate this variation by providing a baseline set of assessments and algorithms for routine patients. However, only through continued refinement will the guidelines meet their full potential. The prior review shows how the evidence base is limited for the diagnostic work up for LUTS, provides limited information on comparative effectiveness of therapies in LUTS and BPH, and has not led to consistency between guidelines.

Validation of preoperative variables and stratification of patients to help predict benefit of cytoreductive nephrectomy in the targeted therapy ERA.

OBJECTIVES: To further elucidate which patients with metastatic renal cell carcinoma (mRCC) may benefit from cytoreductive nephrectomy (CN) before targeted therapy (TT), and to assess the overall survival of patients undergoing CN and TT versus TT alone. MATERIALS AND METHODS: We identified 88 patients who underwent CN at our institution prior to planned TT and 35 patients who received TT without undergoing CN. Preoperative risk factors described in the literature were assessed in our patient population (serum albumin, liver metastasis, symptomatic metastasis, clinical ≥T3 disease, retroperitoneal and supradiaphragmatic lymphadenopathy). Patients were stratified by number of pretreatment risk factors and overall survival (OS) was compared. RESULTS: TT patients had significantly more risk factors compared to CN patients (3.06 vs. 2.11, p<0.01). Patients who received TT alone had median OS of 5.8 months. All but one patient receiving TT alone had two or more risk factors. A comparison of the CN and TT groups was performed by constructing Kaplan-Meier curves. There was no significant difference in median OS for those patients with exactly two risk factors (447 vs. 389 days, p=0.24), and those with three or more risk factors (184 vs. 155 days, p=0.87). CONCLUSIONS: Using previously described pretreatment risk factors we found that patients with two or more risk factors derived no significant survival advantage from CN in the TT era. These risk factors should be incorporated in the assessment of patients for CN.

Prostate Cancer, Version 1.2016.

The NCCN Guidelines for Prostate Cancer address staging and risk assessment after an initial diagnosis of prostate cancer and management options for localized, regional, and metastatic disease. Recommendations for disease monitoring, treatment of recurrent disease, and systemic therapy for metastatic castration-recurrent prostate cancer also are included. This article summarizes the NCCN Prostate Cancer Panel's most significant discussions for the 2016 update of the guidelines, which include refinement of risk stratification methods and new options for the treatment of men with high-risk and very-high-risk disease and progressive castration-naïve disease.

Comparative effectiveness research in urologic cancers.

Controversies abound in urologic cancers. While some work in comparative effectiveness research has been performed, most controversies remain unresolved. In this chapter, we examine the three most common urologic malignancies: Prostate cancer, kidney cancer, and bladder cancer. We will review progress made in comparative effectiveness research for each cancer and outline important topics where future research is needed.

Understanding the diffusion of ambulatory surgery centers.

BACKGROUND: Outpatient surgery is increasingly delivered at freestanding ambulatory surgery centers (ASCs), which are thought to deliver quality care at lower costs per episode. The objective of this study was to understand potential facilitators and/or barriers to the introduction of freestanding ASCs in the United States. METHODS: This is an observational study conducted from 2008 to 2010 using a 20% sample of Medicare claims. Potential determinants of ASC dissemination, including population, system, and legal factors, were compared between markets that always had ASCs, never had ASCs, and those that had new ASCs open during the study. Multivariable logistic regression was used to determine characteristics of markets associated with the opening of a new facility in a previously naïve market. RESULTS: New ASCs opened in 67 previously naïve markets between 2008 and 2010. ASCs were more likely to open in hospital service areas that were urban (adjusted odds ratio [OR], 4.10; 95% confidence interval [CI], 1.51-10.96), had higher per capita income (adjusted OR, 3.83; 95% CI, 1.43-10.45), and had less competition for outpatient surgery (adjusted OR, 2.13; 95% CI, 1.02-4.45). Legal considerations and latent need, as measured by case volumes of hospital-based outpatient surgery in 2007, were not associated with the opening of a new ASC. CONCLUSIONS: Freestanding ASCs opened in advantageous socioeconomic environments with the least amount of competition. Because of their associated efficiency advantages, policy makers might consider strategies to promote ASC diffusion in disadvantaged markets to potentially improve access and reduce costs.

Defining the potential of neoadjuvant chemotherapy use as a quality indicator for bladder cancer care.

PURPOSE: Despite known survival benefits, overall use of neoadjuvant chemotherapy before cystectomy is low, raising concerns about quality of care. However, not all patients undergoing cystectomy are eligible for this therapy. We establish the maximum proportion of patients expected to receive neoadjuvant chemotherapy if all those eligible had a consultation with medical oncology. MATERIALS AND METHODS: From institutional data (January 2010 through December 2012) we identified 215 patients treated with radical cystectomy for bladder cancer. After excluding patients not eligible for neoadjuvant chemotherapy, we fit models assessing patient disease and health factors affecting referral to medical oncology and receipt of neoadjuvant chemotherapy. Expected use of chemotherapy was then determined for increasingly broad groups of patients treated with cystectomy after controlling for factors precluding the use of neoadjuvant chemotherapy. RESULTS: Of the 215 patients identified 127 (59%) were eligible for neoadjuvant chemotherapy. After additional consideration of patient factors (patient refusal, health status and poor renal function), maximum receipt of neoadjuvant chemotherapy increased from 42% to 71% as more restrictive definitions for the eligible patient cohort were used. CONCLUSIONS: Substantial variability exists in the proportion of patients eligible for neoadjuvant chemotherapy based on the population identified. While there is substantial underuse of neoadjuvant chemotherapy, the development of quality metrics for this essential therapy depends on correct identification of the cystectomy population being assessed. Even with referral of all appropriate patients for medical oncology evaluation, use of chemotherapy would likely not exceed 50% of patients in nationally representative cystectomy data.

Prostate cancer, version 2.2014.

Prostate cancer has surpassed lung cancer as the most common cancer in men in the United States. The NCCN Guidelines for Prostate Cancer provide multidisciplinary recommendations on the clinical management of patients with prostate cancer based on clinical evidence and expert consensus. NCCN Panel guidance on treatment decisions for patients with localized disease is represented in this version. Significant updates for early disease include distinction between active surveillance and observation, a new section on principles of imaging, and revisions to radiation recommendations. The full version of these guidelines, including treatment of patients with advanced disease, can be found online at the NCCN website.

Interruptions in bladder cancer care during the COVID-19 public health emergency.

BACKGROUND: Academic and community urology centers participating in a pragmatic clinical trial in non-muscle-invasive bladder cancer completed monthly surveys assessing restrictions in aspects of bladder cancer care due to the COVID-19 Public Health Emergency. Our objective was to describe pandemic-related restrictions on bladder cancer care. METHODS: We invited 32 sites participating in a multicenter pragmatic bladder cancer trial to complete monthly surveys distributed through REDCap beginning in May 2020. These surveys queried sites on whether they were experiencing restrictions in the use of elective surgery, transurethral resection of bladder tumors (TURBT), radical cystectomy, office cystoscopy, and intravesical bacillus Calmette-Guerin (BCG) availability. Responses were collated with descriptive statistics. RESULTS: Of 32 eligible sites, 21 sites had at least a 50% monthly response rate over the study period and were included in the analysis. Elective surgery was paused at 76% of sites in May 2020, 48% of sites in January 2021, and 52% of sites in January 2022. Over those same periods, coinciding with COVID-19 incidence waves, TURBT was restricted at 10%, 14%, and 14% of sites, respectively, radical cystectomy was restricted at 10%, 14%, and 19% of sites, respectively, and cystoscopy was restricted at 33%, 0%, and 10% of sites, respectively. CONCLUSIONS: Bladder cancer care was minimally restricted compared with more pronounced restrictions seen in general elective surgeries during the COVID-19 pandemic.

Survival impact of followup care after radical cystectomy for bladder cancer.

PURPOSE: Due to substantial variation in patient followup after radical cystectomy for bladder cancer, we sought to understand the effect of urine and laboratory tests, physician visits and imaging on overall survival. MATERIALS AND METHODS: We analyzed a cohort of patients treated in the fee for service Medicare population from 1992 through 2007 using Surveillance Epidemiology and End Results (SEER)-Medicare data. Using propensity score analysis, we assessed the relationship between time and geography standardized expenditures on followup care and overall survival during 3 postoperative periods, including perioperative (0 to 3 months), early followup (4 to 6 months) and later followup (7 to 24 months). Using instrumental variable analysis, we assessed the overall survival impact of the quantity of followup care by category, including physician visits, imaging, and laboratory and urine tests. RESULTS: We found no improvement in survival due to followup care in the perioperative and early followup periods. Receiving followup care during later followup was associated with improved survival in the low, middle and high expenditure tertiles (HR 0.23, 95% CI 0.15-0.35, HR 0.27, 95% CI 0.18-0.40 and HR 0.47, 95% CI 0.31-0.71, respectively). Instrumental variable analysis suggested that only physician visits and urine testing improved survival (HR 0.96, 0.93-0.99 and 0.95, 0.91-0.99, respectively). CONCLUSIONS: Followup care after radical cystectomy in the later followup period was associated with improved survival. Physician visits and urine tests were associated with this improved survival. Our results suggest that aspects of followup care significantly improve patient outcomes but imaging could be done more judiciously after cystectomy.

The impact of technology diffusion on treatment for prostate cancer.

BACKGROUND: The use of local therapy for prostate cancer may increase because of the perceived advantages of new technologies such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy. OBJECTIVE: To examine the association of market-level technological capacity with receipt of local therapy. DESIGN: Retrospective cohort. SUBJECTS: Patients with localized prostate cancer who were diagnosed between 2003 and 2007 (n=59,043) from the Surveillance Epidemiology and End Results-Medicare database. MEASURES: We measured the capacity for delivering treatment with new technology as the number of providers offering robotic prostatectomy or IMRT per population in a market (hospital referral region). The association of this measure with receipt of prostatectomy, radiotherapy, or observation was examined with multinomial logistic regression. RESULTS: For each 1000 patients diagnosed with prostate cancer, 174 underwent prostatectomy, 490 radiotherapy, and 336 were observed. Markets with high robotic prostatectomy capacity had higher use of prostatectomy (146 vs. 118 per 1000 men, P=0.008) but a trend toward decreased use of radiotherapy (574 vs. 601 per 1000 men, P=0.068), resulting in a stable rate of local therapy. High versus low IMRT capacity did not significantly impact the use of prostatectomy (129 vs. 129 per 1000 men, P=0.947) and radiotherapy (594 vs. 585 per 1000 men, P=0.579). CONCLUSIONS: Although there was a small shift from radiotherapy to prostatectomy in markets with high robotic prostatectomy capacity, increased capacity for both robotic prostatectomy and IMRT did not change the overall rate of local therapy. Our findings temper concerns that the new technology spurs additional therapy of prostate cancer.

Prostate cancer, version 1.2014.

The NCCN Guidelines for Prostate Cancer provide multidisciplinary recommendations on the clinical management of patients with prostate cancer. This report highlights notable recent updates. Radium-223 dichloride is a first-in-class radiopharmaceutical that recently received approval for the treatment of patients with symptomatic bone metastases and no known visceral disease. It received a category 1 recommendation as both a first-line and second-line option. The NCCN Prostate Cancer Panel also revised recommendations on the choice of intermittent or continuous androgen deprivation therapy based on recent phase III clinical data comparing the 2 strategies in the nonmetastatic and metastatic settings.

Use of advanced treatment technologies among men at low risk of dying from prostate cancer.

IMPORTANCE: The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain. OBJECTIVE: To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer. DESIGN, SETTING, AND PATIENTS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010. MAIN OUTCOMES AND MEASURES: The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both. RESULTS: In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001). CONCLUSION AND RELEVANCE: Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.

Population based analysis of the increasing incidence of kidney cancer in the United States: evaluation of age specific trends from 1975 to 2006.

PURPOSE: An increase in kidney cancer was reported in the United States but overall rates may obscure trends in age specific groups. We explored whether the increase in kidney cancer incidence differs across age groups. MATERIALS AND METHODS: We ascertained the 63,843 incident renal cancer cases in SEER (Surveillance, Epidemiology and End Results) cancer registries for 1975 to 2006. Yearly incidence rates of renal cancer were calculated and stratified by age group. Age specific trends in cancer diagnosis were evaluated by Poisson regression. RESULTS: From 1975 to 2006 the overall age adjusted renal cancer incidence increased 238% from 7.4/100,000 to 17.6/100,000 adults. From 1991 to 2006 the mean age at diagnosis decreased from 64.7 to 62.7 years and the proportion of patients diagnosed before age 65 years increased from 45.9% to 55.3%. Age specific incidence rates of renal cancer increased in all age groups from 1975 to 2006 (p <0.0001). However, the rates changed at different rates. Overall renal cancer diagnosis in the youngest age group (20 to 39 years) increased more quickly than all other age groups (p <0.0001). The renal cancer incidence in patients 60 to 69 and 70 to 79 years old increased more rapidly than in those 40 to 49 and 50 to 59 years old (p <0.01). CONCLUSIONS: In the last 15 years mean age at diagnosis of renal cancer has decreased. During our study period the most rapidly increasing kidney cancer incidence was seen in those younger than 40 and 60 to 79 years old. The renal cancer increase in younger patients should direct attention toward further evaluation of renal cancer risk factors.

Population based comparative effectiveness of transurethral resection of the prostate and laser therapy for benign prostatic hyperplasia.

PURPOSE: As the American population ages, benign prostatic hyperplasia and its associated lower urinary tract symptoms have become increasingly important causes of chronic morbidity. We assessed the comparative effectiveness of 2 common forms of surgical therapy, transurethral prostate resection and laser therapy, for benign prostatic hyperplasia. MATERIALS AND METHODS: Using patient level discharge data and revisit files from the Agency for Healthcare Research and Quality we evaluated a cohort of patients who underwent transurethral prostate resection or laser therapy for benign prostatic hyperplasia in 2005 in California. Short-term outcomes, including in hospital complications, length of stay, 30-day rehospitalization, 30-day repeat surgery and 30-day emergency room visits, were compared between the therapies by regression analysis. Long-term re-treatment, defined as the absence of secondary procedures for benign prostatic hyperplasia or complications of therapy, was assessed by survival analysis. Analysis was adjusted for medical comorbidity, race, age and insurance status. RESULTS: Data on 11,645 hospital discharges showed that mean length of stay was shorter for laser therapy than for transurethral prostate resection (0.70 vs 2.03 days, p<0.0001). The 30-day repeat visit occurred in 16% of laser and 17.7% of resection cases (p=0.0338). The 4-year re-treatment rate was 8.3% for resection and 12.8% for laser therapy (p<0.0001). After adjustment patients with resection were 37% less likely to require repeat therapy than those with laser therapy (HR 0.64, p<0.0001). CONCLUSIONS: Laser procedures and transurethral prostate resection provide effective management of benign prostatic hyperplasia/lower urinary tract symptoms. Laser procedures are associated with less need for hospitalization than transurethral prostate resection but appear to involve a trade-off in long-term efficacy.

Changes in initial expenditures for benign prostatic hyperplasia evaluation in the Medicare population: a comparison to overall Medicare inflation.

PURPOSE: Benign prostatic hyperplasia creates significant expenses for the Medicare program. We determined expenditure trends for benign prostatic hyperplasia evaluative testing after urologist consultation and placed these trends in the context of overall Medicare expenditures. MATERIALS AND METHODS: Using a 5% national sample of Medicare beneficiaries from 2000 to 2007 we developed a cohort of 40,253 with claims for new visits to urologists for diagnoses consistent with symptomatic benign prostatic hyperplasia. We assessed trends in initial inflation and geography adjusted expenditures within 12 months of diagnosis by evaluative test categories derived from the 2003 American Urological Association guideline on the management of benign prostatic hyperplasia. Using governmental reports on Medicare expenditure trends for benign prostatic hyperplasia we compared expenditures to overall and imaging specific Medicare expenditures. Comparisons were assessed by the Z-test and regression analysis for linear trends, as appropriate. RESULTS: Between 2000 and 2007 inflation adjusted total Medicare expenditures per patient for the initial evaluation of patients with benign prostatic hyperplasia seen by urologists increased from $255.44 to $343.98 (p <0.0001). Benign prostatic hyperplasia related imaging increases were significantly less than overall Medicare imaging expenditure increases (55% vs 104%, p <0.001). The increase in per patient expenditures for benign prostatic hyperplasia was significantly lower than the increase in overall Medicare expenditures per enrollee (35% vs 45%, p = 0.0015). CONCLUSIONS: From 2000 to 2007 inflation adjusted expenditures increased for benign prostatic hyperplasia related evaluations. This growth was slower than the overall growth in Medicare expenditures. The increase in BPH related imaging expenditures was restrained compared to that of the Medicare program as a whole.

Medicare payments for outpatient urological surgery by location of care.

PURPOSE: The cost implications associated with offloading outpatient surgery from hospitals to ambulatory surgery centers and the physician office remain poorly defined. Therefore, we determined whether payments for outpatient surgery vary by location of care. MATERIALS AND METHODS: Using national Medicare claims from 1998 to 2006, we identified elderly patients who underwent 1 of 22 common outpatient urological procedures. For each procedure we measured all relevant payments (in United States dollars) made during the 30-day claims window that encompassed the procedure date. We then categorized payment types (hospital, physician and outpatient facility). Finally, we used multivariable regression to compare price standardized payments across hospitals, ambulatory surgery centers and the physician office. RESULTS: Average total payments for outpatient surgery episodes varied widely from $200 for urethral dilation in the physician office to $5,688 for hospital based shock wave lithotripsy. For all but 2 procedure groups, ambulatory surgery centers and physician offices were associated with lower overall episode payments than hospitals. For instance, average total payments for urodynamic procedures performed at ambulatory surgery centers were less than a third of those done at hospitals (p <0.001). Compared to hospitals, office based prostate biopsies were nearly 75% less costly (p <0.001). Outpatient facility payments were the biggest driver of these differences. CONCLUSIONS: These data support policies that encourage the provision of outpatient surgery in less resource intensive settings.

Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery.

PURPOSE: The cost efficiency gains achieved from moving procedures to ambulatory surgery centers and offices may be mitigated if the quality of surgical care at these facilities is not comparable to that at the hospital. Motivated by this, we assessed short-term morbidity and mortality for patients by location of care. MATERIALS AND METHODS: Using a national sample of Medicare claims (1998 to 2006), we identified elderly beneficiaries who underwent one of 22 common outpatient urological procedures. After determining the facility type where each procedure was performed, we measured 30-day mortality, unexpected admissions and postoperative complications. Finally, we fit multivariable logistic regression models to evaluate the association between occurrence of an adverse event and the ambulatory setting where surgical care was delivered. RESULTS: During the study period, there was a substantial increase in the frequency of nonhospital based outpatient surgery. Compared to ambulatory surgery centers and offices, hospitals treated more women (p <0.001). Those patients also tended to be less healthy (p <0.001). While patients experienced fewer postoperative complications following surgery at an ambulatory surgery center, procedures performed outside the hospital were associated with a higher likelihood of a same day admission (ambulatory surgery centers OR 6.96, 95% CI 4.44-10.90 and offices OR 3.64, 95% CI 2.48-5.36). However, notably with case mix adjustment the probability of any adverse event was exceedingly low across all ambulatory settings. CONCLUSIONS: These data indicate that small but measurable variation in surgical quality exists by location of care delivery.

Prostate cancer, Version 3.2012: featured updates to the NCCN guidelines.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer provide multidisciplinary recommendations for the clinical management of patients with prostate cancer. These NCCN Guidelines Insights highlight notable recent updates. Abiraterone acetate is a first-in-class hormonal agent that represents a new standard of care for patients with metastatic castration-recurrent prostate cancer who have previously received docetaxel (category 1 recommendation). Abiraterone acetate also received category 2B recommendations in the prechemotherapy setting for asymptomatic patients or symptomatic patients who are not candidates for docetaxel. The NCCN Prostate Cancer Panel also added new indications for existing agents, including the option of sipuleucel-T as second-line therapy. In addition, brachytherapy in combination with external beam radiation therapy with or without androgen deprivation therapy is now an alternative for patients with high-risk localized tumors or locally advanced disease.

Immediate unplanned hospital admission after outpatient ureteroscopy for stone disease.

PURPOSE: Medicare recently changed reimbursement for ureteroscopy, encouraging migration to ambulatory surgical centers. To our knowledge the risk of immediate unplanned hospital admission, which may discourage ureteroscopy at ambulatory surgical centers, is unknown. We determined the rate of immediate unplanned hospital admission, identified factors associated with admission and developed a risk stratification tool to assist with location selection for outpatient ureteroscopy. MATERIALS AND METHODS: We retrospectively reviewed the records of 1,798 consecutive outpatient ureteroscopic procedures for urolithiasis performed from 1998 to 2008 at our institution. Patients requiring immediate hospital admission were matched 1 to 3 by provider, gender and date with controls who did not require admission. Patient demographics, comorbid conditions, stone history and burden, and operative technique were assessed for impact on admission by bivariate and multivariate logistic regression. A scoring system was developed and estimated admission rates were calculated. RESULTS: There were 70 immediate unplanned admissions (3.9%). Based on multivariate analysis the factors associated with unplanned admission were any previous admission related to stones (p <0.001), history of psychiatric illness (p = 0.016) and bilateral procedure (p = 0.019). Patients with distal ureteral stones were less likely to require admission (p = 0.026). One point was added for each positive factor and 1 was subtracted for a distal ureteral stone. A risk factor score of 2 or greater in 9% of the cohort was associated with an estimated 20.0% admission rate while lower scores in 91% of the cohort were associated with a 2.9% admission rate. CONCLUSIONS: Readily identifiable factors can stratify the risk of unplanned hospital admission and help guide the selection of the most appropriate facility for outpatient ureteroscopy.