The economics of stone disease.

The rising prevalence of kidney stone disease is associated with significant costs to healthcare systems worldwide. This is in part due to direct procedural and medical management costs, as well as indirect costs to health systems, patients, and families. A number of manuscripts evaulating the economics of stone disease have been published since the 2008s International Consultation on Stone Disease. These highlight costs associated with stone disease, including acute management, surgical management, and medical management. This work hopes to highlight optimization in care by reducing inefficient treatments and maximizing cost-efficient preventative strategies.

Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study.

PURPOSE: To describe the differences in the treatment and the outcomes of renal stones treated with flexible ureteroscopy (URS) either with or without the support of a ureteral access sheath (UAS). METHODS: The Clinical Research Office of the Endourological Society URS Global Study involved the collection of prospective data from consecutive patients treated with URS at centers around the world over a 1-year period. Baseline characteristics, stone location, treatment details, postoperative outcomes and complications were recorded. Inverse-probability-weighted regression adjustment (IPWRA) analyses were conducted on outcome from patients treated with or without the use of a UAS to determine the impact on stone-free rates (SFRs). RESULTS: Of 2239 patients treated with flexible URS, 1494 (67 %) patients were treated with the use of a UAS and 745 (33 %) without a UAS. The IPWRA analyses conducted on 1827 patients with complete data and based on treatment and outcome models showed that if URS procedures were performed without the use of an UAS, the average stone-free rate would be 0.504 compared with 0.753 with a UAS. This average treatment effect of 0.248 was not significant (P = 0.604). Using IPWRA analysis on only the treated population in the estimations revealed no significant difference between using and not using a UAS (31 %; ATET: 0.311; P = 0.523). CONCLUSIONS: The study showed no difference in SFR when a UAS was used or not. Whereas UAS did not increase the risk of ureteral damage or bleeding, postoperative infectious complications were reduced.

Effect of supine vs prone position on outcomes of percutaneous nephrolithotomy in staghorn calculi: results from the Clinical Research Office of the Endourology Society Study.

OBJECTIVE: To analyze the effect of patient positioning on outcomes of percutaneous nephrolithotomy (PNL) among patients with staghorn stones. The choice of optimal position for these patients undergoing PNL remains challenging. No previous studies exclusively addressing this point have been performed. METHODS: From November 2007 to December 2009, prospective data were collected by the Clinical Research Office of the Endourological Society. We included all patients with staghorn stones. Patients were divided on the basis of the position used during PNL (prone/supine). Patient characteristics, stone burden, operative details, and outcomes were compared. Multivariate analysis was performed to evaluate the relationship between patient position and stone-free rate and complication rate adjusting for number of access puncture sites. RESULTS: A total of 1079 PNLs were performed in prone and 232 in supine positions. There were no differences in comorbidities or preoperative stone burden. A higher percentage of patients in the prone position had access through the upper pole (P <.001). Surgical time was shorter (P <.001) and stone-free rate was higher (P <.001) for patients in the prone position. There were no differences in complication rates. In multivariate analysis, patients in prone position had a higher stone-free rates (P = .0013) after adjusting for the method used for determining stone-free status and number of renal access. CONCLUSION: Higher stone-free rates are achieved in the prone position during PNL for patients with staghorn calculi. Complication rates were similar for both positions.

Percutaneous nephrolithotomy and chronic kidney disease: results from the CROES PCNL Global Study.

PURPOSE: We compared the characteristics and outcomes of patients treated with percutaneous nephrolithotomy in the CROES (Clinical Research Office of the Endourological Society) Global Study according to preoperative renal function. MATERIALS AND METHODS: Prospective data on consecutive patients treated with percutaneous nephrolithotomy in a 1-year period were collected from 96 participating centers. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula based on preoperative serum creatinine measurement. Patients were divided into 3 groups by glomerular filtration rate, including chronic kidney disease stages 0/I/II-greater than 60, stage III-30 to 59 and stages IV/V-less than 30 ml/minute/1.73 m(2). Patient characteristics, operative characteristics, outcomes and morbidity were assessed. RESULTS: Estimated glomerular filtration rate data were available on 5,644 patients, including 4,436 with chronic kidney disease stages 0/I/II, 994 with stage III and 214 with stages IV/V. A clinically significant minority of patients with nephrolithiasis presented with severe chronic kidney disease. A greater number of patients with stages IV/V previously underwent percutaneous nephrolithotomy, ureteroscopy or nephrostomy and had positive urine cultures than less severely affected patients, consistent with the higher incidence of staghorn stones in these patients. Patients with chronic kidney disease stages IV/V had statistically significantly worse postoperative outcomes than those in the other chronic kidney disease groups. CONCLUSIONS: Poor renal function negatively impacts the post-percutaneous nephrolithotomy outcome. By more aggressive removal of kidney stones, particularly staghorn stones, at first presentation and more vigilantly attempting to prevent recurrence through infection control, pharmacological or other interventions, the progression of chronic kidney disease due to nephrolithiasis may be mitigated.

A randomized control trial evaluating efficacy of nephrostomy tract infiltration with bupivacaine after tubeless percutaneous nephrolithotomy.

PURPOSE: We conducted a randomized controlled trial to assess the efficacy of nephrostomy tract infiltration with bupivacaine in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: All adult patients undergoing unilateral tubeless PCNL from July 1, 2007 to October 31, 2007 were included in the study. Patients were randomized to receive infiltration of bupivacaine in the nephrostomy tract at the end of the procedure or not to receive bupivacaine. To show a 10% difference in postoperative pain, a sample size of 30 persons per group would be needed. Postoperatively, the pain score were obtained at 4 and 24 hours by a nurse who was blinded to the protocol. The perioperative outcome of these patients (study group) was compared with those undergoing tubeless PCNL without nephrostomy tract infiltration of bupivacaine (control group). RESULTS: Patient demographics and intraoperative parameters in both groups were comparable. Supracostal access was needed in 65.7% and 72.7% patients in the study and control group, respectively. The nephrostomy tract were infiltrated with bupivacaine in 31 patients. The visual analogue pain score at 4 hours and 24 hours for the study group was 2.66 ± 1.07 & 2.23 ± 0.50 respectively, while in control group was 5.15 ± 1.52 and 3.22 ± 1.11, respectively (P=0.000). There was a trend toward lesser analgesia requirement in the study group (94.8 vs 124.2 mg of diclofenac sodium). There was no difference in the duration of postoperative catheterization, hospital stay, stone-free rates, and complication between both groups. CONCLUSIONS: Nephrostomy tract infiltration of bupivacaine in tubeless PCNL is associated with less postoperative pain and analgesia requirement.

A plea for centralized care for ureteroscopy: results from a comparative study under different conditions within the same center.

PURPOSE: We stratified factors that affect treatment morbidity, compared the outcomes of ureteroscopy procedures from a single department under different conditions, and provided evidence of treatment benefits when ureteroscopy is performed in an expert setting. PATIENTS AND METHODS: Since the department became a dedicated endourologic center in 2002, we grouped all ureteroscopy procedures into those performed before 2002 (group A) and after 2002 (group B). The modified Clavien classification was used to score morbidity. Independent variables with an influence on postoperative outcomes were studied, including operative time, intraoperative and postoperative complications, and hospitalization time. RESULTS: Of the 248 ureteroscopy procedures performed, 62 comprised group A and 186 comprised group B. Statistical preoperative differences were in the American Society of Anesthesiologists score, patients with diabetes mellitus, cardiovascular disease, and the use of anticoagulants; and the perioperative differences were seen in operative time, hospital stay, and the number of eventful procedures. Group A had a significantly longer operative time and a longer hospital stay compared with group B. The number of failed and eventful procedures are also higher in group A compared with group B. Stone-free rates were similar in both groups. CONCLUSIONS: The dedicated setting for ureteroscopy at our center resulted in decreased operative time, more uneventful procedures, and decreased hospitalization time. The modified Clavien morbidity score is a reliable tool for more objective comparisons of morbidity after ureteroscopic stone treatment.

Tubeless percutaneous nephrolithotomy: 3 years of experience with 454 patients.

OBJECTIVE: To present our experience with 454 patients who had tubeless percutaneous nephrolithotomy (TPCNL) over last 3 years. PATIENTS AND METHODS: From September 2004 to August 2007, all patients aged >14 years and undergoing PCNL were considered for TPCNL. Exclusion criteria were the presence of pyonephrosis, matrix calculi, significant bleeding or residual stone burden and need for three of more percutaneous accesses. These patients had a nephrostomy tube placed after PCNL (control group). The remaining patients undergoing TPCNL (study group) had antegrade ureteric stenting. Demographic and perioperative data were compared retrospectively. RESULTS: Of 840 patients who had PCNL during the study period, 454 had TPCNL. The two groups had comparable demographic data except for a smaller stone burden (322.8 vs 832.2 mm(2)) and fewer staghorn calculi (94 vs 154) in patients undergoing TPCNL (P < 0.001). The mean number of tracts per renal unit and operative duration were statistically higher in patients undergoing standard PCNL (1.5 vs 1.1, and 68.8 vs 52.2 min, respectively). The decrease in haemoglobin, complication and stone-free rates were comparable. TPCNL was associated with less postoperative pain, analgesia requirement and earlier discharge (P < 0.001). CONCLUSIONS: TPCNL can be used with a favourable outcome and no increase in complications in selected patients, with the potential advantages of decreased postoperative pain, analgesia requirement and hospital stay. Its application can be extended to patients with a solitary kidney, previous ipsilateral open surgery, raised serum creatinine level, in the presence of three renal accesses or supracostal access, and in patients undergoing bilateral synchronous PCNL or contralateral endourological stone treatment.

The management of renal matrix calculi: a single-centre experience over 5 years.

OBJECTIVE: To define incidence of renal matrix calculi in patients undergoing percutaneous nephrolithotomy (PCNL), and describe its clinical, laboratory and radiological features; we also studied the efficacy of PCNL in managing this rare entity. PATIENTS AND METHODS: We retrospectively reviewed the records of 1368 PCNLs performed from April 2003 to March 2008, and identified 17 patients (mean age 44.3 years; 11 women and six men) having matrix calculi. The patients' clinical, laboratory and radiological features were studied, and the perioperative outcome and follow-up data analysed. RESULTS: Flank pain was commonest mode of presentation (15) followed by recurrent urinary tract infection (five). Pyuria was present in 14 patients and urine culture showed significant growth in 10. A plain X-ray showed a small radio-opaque calculus (10 renal units) and faint laminated calcification (four). Intravenous urography showed a filling defect and non-visualized system in nine and five patients, respectively. Non-contrast computed tomography and magnetic resonance urography diagnosed calculi in two and one patient, respectively, on haemodialysis. PCNL was abandoned initially in four patients due to pyonephrosis. The mean hospital stay was 3.4 days and decrease in haemoglobin was 0.89 g/dL. One patient developed sepsis. Of 11 stones analysed, two were composed entirely of proteins and the remaining nine had crystalline components. At a mean follow-up of 12.6 months, no patients had recurrence of stone. CONCLUSIONS: Matrix calculi occurred in 1.24% of patients undergoing PCNL. Although considered radiolucent, plain X-ray showed a small radio-opaque calculi or faint laminated calcifications in 10 of 17 patients. PCNL rendered patients stone-free with minimum morbidity.

A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy: small bore v tubeless.

PURPOSE: To compare the outcome of tubeless percutaneous nephrolithotomy (PCNL) with small-bore nephrostomy drainage after PCNL. PATIENTS AND METHODS: We tested the hypothesis that tubeless PCNL is superior to small-bore nephrostomy drainage after PCNL in terms of postoperative pain, analgesic requirement, and hospital stay. To show a 10% difference in these parameters, a sample size of 30 persons per group would be needed. All patients undergoing PCNL from September 2005 to May 2006 were included in the study. Patients meeting the inclusion and exclusion criteria were then randomized to either a tubeless approach with insertion of a ureteral stent or placement of an 8F nephrostomy tube without insertion of a ureteral stent. The perioperative outcomes of patients in the two groups were compared. RESULTS: Tubeless PCNL was performed in 33 patients, and an 8F nephrostomy tube was placed in 32 patients. The two groups had comparable demographic data. The hemoglobin drop and complication rate between the two groups were comparable. Patients undergoing tubeless PCNL experienced less postoperative pain (P = 0.001), needed less analgesia (P = 0.006), and were discharged 9 hours earlier than patients in the other group. Complete stone clearance was achieved in 87.87% patients in the tubeless group and 87.5% patients in the nephrostomy group. In the tubeless group, 39.4% of patients had bothersome stent-related symptoms, of whom 61.5% needed analgesics and/or antispasmodic agents. CONCLUSIONS: Tubeless PCNL offers the potential advantages of decreased postoperative pain, analgesic requirement, and hospital stay without increasing the complications. It was associated with stent-related discomfort in 39% of patients.

Endoscopic management of adult orthotopic ureterocele and associated calculi with holmium laser: experience with 16 patients over 4 years and review of literature.

PURPOSE: To retrospectively evaluate the safety and effectiveness of holmium laser endoscopic incision and laser lithotripsy in adults with orthotopic ureterocele and associated calculi. PATIENTS AND METHODS: From May 2003 to August 2007 at our center, 16 adults underwent transurethral incision of an ureterocele and intracorporeal holmium laser lithotripsy for associated calculi. The perioperative data of these patients were retrospectively analyzed. The literature was reviewed to identify all the reported options for management of this relatively rare condition. RESULTS: Ureterocele was associated with a single system in 13 patients. Two patients had bilateral ureteroceles. Four patients had associated upper tract stones. The procedure was uneventful in all patients. The average postoperative hospital stay was 19.3 hours. All patients were stone free after the procedure. Eleven patients were available for follow-up at 3 and 6 months. None of these patients had any evidence of residual ureterocele and/or hydronephrosis when evaluated with intravenous urography at 3 months. Micturating cystourethrography (MCU) at 3 months revealed low-grade vesicoureteral reflux (VUR) in four patients; no reflux was found with MCU at 6 months. CONCLUSIONS: Laser endoscopic management of adult orthotopic ureterocele and associated calculi effectively decompressed ureterocele and removed stones in all patients without any significant postoperative morbidity. Low-grade VUR that may occur postoperatively resolved at 6 months. A literature review suggests that the ability of the holmium laser to manage both ureterocele and calculi simultaneously should make holmium laser management a procedure of choice at centers that possess the equipment.

Influence of prostate size on the outcome of holmium laser enucleation of the prostate.

OBJECTIVE: To analyse the effect of prostate size on the outcome of holmium laser enucleation of prostate (HoLEP, an established procedure for treating symptomatic benign prostatic hypertrophy, BPH), in the initial 354 patients at 1 year of follow-up. PATIENTS AND METHODS: We retrospectively reviewed the records of 354 patients who had HoLEP at our institution from April 2003 to March 2007. In 235 patients the prostate weighed <60 g (group 1), in 77 it weighed 60-100 g (group 2) and in 42 >100 g (group 3). Demographic data and perioperative variables were recorded and compared among the three groups. RESULTS: The mean prostate size was 38.1, 76.4 and 133.5 g for groups 1, 2 and 3, respectively (P < 0.001), and the respective mean weight of resected prostate was 18.47, 40.8 and 82.76 g, respectively (P < 0.001). The mean procedure efficiency increased from 0.36 g/min in group 1 to 0.49 g/min in group 2 and 0.58 g/min in group 3 (P < 0.001). The decrease in haemoglobin level after HoLEP was greater in group 3 than in the other groups. Overall, HoLEP resulted in a 75% reduction in American Urologic Association symptom score, a 225% increase in peak urinary flow rate and an 86% decrease in postvoid residual urine volume at 1 year of follow-up. Perioperative complications were evenly distributed among the three groups, except for a higher incidence of superficial bladder mucosal injury and stenotic complications in group 3. CONCLUSIONS: HoLEP is a safe and effective procedure for treating symptomatic BPH, independent of prostate size, and is associated with low morbidity. The efficiency of HoLEP increases with increasing prostate size.

Splenic injury: rare complication of percutaneous nephrolithotomy: report of two cases with review of literature.

BACKGROUND: Splenic injury is an uncommon complication of percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: We report herewith two cases of splenic injury that occurred during puncture of the 10th intercostal-space for PCNL. RESULTS AND CONCLUSIONS: One of these patients presented with hypotension on day 5 after discharge from the hospital. Both patients needed emergency laparotomy, and one of them required splenectomy for management of the injury. We reviewed the literature to determine the risk factors and management of splenic injury during PCNL.

Prospective evaluation of the learning curve for holmium laser enucleation of the prostate.

PURPOSE: In a prospective manner we evaluated the learning experience of an endourologist inexperienced with holmium laser prostate enucleation and its impact on surgical outcome. We also reviewed the literature to document technical features of holmium laser prostate enucleation at different institutions. MATERIALS AND METHODS: Patient demographic, perioperative and followup data were analyzed. To assess the impact of the learning curve on postoperative outcome patients were divided into group 1--patients 1 to 50, group 2--51 to 100 and group 3--101 to 162. The effect of the learning curve and weight of resected tissue on enucleation and morcellation efficiency was studied. RESULTS: Holmium laser prostate enucleation was successfully completed in 93.82% of patients. Eight patients required conversion to transurethral prostate resection. Enucleation and morcellation efficiency was 0.49 and 2.75 gm per minute, respectively. Enucleation efficiency attained a plateau after 50 cases. Postoperative outcome was compared in the 3 patient groups. There was a higher incidence of capsular perforation and stenotic urethral complications in group 1. In the literature a mean of 57.09% of tissue (range -9.6 to 81.9%) was retrieved after holmium laser prostate enucleation and mean efficiency was 0.52 gm per minute (range -0.11 to 1.09). Efficiency increased proportionally with resected prostate weight. CONCLUSIONS: An endourologist inexperienced with holmium laser prostate enucleation can perform the procedure with reasonable efficiency after about 50 cases with an outcome comparable to that of experts, as described in the literature. During the learning curve conversion to transurethral prostate resection can be done without any harm to the patient.