Post-Ureteroscopic Lesion Scale: limitaciones en su aplicabilidad clínica / Post-Ureteroscopic Lesion Scale to determine ureteral wall damage, not so easy to employ

Objetivo Analizar el nivel de concordancia de la Post-Ureteroscopic Lesion Scale (PULS), y examinar las consecuencias de su aplicación en la práctica clínica con datos estadísticos más fiables que los utilizados en el trabajo original. Métodos Se realizaron 14 ureteroscopias (URS) y 14 micro-ureteroscopias (micro-URS) en 14 cerdos hembra. Todos los procedimientos se grabaron en vídeo y se realizó un análisis anatomopatológico en cada uréter. Dieciséis urólogos (9 endourólogos y 7 urólogos generales) y 4 médicos internos residentes evaluaron las lesiones ureterales según la escala PULS, con grados 0, 1 y ≥2. La concordancia se calculó mediante porcentajes, el Coeficiente W de Kendall, el índice kappa de Fleiss y el alfa de Krippendorff. La concordancia entre evaluadores se calculó con la Correlación de Spearman y el Coeficiente kappa de Cohen. Resultados El porcentaje de concordancia fue del 11,1%. Los coeficientes se clasificaron como bajos o muy bajos, y encontramos una mayor concordancia entre los evaluadores más inexpertos. Por otro lado, no hubo acuerdo entre el 50% de los evaluadores. Conclusiones La baja concordancia entre evaluadores, la especificidad de la PULS y la correlación clínico/patológica sugieren dificultades del uso de esta escala y una curva de aprendizaje probablemente larga. (AU)

Objective To analyze the level of agreement of the Post-Ureteroscopic Lesion Scale (PULS) and the consequences on its application in clinical practice with more reliable statistical data than the one used in the original work. Methods 14 URS and 14 micro-URS were performed in 14 female porcine model. All the procedures were video recorded and an anatomopathological analysis was performed in each ureter. Sixteen urologists (9 endourologists and 7 general urologists) and 4 residents evaluated the ureteral lesions according to the PULS, with degrees 0, 1 and ≥2. The agreement was calculated with percentages, Kendall's W coefficient and the indicators Fleiss’ Kappa and Krippendorff's Alpha, while the inter-rater agreement was calculated with Spearman's correlation and Cohen's Kappa. Results The percent of agreement was 11.1%. The coefficients were likewise classified as low or very low, with the greatest agreement found among the inexperienced. Also, 50% of the raters did not agree with the rest. Conclusions The low inter-rater agreement, the specificity of the PULS and the clinical-pathological correlation suggests that this scale is not simple, and probably has a long learning curve. (AU)

Influencia del sexo en los resultados de la cirugía retrógrada intrarrenal (CRIR). Datos obtenidos del Flexible Ureteroscopy Outcomes Registry (FLEXOR) / Does gender influence retrograde intrarenal surgery (RIRS) outcomes? Data from the Flexible Ureteroscopy Outcomes Registry (FLEXOR)

Introducción y objetivos Si bien la ureteroscopia flexible es una técnica establecida, a día de hoy no existen datos sobre la influencia del sexo del paciente en los resultados y complicaciones. El objetivo de este estudio es evaluar el papel que desempeña el sexo en la realización de la ureteroscopia flexible a partir de una serie grande de pacientes.MétodosEste estudio analizó retrospectivamente los datos del registro multicéntrico FLEXOR de los pacientes tratados de cálculos renales con CRIR desde enero de 2018 hasta agosto de 2021. Se analizaron los datos demográficos, las características de los cálculos, los hallazgos perioperatorios, los resultados y las complicaciones, y se compararon entre grupos estratificados según el sexo.ResultadosUn total de 6.669 pacientes fueron incluidos, el 66,1% eran varones y el 33,9% mujeres. Las características de los cálculos eran comparables entre los grupos. Las mujeres presentaron tasas significativamente más elevadas de fiebre y urocultivo positivo (12 frente a 8% y 37 frente a 34%). Además, las mujeres tuvieron una estancia hospitalaria ligeramente más larga (3,8 vs. 3,5 días; p < 0,001) y más fragmentos residuales después del procedimiento (23,03 vs. 20,97; p = 0,032). Las complicaciones globales fueron ligeramente superiores en las mujeres (15,74 frente a 14%; p = 0,042), debido principalmente a las tasas de fiebre (6,9 frente a 5,7%); el riesgo de sepsis fue similar en ambos grupos. Según un análisis multivariante, los cálculos de mayor tamaño, múltiples y localizados en el polo inferior parecen tener un efecto negativo en la incidencia de los cálculos residuales y las complicaciones.ConclusiónNuestro estudio de la vida real a nivel mundial refleja que el sexo femenino puede estar correlacionado con unas tasas ligeramente mayores de fragmentos residuales y complicaciones generales de bajo grado. ... (AU)

Introduction and objectives As well established flexible ureteroscopy (RIRS). There is still no evidence if gender can have any influence on the outcomes and complication when performing This study aims to evaluate the role that gender has in performing flexible ureteroscopy from a large series of patients.MethodsThis study retrospectively analyzed patients who underwent RIRS for renal stones from January 2018 to August 2021 within the multicentric FLEXOR registry. Demographics, stone characteristics, perioperative findings, results and complications were analyzed and compared between gender groups.ResultsA total of 6669 patients were included, 66.1% were male and 33.9% were female. Stone characterictis was comparable between groups. Female patients had significant higher fever and positive urine culture rates (12% vs. 8% and 37% vs. 34%). Also, females had a slight longer hospital stay (3.8 vs. 3.5 days; P < 0.001) and more residual fragments after the procedure (23.03% vs. 20.97 (P = 0.032). Overall complications were slightly significantly higher in women (15.74% vs. 14% (P = 0.042)) mainly at the expense of fever rates (6.9% vs. 5.7%) whereas the risk of sepsis was similar in both groups. A multivariate analysis showed that larger stone size, multiple and lower pole stones seem to have a negative impact in the incidence of residual stones and complications.ConclusionOur real life global study reflects that female gender may have a correlation with a slightly increased residual fragment rate and overall low grade complications. However, women can safely be treated with RIRS with no increased the rate of sepsis with appropriate care. (AU)

Trends and patterns of initial percutaneous nephrolithotomy and subsequent procedures among commercially-insured US adults with urinary system stone disease: a 10-year population-based study.

PURPOSE: To describe trends and patterns of initial percutaneous nephrolithotomy (PCNL) and subsequent procedures from 2010 to 2019 among commercially-insured US adults with urinary system stone disease (USSD). METHODS: Retrospective study of administrative data from the IBM® MarketScan® Database. Eligible patients were aged 18-64 years and underwent PCNL between 1/1/2010 and 12/31/2019. Measures of interest for analysis of trends and patterns included the setting of initial PCNL (inpatient vs. outpatient), percutaneous access (1 vs. 2-step), and the incidence, time course, and type of subsequent procedures (extracorporeal shockwave lithotripsy [SWL], ureteroscopy [URS], and/or PCNL) performed up-to 3 years after initial PCNL. RESULTS: A total of 8,348 patients met the study eligibility criteria. During the study period, there was a substantial shift in the setting of initial PCNL, from 59.9% being inpatient in 2010 to 85.3% being outpatient by 2019 (P < 0.001). The proportion of 1 vs. 2-step initial PCNL fluctuated over time, with a low of 15.1% in 2016 and a high of 22.0% in 2019 but showed no consistent yearly trend (P = 0.137). The Kaplan-Meier estimated probability of subsequent procedures following initial PCNL was 20% at 30 days, 28% at 90 days, and 50% at 3 years, with slight fluctuations by initial PCNL year. From 2010 to 2019, the proportion of subsequent procedures accounted for by URS increased substantially (from 30.8 to 51.8%), whereas SWL decreased substantially (from 39.5 to 14.7%) (P < 0.001). CONCLUSIONS: From 2010 to 2019, PCNL procedures largely shifted to the outpatient setting. Subsequent procedures after initial PCNL were common, with most occurring within 90 days. URS has become the most commonly-used subsequent procedure type.

Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct?

PURPOSE: To describe the change in upper urinary tract stone management in Germany over a 14-year period. METHODS: Using remote data processing we analyzed the nationwide German billing data from 2006 to 2019. To analyze the clinics' case numbers and regional trends, we used the reimbursement.INFO tool based on standardized quality reports of all German hospitals. To also cover shock wave lithotripsy (SWL) as an outpatient procedure, we analyzed the research database of the Institute for Applied Health Research with a representative anonymous sample of 4 million insured persons. RESULTS: The number of inpatient interventional therapies for upper tract urolithiasis in Germany increased from 70,099 cases in 2006 to 94,815 cases in 2019 (trend p < 0.0001). In-hospital SWL declined from 41,687 cases in 2006 to 10,724 cases in 2019 (decline of 74%; trend p < 0.0001). The percentage of SWL as an outpatient procedure increased between 2013 and 2018 from 36 to 46% of all performed SWL, while total SWL case numbers declined. Contrarily, the number of ureteroscopies increased from 32,203 cases in 2006 to 78,125 cases in 2019 (increase of 143%; trend p < 0.0001). The number of percutaneous nephrolithotomy also increased from 1673 cases in 2006 to 8937 in 2019 (increase of 434%; trend p < 0.0001). CONCLUSION: We observed an increase in interventional therapy for upper tract urolithiasis in Germany with a dramatic shift from SWL to endoscopic/percutaneous treatment. These changes may be attributed to enormous technological advances of the endoscopic armamentarium and to reimbursement issues.

Development and Validation of a Risk-Adapted Scoring Model for Metachronous Upper Tract Urothelial Carcinoma following Radical Cystectomy.

PURPOSE: The incidence and risk factors for metachronous upper tract urothelial carcinoma (UTUC) following radical cystectomy (RC) remain incompletely defined, which has limited the ability to individualize postoperative surveillance. MATERIALS AND METHODS: A retrospective review of 2 institutional registries was performed to identify patients undergoing RC for urothelial carcinoma. Multivariable Cox proportional hazard models for metachronous post-RC UTUC were developed in one institutional data set and validated in the second institutional data set. A post-RC UTUC risk score was then developed from these models. RESULTS: A total of 3,170 RC patients were included from the training cohort and 959 RC patients from the validation cohort. At a median followup after RC of 4.6 years (IQR 2.1-8.7), 167 patients were diagnosed with UTUC. On multivariable analysis in the training cohort, risk factors for metachronous UTUC were the presence of positive urothelial margin (HR 2.60, p <0.01), history of bacillus Calmette-Guérin treatment prior to RC (HR 2.20, p <0.01), carcinoma in situ at RC (HR 2.01, p <0.01) and pre-RC hydronephrosis (HR 1.48, p=0.04). These factors had similar discriminative capacity in the training and validation cohorts (C-statistic 0.71 and 0.73, respectively). A UTUC risk score was developed with these variables which stratified patients into low (0 points), intermediate (1-3 points), and high risk (4+ points) for post-RC UTUC, with respective 5-year UTUC-free survivals of 99%, 96%, 89% in the training cohort and 98%, 96%, and 91% in the validation cohort. CONCLUSIONS: We developed and validated a risk score for post-RC UTUC that may optimize UTUC surveillance protocols after RC.

Image Enhancement Model Based on Deep Learning Applied to the Ureteroscopic Diagnosis of Ureteral Stones during Pregnancy.

OBJECTIVE: To explore the image enhancement model based on deep learning on the effect of ureteroscopy with double J tube placement and drainage on ureteral stones during pregnancy. We compare the clinical effect of ureteroscopy with double J tube placement on pregnancy complicated with ureteral stones and use medical imaging to diagnose the patient's condition and design a treatment plan. METHODS: The image enhancement model is constructed using deep learning and implemented for quality improvement in terms of image clarity. In the way, the relationship of the media transmittance and the image with blurring artifacts was established, and the model can estimate the ureteral stone predicted map of each region. Firstly, we proposed the evolution-based detail enhancement method. Then, the feature extraction network is used to capture blurring artifact-related features. Finally, the regression subnetwork is used to predict the media transmittance in the local area. Eighty pregnant patients with ureteral calculi treated in our hospital were selected as the research object and were divided into a test group and a control group according to the random number table method, 40 cases in each group. The test group underwent ureteroscopy double J tube placement, and the control group underwent ureteroscopy lithotripsy. Combined with the ultrasound scan results of the patients before and after the operation, the operation time, time to get out of bed, and hospitalization time of the two groups of patients were compared. The operation success rate and the incidence of complications within 1 month after surgery were counted in the two groups of patients. RESULTS: We are able to improve the quality of the images prior to medical diagnosis. The total effective rate of the observation group was 100.0%, which is higher than that of the control group (90.0%). The difference between the two groups was statistically significant (P < 0.05). The adverse reaction rate in the observation group was 5.0%, which was lower than 17.5% in the control group. The difference between the two groups was statistically significant (P < 0.05). The comparison results are then prepared. CONCLUSIONS: The image enhancement model based on deep learning is able to improve medical diagnosis which can assist radiologists to better locate the ureteral stones. Based on our method, double J tube placement under ureteroscopy has a significant effect on the treatment of ureteral stones during pregnancy, and it has good safety and is worthy of widespread application.

Comparison of the effects of retroperitoneoscopic ureterolithotomy and ureteroscopic lithotripsy in the treatment of upper ureteral calculi.

ABSTRACT: This study compares the efficacy of retroperitoneoscopic ureterolithotomy (RPUL) and ureteroscopic lithotripsy (URL) in the treatment of upper ureteral calculi.The clinical data of 150 patients with upper ureteral calculi who underwent RPUL and 136 patients who underwent URL between January 2014 and October 2019 were retrospectively analyzed. The operation time, postoperative hospital stay, operation success rate, stone clearance rate, and surgical complications were evaluated between the two groups.For the RPUL and URL groups, respectively, the average operation time was 74.5 ±â€Š24.6 minutes and 54.5 ±â€Š13.2 minutes; the postoperative hospital stay was 5.8 ±â€Š1.4 days and 3.2 ±â€Š1.2 days; the operation success rate was 96.0% (144/150) and 85.3% (116/136); the incidence rate of complications was 3.5% (5/144) and 17.5% (18/103); and the stone clearance rate was 100% (144/144) and 88.8% (103/116), which were all statistically significant (P < .05).Both RPUL and URL had the advantages of low trauma and fast recovery rate for patients with upper ureteral calculi. However, patients who underwent RPUL showed higher success and fewer complication rate. RPUL might be a safe and effective laparoscopic method for the treatment of patients with upper ureteral calculi.

Natural History of Post-Treatment Kidney Stone Fragments: A Systematic Review and Meta-Analysis.

PURPOSE: We assessed the literature around post-treatment asymptomatic residual stone fragments and performed a meta-analysis. The main outcomes were intervention rate and disease progression. MATERIALS AND METHODS: We searched Ovid®, MEDLINE®, Embase™, the Cochrane Library and ClinicalTrials.gov using search terms: "asymptomatic", "nephrolithiasis", "ESWL", "PCNL", "URS" and "intervention." Inclusion criteria were all studies with residual renal fragments following treatment (shock wave lithotripsy, ureteroscopy or percutaneous nephrolithotomy). Analysis was performed using 'metafor' in R and bias determined using Newcastle-Ottawa scale. RESULTS: From 273 articles, 18 papers (2,096 patients) had details of intervention rate for residual fragments. Aggregate intervention rates for ≤4 mm fragments rose from 19% (20 months) to 22% (50 months), while >4 mm fragments rose from 22% to 47%. Aggregate disease progression rates for ≤4 mm rose from 25% to 47% and >4 mm rose from 26% to 88%. However, there was substantial difference in definition of "disease progression." Meta-analysis comparing >4 mm against ≤4 mm fragments: intervention rate for >4 mm (vs ≤4 mm): OR=1.50 (95% CI 0.70-2.30), p <0.001, I2=67.6%, tau2=0.48, Cochran's Q=11.4 (p=0.02) and Egger's regression: z=3.11, p=0.002. Disease progression rate for >4 mm: OR=0.06 (95% CI -0.98-1.10), p=0.91, I2=53.0%, tau2=0.57, Cochran's Q=7.11 (p=0.07) and Egger's regression: z=-0.75, p=0.45. Bias analysis demonstrated a moderate risk. CONCLUSIONS: Larger post-treatment residual fragments are significantly more likely to require further intervention especially in the long term. Smaller fragments, although less likely to require further intervention, still carry that risk. Notably, there is no significant difference in disease progression between fragment sizes. Patients with residual fragments should be appropriately counselled and informed decision-making regarding further management should be done.

The Impact of Upper Tract Urothelial Carcinoma Diagnostic Modality on Intravesical Recurrence after Radical Nephroureterectomy: A Single Institution Series and Updated Meta-Analysis.

PURPOSE: Diagnostic ureteroscopic biopsy for upper tract urothelial carcinoma (UTUC) has been hypothesized to increase intravesical recurrence of urothelial carcinoma after radical nephroureterectomy (RNU). Moreover, the impact of ureteroscopy without biopsy or percutaneous biopsy on intravesical recurrence remains unknown. Herein, we compared post-RNU intravesical recurrences across UTUC diagnostic modalities. MATERIALS AND METHODS: Patients undergoing RNU at our institution between 1995 and 2019 were categorized by UTUC diagnostic modality: 1) no ureteroscopy or percutaneous biopsy; 2) percutaneous biopsy; 3) ureteroscopy without biopsy; 4) ureteroscopic biopsy. Intravesical recurrences were compared using Kaplan-Meier analyses and Cox-proportional hazard models. Results of group 4 vs 1 were pooled with the literature using a fixed effects meta-analysis. RESULTS: In a cohort of 834 RNU patients, 210 (25.2%) had undergone no ureteroscopy, 57 (6.6%) percutaneous biopsy, 125 (15.0%) ureteroscopy without biopsy, and 442 (53.0%) ureteroscopic biopsy. Two-year intravesical recurrence rates were 15.0%, 12.7%, 18.4%, and 21.9% for groups 1 through 4, respectively (p=0.09). Multivariable analysis found that group 4 had increased intravesical recurrences (HR 1.40, p=0.04) relative to group 1 while group 2 (HR 1.07, p=0.87) and group 3 (HR 1.15, p=0.54) did not. Group 4 remained associated with intravesical recurrence on subset analyses accounting for post-RNU surveillance cystoscopy frequency. On meta-analysis including 11 other series, ureteroscopic biopsy was associated with intravesical recurrence (HR 1.47, p <0.01). CONCLUSIONS: Ureteroscopic biopsy before RNU, but not percutaneous biopsy or ureteroscopy without biopsy, was associated with increased intravesical recurrence. Clinical trials of intravesical chemotherapy after ureteroscopic biopsy are warranted to reduce intravesical recurrences.

Resident involvement in the prostatic urethral lift: implementing innovative technology in an academic setting.

Adoption of the prostatic urethral lift (PUL) as a treatment for benign prostatic hyperplasia highlights the importance of training residents with novel technology without compromising patient care. This study examines the effect of resident involvement during PUL on patient and procedural outcomes. Retrospective chart review was conducted on all consecutive PUL cases performed by a single academic urologist between October 2017 and November 2019. Trainees in post-graduate year (PGY) 1-3 are considered junior residents, while those in PGY 4-6 are senior residents. The International Prostate Symptom Score (IPSS) and quality of life (QOL) scores were used to measure outcomes. Simple and mixed-effects linear regression models were used to compare differences. There were 110 patients with a median age of 66.4 years. Residents were involved in 73 cases (66.4%), and senior residents were involved in 31 of those cases. Resident involvement was not associated with adverse perioperative outcomes with respect to the number of implants fired, the percentage of implants successfully placed, or the postoperative catheterization rate. After adjustment for confounding factors, junior residents were associated with significantly longer case length compared to the attending alone (+12.6 min, P = 0.003) but senior residents were not (+2.4 min, P = 0.59). IPSS and QOL scores were not significantly affected by resident involvement (P = 0.12 and P = 0.21, respectively). The presence of surgeons-in-training, particularly those in the early stages, prolongs PUL case length but does not appear to have an adverse impact on patient outcomes.

An Empirical Study on the Operative Treatment of Symptomatic Urolithiasis in Germany.

PURPOSE: The guidelines of the German, European, and American Urological Associations on urolithiasis advise against general ureteral stenting before and after an uncomplicated ureterorenoscopy (URS). However, German and European guidelines state that stenting prior to URS facilitates stone extraction and reduces intraoperative complications. According to the published literature, German practice seems to deviate from recommendations. This nationwide survey aimed to evaluate the treatment modalities of urolithiasis. METHODS: In November 2018 and March 2019, a total of 199 urological hospital departments in Germany were anonymously surveyed about operative care of symptomatic urolithiasis. The response rate was 72.9%. The survey consisted of 25 questions about diagnostics, surgical technique, and aftercare of the URS. This questionnaire is available in the appendix. RESULTS: A primary URS is performed in ≤10% in 49.6% of the hospitals. In every second urological department (49.7%), the German Diagnosis Related Group (G-DRG) system influences the period of pre-stenting before a secondary URS. After a secondary URS, which is performed in 53.8% of the departments in over 80% of the patients, 14% of the departments omit stenting. The standard for stenting seems to be a 28-cm-long 7 Charrière double-J stent in Germany. CONCLUSION: In Germany, the percentage of primary URS is low, and a ureter stenting is performed in most of the urological departments after URS. Delaying therapy due to economic aspects is the standard in almost half of all urological departments.

In-vitro and in-vivo new evidence for Flexor® Vue™ deflecting endoscopic system use: optimization of the stone free rate (SFR) after flexible ureteroscopy and Ho:YAG laser lithotripsy.

To test in-vitro and in-vivo the Flexor® Vue™ deflecting endoscopic system (FVDES) as a new technology able to improve the removal of residual intrarenal fragments.This is an observational prospective "proof of concept" study performed in patients with renal calculi treated with flexible ureteroscopy and Ho:YAG laser lithotripsy (f-URS) in Humanitas Research Hospital (Rozzano, Italy). We assessed feasibility, efficacy and safety of FVDES as an in-vivo tool for removing residual fragments after f-URS. The stone-free rate (SFR) at 30 days post-operatively was evaluated using CT. An in-vitro model was developed to evaluate the FVDES when used for this purpose.Eleven patients (M/F ratio: 7/4, mean age 63.5 ± 8.3) were treated. The stones were located in the lower calyces and the renal pelvis in 3 and 8 patients, respectively. Mean stone size was 18 ± 3.2 mm. The procedure with FVDES was feasible and effective in all the patients. Mean operative time was 82 ± 13.7 min and median hospitalization was of 1.5 days. The SFR after 90 days was 81% (9/11). We reported no relevant complications (Clavien-Dindo > 2); one patient had fever and was treated with antibiotics. The experimental in-vitro model demonstrated the efficacy of FVDES, allowing the removal of about 90% of fragments.Our study showed that FVDES is effective when used as a tool for retrieval of residual fragments at the end of f-URS. This technology could ensure a complete cleaning of the intrarenal collecting system and represent a safe alternative to basketing.

Is health-related quality of life of patients after single-use flexible ureteroscopy superior to extracorporeal shock wave lithotripsy? A randomised prospective study.

The aims of the study were to compare the change in the Wisconsin Stone Quality of Life (WISQOL) score in patients who underwent retrograde intrarenal surgery (RIRS) single-use ureteroscope or extracorporeal shock wave lithotripsy (ESWL) with a calculation of quality-adjusted life-years (QALYs). 158 patients treated with urinary stone disease were randomly divided into 80 patients in the validation and 78 patients in the intervention arm. Patients in the intervention arm were randomly divided into the RIRS or the ESWL group. Linguistic validation of the WISQOL into the Slovak language was performed using a standardised multistep process. Discriminant validity was assessed by comparing stone-forming patients to an additional 34 healthy individuals. Patients were asked to fill in the WISQOL before and in the 24th week after the intervention. The QALYs were calculated by the formula QALY = weight factor (WF) x time period after intervention. The Cronbach's α of the WISQOL was 0.94, the Pearson's coefficient for test-retest reliability was 0.91, and the discriminant validity confirmed a higher score for healthy individuals (p < 0.001). The median WISQOL score changed from 45.5 to 95.5 vs. 33.9 to 87.1 in the RIRS and ESWL groups, respectively (p < 0.001). Patients from the RIRS group had a good possibility of reaching 19.727 QALYs gained during life expectancy compared to 15.780 for the ESWL group (p < 0.001). RIRS single-use ureteroscope is significantly superior to ESWL in reaching more QALYs gained during life expectancy. The WISQOL Slovak version is valid, reliable and strictly specific for stone-forming patients.

Impacts of the COVID-19 outbreak on visits and treatments for patients with ureteral stones in a general hospital emergency department.

BACKGROUND: The COVID-19 is a challenge for both patients and physicians in emergency department (ED). This study was aimed to report the impacts of the COVID-19 outbreak on visits and treatments for patients with ureteral stones in a general hospital ED. METHODS: The patients with ureteral stones were collected from 24 January to 24 March 2020 during the COVID-19 outbreak in Beijing. Two periods were divided for study: 24 January to 24 February (Period 1) and 25 February to 24 March (Period 2). Data on patients' characteristics, attendance, visual analog scale (VAS) scores, stone features, and final treatment choices were retrieved from the computer and compared with the data in the same periods in 2019. RESULTS: The study included 376 patients with ureteral stones during the COVID-19 outbreak periods in 2020 and 343 patients during the same periods in 2019. Compared with the same periods in 2019, the number of patients with ureteral stones was less in Period 1 (137 vs 163) but had a rebound phenomenon in Period 2 (239 vs 180). The visit frequency was significantly reduced (2.6 ± 0.4 vs 3.6 ± 0.8, p < 0.01) and the VAS scores and the onset time increased (7.7 ± 1.3 vs 5.5 ± 1.6, p < 0.01; 7.4 ± 1.8 vs 8.2 ± 1.5, p < 0.01, respectively) in Period 1. More patients chose oral analgesics medication to release from renal colic in the COVID-19 outbreak period instead of ESWL and intravenous analgesics medication (Period 1, 54.0% vs 20.2%, p < 0.01; Period 2, 20.9% vs 13.3%, p = 0.044; respectively). However, the percentage of patients underwent endoscopy surgery in outbreak period showed no significant difference compared with that in 2019. CONCLUSION: These results showed that the COVID-19 outbreak can directly affect the visits and final treatment choices for patients with ureteral stones.

Decreased Recurrence of Urolithiasis After Simultaneous Ureteroscopic Surgery for Ureter and Ipsilateral Renal Calculi: Comparison to Shockwave Lithotripsy for Ureter Calculi Alone.

OBJECTIVE: To compare follow-up outcomes of ureteroscopy (URS) and shockwave lithotripsy (SWL) for ureter calculi in the setting of asymptomatic renal calculi <15 mm. METHODS: This study included 789 patients who underwent URS (n = 301) or SWL (n = 488) as primary treatment for ureter calculi and who had ipsilateral renal calculi <15 mm between January 2012 and December 2019. For the URS group, all renal calculi were simultaneously treated unless contraindicated. One-to-one matching was performed using the propensity score (PS). RESULTS: After PS matching, analysis included 262 matched pairs of URS and SWL patients. The stone-free rate for ureter calculi without auxiliary procedure was 97.3% in the URS group and 93.9% in the SWL group. Any complication rates were 11.0% and 9.2% in the URS and SWL group, respectively; 1.1% of the URS patients experienced complications classified as Clavien-Dindo ≥IIIb. The estimated 2-year intervention-free survival was 88.1% in the URS group and 84.2% in the SWL group (P = 0.045). The estimated 2-year stone-event-free survival was 80.1% in the URS group and 71.0% in the SWL group (P = 0.009). Cox multivariate analysis showed that the hazard ratios of URS were 0.62 (P = 0.025) for surgical interventions and 0.64 (P = 0.008) for stone-related events after adjusting for baseline variables. CONCLUSION: For patients with symptomatic ureter calculi and asymptomatic renal calculi <15 mm, URS with active treatment for renal calculi reduces future ipsilateral surgical intervention and stone-related events compared with SWL for ureter calculi.

Resident involvement in the prostatic urethral lift: implementing innovative technology in an academic setting / 亚洲男科学杂志(英文版)

Adoption of the prostatic urethral lift (PUL) as a treatment for benign prostatic hyperplasia highlights the importance of training residents with novel technology without compromising patient care. This study examines the effect of resident involvement during PUL on patient and procedural outcomes. Retrospective chart review was conducted on all consecutive PUL cases performed by a single academic urologist between October 2017 and November 2019. Trainees in post-graduate year (PGY) 1-3 are considered junior residents, while those in PGY 4-6 are senior residents. The International Prostate Symptom Score (IPSS) and quality of life (QOL) scores were used to measure outcomes. Simple and mixed-effects linear regression models were used to compare differences. There were 110 patients with a median age of 66.4 years. Residents were involved in 73 cases (66.4%), and senior residents were involved in 31 of those cases. Resident involvement was not associated with adverse perioperative outcomes with respect to the number of implants fired, the percentage of implants successfully placed, or the postoperative catheterization rate. After adjustment for confounding factors, junior residents were associated with significantly longer case length compared to the attending alone (+12.6 min, P = 0.003) but senior residents were not (+2.4 min, P = 0.59). IPSS and QOL scores were not significantly affected by resident involvement (P = 0.12 and P = 0.21, respectively). The presence of surgeons-in-training, particularly those in the early stages, prolongs PUL case length but does not appear to have an adverse impact on patient outcomes.

The Risk Factors of Febrile Urinary Tract Infection After Ureterorenoscopic Lithotripsy.

We aimed to evaluate the risk factors for febrile urinary tract infection (fUTI) following ureterorenoscopic lithotripsy (URSL) for upper urinary tract stones. We retrospectively reviewed the data of 109 patients with upper urinary tract stones who underwent URSL at our hospital from October 2016 to March 2019. We divided the patients into two groups: those who developed fUTI after URSL (fUTI group) and those who did not (non-fUTI group). The retrospectively collected data, including age, sex, body mass index (BMI), mobility, diabetes mellitus, operative duration, preoperative ureteral stent placement, number of stones, stone diameter, CT value of stone, stone location, preoperative UTI, preoperative urine culture, preoperative pyelonephritis, and stone-free status were compared between the two groups. Postoperative fUTI occurred in three of the 109 patients (2.8%). Comparing the two groups, a significant risk factor for developing fUTI after URSL was a low BMI. However, in our study, only three cases developed fUTI after URSL; thus, a multivariate analysis could not be performed. One of the three cases in which fUTI occurred was accompanied by anorexia nervosa and an extremely low BMI of 11 kg/m². In summary, even though we had only 3 fUTI patients and did not perform multivariate analysis, our data suggested a significant risk factor for developing fUTI was a low BMI. Increasing the sample size, and further study seem desirable.

Treatment Setting Influences Treatment Modality for Urinary Stone Disease.

OBJECTIVE: To determine whether selection of treatment modality for urinary stone disease differs between primary and outreach healthcare centers, and if patient rurality predicts treatment modality. METHODS: We retrospectively evaluated Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) procedural data from the Iowa Office of Statewide Clinical Education Programs (OSCEP) and Iowa Hospital Association (IHA) databases from 2007 to 2014. Geographical data was used to analyze travel metrics and patient proximity to sites of stone treatment. Rural-urban commuting area (RUCA) codes were used to characterize patient rurality. Chi-square tests and t tests were used to compare ESWL and URS patients, and multilevel logistic regression model was used to assess influence of treatment setting on surgical modality. RESULTS: A total of 18,831 stone procedures were performed by urologists in Iowa on patients from Iowa (10,495 URS; 8336 ESWL). Around 2630 procedures occurred at outreach centers. Ureteroscopy comprised 59.7% of procedures at primary centers, but only 31.2% at outreach centers. On multilevel analysis, outreach location was associated with 2.236 OR toward ESWL (P <.001). Individual physician treatment patterns accounted for 32% of treatment variation. Patient rurality was not significantly associated with treatment modality as an independent factor (P = .879). CONCLUSIONS: Wide variation exists in urolithiasis treatment modality selection between outreach and primary centers. Outreach locations perform a significantly higher frequency of ESWL compared to URS, and much of the variation in treatment selection (32%) arises from individual physician practice patterns.

[Causes and predictive factors of prolonged length of hospital stay after flexible ureteroscopy: Experience of a large volume institution]. / Causes et facteurs prédictifs d'une hospitalisation postopératoire prolongée après urétéroscopie souple : expérience d'un centre hospitalo-universitaire.

PURPOSE: To identify the causes of prolonged length of hospital stay (LOHS) of patients treated with flexible ureteroscopy (fURS). The secondary endpoint was to identify the predictors of complications. METHODS: A retrospective single-center cohort study was conducted between January 2011 and December 2015. All consecutive patients treated with a planned fURS, regardless of the indication, AND stayed hospitalized for at least one additional day compared to the traditional postoperative LOHS of our center (=1 day) were included. A multivariate analysis was performed to investigate predictive factors of prolonged LOHS. RESULTS: Two hundred and seventy-two patients were included in the final analysis. The median duration of LOHS was two days [2-18]. Forty-seven percent of patients were discharged beyond day 1 and had no complication. Among them, 56% stayed for simple surveillance decided by the surgeon without any specific treatment introduced and 52% stayed for continuation of intravenous preoperative antibiotics. Of the remaining 144 patients who had a complication, 85.4% (123/144) had a minor complication (Clavien 1 or 2). In multivariate analysis, predictive factors of prolonged LOHS (discharge after day 1) were neurological comorbidities (paraplegia, spina bifida, multiple sclerosis) with an odds ratio of 4.39 [1.7; 11.4]. CONCLUSIONS: The causes of prolonged LOHS were mainly related to comorbidities. A number of patients stayed hospitalized without complications. The identification of predictive factors of complications and prolonged LOHS may allow better selection of patients eligible for outpatient surgery and select those for whom inpatient surgery is still recommended. LEVEL OF EVIDENCE: 3.

Outcomes of ureteroscopy (URS) for stone disease in the paediatric population: results of over 100 URS procedures from a UK tertiary centre.

PURPOSE: To report the outcomes of paediatric ureteroscopy (URS) for stone disease from a specialist endourology centre in the UK. Ureteroscopy for management of stone disease has increased worldwide and is now being done more commonly in the paediatric age group. METHODS: Data were analysed retrospectively from a database maintained between April 2010 and May 2018. Consecutive patients ≤ 16 years of age undergoing semi-rigid or flexible URS for stone disease were included. Stone size and stone-free rate (SFR) were routinely assessed using an ultrasound (USS) and/or plain KUB XR. Complications were graded according to the Clavien-Dindo classification and recorded within 30 days post-procedure and readmissions within 90 days after the procedure were also captured. RESULTS: Over the 8-year period between April 2010 and April 2018, 81 patients with a mean age of 8.8 years (range 18 months-16 years) and a male to female ratio 1:1.1 underwent 102 procedures (1.28 procedure/patient to be stone free). Of the 81 patients, 29 (35.8%) had comorbidities, with 26 (32%) having multiple comorbidities. The mean (± SEM) single and overall stone size was 9.2 mm (± 0.48, range 3-30 mm) and 11.5 mm (± 0.74, range 4-46 mm) respectively, with 22 (27.1%) having multiple stones. Thirty-five (34.7%) had stent in situ pre-operatively. The stone location was in the ureter (26.6%), lower pole (35.4%), and renal pelvis (16.5%), with 22/81(27%) having multiple stones and 21/102 (20.5%) where a ureteral access sheath (UAS) was used. With a mean hospital stay of 1.2 days, the initial and final SFR was 73% and 99%, respectively, and 61/102 (60%) had ureteric stent placed at the end of the procedure. While there were no intra-operative complications, the readmission rate was less than 1% and there were only three early complications recorded. This included a case each of prolonged admission for pain control (grade I), urinary retention (grade II) and post-operative sepsis requiring a brief ITU admission (grade IV). CONCLUSION: Our study demonstrates that in appropriate setting a high stone-free rate can be achieved with minimal morbidity for paediatric patients. There is potentially a need to factor the increasing role of URS in future paediatric urolithiasis guidelines.