The prospective evaluation of the effectiveness of scoring systems in the emergency department in cases with suspected ureteral stones: STONE? CHOKAI?

INTRODUCTION: This study evaluates the effectiveness of CHOKAI and STONE scores in patients presenting to the emergency department with ureteral stones. METHODS: Patients over the age of 18 who were admitted to the emergency department with flank pain, groin pain, scrotal pain, and hematuria and who were performed non-contrast abdominal computed tomography (CT) for diagnostic imaging were included. The numeric pain, CHOKAI, and STONE scores of the patients were calculated. The effectiveness of these scoring systems in the presence of stones was examined. RESULTS: A total of 105 patients were included in the study. In the analysis performed to investigate whether there was a difference between the numeric pain, STONE, and CHOKAI scores in terms of the presence of stones on CT, it was seen that the CHOKAI score was significantly different from the others (p < 0.001). A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001).When the cut-off value of the CHOKAI score was >7, the sensitivity was found to be 60.49%, and specificity was 83.33%. The cut-off value for the STONE score was >8 with a sensitivity of 70.37% and specificity of 58.33%. The corresponding area under curve values for the CHOHAI and STONE scores was 0.788 (p < 0.0001) and 0.615 (p = 0.087). Male sex, the CHOKAI, and STONE scores were the independent risk factors for ureteral stone. A significant positive correlation was found between the CHOKAI score and stone size (r = 0.343, p < 0.001). CONCLUSION: The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones. NEW KNOWLEDGE ADDED BY THIS STUDY: The CHOKAI score has a higher performance than the STONE score in detecting the presence of ureteral stones. Especially in countries such as Turkey, where there are no specific racial differences, the STONE score may be diagnostically insufficient. The CHOKAI score shows the presence of the patient's stone and positively correlates with the size of the stone and the stone location. IMPLICATION FOR CLINICAL PRACTICE OR POLICY: In the functioning of the emergency department, it is important to make the differential diagnosis of patients quickly and provide effective treatment. The use of diagnostic scoring systems saves time for the emergency physician in the differential diagnosis phase and guides in terms of applying for possible additional imaging methods.

[Interrater reliability and clinical impact of the Post-Ureteroscopic Lesion Scale (PULS) grading system for ureteral lesions after ureteroscopy : Results of the German prospective multicenter BUSTER project]. / Interrater-Übereinstimmung und klinischer Nutzen der "Post-Ureteroscopic Lesion Scale" (PULS) zur Graduierung von intraoperativen Harnleiterverletzungen einer Ureterorenoskopie : Ergebnisse der deutschen prospektiv-multizentrischen BUSTER-Studie.

BACKGROUND: The Post-ureteroscopic Lesion Scale (PULS) was designed as a standardized classification system for ureteral lesions after uretero(reno)scopy (URS). This study evaluates its routine use and a possible clinical impact based on a representative patient cohort. MATERIALS AND METHODS: Data of 307 patients in 14 German centers within the BUSTER project were used to test 3 hypotheses (H): PULS score shows a high interrater reliability (IRR) after independent assessment by urologic surgeon and assistance personnel (H1); PULS score is correlated with the frequency of postoperative complications during hospital stay (H2); post-URS stenting of the ureter is associated with higher PULS scores (H3). RESULTS: Median age of patients was 54.4 years (interquartile range [IQR] 44.4-65.8; 65.5% male). Median diameter of index stones was 6 mm (IQR 4-8) with 117 (38.4%) pyelo-caliceal and 188 (61.6%) ureteral stones. Overall, 70 and 82.4% of patients had pre-stenting and post-URS stenting, respectively. Stone-free status was achieved in 68.7% after one URS procedure with a complication rate of 10.8% (mostly grade 1-2 according to Clavien-Dindo). PULS scores 0, 1, 2 and 3 were assessed in 40%, 52.1%, 6.9% and 1% of patients, respectively, when estimated by urologic surgeons. PULS score showed a high IRR between the urologic surgeon and assistance personnel (κ = 0.883, p < 0.001), but was not significantly correlated with complications (ρ = 0.09, p = 0.881). In contrast, a significant positive correlation was found between PULS score and post-URS stenting (ρ = 0.287, p < 0.001). A PULS score of 1 multiplied the likelihood of post-URS stenting by 3.24 (95% confidence interval 1.43-7.34; p = 0.005) as opposed to PULS score 0. CONCLUSIONS: Removal of upper urinary tract stones using URS is safe and efficacious. Real-world data provided by this study confirm a high IRR of the PULS score and its clinical impact on the indication for post-URS stenting. A future prospective randomized trial should evaluate a possible standardization of post-URS stenting based on PULS score assessment.

[Implementation of a scale on stone baskets]. / Implementierung einer Skala auf Steinfangkörben.

BACKGROUND: Complications after endoscopic retrieval of kidney and ureter stones are obviously related to the size of the stones as well as the experience of the surgeon and other factors. During the procedure it is sometimes difficult for surgeons to estimate stone size and therefore give prognostic advises. The visual perception of the stone size depends on the shape, colour, distance to the renoscope and dilatation of the ureter. This is the so-called binding problem, because shape, color and direction of motion are processed separately by different population of optical neurons. In order to establish a better prognostic ratio, especially for less experienced surgeons we established an intraoperative semi-quantitative measurement of the stone size supported by a stone basket. MATERIALS AND METHODS: We modified the tipped nitinol stone baskets from the company Urotech with diameters of 2.5, 3.0 and 4 Ch. The handle of this basket has a spring mechanism, which automatically closes the basket and provides a predefined fixation force of the stones within the basket. On the handle we established a non-linear scale in mm by grabbing standardized balls or standardized screws. RESULTS: The scales are nonlinear because of the nonlinear relation between the diameter of the stone and the distance of the slider. Also the scales differ in between the basket size, because of the different strain conditions due to the different wire sizes and materials or the spring and basket. CONCLUSIONS: This scale could be an important orientation for a surgeon during endourological procedures to estimate stone sizes. It could be used also for the documentation of the size of fragments after an endourologic lithotripsy and could help in the decision for or against an extraction. Finally it could be very interesting for other disciplines like gastroenterology. The scale should be validated in further clinical trials.

Treatment of large impacted proximal ureteral stones: randomized comparison of minimally invasive percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy.

OBJECTIVE: To provide appropriate evidence for treatment planning of patients with an impacted proximal ureteral stones ≥1.5 cm in size, by analyzing the therapeutic outcomes for those undergoing minimally invasive percutaneous antegrade ureterolithotripsy and retrograde ureterolithotripsy. PATIENTS AND METHODS: From September 2010 to November 2011, eligible patients with impacted proximal ureteral stones ≥1.5 cm in size referred to our institute were considered for this study. The closed envelope method was used to randomize the enrolled patients to mini-PCNL (30) or retrograde ureterolithotripsy (29). The efficiency quotient (EQ) was calculated to specifically address the efficiency for both the techniques. All preoperative and postoperative data for both groups were recorded. RESULTS: The initial stone-free rate was 93.3% in the mini-PCNL group and 41.4% in the URSL group (p < 0.001). However, the overall stone-free rate at the 1-month follow-up visit after initial treatment was 100% in the mini-PCNL group and 89.7% in the URSL group (p = 0.07). The EQs for the mini-PCNL and URSL groups were 0.83 and 0.50, respectively. CONCLUSIONS: Our study shows that mini-PCNL removal of large impacted proximal ureteral calculi can achieve higher stone-free rates and safe.

Validity of administrative coding in identifying patients with upper urinary tract calculi.

PURPOSE: Administrative databases are increasingly used for epidemiological investigations. We performed a study to assess the validity of ICD-9 codes for upper urinary tract stone disease in an administrative database. MATERIALS AND METHODS: We retrieved the records of all inpatients and outpatients at Johns Hopkins Hospital between November 2007 and October 2008 with an ICD-9 code of 592, 592.0, 592.1 or 592.9 as one of the first 3 diagnosis codes. A random number generator selected 100 encounters for further review. We considered a patient to have a true diagnosis of an upper tract stone if the medical records specifically referenced a kidney stone event, or included current or past treatment for a kidney stone. Descriptive and comparative analyses were performed. RESULTS: A total of 8,245 encounters coded as upper tract calculus were identified and 100 were randomly selected for review. Two patients could not be identified within the electronic medical record and were excluded from the study. The positive predictive value of using all ICD-9 codes for an upper tract calculus (592, 592.0, 592.1) to identify subjects with renal or ureteral stones was 95.9%. For 592.0 only the positive predictive value was 85%. However, although the positive predictive value for 592.1 only was 100%, 26 subjects (76%) with a ureteral stone were not appropriately billed with this code. CONCLUSIONS: ICD-9 coding for urinary calculi is likely to be sufficiently valid to be useful in studies using administrative data to analyze stone disease. However, ICD-9 coding is not a reliable means to distinguish between subjects with renal and ureteral calculi.

[Fragmentation of ureteral calculi using a holmium YAG laser]. / Fragmentation des calculs urétéraux par laser Holmium Yag.

PURPOSE: Evaluation of the Holmium YAG laser wave length in the treatment of ureteric calculi. MATERIAL AND METHODS: 84 ureteric stones in 62 patients were subjected to lithotripsy by the Ho-YAG laser (wave length 2100 nm). Of the stones treated 54 were lower ureteric, 21 were middle ureteric and 9 were upper uireteric stones. Thirty five stones were subjected to previous unsuccessful endoscopic lithotripsy procedures or ESWL. The mean diameter of the stones was 1.6 cm. The energy parameters followed in the study were 1.5 joules with frequency of 15 to 20 pulse/sec (22-30 watts). KUB was carried out one week and one month after the procedure and intravenous urography was performed 2 months later to evaluate upper tract improvement and to detect any stricture formation alone the ureter. RESULTS: Of the 84 stones, 75 (89.2%) were successfully fragmented: 52 (96%) of the lower, 17 (80.9%) of the middle and 6 (66.6%) of the upper ureteric stones. The cause of failure in fragmentation of the remaining 9 stones (10.7%) was due to failure of instrumentation nor machine malfunction that aborted the procedure. The average operative time per case was approximately 30 minutes and the lasing time was approximately 7 minutes. No major complications related to the laser treatment were encountered except in one patient who needed prolonged internal ureteral stenting. CONCLUSION: Ho-YAG laser lithotripsy is useful and very effective in the endoscopic treatment of ureteric stones. It is safe, if carefully applied and most of the cases can be carried out as an outpatient procedure.

[Significance of "clinically insignificant residual fragments" (CIRF) after ESWL]. / Zur Bedeutung der "clinically insignificant residual fragments" (CIRF) nach ESWL.

Almost 75% of all urinary calculi can be treated by extracorporeal shock wave lithotripsy (ESWL). In contrast to endoscopic and open-surgical procedures the patients are not immediately free of stones. The residual fragments after ESWL are called clinically insignificant residual fragments (CIRF), if the fragments are less than 5 mm in size and if there is the possibility of a spontaneous passage. But CIRF can cause ureteral obstruction. In addition, CIRF play an important role for the risk of stone growth and stone recurrence. The metaanalysis shows that it is not advisable to classify the CIRF only by their size. The morphological conditions of the urinary tract also have to be evaluated. Therefore, stone patients with CIRF after ESWL require a close follow-up and timely adjuvant therapy. All aspects mentioned lead to the conclusion to use the term "CIRF" with caution.

A new system for descriptive classification of stones in the upper urinary tract.

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

[CEP/LTS-X: a simple clinical classification of urinary calculi]. / CEP/LTS-X: une classification clinique simple des calculs urinaires.

The introduction of new treatment techniques for urinary stones requires a classification of our concepts concerning the application of these various modalities. In order to individualize the treatment of stones as precisely as possible, the authors propose a clinical and therapeutic classification based on the characteristics of the stone, the state of the urinary tract, the state of the parenchyma and renal function, the site of the stone, its dimensions and consistency and the number of stones. On the basis of these criteria, renal stones can be classified into 4 types, ureteric stones can be classified into 3 types and bladder and urethral stones can be classified into 2 types. The stones observed in each category are described together with the most appropriate treatment.

[A new classification of reno-ureteral lithiasis]. / Nuova classificazione della litiasi reno-ureterale.

The Authors suggest a change in their surgical classification of renal calculi to conform the description to the new techniques in the treatment of renal calculosis. Category "C" describes the morphology and topography of renal stones in five degrees (C1-C5); small letters "p, s, m, i" indicate the pelvis, superior, middle, inferior calyces; "n" and "a" symbolize stone having a size similar to or exceeding normal shaped renal cavities. "Cu" indicates ureteral calculi; small letters "l, i, p" indicate lumbar, iliac, pelvic ureteral stones. "N" describes the nature of the calculi. Category "E" stands for the excretory tract; "+" and "-" indicate the presence or absence of dilatation, the small letters "e, i" show the extra or intrarenal position of renal cavities; "no" and "o" indicate absence or presence of intrinsic obstruction of the excretory tract. "R" points out the number of surgical recurrences. Category "P" indicates the function of the parenchyma; numbers 1, 2, 3, refer to normal renal function, moderate or serious insufficiency. "U" stands for unique functional or anatomical kidney; "I" indicates the presence of infection.

[New surgical classification of renoureteral lithiasis]. / Nueva clasificación quirúrgica de la litiasis renoureteral.

The authors suggest a change in their surgical classification of renal calculi to conform the description to the new techniques in the treatment of renal calculosis. Category "C" describes the morphology and topography of renal stones in five degrees (C1-C5); small letters "p", "s", "m", "i" indicate the pelvis, superior, middle, inferior calyces; "n" and "a" symbolize a stone having a size similar to or exceeding normal shaped renal cavities. "Cu" indicates ureteral calculi; small letters, "l", "i", "p" indicate lumbar, iliac, pelvic ureteral stones. "N" describes the nature of the calculi. Category "E" stands for the excretory tract: "+" and "-" indicate the presence or absence of dilatation; the small letters "e", "i" show the extra or intrarenal position of renal cavities; "no" and "o" indicate absence or presence of intrinsic obstruction of the excretory tract. "R" points out the number of surgical recurrences. Category "P" indicates the function of the parenchyma; numbers 1, 2, 3 refer to normal renal function, moderate or serious insufficiency. "U" stands for unique functional or anatomical kidney; "I" indicates the presence of infection.