The effect of shock wave lithotripsy and retrograde intrarenal surgery on health-related quality of life in 10-20 mm renal stones: a prospective randomized pilot study.

The effects of treatment modalities such as retrograde intrarenal surgery (RIRS) and shock wave lithotripsy (SWL) on health-related quality of life (HRQoL) were determined in patients with renal stones between 10 and 20 mm. A total of 120 patients were included in the study and prospectively randomized to RIRS or SWL group. A total of 39 patients experienced treatment failure and finally 81 patients (45 patients in the RIRS group, 36 patients in the SWL group) were analyzed for HRQoL. SF-36 survey was used to determine HRQoL pre-operatively, post-operative day 1 and 1 month. The patient and stone characteristics such as age, gender, stone size, grade of hydronephrosis and body mass index were similar between the two groups. At post-operative day 1, the RIRS group was associated with lower scores of role functioning/physical (p = 0.008), role functioning/emotional (p = 0.047) energy/fatigue (p = 0.011), social functioning (p = 0.003) and pain (p = 0.003) when compared to the SWL group. At post-operative 1 month, only pain and emotional well-being scores (p = 0.012 and p = 0.011, respectively) in the RIRS group were statistically lower according to the SWL group. In our study, patients in the SWL group showed more favorable HRQoL scores when compared to the patients in the RIRS group in short-term follow-up.

Performance Optimization Strategies for Complex Endourologic Procedures.

OBJECTIVE: To identify and address factors that may impact a surgeon's performance during endourologic procedures. METHODS: A literature review was performed for articles focusing on surgical ergonomics, education, sports and performance psychology. RESULTS: As urologists and trainees have become more comfortable approaching complex pathology endoscopically, there remains an opportunity to refine surgeon-related factors and optimize extrinsic factors to maximize efficiency and provide patients with the highest quality outcomes and safety. CONCLUSION: Medical centers and training programs should strive to include formal lessons on stress-coping mechanisms, communication, and dedicated ergonomic training, as these all play a role in physician well-being and may lead to improved clinical outcomes.

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy.

PURPOSE: Emergency department visits after ureteroscopy are costly and inconvenient. To better understand those at risk we aimed to identify patient demographic, medical and surgical factors associated with 30-day emergency department presentation following ureteroscopy for urolithiasis with particular attention to those with a history of a psychiatric diagnosis. MATERIALS AND METHODS: We retrospectively reviewed 1,576 cases (1,395 adults) who underwent stone related ureteroscopy during 3 years at a total of 2 hospitals. We collected patient demographics, medical history and operative details. The primary outcome was return to the emergency department within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with emergency department presentation. RESULTS: Of the patients 613 (43.9%) had a history of psychiatric diagnosis. Of those with ureteroscopy encounters 12.6% returned to the emergency department within 30 days of ureteroscopy, including 58.8% with a history of psychiatric diagnosis. On multivariable analysis variables associated with emergency department return included a history of psychiatric diagnosis (OR 1.57, p = 0.012), uninsured status (OR 2.46, p = 0.001) and a stone only in the kidney (OR 1.76, p = 0.022). Patients who returned to the emergency department had had more emergency department visits in the year prior to surgery (OR 1.40, p <0.001). On univariable analysis older patients and those with longer operative time were more frequently admitted from the emergency department (OR 1.03, p = 0.002 and OR 1.96, p = 0.03. respectively) while uninsured patients were admitted less frequently (OR 0.19, p = 0.013). No difference was noted in admissions between those with a psychiatric diagnosis and all others (60.7% vs 55.8%, p = 0.48). CONCLUSIONS: We identified factors associated with emergency department return after ureteroscopy, including a history of psychiatric diagnosis, uninsured status and emergency department visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary emergency department visits.

Shared decision making: why do patients choose ureteroscopy?

To evaluate patient's characteristics that affects their decision on the management of asymptomatic renal calculi, and to determine the impact of anesthetic on the selection of shockwave lithotripsy (SWL). A survey was distributed to 100 patients in our multi-disciplinary stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8 mm lower pole stone and descriptions for managements options including active surveillance (annual radiography, 40% chance of growth >10 mm within 4 years, 20% chance of passage), SWL under conscious sedation (65% success rate), and URS (90% success rate, with stent placement for 1 week). Patients were asked what was the most important variable impacting the choice of treatment. Patients preferred SWL (45%) over URS (32%) and active surveillance (23%). Patients with a previous experience with URS were more likely to choose it again (p = 0.0433). Decisions were driven primarily by success rate (52%), followed by risk of complications (29%), postoperative pain (7%) and others (12%). Patients choosing URS had the highest magnitude of history of pain (p = 0.03) and were more likely to prioritize success (78%) and less likely to prioritize surgical risk (13%) or anticipated pain after surgery (0%) (p = 0.01). Most (85%) of the patients would rely on the physician's recommendation for the treatment modality. Patients place differing value on risk versus success. As they rely heavily on the physician's recommendation, it is important that their urologist determine whether risk or success is of highest priority for them to facilitate a shared medical decision.

Anxiety and patient participation in clinical decision-making: the case of patients with ureteral calculi.

Ninety-six patients with a ureteral calculus participated in a study whose purpose was to identify those subjects who would benefit from participation in clinical decision-making. Forty-two of the subjects (the experimental group) were given information about two alternative treatments, Extra Corporeal Shock Wave Lithotripsy (ESWL) and ureteroscopy, and were asked to choose which therapy they preferred. Fifty-four subjects (the control group) were not given information, not allowed to choose, and were treated according to the physician's decision. Subjects' level of anxiety was compared within each group on three occasions: before meeting with the physician, immediately afterwards and upon hospitalization for treatment of the stone. Patients perception of receipt of information and participation in clinical decision-making, coping style, educational level, and knowledge about treatment alternatives were also measured. A statistically significant decrease in anxiety after meeting with the urologist was found among patients who were not asked to participate in the decision-making process and among patients who perceived that they had received information. A decrease in anxiety after meeting with the physician was also found among patients who, according to their own perception, did not participate in decision-making. Patients' educational level and coping style were related to their anxiety. A decline in anxiety was found among those with a lower educational level who perceived that they had received information and among higher educated patients who perceived that they participated in clinical decision-making. Anxiety also declined among patients with a passive coping style who perceived that they had received information or had participated in the decision-making process. The results emphasize the need to tailor the therapeutic approach to patient characteristics.