Impact of case volume on outcomes of ureteroscopy for ureteral stones: the clinical research office of the endourological society ureteroscopy global study.

BACKGROUND: The Clinical Research Office of the Endourological Society (CROES) undertook the Ureteroscopy Global Study to establish a prospective global database to examine the worldwide use of ureteroscopy (URS) and to determine factors affecting outcome. OBJECTIVE: To investigate the influence of case volume on the outcomes of URS for ureteral stones. DESIGN, SETTING, AND PARTICIPANTS: The URS Global Study collected prospective data on consecutive patients with urinary stones treated with URS at 114 centres worldwide for 1 yr. Centres were identified as low or high volume based on the median overall annual case volume. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Pre- and intraoperative characteristics, and postoperative outcomes in patients at low- and high-volume centres were compared. The relationships between case volume and stone-free rate (SFR), stone burden, complications, and hospital stay were explored using multivariate regression analysis. RESULTS AND LIMITATIONS: Across all centres, the median case volume was 67; 58 and 56 centres were designated as low volume and high volume, respectively. URS procedures at high-volume centres took significantly less time to conduct. Mean SFR was 91.9% and 86.3% at high- and low-volume centres, respectively (p<0.001); the adjusted probability of a stone-free outcome increased with increasing case volume (p<0.001). Patients treated at a high-volume centre were less likely to need retreatment, had shorter postoperative hospital stay, were less likely to be readmitted within 3 mo, and had fewer and less severe complications. At case volumes approximately >200, the probability of complications decreased with increasing case volume (p=0.02). The study is limited by the heterogeneity of participating centres and surgeons and the inclusion of patients treated by more than one approach. CONCLUSIONS: In the treatment of ureteral stones with URS, high-volume centres achieve better outcomes than low-volume centres. Several outcome measures for URS improve with an increase in case volume. PATIENT SUMMARY: Outcomes following treatment of ureteral stones by ureteroscopy (URS) were studied in a large group of patients at centres worldwide. The proportion of successful procedures (ie, those in which patients became stone free) increased as the annual volume of URS at a hospital increased. Hospital stays were shorter and postoperative complications were less likely at high-volume hospitals. We conclude that for URS, the best outcomes are seen in patients treated at high-volume hospitals.

Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy.

BACKGROUND: Although widely used, the validity and reliability of the Clavien classification of postoperative complications have not been tested in urologic procedures, such as percutaneous nephrolithotomy (PCNL). OBJECTIVE: To validate the Clavien score and categorise complications of PCNL. DESIGN, SETTING, AND PARTICIPANTS: Data for 528 patients with complications after PCNL were used to create a set of 70 unique complication-management combinations. Clinical case summaries for each complication-management combination were compiled in a survey distributed to 98 urologists, who rated each combination using the Clavien classification. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Interrater agreement for Clavien scores was estimated using Fleiss' kappa (κ). The relationship between Clavien score and the duration of postoperative hospital stay was analysed using multivariate nonlinear regression models that adjusted for operating time, preoperative urine microbial culture, presence of staghorn stone, and use of postoperative nephrostomy tube. RESULTS AND LIMITATIONS: Overall interrater agreement in grading postoperative complications was moderate (κ=0.457; p<0.001). Agreement was highest for Clavien score 5 and decreased with lower Clavien scores. Higher agreement was found for Clavien scores 3 and 4 than in subcategories of these scores. Postoperative stay increased with higher Clavien scores and was unaffected by inherent differences between study centres. A standard list of post-PCNL complications and their corresponding Clavien scores was created. CONCLUSIONS: Although the Clavien classification demonstrates high validity, interrater reliability is low for minor complications. To improve the reliability and consistency of reporting adverse outcomes of PCNL, we have assigned Clavien scores to complications of PCNL.