Management of large kidney stones in the geriatric population.

PURPOSE: The aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population. METHODS: PubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments. RESULTS: Few prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates. CONCLUSIONS: Unique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.

Evaluating the American Urologic Association (AUA) dietary recommendations for kidney stone management using the National Health And Nutritional Examination Survey (NHANES).

The objective of this study is to evaluate the conventional dietary recommendations for stone prevention among patients in the National Health and Nutritional Examination Survey (NHANES) and compare dietary components and special diets between stone formers and non-stone formers. We analyzed the NHANES 2011-2018 dietary and kidney condition questionnaires, among 16,939 respondents who were included in this analysis. Dietary variables were selected based on the American Urological Association (AUA) guideline for Medical Management of Kidney Stones and from other studies on kidney stone prevention. Weighted multivariate logistic regression models were used to assess the relationship of dietary food components (categorized into quartiles) and dietary recommendations with kidney stone formation (yes vs no), adjusted for total caloric intake, comorbidities, age, race/ethnicity, and sex. The prevalence of kidney stones was 9.9%. Our results showed association of kidney stones with lower levels of potassium (p for trend = 0.047), which was strongest for < 2000 mg (OR = 1.35; 95% CI 1.01-1.79). Higher vitamin C intake was inversely associated with stone formation (p for trend = 0.012), particularly at daily intake levels between 60 and 110 mg (OR = 0.76; 95% CI 0.60-0.95) and above 110mcg (OR = 0.80; 95% CI 0.66-0.97). There were no associations between other dietary components and kidney stone formation. Higher levels of dietary vitamin C and potassium intake may be indicated for stone prevention and warrants further investigation.

Should Men Eat More Plants? A Systematic Review of the Literature on the Effect of Plant-Forward Diets on Men's Health.

OBJECTIVE: To perform a systematic review of the literature on plant-based and plant-forward diets and the prevention/treatment of the following common men's health conditions: prostate cancer (PCa), erectile dysfunction (ED), and benign prostatic hyperplasia (BPH). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses system criteria were utilized to search PubMed and Medline databases for the following search terms: "Diet (Mesh)" OR "Diet Therapy (Mesh)" AND "Prostatic Hyperplasia (Mesh)" OR "Prostatic Neoplasm (Mesh)" OR "Erectile Dysfunction (Mesh)." Articles in English published from 1989 to 2022 using human participants were analyzed, data summarized, and assessed for bias. RESULTS: Studies reporting on plant-based or vegetable-forward diets (Mediterranean) as an intervention were included. Cohort and cross-sectional studies using food frequency questionnaires or diet classification indices to quantify plant-based food intake patterns were included in the study. Ultimately, 12 PCa articles, 4 BPH articles, 6 ED articles, and 2 articles related to both BPH and ED were reviewed. Overall, the literature suggests plant-forward diets confer a protective effect on the men's health conditions reviewed. CONCLUSIONS: Evaluation of the literature on the impact of plant-forward diets on urologic conditions includes a heterogenous range of dietary patterns and study designs. The greatest amount of research has evaluated the application of plant-forward diets for PCa. While there is currently a lack of high-quality evidence for the use of plant-forward diets as prevention and/or treatment for PCa, ED, or BPH, reported outcomes suggest a consistent small beneficial impact alongside well-established benefits for common chronic conditions.

Implementation and Usability of an Electronic Medical Record-based Ureteral Stent Tracker.

OBJECTIVE: To design and implement a simple electronic medical record-based ureteral stent tracker. To assess its impact on stent dwell time and stent-related complications. METHODS: Patients with stents placed 12 months before and 6 months after stent tracker implementation were identified at 3 urban hospitals. Those with stents-on-strings and intentional chronic indwelling stents (greater than 90 days) were excluded. Patient demographics, stent characteristics (eg, indication, string, dwell time), and clinical outcomes (eg, positive urine cultures, complications) were reviewed and compared between pre- and posttracker cohorts. A 12-question usability survey was administered to surgical nurses to assess usability. RESULTS: A total of 323 stents (173 pre- and 150 posttracker) were placed in 217 patients. The prestent tracker cohort had a longer mean dwell time (pre: 40.9 ± 59.1 days vs post: 28.8 ± 22.0 days, P = .02) and a higher retention rate >90 days (pre: 8.1% [14/173] vs post: 1.3% [2/150], P = .005). The 2 cohorts had no significant differences in positive urine culture rates, patient phone calls to providers, stent-related emergency department visits, or hospitalizations. The usability survey showed that 86.4% of surgical nurses found the tracker to be user-friendly and 95.5% reported that it added less than 1 minute of work per procedure. CONCLUSION: Implementation of an electronic medical record-based ureteral stent tracker decreased average stent dwell time and frequency of retained stents. Surgical nurses reported the tracker to be user-friendly and convenient. Stent trackers can improve the efficiency of postoperative removal of indwelling ureteral stents.

Financial Toxicity of Nephrolithiasis: The First Assessment of the Economic Stresses of Kidney Stone Treatment.

OBJECTIVE: To investigate the financial toxicity (FT) related to kidney stone treatment. METHODS: We performed a cross-sectional cohort study with multi-institutional in-person and online cohorts of stone formers.  Participants were surveyed using the validated COST tool (COmprehensive Score for financial Toxicity). The maximum score is 44 and lower scores indicate increased FT. "Moderate FT" was defined by COST scores between 25 and 14 points and "severe FT" for scores <14. Descriptive statistics, X2 tests, T tests, Spearman correlation, and logistic regression were performed using SPSS v28. RESULTS: Two hundred and forty-one participants were surveyed, including 126 in-person participants and 115 online. A total of 60% of participants reported at least moderate FT (COST score <26) and 26% reported severe FT (COST score <14). Patients who reported moderate to severe FT were younger than those with low FT by a median difference of 8 years (95%CI = 4, 12). There was a significant correlation between out-of-pocket expense and COST scores, such that as out-of-pocket expenses increased, COST scores decreased, (Spearman's rho =-0.406, P = <.001). Participants with moderate to severe FT tended to miss more workdays (P = .002), and their caretakers tended to miss more workdays (P = .007) due to their stone disease. CONCLUSION: Most participants reported moderate to severe FT. As prior studies have shown that patients with "moderate FT" employ cost-coping strategies (i.e., medication rationing) and those with "severe FT" have worse health outcomes, urologists need to be sensitive to the financial burdens of treatment experienced by such patients undergoing kidney stone treatment.

Evaluating the association between food insecurity and risk of nephrolithiasis: an analysis of the National Health and Nutrition Examination Survey.

PURPOSE: This study aimed to investigate the relationship between self-reported food security and kidney stone formation. METHODS: Data were collected from the National Health and Nutrition Examination Survey (NHANES), a database representative of the United States population. Food security status was assessed using the US Household Food Security Survey Module: Six-Item Short Form. Characteristics of patients were compared using the Chi-square test and the student t-test. Multivariate logistic regression was performed using a multi-model approach. RESULTS: We analyzed 6,800 NHANES survey respondents. 37.2% of respondents were categorized as having "low food security" (scores 2-4) and 24.0% having "very low food security" (scores 5-6). 8.4% of respondents had a history of kidney stones. We found that people with very low food security had a 42% increased likelihood of developing kidney stones compared to those with high or marginal food security, after controlling for race, age, and comorbidities (OR 1.42; 95% CI 1.01-1.99). Between the different food security groups, no significant differences were observed in age, race/ethnicity, body mass index, gout history, osteoporosis history, or coronary artery disease history. Lower food security was associated with slightly younger age (< 1 year difference, p = 0.001), higher poverty-income ratio (p = 0.001), and many comorbidities, including kidney stones (p = 0.007). CONCLUSION: Our study provides evidence for an association between food access and the risk of kidney stone disease. Given these findings, food insecurity should be investigated as a modifiable risk factor for the development of kidney stone disease.

Medium-Term Real-World Outcomes of Minimally Invasive Surgical Therapies for Benign Prostatic Hyperplasia: Water Vapor Thermal Therapy (Rezum) vs Prostatic Urethral Lift (UroLift) in a High-Volume Urban Academic Center.

Purpose: Water vapor thermal therapy (WVTT, i.e., Rezum®) and prostatic urethral lift (PUL, i.e., Urolift®) are minimally invasive surgical therapy (MIST) options for benign prostatic hyperplasia (BPH). Few studies have directly compared the two procedures. We examined the clinical characteristics and postoperative outcomes of patients undergoing WVTT and PUL at our high-volume urban academic center. Methods: We reviewed our institutional MIST database to identify patients with prostate sizes ≥30 and ≤80 cc who underwent WVTT or PUL for treatment of BPH between January 2017 and September 2021. Pre- and postoperative outcomes, including retreatment rates, American Urological Association symptom score (AUA-SS), maximum flow (Qmax), postvoid residual (PVR), medication usage, trial of void success rates, catheterization requirements, and postoperative complications within 90 days were extracted and compared between procedures. Results: Three hundred seven patients received WVTT and 110 patients received PUL with average follow-up times of 11.3 and 12.8 months, respectively. WVTT patients showed significant improvements in AUA-SS, Qmax, and PVR, whereas PUL patients showed improvements in only AUA-SS and Qmax. Both WVTT and PUL patients with longitudinal follow-up demonstrated improvements in AUA-SS, Qmax, and PVR. Postoperatively, alpha-blocker utilization was significantly decreased following both WVTT and PUL (WVTT: 73.9%-46.6%, PUL: 76.4%-38.2%, both p < 0.001). Compared to patients receiving PUL, WVTT patients more frequently reported postoperative dysuria (22.8% vs 8.3%, p = 0.001) and nonclot-related retention (18.9% vs 7.3%, p = 0.005); PUL patients more frequently experienced postoperative clot retention (7.3% vs 2.6%, p = 0.027). There were no differences in rates of postoperative bladder spasm, trial of void success, urinary tract infections, or emergency department visits. Postoperative erectile dysfunction and retrograde ejaculation were rare and occurred at similar rates. Conclusion: In the real-world setting, WVTT and PUL have similar medium-term efficacy in improving symptoms and decreasing medication utilization for patients with BPH. Differences in postoperative complication profiles should inform patient counseling.

Evaluating perceptions and usage of natural remedies, herbal medicine, and dietary supplements for kidney stones among a diverse, international, urban patient population.

Our goal was to assess the use and perceptions of complementary and alternative medicine (CAM) for kidney stones among a diverse, urban population. This was a cross-sectional study of patients treated for kidney stones in the Bronx, NY. We assessed demographic information, personal history of kidney stones, as well as knowledge and use of CAM for kidney stones. Patient demographics and responses were analyzed using chi-squared, t tests, and binomial logistic regression. 113 patients were surveyed. 90% identified as non-white, of whom 58% indicated Hispanic, 46% Latinx, and 23% Black. 56% of patients were born outside the United States. 56% of patients had heard of CAM for kidney stones and 44% had used CAM for kidney stones. The most common CAM were fruits (N = 42, 84%). Recurrent stone formers were more likely than first-time stone formers to have heard of CAM (68 vs 44% p = 0.013) and to have used CAM (56 vs 30%, p = 0.008). Those identifying as Hispanic were more likely to have both heard of and tried CAM for kidney stones (p = 0.036 and 0.022, respectively) compared to non-Hispanic patients. CAM are commonly used among our diverse, urban patient population. While some remedies are high in citrate and alkali (i.e., lemon, cranberry), others are high in oxalate (i.e., beets) and could potentially contribute to stone formation. These findings underpin the importance that medical providers educate themselves on the CAM used in their specific patient populations and discussing use with patients. Providers should aim to identify and reconcile therapeutics that oppose goals of treatment.

The Utilization and Safety of Same-Day Discharge After Transurethral Benign Prostatic Hyperplasia Surgery: A Case-Control, Matched Analysis of a National Cohort.

OBJECTIVE: To analyze the utilization and safety of same-day (SDD) vs standard-length discharge (SLD) for transurethral resection (TURP), holmium laser enucleation (HoLEP), and GreenLight photovaporization (GL-PVP) of the prostate. METHODS: Using the 2015-2019 ACS-NSQIP files, the annual proportion of TURP, HoLEP, and GL-PVP performed with SDD (length of stay [LOS] = 0 days) was calculated. Patients were stratified by LOS into SDD and SLD (TURP: LOS = 1-3 days, HoLEP and GL-PVP: LOS = 1-2 days); those with longer LOS were excluded. Patients were matched 1:1 by age, body mass index, American Society of Anesthesiologists score, and modified Charlson Comorbidity Index score. We compared 30-day unplanned readmissions, reoperations, and Clavien-Dindo (CD) complications between SLD and SDD, and evaluated predictors of adverse outcomes using logistic regression. RESULTS: Most GL-PVP patients underwent SDD, compared to a minority of TURP and HoLEP patients. SDD utilization increased, remained stable, and decreased over time for HoLEP, TURP, and GL-PVP, respectively. For 46,898 included cases (31,872 TURP, 2,901 HoLEP, 12,125 GL-PVP), rates of reoperation, CD I/II, or CD IV complications were comparable before and after matching. Compared to SLD, 30-day unplanned readmission rates for matched SDD patients were lower following TURP (3.48% vs 4.25%, P = .013) and HoLEP (1.93% vs 4.43%, P = .003). On multivariate regression, SLD correlated with unplanned readmission after TURP and HoLEP for both unmatched and matched cohorts. CONCLUSION: For appropriately selected patients, SDD after TURP, HoLEP, and GL-PVP did not confer increased risk of 30-day complications, suggesting patient selection for SDD is being done with appropriate safety nationally.

Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database.

BACKGROUND: Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. METHODS: All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). RESULTS: 4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. CONCLUSIONS: Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.

A Comparison of Pharmaceutical Prices for Generic Erectile Dysfunction and Benign Prostatic Hyperplasia Medication in 2 Socioeconomically Disparate New York City Neighborhoods.

INTRODUCTION: Erectile dysfunction (ED) and benign prostatic hyperplasia (BPH) are frequently managed with medications. Variability and poor understanding of medication prices have been shown to hinder patient adherence, leading to worse clinical outcomes. We sought to explore how pharmacy type and neighborhood socioeconomic status influence pricing for generic ED and BPH medications. METHODS: A total of 96 pharmacies within the adjacent higher income Upper East Side (UES) and lower income East Harlem (EH) New York City neighborhoods were classified as chain or independent. Telephone surveys identified cash prices for 30-day supplies of 14 medications including phosphodiesterase 5-inhibitors, 5-alpha reductase inhibitors, alpha blockers and antispasmodics. Pricing variability based on pharmacy type and neighborhood was evaluated using Mann-Whitney U-tests. RESULTS: Of 96 pharmacies, 81 responded (84.4%). Independent pharmacies showed significantly reduced prices for 9/14 and 14/14 medications in UES and EH, respectively. The greatest independent pharmacy price reductions were for tadalafil 20 mg (15.0-fold in UES, 26.7-fold in EH) and sildenafil (8.4-fold in UES, 15.4-fold in EH). The least significant reductions were in mirabegron (1.1-fold in UES, 1.2-fold in EH). Independent pharmacies in EH showed lower prices for 9/14 medications compared to those in UES. CONCLUSIONS: Across both neighborhoods, independent pharmacies offered consistently lower cash prices for ED and BPH medications. Lower independent pharmacy prices in the lower income EH neighborhood suggest that neighborhood socioeconomic status may impact pricing. Physicians and patients alike must understand the factors that influence pricing to ensure more optimal patient compliance for uninsured patients.

Comparison of Patient Satisfaction and Safety Outcomes for Postoperative Telemedicine vs Face-to-Face Visits in Urology: Results of the Randomized Evaluation and Metrics Observing Telemedicine Efficacy (REMOTE) Trial.

INTRODUCTION: There is a need to better understand the role of postoperative care via telemedicine (TM). We evaluated patient satisfaction and outcomes of postoperative face-to-face (F2F) versus TM visits for adult ambulatory urological surgeries in an urban academic center. Methods:This was a prospective, randomized controlled trial. At surgery, patients undergoing ambulatory endoscopic procedures or open surgery were randomized 1:1 to a postoperative F2F or TM visit. After the visit, a telephone survey assessing satisfaction was administered. Primary outcome was patient satisfaction; secondary outcomes were time and cost savings, and 30-day safety outcomes. Results:A total of 197 patients were approached; 165 (83%) consented and were randomized-76 (45%) to F2F and 89 (54%) to TM cohorts. There were no significant differences in baseline demographics between the cohorts. Both cohorts were equally satisfied with their postoperative visit (F2F 98.6% vs TM 94.1%, p=0.28) and found their visit to be an acceptable form of health care (F2F 100% vs TM 92.7%, p=0.06). The TM cohort saved a significant amount of time (TM 66.2% spent <15 minutes vs F2F 43.1% spent 1-2 hours, p <0.0001) and money (44.1% TM saved $5-$25 vs 43.1% F2F spent $5-$25, p=0.041) associated with travel. There were no significant differences in 30-day safety outcomes between the cohorts. Conclusions:TM for postoperative visits after ambulatory adult urological surgery saves patients time and money without compromising satisfaction or safety. TM should be offered as an alternative to F2F for routine postoperative care for certain ambulatory urological surgeries.

Real World Outcomes of Patients with Bladder Cancer: Effectiveness Versus Efficacy of Modern Treatment Paradigms.

Bladder cancer remains a common and insidious disease in the United States. There have been several advances in the understanding of the biology of bladder cancer, novel diagnostic tools, improvements in multidisciplinary care pathways, and new therapeutics for advanced disease over the past few decades. Clinical trials have demonstrated efficacy for new treatments in each disease state, but additional work is needed to advance the effectiveness of bladder cancer care. Real world data provide critical information regarding patterns of care, adverse events, and outcomes helping to bridge the efficacy versus effectiveness gap.

Rezum therapy for patients with large prostates (≥ 80 g): initial clinical experience and postoperative outcomes.

PURPOSE: Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guidelines recommend Rezum for prostates < 80 cc, but little data exist describing outcomes in patients with prostates ≥ 80 cc. We compare outcomes after Rezum between men with small < 80 cc (SP) and large ≥ 80 cc prostates (LP). METHODS: Patients undergoing Rezum between Jan 2017-Feb 2020 were subdivided by prostate volume (< 80, ≥ 80 cc). Outcomes were documented pre- and postoperatively. Descriptive analyses of urodynamics data (Qmax, PVR), symptom scores (AUA-SS, SHIM), disease management (medications, catheterization, retreatments), and clinical outcomes were conducted. RESULTS: 36 (17.6%) men had prostates ≥ 80 cc (LP mean prostate size 106.8 cc). LP men had improved Qmax and PVR postoperatively; those with longitudinal follow-up exhibited improved Qmax, PVR, and AUA-SS. After one year, alpha-blocker usage decreased significantly (LP 94.44-61.11%, p = 0.001, SP 73.96-46.15%, p = 0.001); other medication usage and self-catheterization rates remained unchanged. Compared to SP patients, differences in passing trial void (LP 94.44%, SP 93.45%), postoperative UTI (LP 19.44%, SP 10.12%), ED visits (LP 22.22%, SP 17.86%), readmissions (LP 8.33%, SP 4.76%), and retreatment (LP 8.33%, SP 4.76%) were insignificant. However, mean days to foley removal (LP 9, SP 5.71, p = 0.003) and urosepsis rates (LP 5.56%, SP 0.00%, p = 0.002) differed. CONCLUSION: In select LP patients, Rezum provided short-term symptomatic relief and improved voiding function comparable to SP patients. Postoperatively, though alpha-blocker usage decreased significantly, use of other medications did not change, and nearly two-thirds of patients still needed alpha-blockade. Further efforts should explore the possibility of expanding Rezum's inclusion criteria.

Disposable versus Reusable Cystoscopes: A Micro-Costing Value Analysis in High-Volume and Low-Volume Urology Practices.

INTRODUCTION: Disposable single-use cystoscopes have become increasingly available, demonstrating comparable quality to reusable cystoscopes while eliminating the need for reprocessing and repairs. However, high costs remain a concern. To clarify the role for these scopes, we performed a cost analysis comparison between the single-use Ambu® aScope™ 4 cystoscope and reusable Olympus® CYF-VHR and V2 cystoscopes in 2 clinical settings: a high-volume multi-provider practice and low-volume single-provider practice. METHODS: The number of cystoscopies at each center was recorded between January and December 2019. Elements in the micro-costing analysis included the original purchasing price of the cystoscopes plus accessory equipment, sterilization supplies, repair costs, and personnel. Costs were amortized over 5 or 10 years and calculated on a per-case basis. An annual total cost analysis was performed to evaluate the cost-effectiveness of each device for each facility. RESULTS: In 2019, 1,984 and 245 cystoscopic procedures were performed at the high and low-volume clinics, respectively. At the high-volume multi-provider practice, per-case cost for reusable cystoscopy amounted to $65.98 compared to $227.18 for single-use cystoscopy, with reusable equipment more cost-effective after 294 cystoscopies. At the low-volume single-provider practice, the per-case cost for reusable cystoscopy was $232.62 compared to $461.18 for single-use cystoscopy, with reusable equipment more cost-effective after 19 cases. CONCLUSIONS: Based on this micro-costing analysis, per-case costs favor reusable cystoscopes. While single-use cystoscope pricing may be prohibitive for large and small facilities at this present time, these instruments are powerful adjuncts to urologists' armamentaria when portability and efficiency are prioritized.

Robotic-assisted simple prostatectomy versus open simple prostatectomy: a New York statewide analysis of early adoption and outcomes between 2009 and 2017.

The factors driving early adoption of robotic-assisted simple prostatectomy (RASP) for large gland BPH have not yet been identified. This study aims to determine the patient, provider, and facility level differences and predictors in undergoing RASP versus OSP. This population-based cohort study used data from the all-payer New York State Statewide Planning and Research Cooperative System (SPARCS) database. Patient, provider, and facility characteristics for each cohort were analyzed, and a multivariate analysis was conducted to identify predictive factors associated with undergoing RASP versus OSP. From 2009 to 2017, 1881 OSP and 216 RASP cases were identified. RASP utilization increased from 2.6% of all cases in 2009 to 16.8% in 2017. Patient demographics were similar between both cohorts. Median length of stay was shorter for RASP patients (3 vs. 4 days, p < 0.001), and OSP was associated with a long length of stay (> 7 days) (p < 0.001). There were no significant differences in 30- and 90-day readmission rates or 1-year mortality. More OSP patients were discharged to continued care facilities than RASP patients (p = 0.049), and more RASP patients were discharged to home compared to OSP patients (p = 0.035). Positive predictors for undergoing RASP included teaching hospital status, medium and high hospital bed volume, high hospital operative volume, high surgeon volume, and surgeons that graduated within 15 years of surgery. As RASP shows favorable perioperative outcomes, the diffusion of robotic technology and newer graduates entering the workforce may augment the upward trend of RASP utilization.

Endoscopic Combined Intrarenal Surgery Can Accurately Predict High Stone Clearance Rates on Postoperative CT.

OBJECTIVE: To determine stone clearance rates using endoscopic combined intrarenal surgery (ECIRS) and assess the accuracy of intraoperative prediction of stone-free (SF) status compared to postoperative CT scan. METHODS: A single institution, prospectively maintained database of ECIRS was queried for procedures performed 8/2017 to 1/2018. Retrograde access was performed using a ureteral sheath and flexible ureteroscope. Percutaneous nephrolithotomy was performed through a 30fr or 18fr sheath in prone position. Residual stone status was estimated at the end of each procedure and was verified with postoperative CT scan. SF was defined as no single stone >2mm3 on CT. RESULTS: One hundred and ten procedures were reviewed. Average age was 58.9 ± 12.6 years (range 26-87) and 69 (63%) were male. The mean stone size was 33.3 ± 23.5 mm (range 4-140 mm). Ninty-three patients (84.5%) were endoscopically estimated to be SF, of which 84 (90% of predicted SF cohort, 76% of total cohort) were confirmed SF via CT scan. The sensitivity for estimating SF status with ECIRS was 65.4% (95%CI 44.3%-82.8%), specificity was 100% (95%CI 95.7%-100.0%) and accuracy was 91.8% (95%CI 85.0%-96.2%). SF patients had significantly smaller stones than those with residual fragments (28.5 ± 2.1 vs 48.4 ± 5.7mm, P <.0001). On logistic regression, the factors associated with residual stones were preoperative stone burden (OR 1.03 per mm, 95%CI 1.01-1.05, P = .0004) and fluoroscopy time (OR 1.01 per minute, 95%CI 1.0-1.02, P = .0081). CONCLUSION: ECIRS accurately predicts clinical SF status and may obviate the need for additional CT scans. Consistent with prior studies, the primary determinant of residual stone after percutaneous nephrolithotomy is initial stone size.