Comparative Analyses and Ablation Efficiency of Thulium Fiber Laser by Stone Composition.

PURPOSE: There are limited data on ablation effects of thulium fiber laser (TFL) settings with varying stone composition. Similarly, little is known surrounding the photothermal effects of TFL lithotripsy regarding the chemical and structural changes after visible char formation. We aim to understand the TFL's ablative efficiency across various stone types and laser settings, while simultaneously investigating the photothermal effects of TFL lithotripsy. MATERIALS AND METHODS: Human specimens of calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, struvite, cystine, carbonate apatite, and brushite stones were ablated using 13 prespecified settings with the Coloplast TFL Drive. Pre- and postablation mass, ablation time, and total energy were recorded. Qualitative ablative observations were recorded at 1-minute intervals with photographs and gross description. Samples were analyzed with Fourier-transform infrared spectroscopy pre- and postablation and electron microscopy postablation to assess the photothermal effects of TFL. RESULTS: Across all settings and stone types, 0.05 J × 1000 Hz was the best numerically efficient ablation setting. When selected for more clinically relevant laser settings (ie, 10-20 W), 0.2 J × 100 Hz, short pulse was the most numerically efficient setting for calcium oxalate dihydrate, cystine, and struvite stones. Calcium oxalate monohydrate ablated with the best numerical efficiency at 0.4 J × 40 Hz, short pulse. Uric acid and carbonate apatite stones ablated with the best numerical efficiency at 0.3 J × 60 Hz, short pulse. Brushite stones ablated with the best numerical efficiency at 0.5 J × 30 Hz, short pulse. Pulse duration impacted ablation effectiveness greatly with 6/8 (75%) of inadequate ablations occurring in medium or long pulse settings. The average percent of mass lost during ablation was 57%; cystine stones averaged the highest percent mass lost at 71%. Charring was observed in 36/91 (40%) specimens. Charring was most often seen in uric acid, cystine, and brushite stones across all laser settings. Electron microscopy of char demonstrated a porous melting effect different to that of brittle fracture. Fourier-transform infrared spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate. CONCLUSIONS: We describe the optimal ablation settings based on stone composition, which may guide urologists towards more stone-specific care when using thulium laser for treating renal stones (lower energy settings would be safer for ureteral stones). For patients with unknown stone composition, lasers can be preset to target common stone types or adjusted based on visual cues. We recommend using short pulse for all TFL lithotripsy of calculi and altering the settings based on visual cues and efficiency to minimize the charring, an effect which can make the stone refractory to further dusting and fragmentation.

Indications for and results of renal autotransplantation.

PURPOSE OF REVIEW: To understand the indications and outcomes of renal autotransplantation, and when to consider this unique procedure for patients. RECENT FINDINGS: Renal autotransplantation confers acceptably low rates of graft failure and prevents need for long-term dialysis. Renal autotransplantation remains an important management strategy in very select patients for complex renovascular disease, ureteral stricture disease, ureteral trauma, upper urinary tract urothelial carcinoma, renal cell carcinoma, and Loin-Pain Hematuria Syndrome. With advancements in minimally invasive procedures, the application of renal autotransplantation for refractory stone disease is rare but exists. Robot-assisted laparoscopic renal autotransplantation demonstrates reproducible graft success and complication rates with improved perioperative outcomes (ex. hospital length of stay) - though comparative studies are lacking. Patients would benefit from a multidisciplinary approach from renal transplant surgeons, vascular surgeons, urologists, nephrologists, dieticians, pain management providers, social workers, and psychiatrists. SUMMARY: In experienced hands, renal autotransplantation is a reasonable treatment approach for complex and refractory renal vascular disease, Loin-Pain Hematuria Syndrome, ureteral strictures and trauma, upper urinary tract malignancy, and stone disease in highly select patients.

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.

A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium.

PURPOSE: Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy. MATERIALS AND METHODS: Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay. RESULTS: A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group. CONCLUSIONS: Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.

Stent duration and increased pain in the hours after ureteral stent removal.

INTRODUCTION To assess the relationship between pain after ureteral stent removal and patient and procedural factors. MATERIALS AND METHODS: A validated survey designed to assess the relationship between quality of life and treatment decisions in kidney stone disease was randomly distributed to patients with a history of a ureteral stent in seven medical centers across North America participating in an endourology research collaborative between July 2016 and June 2018. The primary outcome was increased pain after ureteral stent removal. Statistical analyses were performed using Chi-square and multiple logistic regression. RESULTS: A total of 327 surveys were analyzed. Twenty seven percent of patients reported increased pain in the hours after ureteral stent removal. Patients with a stent ≤ 7 days were significantly more likely to experience pain after stent removal compared to those with a stent > 7 days (33.3% versus 22.8%, p = 0.04). Female gender (OR: 2.41, 95% CI: 1.42-4.10) was associated with increased pain after stent removal, while increasing age was inversely associated (OR: 0.52, 95% CI: 0.36-0.74). After adjustment, patients with a stent > 7 days were significantly less likely to report pain in the hours after removal (OR: 0.59, 95% CI: 0.35-0.99). CONCLUSIONS: Approximately one in four patients will experience increased pain after ureteral stent removal. Female patients, younger patients, and patients with a stent ≤ 7 days were more likely to experience an increase in pain immediately following stent removal. Understanding factors associated with post-stent removal pain may be helpful in counseling patients at high risk stent removal morbidity.

Delayed Decompression of Obstructing Stones with Urinary Tract Infection is Associated with Increased Odds of Death.

PURPOSE: Obstructive pyelonephritis is considered a urological emergency but there is limited evidence regarding the importance of prompt decompression. We sought to investigate whether delay in decompression is an independent predictor of in-hospital mortality. Secondarily, we aimed to determine the impact of patient, hospital and disease factors on the likelihood of receipt of delayed vs prompt decompression. MATERIALS AND METHODS: Using the National Inpatient Sample from 2010 to 2015, all patients 18 years old or older with ICD-9 diagnosis of urinary tract infection who had either a ureteral stone or kidney stone with hydronephrosis (311,100) were identified. Two weighted sample multivariable logistic regression models assessed predictors of the primary outcome of death in the hospital and secondly, predictors of delayed decompression (2 or more days after admission). RESULTS: After controlling for patient demographics, comorbidity and disease severity, delayed decompression significantly increased odds of death by 29% (OR 1.29, 95% CI 1.03-1.63, p=0.032). Delayed decompression was more likely to occur with weekend admissions (OR 1.22, 95% CI 1.15-1.30, p <0.001), nonwhite race (OR 1.34, 95% CI 1.25-1.44, p <0.001) and lower income demographic (lowest income quartile OR 1.25, 95% CI 1.14-1.36, p <0.001). CONCLUSIONS: While the overall risk of mortality is fairly low in patients with obstructing upper urinary tract stones and urinary tract infection, a delay in decompression increased odds of mortality by 29%. The increased likelihood of delay associated with weekend admissions, minority patients and lower socioeconomic status suggests opportunities for improvement.

The use of outpatient opioid medication for acute renal colic and ureteral stents: Insights from a multi-institutional patient survey
.

AIMS: To investigate the main reasons for use of opioids during acute episodes of renal colic and for ureteral stent symptoms post-operatively. MATERIAL AND METHODS: A survey assessing the impact of decreased quality of life and use of opioid pain medication was distributed to patients with a history of ureteral stent at seven academic centers between July 2016 and June 2018. RESULTS: A total of 365 surveys were completed. Opioid use for stone (63.9%) and stent-related pain (39.0%) was common among respondents. When assessing whether patients used more opioids for stone or stent-related pain, 47.7% reported using more for stone pain while 15.0% reported using more for stent pain. 22.6% of patients required opioids for stent-related pain and not stone pain. Increasing patient age was found to be negatively associated with using opioids for stent-related pain (OR: 0.4, 95% CI: 0.3 - 0.6). Increasing age was also found to be negatively associated with opioid use for stone pain (OR: 0.6, 95% CI: 0.4 - 0.8). Patients with a greater number of prior stones had 3.2 times the odds of using opioids for stone pain, in our adjusted model (95% CI: 2.1 - 4.7). CONCLUSION: Patients with more prior stone episodes are more likely to have used opioids for their most recent episode. Although ureteral stents have been shown to be associated with a decreased quality of life, we showed that the use of opioids for stent-related pain is less than that for stone pain. Younger patients are less likely to tolerate a stent without opioid analgesics.

Use of the Quick Sequential Organ Failure Assessment Score for Prediction of Intensive Care Unit Admission Due to Septic Shock after Percutaneous Nephrolithotomy: A Multicenter Study.

PURPOSE: Recent studies have demonstrated that quick sequential organ failure assessment criteria may be more accurate than systemic inflammatory response syndrome criteria to predict postoperative sepsis. In this study we evaluated the ability of these 2 criteria to predict septic shock after percutaneous nephrolithotomy. MATERIALS AND METHODS: We performed a retrospective multicenter study in 320 patients who underwent percutaneous nephrolithotomy at a total of 8 institutions. The criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome were collected 24 hours postoperatively. The study primary outcome was postoperative septic shock. Secondary outcomes included 30 and 90-day emergency department visits, and the hospital readmission rate. RESULTS: Three of the 320 patients (0.9%) met the criteria for postoperative septic shock. These 3 patients had positive criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome. Of the entire cohort 23 patients (7%) met quick sequential organ failure assessment criteria and 103 (32%) met systemic inflammatory response syndrome criteria. Specificity for postoperative sepsis was significantly higher for quick sequential organ failure assessment than for systemic inflammatory response syndrome (93.3% vs 68.4%, McNemar test p <0.001). The positive predictive value was 13% for quick sequential organ failure assessment criteria and 2.9% for systemic inflammatory response syndrome criteria. On multivariate logistic regression systemic inflammatory response syndrome criteria significantly predicted an increased probability of the patient receiving a transfusion (ß = 1.234, p <0.001). Positive quick sequential organ failure assessment criteria significantly predicted an increased probability of an emergency department visit within 30 days (ß = 1.495, p <0.05), operative complications (ß = 1.811, p <0.001) and transfusions (p <0.001). The main limitation of the study is that it was retrospective. CONCLUSIONS: Quick sequential organ failure assessment criteria were superior to systemic inflammatory response syndrome criteria to predict infectious complications after percutaneous nephrolithotomy.

Discordance between Ureteroscopic Biopsy and Final Pathology for Upper Tract Urothelial Carcinoma.

PURPOSE: We evaluated the discordance between ureteroscopic biopsy and surgical pathology findings for grading and staging upper tract urothelial carcinoma. We also sought to establish preoperative predictors of aggressive tumors. MATERIALS AND METHODS: We retrospectively reviewed the records of 314 patients who underwent ureteroscopic biopsy followed by surgical management of upper tract urothelial carcinoma from 2000 to 2016 at a total of 3 institutions. Our primary outcomes were muscle invasive (pT2 or greater) disease at surgical pathology and upgrading of clinical low grade tumors to pathological high grade. RESULTS: At biopsy 61% of the patients had clinical high grade tumors and 21% had subepithelial connective tissue invasion (cT1+). On final pathology 79% of the patients had pathological high grade tumors and 45% had stage pT2 or greater. On multivariate analysis advanced patient age, clinical high grade and cT1+ were independently associated with pT2 or greater. The combined presence of clinical high grade and cT1+ had 86% positive predictive value for muscle invasion while the combined absence of clinical high grade and cT1+ had 80% negative predictive value. The likelihood of missing invasion on biopsy in patients with muscle invasive disease was increased when biopsy fragments were limited to 1 mm or less. Of clinical low grade cases on biopsy 51% were upgraded at surgery. The presence of positive urine cytology was associated with an increased risk of upgrading but this was not statistically significant. CONCLUSIONS: Clinical high grade, cT1+ on biopsy and advanced patient age are independent risk factors for muscle invasive upper tract urothelial carcinoma. There is a significant risk of upgrading in patients with clinical low grade tumors on biopsy, especially when urine cytology is positive. The predictive value of biopsy can likely be improved by more extensive ureteroscopic sampling.

Dusting versus Basketing during Ureteroscopy-Which Technique is More Efficacious? A Prospective Multicenter Trial from the EDGE Research Consortium.

PURPOSE: There is scant evidence in the literature to support dusting vs active basket extraction during ureteroscopy for kidney stones. We prospectively evaluated and followed patients to determine which modality produced a higher stone-free rate with the fewest complications. MATERIALS AND METHODS: Members of the Endourologic Disease Group for Excellence research consortium prospectively enrolled patients with a renal stone burden ranging from 5 to 20 mm in this study. A holmium laser was used and all patients were stented postoperatively. Ureteral access sheaths were used in 100% of basketing cases while sheaths were optional when dusting. The primary study outcome was the stone-free rate at 6 weeks as determined by x-ray and ultrasound. RESULTS: A total of 84 and 75 patients were enrolled in the basketing and dusting arms, respectively. Stones in the dusting group were significantly larger (mean ± SD stone area 96.1 ± 65.3 vs 63.3 ± 46.0 mm2, p <0.001). The stone-free rate was significantly higher in the basketing group on univariate analysis (74.3% vs 58.2%, p = 0.04) but not on multivariate analysis (1.9 OR, 95% CI 0.9-4.3, p = 0.11). In patients who underwent a basketing procedure operative time was 37.7 minutes longer than in those treated with a dusting procedure (95% CI 23.8-51.7, p <0.001). There was no statistically significant difference in complication rates, hospital readmissions or additional procedures between the groups. CONCLUSIONS: The stone-free rate was higher for active basket retrieval of fragments at short-term followup on univariate analysis but not on multivariate analysis. There was no difference in postoperative complications or procedures. The 2 techniques should be in the armamentarium of the urologist.

Analysis of evidence within the AUA's clinical practice guidelines.

INTRODUCTION: Surgical subspecialty societies release clinical practice guidelines (CPGs) to provide topic-specific recommendations to healthcare providers. We hypothesize that there may be significant differences in statement strength and evidence quality both within the American Urological Association (AUA) guidelines and compared to those published by the American Academy of Orthopedic Surgeons (AAOS) and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). MATERIALS AND METHODS: CPGs issued through 2017 were extracted from the AUAnet.org. Statements were characterized by evidence basis, strength, and evidence quality. CPGs were compared among urologic subspecialties and to those from the AAOS and AAO-HNS. Analysis used Fisher's exact tests and Student's t-tests with significance p < 0.05. RESULTS: A total of 25 AUA CPGs (672 statements) were reviewed and 34.6% were non-evidence based with the highest proportions in pediatrics (47.5%) and sexual medicine (46.5%). The AUA has published over twice as many statements as the AAOS and quadruple that of the AAO-HNS. A smaller proportion of the AUA statements were evidence-based (65.4%) compared to the AAOS (80.5%, p < 0.001) and AAO-HNS (99.8%, p < 0.001), and fewer used "high" quality evidence (AUA 7.2% versus AAOS 21.2%, p < 0.001; versus AAO-HNS 16.1%, p < 0.001). CONCLUSIONS: The AUA has published broad CPGs that far exceed those from the AAOS and AAO-HNS. The AUA has utilized extensive resources to provide guidance to help standardize care among urologists. The AAOS and AAO-HNS may not provide guidelines when evidence is limited. With the continued increase of high quality clinical trials, the AUA will be able to continue improving its robust set of evidence-based CPGs.

Salvage Percutaneous Nephrolithotomy: Analysis of Outcomes following Initial Treatment Failure.

PURPOSE: Percutaneous nephrolithotomy has high potential for morbidity or failure. There are limited data regarding risk factors for failure and to our knowledge no published reports of surgical outcomes in patients with prior failed attempts at percutaneous stone removal. MATERIALS AND METHODS: We identified patients referred to 3 medical centers after prior failed attempts at percutaneous nephrolithotomy. A retrospective chart review was performed to analyze reasons for initial failure and outcomes of salvage percutaneous nephrolithotomy. Outcomes were compared to those in a prospectively maintained database of more than 1,200 patients treated with a primary procedure. RESULTS: Salvage percutaneous nephrolithotomy was performed in 31 patients. Unsuitable access to the stone was the reason for failure in 80% of cases. Other reasons included infection, bleeding and inadequate instrument availability in 6.5% of cases each. Compared to patients who underwent primary percutaneous nephrolithotomy those treated with salvage were more likely to have staghorn calculi (61.3% vs 31.4%, p <0.01) and a larger maximum stone diameter (3.7 vs 2.5 cm, p <0.01), and require a secondary procedure (65.5% vs 42.1%, p <0.01). There was no significant difference between the cohorts in the remaining demographics or perioperative outcomes. All patients were deemed completely stone free except one who elected observation for a 3 mm nonobstructing fragment. CONCLUSIONS: Despite the more challenging nature and prior unsuccessful attempts at treatment, the outcomes of salvage percutaneous nephrolithotomy were no different from those of primary percutaneous nephrolithotomy when performed by experienced surgeons.

Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II.

PURPOSE: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part II of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part I for introductory information and a discussion of pre-operative imaging and special cases. MATERIALS AND METHODS: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed. RESULTS: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe the more commonly encountered special cases, including pediatric and pregnant patients. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management. CONCLUSIONS: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy.

Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I.

PURPOSE: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part I of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part II for an in-depth discussion of patients presenting with ureteral or renal stones. MATERIALS AND METHODS: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed. RESULTS: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe pediatric and pregnant patients with such stones. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management. CONCLUSIONS: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy.

Institutional characteristics associated with receipt of emergency care for obstructive pyelonephritis at community hospitals.

PURPOSE: Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients. MATERIALS AND METHODS: We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care. RESULTS: Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01). CONCLUSIONS: High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented.

A prospective, multi-institutional study of flexible ureteroscopy for proximal ureteral stones smaller than 2 cm.

PURPOSE: Flexible ureteroscopy is rapidly becoming a first line therapy for many patients with renal and ureteral stones. However, current understanding of treatment outcomes in patients with isolated proximal ureteral stones is limited. Therefore, we performed a prospective, multi-institutional study of ureteroscopic management of proximal ureteral stones smaller than 2 cm to better define clinical outcomes associated with this approach. MATERIALS AND METHODS: Adult patients with proximal ureteral calculi smaller than 2 cm were prospectively identified. Patients with concomitant ipsilateral renal calculi or prior ureteral stenting were excluded from study. Flexible ureteroscopy, holmium laser lithotripsy and ureteral stent placement was performed. Ureteral access sheath use, laser settings and other details of perioperative and postoperative management were based on individual surgeon preference. Stone clearance was determined by the results of renal ultrasound and plain x-ray of the kidneys, ureters and bladder 4 to 6 weeks postoperatively. RESULTS: Of 71 patients 44 (62%) were male and 27 (38%) were female. Mean age was 48.2 years. ASA(®) score was 1 in 12 cases (16%), 2 in 41 (58%), 3 in 16 (23%) and 4 in 2 (3%). Mean body mass index was 31.8 kg/m(2), mean stone size was 7.4 mm (range 5 to 15) and mean operative time was 60.3 minutes (range 15 to 148). Intraoperative complications occurred in 2 patients (2.8%), including mild ureteral trauma. Postoperative complications developed in 6 patients (8.7%), including urinary tract infection in 3, urinary retention in 2 and flash pulmonary edema in 1. The stone-free rate was 95% and for stones smaller than 1 cm it was 100%. CONCLUSIONS: Flexible ureteroscopy is associated with excellent clinical outcomes and acceptable morbidity when applied to patients with proximal ureteral stones smaller than 2 cm.

Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients.

OBJECTIVE: To evaluate the long-term outcomes of robotic-assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction performed at a tertiary referral centre. MATERIALS AND METHODS: Data from 250 consecutive patients undergoing RAL UUT reconstruction, including pyeloplasty with or without stone extraction, ureterolysis, uretero-ureterostomy, ureterocalicostomy, ureteropyelostomy, ureteric reimplantation and buccal mucosa graft ureteroplasty, were collected at a tertiary referral centre between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months. RESULTS: Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure, with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications, none greater than Clavien grade 3. CONCLUSION: Robotic-assisted laparoscopic UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons.

Trends in Opioid and Nonsteroidal Anti-Inflammatory Drug Use for Patients with Kidney Stones in United States Emergency Departments from 2015 to 2021.

Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.

Surgical decompression is associated with decreased mortality in patients with sepsis and ureteral calculi.

PURPOSE: The combination of sepsis and ureteral calculus is a urological emergency. Traditional teaching advocates urgent decompression with nephrostomy tube or ureteral stent placement, although published outcomes validating this treatment are lacking. National practice patterns for such scenarios are currently undefined. Using a retrospective study design, we defined the surgical decompression rate in patients admitted to the hospital with severe infection and ureteral calculi. We determined whether a mortality benefit is associated with this intervention. MATERIALS AND METHODS: Patient demographics and hospital characteristics were extracted from the 2007 to 2009 Nationwide Inpatient Sample. We identified 1,712 patients with ureteral calculi and sepsis. Multivariate logistic regression was performed to determine the association between mortality and surgical decompression. RESULTS: Of the patients 78% underwent surgical decompression. Mortality was higher in those not treated with surgical decompression (19.2% vs 8.82%, p <0.001). Lack of surgical decompression was independently associated with an increased OR of mortality even when adjusting for patient demographics, comorbidities and geographic region of treatment (OR 2.6, 95% CI 1.9-3.7). CONCLUSIONS: Absent surgical decompression is associated with higher odds of mortality in patients with sepsis and ureteral calculi. Further research to determine predictors of surgical decompression is necessary to ensure that all patients have access to this life saving therapy.

Predictive value of current imaging modalities for the detection of urolithiasis during pregnancy: a multicenter, longitudinal study.

PURPOSE: We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis. MATERIALS AND METHODS: A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated. RESULTS: A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively. CONCLUSIONS: The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention.