Renal autotransplantation: association between preoperative disease duration and surgical outcomes.

OBJECTIVE: To determine whether early vs. delayed autotransplantation are associated with adverse outcomes in patients undergoing renal autotransplantation. METHODS: Patients who underwent renal autotransplantation from June 2012 to September 2022 were divided into two groups based on timing of autotransplant in relation to initial intervention or diagnosis (early cohort: ≤1-year; delayed cohort: >1-year). Primary outcomes were perioperative complications, aborted surgery, renal function (glomerular filtration rate [GFR]), and postoperative complications at most recent follow-up. RESULTS: Autotransplantation patients (N=72) were predominantly female (68%) and White (54%), with a median age of 49 years. 90% of patients had undergone previous interventions, including stenting (40%) and nephrostomy tubes (49%), primarily for obstruction (64%). Early vs. delayed cohorts had median preoperative disease durations of 143 (IQR 83-222) vs. 673 days (IQR 529-1,703, p<0.001), with similar median follow-up times (879 vs. 818 days, p=0.8). Groups were similar in demographics and comorbidities. There were no significant differences in rates of aborted surgery (15% vs. 4.2%, p=0.3), perioperative complications (15% vs. 17%, p>0.9), long-term complications (49% vs. 48%, p>0.9), or changes in GFR (median change +3 vs. +4, p=0.7). Outcomes were comparable across preoperative disease durations ranging from 6 to 24 months. These findings were confirmed following adjustments for sex, body mass index, American Society of Anesthesiologists classification, race, preoperative creatinine levels, laterality, gastroesophageal reflux disease, diabetes, hypertension, nephrolithiasis, hyperlipidemia, history of colon surgery, urologic surgery, abdominal surgery, and prior interventions in separate logistic models. CONCLUSIONS: Disease duration before autotransplantation does not influence outcomes, offering reassurance for clinical decision-making in complex cases.

Reimagining Ambulatory Care in Urology: Conversion of the Urology Clinic into a Procedure Center Improves Patient's Experience.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic made it necessary to practice social distancing and limited in-person encounters in health care. These restrictions created alternative opportunities to enhance patient access to care in the ambulatory setting. We hypothesized that by transforming clinics into centers that prioritize procedures and transitioning ambulatory appointments to telehealth, we could establish a secure, streamlined, and productive method for providing patient care. Methods: Clinic templates were restructured to allow the use of the physical space to perform procedure-based clinics exclusively, while switching to virtual telemedicine for all nonprocedural encounters. Staff members were given specific roles to support one of the patient care modalities for a given day (Procedures vs. Telehealth). Performance and patient satisfaction metrics were collected between two periods of time defined as P1 (February-June 2019) and P2 Post-COVID (February-June 2020) and compared. These served as proxies of periods when the clinic workflow and templates were structured in the traditional versus the emerging way. Statistical analysis was performed using bivariate analyses. Results: The percentage of procedures performed among all in-person visits were higher in P2 compared to P1 (45% vs. 29%, p < 0.001). Although total charges and relative value units were lower in P2, the overall revenue generated was higher compared to P1 ($4,597,846 vs. $4,517,427$, respectively). This increase in revenue was mainly driven by the higher relative income generated by procedures. Patient experience, reflected through patient-reported outcomes, was more favorable in P2 where patients seemed more likely to "Recommend this provider office" (90% vs. 85.7%, p = 0.01), report improved "Access overall" (56% vs. 49%, p = 0.02), and felt they were "Moving through your visit overall" (59% vs. 51%, p = 0.007). Conclusions: Our data suggest that reorganizing urology clinics into a space that is centered around outpatient procedures can represent a model that improves the patient's access to care and clinical experience, while simultaneously improving operational financial strength. This efficient care model could be considered for many practice settings and drive high-value outpatient care.

Comparison of Minimally Invasive Procedures for Benign Prostatic Hyperplasia: A Cost-effectiveness Analysis.

Background Benign prostatic hyperplasia (BPH) is a disease that affects millions of U.S. men and is costly to treat. Purpose To compare the cost-effectiveness of four minimally invasive therapies (MITs) and medical management for the treatment of BPH. Materials and Methods A cost-effectiveness analysis from a payer's perspective with Markov modeling was performed, comparing prostatic artery embolization (PAE), prostatic urethral lift, aquablation, water vapor thermal therapy, and medical management for BPH spanning a time horizon of 5 years. The model incorporated the probability of procedural complications and recurrent symptoms necessitating retreatment, which were extracted from published studies with long-term follow-up. Costs were based on Medicare reimbursements using CPT codes for ambulatory surgery centers. Outcomes were measured using the quality-adjusted life year (QALY), incorporating both life quality and expectancy. Statistical analyses included a base case calculation (using the most probable value of each parameter) and probabilistic and deterministic sensitivity analyses. Results In the base case calculation, outcomes for the strategies were comparable, with a difference of 0.030 QALY (11 days of life in perfect health) between the most (PAE) and least (medical management) effective strategies. PAE was the most cost-effective strategy relative to medical management, with an incremental cost-effectiveness ratio of $64 842 per QALY. Probabilistic sensitivity analysis showed PAE was more cost-effective compared with prostatic urethral lift, aquablation, water vapor therapy, and medical management in pairwise comparisons. In sensitivity analysis of retreatment risk, PAE remained the most cost-effective strategy until its repeat treatment rates exceeded 2.30% per 6 months, at which point water vapor therapy became the optimal choice. PAE was the most cost-effective procedure when its procedural cost was lower than $4755. Aquablation and prostatic urethral lift became more cost-effective when their procedural costs were lower than $3015 and $1097, respectively. Conclusion This modeling-based study showed that PAE appears to be a cost-effective modality among medical management and MITs for patients with BPH, with comparable outcomes to prostatic urethral lift, water vapor therapy, and aquablation at a lower expected cost. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Gemmete in this issue.

The Impact of Bilateral Stone Disease on Patients' Disease Progression and Health-Related Quality of Life.

Purpose: Patients with recurring kidney stone events can expect significant morbidity and functional impairment. Few studies have evaluated the effect of bilateral kidney stones on disease progression and quality of life. We wanted to determine the association of bilateral stone disease on age of onset, and the impact on number of stone events and individual kidney stone disease-specific health-related quality of life (HRQOL) by analyzing the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Materials and Methods: We studied 2906 stone patients from 16 centers in North America after having completed the WISQOL questionnaire from 2014 to 2019. Kidney stone formers were assessed if kidney stones were bilateral or unilateral on imaging. Analysis with a chi-square test compared categorical variables. Bilateral kidney stone disease and its impact on HRQOL were evaluated through a multivariable linear regression model. Results: Of 2906 kidney stone formers, 1340 had unilateral kidney stones and 1566 had bilateral kidney stones. We observed more frequently that patients with bilateral stones had an increased number of depression/anxiety symptoms, renal tubular acidosis, and rheumatoid arthritis (all p < 0.05). Patients with bilateral stones had a younger mean (standard deviation [SD]) age of kidney stone disease onset (37.2 ± 15.8 vs 46.4 ± 15.9 years of age, p < 0.001). Bilateral kidney stone formers had a higher mean (SD) number of stone events (11.3 ± 21.8) than unilateral kidney stone formers (3.0 ± 5.1) (p < 0.001). Within our multivariable analysis, we found that HRQOL was negatively affected by the presence of bilateral stones for kidney stone patients (ß = -11.2 [confidence interval: -19.5 to -3.0] points, p < 0.05). Conclusions: Bilateral kidney stone formers had a younger age of kidney stone disease onset and a higher number of stone events compared with unilateral kidney stone disease formers. The presence of bilateral kidney stone disease negatively impacted HRQOL.

Voided volume may not impact stone outcomes: Review of a large institutional nephrolithiasis cohort.

Background: Urologic guidelines universally recommend increasing fluid intake for kidney stone prevention. Increased voided volume is thought to help reduce stone recurrence and severity, but supporting evidence is limited. Patients and Methods: Nephrolithiasis outcomes and 24-h urine data for patients from the Registry for Stones of the Kidney and Ureter (ReSKU), a registry of nephrolithiasis patients collected between 2015 and 2020, were retrospectively analysed. Outcome was stone events, either an office visit where a patient reports symptomatic passage of stones or surgery for stone removal. Results: We identified 450 stone patients with 24-h urine and kidney stone outcome data. There was no significant difference in 24-h voided volume between patients with one stone event and patients with two or more stone events. On multivariable logistic regression, after controlling for age, gender, BMI, and 24-h sodium and creatinine per kilogram, no significant associations were found between voided volume and stone events. There was a statistically significant negative correlation noted between voided volume and stone events in calcium oxalate dihydrate stone formers (Spearman R = -0.42, p = 0.04), but not others. Conclusions: Twenty-four-hour voided volume was not associated with stone events in a large institutional cohort, and subset analysis reveals that some stone formers may benefit more from increased voided volume than others; identifying such patients represents a novel precision medicine opportunity.

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.

Effects of Delayed Surgical Intervention Following Emergency Department Presentation on Stone Surgery Complexity.

Introduction and Objective: Prior literature had demonstrated increased stone burden and higher rates of staged surgery in individuals of lower socioeconomic status (SES). Low SES individuals are more likely to experience delays in definitive stone surgery after initial presentation to the emergency department (ED) for kidney stones. This study aims to investigate the relationship between delays in definitive kidney stone surgery and the subsequent need for percutaneous nephrolithotomy (PNL) and/or staged surgical procedures using a statewide data set. Methods: This retrospective cohort study gathered longitudinal data from 2009 to 2018 using the California Department of Health Care Access and Information data set. Patient demographic characteristics, comorbidities, diagnosis/procedure codes, and distance were analyzed. Complex stone surgery was defined as initial PNL and/or undergoing more than one procedure within 365 days of initial intervention. Results: A total of 1,816,093 billing encounters from 947,798 patients were screened, resulting in 44,835 patients with ED visits for kidney stones followed by a urologic stone procedure. Multivariable analysis revealed that relative to patients who underwent surgery within 1 month of initial ED visit for stone disease, patients were at increased odds of undergoing complex surgery if waiting ≥6 months (odds ratio [OR] 1.18, p = 0.022), ≥1 year (OR 1.29, p < 0.001), and ≥3 years (OR 1.43, p < 0.001). Conclusions: Delays in definitive stone surgery after initial ED encounter for stone disease were associated with increased likelihood of undergoing a complex stone treatment.

Ultrasound-Only Percutaneous Nephrolithotomy Is Safe and Effective Compared to Fluoroscopy-Directed Percutaneous Nephrolithotomy.

Introduction: Outcomes after ultrasound-only percutaneous nephrolithotomy (PCNL), in which no fluoroscopy is used, are not well known. The goal of this study was to compare outcomes of ultrasound-only and fluoroscopy-directed PCNL. Materials and Methods: Prospectively collected data from the Registry for Stones of the Kidney and Ureter database were reviewed for all patients who underwent PCNL at one academic center from 2015 to 2021. Primary outcomes were complications and stone-free rates (no residual fragments ≥3 mm). Results: Of the 141 patients who underwent ultrasound-only PCNL and 147 who underwent fluoroscopy-directed PCNL, there was no difference in complication rates (15% vs 16%, p = 0.87) or stone-free status (71% vs 65%, p = 0.72), respectively. After adjusting for body mass index, American Society of Anesthesiologists (ASA), stone size, and stone complexity by Guy score, ultrasound-only PCNL was not associated with any increased odds of complications (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.3-1.6, p = 0.41) or residual stone fragments ≥3 mm (OR 1.0, 95% CI 0.5-1.9, p = 0.972) compared with fluoroscopy-directed PCNL. Ultrasound-only PCNL was associated with shorter operative time (median 99.5 vs 126 minutes, p < 0.001), and the use of ultrasound remained a significant predictor of short operative time (<100 minutes) after controlling for supine positioning, stone size, and stone complexity by Guy score (OR 2.31, 95% CI 1.01-5.29, p = 0.048). Patients in the ultrasound-only group were spared a mean radiation exposure dose of 10 mGy per procedure. Conclusions: Ultrasound-only PCNL is safe and achieves similar stone-free rates compared with fluoroscopy-directed PCNL with the added benefit of avoidance of radiation.

Single-Use Ureteroscopes Are Associated with Decreased Risk of Urinary Tract Infection After Ureteroscopy for Urolithiasis Compared to Reusable Ureteroscopes.

Objective: Urinary tract infection (UTI) is a common complication after ureteroscopy. Despite sterilization, there is evidence that reusable ureteroscopes can still harbor bacteria. Whether this property is associated with increased risk of UTI is unknown. The objective of this study was to compare rates of postoperative UTI after ureteroscopy for urolithiasis performed with single-use ureteroscopes vs reusable ureteroscopes. Materials and Methods: This was a single-center, retrospective cohort study of all patients who underwent ureteroscopy for urolithiasis between June 2012 and March 2021. Outcomes were compared between those who underwent stone removal with single-use and reusable ureteroscopes. The primary endpoint was postoperative UTI. The secondary endpoints were intra-operative and postoperative outcomes, and health service utilization after surgery. Results: Of 991 patients identified, 500 (50.4%) underwent ureteroscopy with a single-use ureteroscope. Rates of postoperative UTI were lower in those undergoing ureteroscopic stone removal with a single-use ureteroscope compared to a reusable ureteroscope (6.5% vs 11.9%, p = 0.018). In multivariable analysis, use of a single-use ureteroscope was associated with lower odds of postoperative UTI compared to a reusable ureteroscope when adjusting for risk (odds ratio 0.37, p = 0.015). Use of a single-use ureteroscope was associated with a higher stone clearance rate compared to a reusable ureteroscope (90.0% vs 83.9%, p = 0.005). There was no difference in operative time, overall complication rate, readmission, or emergency department visits between two groups. Conclusion: Single-use ureteroscopes are associated with a twofold decreased risk of UTI and increased stone clearance rate after ureteroscopy for urolithiasis compared to reusable ureteroscopes.

Maternal family history of urolithiasis is associated with earlier age of onset of stone disease.

PURPOSE: To evaluate the impact of detailed family history on the severity of disease and age of onset in patients with urolithiasis. METHODS: Prospectively collected data from a single institution between October 2015 and December 2020 were analyzed. Our primary endpoint was the number of patients experiencing at least one recurrent stone during the follow-up period. RESULTS: Of 1566 patients analyzed, 603 (39%) reported at least one family member with a history of stones. The percentage of patients experiencing at least one recurrent stone event was higher in patients with a family history of stones (38%) compared to those without a family history of stones (28%) over a median follow-up period of 8 months (p = 0.001). On multivariate analysis, the presence of any family history of urolithiasis increased risk of recurrent stone events (odds ratio [OR] 1.62, p < 0.001). The presence of both a first- and a second-degree relative with urolithiasis was associated with higher odds for a recurrent stone event (OR 2.17; p = 0.003) and a younger age of onset for stones, (OR 3.32; < 0.001). A maternal-side relative with stones conferred a higher odds ratio for younger age of first onset of stones (OR 2.93; p < 0.001). CONCLUSION: Any family history of kidney stone disease imparts an increased risk of recurrent stone event and an earlier age of onset for urolithiasis. The presence of both first- and second-degree relatives or a maternal-side relative with kidney stones may be a predictor for an earlier age of onset for urolithiasis.

Underinsurance And Multiple Surgical Treatments for Kidney Stones.

OBJECTIVE: To further elucidate the relationship between low socioeconomic status (SES) and larger, more complex stones requiring staged surgical interventions. Specifically, we aimed to determine if underinsurance (Medicaid, Medicare, and self-pay insurance types) is associated with multiple surgeries within 1 year. METHODS: We performed a retrospective longitudinal analysis of prospectively collected data from the California statewide Department of Health Care Access and Information (HCAI) dataset. We included adult patients who had their first recorded kidney stone encounter between 2009 and 2018 and underwent at least 1 urologic stone procedure. We followed these patients within the dataset for one year after their initial surgery to assess for factors predicting multiple surgical treatments for stones. RESULTS: A total of 156,319 adults were included in the study. The proportions of individuals in private insurance, Medicaid, Medicare and self-pay/indigent groups differed by the presence or absence of additional surgeries (64.0%, 13.5%, 19.4%, and 0.1%, vs 70.3%, 10.1%, 16.6%, and 0.1%, respectively). Compared to private insurance, Medicaid (1.46 [1.40-1.53] P < .001) and Medicare (1.15 [1.10-1.20] P < .001) insurance types were associated with significantly greater odds of multiple surgeries, whereas no significant association was seen in the self-pay/indigent insurance type (1.35 [0.83-2.19], P = 1.0). CONCLUSION: In a statewide, California database from 2009 to 2018, underinsured adults had higher odds of undergoing a second procedure for kidney stones within 1 year of initial surgical treatment. This study adds to the expanding body of literature linking suboptimal healthcare access and disparate outcomes for kidney stone patients.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Determinants of ureteral obstruction after percutaneous nephrolithotomy.

BACKGROUND: Ureteral obstruction after percutaneous nephrolithotomy (PCNL) may require prolonged drainage with a nephrostomy tube (NT) or ureteral stent, but it is not well understood how and why this occurs. The goal of this study was to identify risk factors associated with postoperative ureteral obstruction to help guide drainage tube selection. METHODS: Prospective data from adult patients enrolled in the Registry for Stones of the Kidney and Ureter (ReSKU) who underwent PCNL from 2016 to 2020 were used. Patients who had postoperative NTs with antegrade imaging-based flow assessment on postoperative day one (POD1) were included. Patients with transplanted kidneys or those without appropriate preoperative imaging were excluded. We assessed the association between patient demographics, stone characteristics, and intraoperative factors using POD1 antegrade flow, a proxy for ureteral patency, as the primary outcome. Stepwise selection was used to develop a multivariate logistic regression model controlling for BMI, stone location, stone burden, ipsilateral ureteroscopy (URS), access location, estimated blood loss, and operative time. RESULTS: We analyzed 241 cases for this study; 204 (84.6%) had a visual clearance of stone. Antegrade flow on POD1 was absent in 76 cases (31.5%). A multivariate logistic regression model found that stones located anywhere other than in the renal pelvis (OR 2.63, 95% CI 1.29-5.53; p = 0.01), non-lower pole access (OR 2.81, 95% CI 1.42-5.74; p < 0.01), and concurrent ipsilateral URS (OR 2.17, 95% CI 1.02-4.65; p = 0.05) increased the likelihood of obstruction. BMI, pre-operative stone burden, EBL, and operative time did not affect antegrade flow outcomes. CONCLUSION: Concurrent ipsilateral URS, absence of stones in the renal pelvis, and non-lower pole access are associated with increased likelihood of ureteral obstruction after PCNL. Access location appears to be the strongest predictor. Recognizing these risk factors can be helpful in guiding postoperative tube management.

Multi-Institutional Variation in Performance of Low-Dose Computed Tomography for the Evaluation of Suspected Nephrolithiasis.

Introduction and Objective: Guidelines from the American Urological Association (AUA) and American College of Radiology (ACR) recommend that patients with suspected nephrolithiasis undergo low-dose CT of the kidney, ureter, and bladder (LD CT KUB) as opposed to higher dose conventional imaging. We hypothesized that even at institutions with established LD protocols, higher dose imaging is common. Materials and Methods: We identified four academic medical centers where LD CT KUB protocols were implemented to yield an effective dose (EDose) consistent with national guidelines. Fifty consecutive adult patients who underwent CT KUB specifically for the evaluation of nephrolithiasis were retrospectively reviewed at each site. Patient age, sex, body mass index (BMI), imaging location, and EDose (millisieverts [mSv]) were recorded. Results: Two hundred patients with a mean age of 54 years were identified. Forty-six patients (23%) underwent CT KUB with an EDose ≤4 mSv, accounting for 10% to 48% of each institution's cohort. One hundred sixteen patients had a BMI <30, and would have been expected to receive LD CTs by the AUA criteria for LD CT KUB. Within this subset, only 37 patients (32%) actually underwent LD CT KUB. The highest dose CT KUB at each institution resulted in an EDose of 33.8 to 44.6 mSv, exceeding the recommended exposure of LD CT KUB by 10-fold. Conclusions: At academic institutions where LD CT KUB was implemented for the evaluation of nephrolithiasis, a minority of patients with BMI <30 received guideline-concordant imaging. Differences in patient BMI did not account for the variation in radiation exposure. Further research is necessary to elucidate barriers to LD CT implementation.

The Duration of Stone Disease and the Impact of a Stone Event on Patients' Quality of Life.

Introduction: With a 5-year stone recurrence rate of 30% to 50%, kidney stone formers are subject to significant morbidity that negatively impacts their health-related quality of life (HRQOL). We sought to determine the impact of age at kidney stone onset, duration of stone disease, and kidney stone event (surgery or stone passage) on HRQOL of individual patients by querying the validated and prospectively collected Wisconsin Stone Quality of Life (WISQOL) database. Patients and Methods: Cross-sectional data were obtained from a total of 2438 kidney stone formers from 14 institutions in North America who completed the WISQOL questionnaire during the period from 2014 to 2019. The 28-question survey has a 1- to 5-point scale for each item (total score range 0-140). Multivariable linear regression models assessed the impact of age at kidney stone onset, duration of stone disease, and time since most recent surgery or stone passage on HRQOL. Results: Of 2438 patients, older age at kidney stone onset and longer duration of disease were both independent predictors of better WISQOL scores (ß = 0.33 points/year; confidence interval [CI] 0.17-0.49; p < 0.001; and ß = 0.50 points/year; CI 0.32-0.68; p < 0.001, respectively). Of 1376 patients who underwent surgery between 2010 and 2019, longer time since most recent surgery was an independent predictor of better WISQOL scores (ß = 2.28 points/year; CI: 1.47-3.10; p = <0.001). Of 1027 patients with spontaneous stone passage occurring between 2010 and 2019, longer time since most recent stone passage was an independent predictor of better WISQOL scores (ß = 1.59 points/year; CI: 0.59-2.59; p = <0.05). Conclusions: Our study demonstrates that older age at onset, longer duration of disease, and longer time since most recent surgery or stone passage were independent predictors of better HRQOL in kidney stone formers. Results of future studies that focus on optimizing stone-related modifiable risk factors to decrease the number of recurrent stone episodes and thus the need for recurrent surgeries will be essential.

Therapeutic Living Donor Nephrectomy for Proximal Ureteral Pathology: A Longitudinal Case Series.

OBJECTIVE: To raise awareness that patients with proximal ureteral stricture who elect for nephrectomy can consider donating the kidney. We present a series of patients undergoing therapeutic living donor nephrectomy (TLDN), a scenario in which a patient undergoing nephrectomy for an underlying medical problem donates the kidney to a person with end-stage renal disease. This practice is underutilized, and only a single TLDN with proximal ureteral stricture has been previously described. We aim to help define the indications, risks, and benefits for patients. METHODS: This is a retrospective case series of seven therapeutic donors with proximal ureteral pathology and stone disease. Patient characteristics, donor work up, operative details, and donor and recipient outcome were collected. RESULTS: All seven donors had proximal ureteral pathology, and six of the seven had nephrolithiasis or ureterolithiasis. After electing for nephrectomy, the mean time to TLDN was 57.9 days. No recipients experienced delayed graft function . Mean follow up was 40.1 months (range 8-131), and the most recent follow-up mean creatinine was 1.08 (mg/dL). Graft and recipient survival is 100%. No recipients developed recurrence of ureteral stricture or stones. CONCLUSION: This is the first series demonstrating patients with proximal ureteral stricture, even with concomitant stone disease, may donate kidneys for transplantation. Recipient outcomes suggest this practice is safe, and appropriately selected patients that have already elected for nephrectomy should receive counseling about this opportunity. Importantly, patients who donate a kidney receive waiting list priority if they ever need a kidney transplant in the future.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy.

CONTEXT: Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol. OBJECTIVE: To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up. EVIDENCE ACQUISITION: An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL. EVIDENCE SYNTHESIS: The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus. CONCLUSIONS: Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL. PATIENT SUMMARY: Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

Community Income, Healthy Food Access, and Repeat Surgery for Kidney Stones.

OBJECTIVE: To determine if limited food access census tracts and food swamp census tracts are associated with increased risk for repeat kidney stone surgery. And to elucidate the relationship between community-level food retail environment relative to community-level income on repeat stone surgery over time. METHODS: Data were abstracted from the University of California, San Francisco Information Commons. Adult patients were included if they underwent at least one urologic stone procedure. Census tracts from available geographical data were mapped using Food Access Research Atlas data from the United States Department of Agriculture Economic Research Service. Kaplan-Meier curves were employed to illustrate time to a second surgical procedure over 5 years, and log-rank tests were used to test for statistically significant differences. A multivariate Cox regression model was used to generate hazard ratios for undergoing second surgery by group. RESULTS: A total of 1496 patients were included in this analysis. Repeat stone surgery occurred in 324 patients. Kaplan-Meier curves demonstrated a statistically significant difference in curves depicting patients living in low income census tracts (LICTs) vs those not living in LICTs (P <.001). On Cox regression models, patients in LICTs had significantly higher risk of undergoing repeat surgery (P = .011). Patients from limited food access census tracts and food swamp census tracts did not have a significantly higher adjusted risk of undergoing second surgery (P = .11 and P = .88, respectively). CONCLUSION: Income more so than food access associates with increased risk of repeat kidney stone surgery. Further research is needed to explore the interaction between low socioeconomic status and kidney stone outcomes.

A large staghorn stone diagnosed and managed in an asymptomatic patient using the "Kidney Injury Test (Kit)" spot urine assay: A case report.

The Kidney Injury Test (KIT) Stone-Score provides an objective measure of stone burden. Unlike urinary supersaturation the KIT Stone-Scores assess underlying stone disease rather than urinary solute composition. We report a case of a 43-year-old woman with no history of nephrolithiasis who underwent an elective, voluntary KIT assay and was diagnosed with a large staghorn renal stone after an unanticipated markedly elevated score. This clinical scenario highlights the potential future use of the non-invasive urinary KIT assay as a reliable non-invasive tool to detect and monitor urinary stone disease.