Real-world Practice Stone-free Rates After Ureteroscopy: Variation and Outcomes in a Surgical Collaborative

Abstract

BackgroundStudies assessing the stone-free rate (SFR) after ureteroscopy are limited to expert centers with varied definitions of stone free. Real-world data including community practices related to surgeon characteristics and outcomes are lacking. ObjectiveTo evaluate the SFR for ureteroscopy and its predictors across diverse surgeons in Michigan. Design, setting, and participantsWe assessed the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry for patients with renal or ureteral stones treated with ureteroscopy between 2016 and 2021 who had postoperative imaging. Outcome measurements and statistical analysisStone free was defined as no fragments on imaging reports within 60 d entered by independent data abstractors. Factors associated with being stone free were examined using logistic regression, including annual surgeon volume. We then assessed variation in surgeon-level SFRs adjusted for risk factors. Results and limitationsWe identified 6487 ureteroscopies from 164 surgeons who treated 2091 (32.2%) renal and 4396 (67.8%) ureteral stones. The overall SFRs were 49.6% (renal) and 72.7% (ureteral). Increasing stone size, lower pole, proximal ureteral location, and multiplicity were associated with not being stone free. Female gender, positive urine culture, use of ureteral access sheath, and postoperative stenting were associated with residual fragments when treating ureteral stones. Adjusted surgeon-level SFRs varied for renal (26.1–72.4%; p < 0.001) and ureteral stones (52.2–90.2%; p < 0.001). Surgeon volume was not a predictor of being stone free for renal stones. Limitations include the lack of imaging in all patients and use of different imaging modalities. ConclusionsThe real-world complete SFR after ureteroscopy is suboptimal with substantial surgeon-level variation. Interventions focused on surgical technique refinement are needed to improve outcomes for patients undergoing ureteroscopy and stone intervention. Patient summaryResults from a diverse group of community practicing and academic center urologists show that for a large number of patients, it is not possible to be completely stone free after ureteroscopy. There is substantial variation in surgeon outcomes. Quality improvement efforts are needed to address this.