Presence Of Residual Fragments Research Articles

Endourological society fellowship program: a real contribution to improve surgical outcomes of stone patients treated with ureteroscopy.

We assessed the impact of the one-year endourological society fellowship program (ESFP) on the achievement of optimal surgical outcomes (OSO) in stone patients treated with ureteroscopy (URS). We identified 303 stone patients treated with URS from January 2018 to June 2022 by five experienced surgeons (ES). Of those, two attended ESFP. OSO was defined as the presence of residual fragments ≤ 4mm at 1-month post-operative imaging (Ultrasound + X - Ray or CT scan). Descriptive statistics explored patients' characteristics and the rate of OSO according to the attendance of ESFP. Uni- and multivariate logistic regression analyses (UVA and MVA) tested the impact of stone characteristics, surgical data, ESFP, and imaging technique on the rate of OSO. The LOWESS curve explored the graphical association between stone size and the multivariable-adjusted probability of OSO in the two groups of surgeons. Of 303 patients, 208 (69%) were treated by the two surgeons who attended ESFP. OSO was achieved in 66% and 52% of patients treated by ES with and without ESFP, respectively (p = 0.01). At UVA, ESFP (OR = 1.78; 95% CI = 1.09-2.90), stone diameter (OR = 0.92; 95% CI = 0.88-0.96), stone location (kidney vs. ureter; OR = 0.34; 95% CI = 0.21-0.58), imaging technique (CT scan vs. Ultrasound + X-Ray; OR = 0.28; 95% CI = 0.16-0.47) predicted OSO achievement (all p < 0.05). At MVA analyses, ESFP was associated with OSO (OR = 2.24; 95% CI = 1.29-3.88; p < 0.05), along with the other aforementioned variables. The LOWESS curve showed that the greater the stone size, the greater the difference in OSO in the two groups of surgeons. ESFP positively affects OSO achievement after URS, especially in patients with a high stone burden.

A randomized trial of adjuvant tamsulosin as a medical expulsive therapy for renal stones after shock wave lithotripsy.

Adjuvant medical expulsive therapy (MET) for shock wave lithotripsy (SWL) is controversial. With limited use of the computed tomography (CT), the stone free rate (SFR) become overestimated. Herein we evaluate tamsulosin post-SWL for renal stone using the CT to assess SFR. A randomized controlled trial (NCT05032287) was carried out for renal stone patients amenable for SWL. Patients were allocated after 1st session of SWL to receive tamsulosin 0.4 mg or placebo once daily from the 1st day of SWL and for 3-months or becoming stone free. The primary outcome was SFR, defined by presence of residual fragments (RF) ≤ 3 mm (3C-SFR). The 3C-SFR were 73.8% and 59.6% in tamsulosin and placebo groups, respectively (p=0.03). The median (IQR) pain scores were 3 (3, 5) and 5 (3, 6) in tamsulosin and placebo groups, respectively (p=0.04), However, the post-SWL complication and add-on analgesia needed showed no significance differences between groups. The median time for stone free were 30 days (95% CI: 27.29-32.71) in tamsulosin arm, and 36 days (95% CI: 31.01-40.99) in placebo arm, HR= 1.42 (95% CI: 1.02-1.98). Tamsulosin has more reversible adverse effect, compared to placebo (p=0.03). In our study, the use of tamsulosin as MET following SWL facilitates expulsion of retained residual fragments. Tamsulosin shortens time to reach stone free, decreases pain scores. However, tamsulosin does not affect the add-on IV analgesics and have more reversible adverse effect, compared to placebo.

Retrospective Analysis of the Factors Affecting Intraoperative and Immediate Postoperative Complications of Retrograde Intrarenal Surgery Classified by the Clavien and Satava Grading Systems.

Background: To classify intraoperative and postoperative complications using the modified Clavien classification system (MCCS) and modified Satava classification system (SCS) and to evaluate the parameters associated with complications in patients undergoing retrograde intrarenal surgery (RIRS) for renal and proximal ureteral stones. Materials and Methods: We performed a retrospective analysis of 949 patients who underwent RIRS for renal stones and proximal ureteral stones at two institutions between March 2015 and June 2020. Intraoperative complications were assessed using the SCS, and postoperative complications were graded according to the MCCS. Univariate and multivariate analyses were undertaken to determine predictive factors affecting complication rates. Results: The median stone size was determined as 13 mm (range 10-20 mm). The stone-free rate was 83.6% after the first intervention. Reprocedure was applied to 89 of the patients with residual stones and the final stone-free rate was 94.4% after reprocedure. According to SCS, the number of intraoperative events and complication incidences was 153 (16.1%). MCCS revealed postoperative complications in 121 (12.8%) patients. Major complications were observed in 18 (1.9%) patients. The rate of complications was higher in patients with renal anomalies (9.9% vs 3.4%, p = 0.001). Stone location, stone size, stone burden, stone number, stone density, and residual fragments were determined to be associated with the development of complications (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.002, and p < 0.001, respectively). In addition, the multivariate analysis revealed that only the presence of residual fragments was a significant predictor of complication development for the patients with Grade ≥3 complications according to MCCS (p = 0.032). However, significant predictors were stone burden (p < 0.001), stone density (p = 0.002), and fluoroscopy time (p < 0.001) for those with Grade ≥2b complications according to SCS. Conclusion: This study showed that abnormal kidney anatomy, operation time, stone burden, and residual fragments were reliable predictors of complication development during and after RIRS. Appropriate preoperative management should be planned according to these predictors to prevent intraoperative and postoperative complications.

Initial Experience and Evaluation of a Nomogram for Outcome Prediction in Management of Medium-sized (1–2 cm) Kidney Stones

BackgroundThe gold standard treatment for solitary medium-sized (1–2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients’ counseling and decision-making. ObjectiveTo develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting. Design, setting, and participantsWe recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1–2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis. Outcome measurements and statistical analysisMultivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function. Results and limitationsA total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature. ConclusionsThis nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity. Patient summaryWe developed a preoperative model of treatment outcomes for 1–2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality.

Postoperative Progress after Stone Removal Following Treatment for Obstructive Acute Pyelonephritis Associated with Urinary Tract Calculi: A Retrospective Study.

We aimed to identify the prevalence and risk factors of three outcomes after stone removal following treatment for obstructive acute pyelonephritis (APN) associated with urinary tract calculi: immediate postoperative febrile urinary tract infection (UTI), stone recurrence, and APN recurrence during the follow-up period. We retrospectively reviewed the charts of 107 patients who underwent stone removal following treatment for obstructive APN associated with urinary tract calculi. Logistic regression analysis was used to identify the factors that contributed to postoperative febrile UTI after stone removal. Cox proportional hazard analyses were used to identify the factors contributing to stone recurrence and APN recurrence during the follow-up period. Postoperative febrile UTI was observed in 23 out of 107 patients (21.5%). Multivariate logistic regression analysis revealed that female sex (P = .02) and having multiple stones (P < .01) were independently significant predictors of postoperative febrile UTI. One-year recurrence-free survival rates of stone disease and APN were 76.1% and 82.5%, respectively. Multivariable cox proportional hazard analyses revealed that presence of residual fragments was the only significant risk factor for stone recurrence (P < .01) and marginally significant for APN recurrence (P = .05). Patients presenting with obstructive APN frequently develop postoperative febrile UTI after active stone removal with the risk factors being female sex and having multiple stones. Residual fragments after stone removal in patients with obstructive APN can cause urolithiasis and APN recurrence, indicating that complete removal of stone fragments ? 4 mm is imperative to the disease management.

Semirijit Üreteroskopik Litotripsi Sonrası Gelişen İdrar Yolu Enfeksiyonunu Öngören Risk Faktörleri

INTRODUCTION: The aim of this study is to determine the frequency and predictive factors of postoperative UTI in patients who underwent URS regarding ureteral stones. METHODS: Data from 425 patients undergoing semi-rigid ureteroscopic lithotripsy between December 2015 and December 2019 at a single center were reviewed to detect factors predicting postoperative urinary tract infections. RESULTS: Of the 425 patients, 35 were infective (8.2%). Proximal ureteral stones were the majority in infective group (48.5%); distal ureteral stones were the majority in non-infective group (42.6%)(p=0.026). Stone number and stone size were also higher in the postoperative infective group (p&lt;0.05). UTI history and preoperative DJS insertion were higher in Group 1 (p &lt;0.001, p = 0.001, respectively). Multivariate regression analyses revealed that history of UTI (OR=5.513, 95% CI; 2.622–11.591, p value &lt;0.001) and presence of residual fragments (OR=4.274, 95% CI; 1.892–9.657, p value &lt;0.001) were independent risk factors for infectious complications after URS. DISCUSSION AND CONCLUSION: Even if URS is considered an innocuous procedure, the probability of postoperative infectious complications is far from negligible. Our results showed that the presence of UTI history and residual fragments were associated with an increased risk of subsequent UTI after URS. These infectious complications also have significant morbidity, mortality and expenditure if not treated timely. Therefore, to avoid this preventable complication, all variables should be reviewed and more careful.

Ureteroscopic lithotripsy for ureteral stones in children using holmium: yag laser energy: results of a multicentric survey

Holmium:YAG (Ho:YAG) laser lithotripsy has broadened the indications for ureteroscopic stone managements in adults, but few evidence are currently available in the pediatric population. This article aimed to assess the outcome of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral stones in different locations in children. The medical records of 149 patients (71 boys and 78 girls; median age 9.2 years) treated with Ho:YAG laser ureteroscopic lithotripsy in five international pediatric urology units over the last 5 years were retrospectively reviewed. Exclusion criteria included patients with renal calculi and/or with a history of ipsilateral stricture, renal failure, active urinary tract infection, or coagulation disorder. Stones were treated with dusting technique in all cases. The median stone size was 10.3mm (range 5-17). Stones were located in the distal ureter in 77 cases (51.7%), in the middle ureter in 23 cases (15.4%), and in the proximal ureter in 49 cases (32.9%). The median operative time was 29.8min (range 20-95). Intra-operative complications included five bleedings (3.3%) and seven stone retropulsions (4.7%). Overall stone-free rate was 97.3%. Overall postoperative complications rate was 4.0% and included two cases of stent migration (1.3%) (Clavien II) and four residual stone fragments (2.7%) that were successfully treated using the same technique (Clavien IIIb). On multivariate analysis, re-operation rate was significantly dependent on the proximal stone location and presence of residual fragments >2mm (P=0.001). This study is one of the largest pediatric series among those published until now. The study series reported a shorter operative time, a higher success rate, and a lower postoperative complications rate compared with previous series. A limitation of this study is that stone-free rates may be somewhat inaccurate using ultrasonography and plain X-ray compared with computed tomography (CT); the study's 97.3% success rate may be overestimated because no CT scan was done postoperatively to check the stone-free rate. Other limitations of this article include its retrospective nature, the multi-institutional participation, and the heterogeneous patient collective. The Ho:YAG laser ureteroscopic lithotripsy seems to be an excellent first-line treatment for children with ureteral stones, independently from primary location and size. However, patients with proximal ureteral stones and residual fragments >2mm reported a higher risk to require a secondary procedure to become stone-free. Combination of techniques as well as appropriate endourologic tools are key points for the success of the procedure regardless of stones' size and location.

Does leaving residual fragments after percutaneous nephrolithotomy in patients with positive stone culture and/or renal pelvic urine culture increase the risk of infectious complications?

The residual fragments in patients with preoperative and intraoperative culture positivity may serve as an infection focus. The aim of this study was to assess the importance of residual fragments for developing SIRS in patients with stone culture and/or RPUC positivity. After obtaining institutional review board approval, a total of 729 patients who undergone PCNL for renal stones were included in this study. Residual fragments accepted to be positive if any fragment was detected irrespective of size. All patients were followed-up postoperatively for SIRS criteria. The patients were then followed-up for residual stone-related events and infectious complications. 94 of the 729 patients have developed SIRS postoperatively. SIRS positivity was more common among males and found to be associated with higher stone burden and presence of staghorn stone. Patients with residual fragments after PCNL also had higher rates of SIRS. In the subgroup analysis of 203 patients who had post-PCNL residual fragments, the peroperative stone and/or RPUC positivity was not found to be associated with the development of the SIRS. Although presence of residual fragments after PCNL is associated with SIRS development, stone culture and/or RPUC positivity has no additional risk for development of post-PCNL infectious complications in patients with residual fragments.

EFFICACY AND SAFETY OF LUBRICATING JELLY INSTILLATION TO PREVENT RETROPULSION DURING URETEROLITHOTRIPSY FOR URETERAL STONES

Objective: We studied the efficacy and safety of lubricating jelly instillation before ureterolithotripsy for prevention of retropulsion and improvement in stone-free rate. Material &amp; methods: We enrolled 22 subjects with ureteral stone in this prospective, randomized, single-blind and controlled clinical trial. Each subject was randomly assigned to the lubricating jelly instillation group (n=11) and control group (n=11). Ureteroscopy and lithotripsy was performed according the standard protocol, using 9.8 F semirigid ureteroscope and pneumatic lithotripter. A 6 F ureteral catheter was advanced beyond the stone, and lubricating jelly was instilled through the catheter lumen. Retropulsion and the presence of residual fragments were evaluated with plain kidneys, ureters and bladder x-ray and ultrasonography, or Non Contrast-enhanced Computed Tomography. Any complication was reported and graded using the Modified Clavien Classification System.Results: The 2 groups had comparable preoperative characteristics. There were no statistically significant difference between the lubricating jelly instillation group and control group regarding the retropulsion rate (54.5% vs 72.7%, ρ=0.375), the stone-free rate (54.5% vs 36.4%, ρ=0.392), and the complication rate (45.5% vs 54.5%, ρ=0.670). Conclusion: Lubricating jelly instillation during ureterolithotripsy has limited value for prevention of retropulsion and improvement in stone-free rate.

Retrograde intrarenal surgery in the management of pediatric cystine stones

To investigate the efficacy and safety of retrograde intrarenal surgery (RIRS) in the treatment of pediatric cystine stones. Data of the pediatric patients who underwent RIRS for kidney stones were retrospectively evaluated. A total of 14 children with cystine stones managed with RIRS were identified. In addition to the patient demographics and stone characteristics, all retrospectively obtained operative data were evaluated and discussed in detail, with an emphasis on the success and complication rates. Mean age of the 14 cases was 10.9±2.2 years (range: 7-15). Mean stone size was 13.6±2.4mm (range: 10-18) (Summary table). Of these stones, four were located in the renal pelvis, three were in the lower, three were in the middle and the remaining four were located in upper calyx. Ureteral access sheath was used in 12 (85.7%) patients. The double-J ureteral stent was placed pre-operatively in one case and was inserted postoperatively in 12 cases. Mean operation time was 38.2±7.2min (range: 30-50). Complications were observed in two cases: mild ureteral laceration in the first and fever on the second postoperative day in the second patient. All of the patients were stone free on sonographic evaluation at the 4-week follow-up evaluation. Although potassium citrate treatment was initiated in 11 patients, tiopronin treatment was initiated in four patients for recurrence prophylaxis during long-term follow-up. During a mean follow-up period of 25.7±5.2 months, stone recurrence was noted in one patient. Treatment of patients with cystine stones is challenging, due to high risk of rapid recurrence in the presence of residual fragments. Besides allowing complete stone clearance in all cases in the current series, RIRS is a highly reproducible method that can be safely performed, even in recurrences. The major limitations of the current study were low number of patients and short follow-up period. The results clearly indicated that RIRS is a safe treatment modality in the management of pediatric cystine stones.

Néphrolithotomie percutanée des calculs rénaux des personnes âgées : méta-analyse des résultats et complications

Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for kidney stones regardless of age. Elderly patients (EP)≥65years old, in growing numbers, have more comorbidities than the general population, may alter results of PCNL. The aim of this meta-analysis was to compare efficacy and complications of this procedure between EP and young patients (YP). Original studies of prospective and historical cohorts, in English or French, presenting PCNL series published on PubMed until 2015were identified using the keywords percutaneous nephrolithotomy, elderly patients, kidney stones and staghorn calculi. Our analysis focused on therapeutic efficacy, defined by absence of residual fragment or the presence of residual fragments<4mm at 3postoperative months, and postoperative complications according to patient age: YP<65years old and EP≥65years old. Binary qualitative data were analyzed using odds ratio (OR) and quantitative data by estimating the difference of means. In total 397studies were identified among which 23were checked and 8included in the meta-analysis for methodological quality corresponding to 4995YP and 820EP. No efficacy difference (OR=0.96; [IC95%: 0.80; 1.17]; P=0.71), operating time (+1.15min in EP [IC95%: -2.83; 5.12]; P=0.57) and average length of stay (+0.29days in EP [IC95%: -0.14; 0.72]; P=0.19) has been reported. It was a trend to more urinary infections (OR=2.24; [IC95%: 0.74-6.80]; P=0.16) and a significantly increase of postoperative blood transfusions in EP (OR=1.41; [IC95%: 1.00-1.97]; P=0.04). PCNL for kidney stones n EP is effective with a significantly increase the risk of postoperative blood transfusions compared to YP.

Infective complications after retrograde intrarenal surgery: a new standardized classification system.

Retrograde intrarenal surgery (RIRS) is considered a safe procedure; however, infective complications are potentially serious postoperative complications. The aim of this multicentre study was to evaluate prospectively the prevalence of infective complications after RIRS and identify risk factors. Baseline data were collected, and patients were questioned regarding postoperative infective complications following RIRS. The Fisher exact test, Student t test, Mann-Whitney U test, and multivariate regression analysis were used for data analysis. A total of 403 patients from five European centers were included. Antibiotic prophylaxis was administered prior to RIRS in 100%. Infection complications were recorded in 31 patients (7.7%), consisting of fever in 18 (4.4%), SIRS in 7 (1.7), and sepsis in 3 (0.7%). Three required hospitalization for non-obstructive pyelonephritis (0.7%). Univariate analysis revealed that coronary heart disease, chronic kidney disease, alteration of lipid metabolism, anticoagulant therapy, past surgery for renal stone, presence of residual fragments were predictors of infective complications. Multivariate analysis did not identify any patient subgroups at a significantly higher risk of infection. The low rate of complications may have limited the conclusions from our study. Using a standardized method for the definition and classification of infective complication from a multicentre prospective large database, we find a prevalence of 7.7% of infective complication among patients undergoing RIRS for renal stone. However, to predict which patients will develop infective complications still remains a clinical challenge.

Contemporary Imaging Practice Patterns Following Ureteroscopy for Stone Disease.

Routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. However, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. We sought to identify post-ureteroscopy imaging practices among experienced urologists. A REDcap questionnaire was sent to urologists in North America. The questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. Additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors influenced these preferences. The likelihood of altering clinical practice and the desire for specific imaging guidelines were also assessed. The interquartile range (IQR) was utilized as a measure of median consensus. Three hundred twenty-two urologists completed the questionnaire. The mean number of years in practice was 18 ± 10; 82% of respondents performed more than five ureteroscopic stone procedures monthly. Routine postoperative imaging was obtained by 48% of participants as follows: ultrasound (US) (47%), kidneys, ureters, and bladder (KUB) (17%), CT (4%), intravenous pyelogram (IVP) (2%), and KUB+US (30%). Urologists who did not routinely image patients were more concerned about cost (55% vs 25%, p ≤ 0.0001), radiation exposure (69% vs 44%, p ≤ 0.0001), and diagnostic inaccuracy of US (57% vs 44%, p ≤ 0.02). These urologists were also less likely to have completed an endourology fellowship (7% vs 23%, p ≤ 0.0001). The most compelling predictors of obtaining postoperative imaging were postoperative pain and fever (median 5, IQR 1), residual stones (median 5, IQR 1), ureteral perforation (median 5, IQR 2), and presence of a solitary kidney (median 4.5, IQR 2). Currently, about 50% of urologists who regularly perform ureteroscopic stone procedures obtain postoperative imaging. Imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever.

Comparison between retrograde intrarenal surgery and extracorporeal shock wave lithotripsy in the treatment of lower pole kidney stones up to 15 mm. Prospective, randomized study

IntroductionExtracorporeal Shock Wave Lithotripsy (ESWL) is currently the recommended treatment for intra-renal calculi smaller than 2cm. However the low Stone Free Rate (SFR) in lower pole calculi gives rise to new techniques, such us retrograde intrarenal surgery (RIRS), for improve the surgery outcomes. ObjectiveTo compare the efficacy of a treatment with ESWL with RIRS, in terms of SFR after surgery, in patients with kidney stones up to 15mm in the lower pole. Materials and methodsA prospective study was carried out in order to assess the results of ESWL and RIRS in patients with lower pole stones less than 15mm. Among a total of 55 patients, 31 were underwent to ESWL (Group 1) and the remaining 24 to RIRS (Group 2). Clinical data recorded, including general characteristics of each patient, were: calculi size, side, operative time, complications according to Clavien scale, SFR and the presence of residual fragments at 2 months post-treatment assessed by a CT scan. STATA 11 was used to perform the statistical analysis. ResultsThere were no differences for general descriptors among groups with the exception of a significantly longer operative time for RIRS. The rates of SFR and residual fragments lesser than 3mm were lower in the RIRS group than in ESWL ones. RIRS also showed a lower rate of clinically significant fragments (0% versus 42.3%. p<0.05). In the subgroup of patients with stones between 10 and 15mm RIRS showed higher SFR (75% versus 41.2%) and a lower rate of stones>3mm (0% versus 58.8%), being statistically significant (p<0.05). Clavien III or higher complications were not reported in any of the groups. ConclusionsIn the treatment of lower pole stone RIRS has the same results than ESWL in terms of SFR. Regarding absence of a clinically significant residual fragment, RIRS was superior to ESWL. A bigger sample size is required in order to confirm this result.

MP11-03 CONTEMPORARY IMAGING PRACTICE PATTERNS AFTER URETEROSCOPY FOR STONE DISEASE

You have accessJournal of UrologyImaging/Radiology: Uroradiology II1 Apr 2015MP11-03 CONTEMPORARY IMAGING PRACTICE PATTERNS AFTER URETEROSCOPY FOR STONE DISEASE Mohamed Omar, Hemant Chaparala, Manoj Monga, and Sri Sivalingam Mohamed OmarMohamed Omar More articles by this author , Hemant ChaparalaHemant Chaparala More articles by this author , Manoj MongaManoj Monga More articles by this author , and Sri SivalingamSri Sivalingam More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.384AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. However, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. We sought to identify post-ureteroscopy imaging practices amongst experienced urologists. METHODS A REDcap questionnaire was sent to urologists in North America. The questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. Additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors influenced these preferences. The likelihood of altering clinical practice and the desire for specific imaging guidelines were also assessed. The Interquartile range (IQR) was utilized as a measure of median consensus, with a lower IQR denoting increased agreement. RESULTS Three hundred twenty two urologists completed the questionnaire. The mean number of years in practice was 18±10; 82% of respondents performed more than 5 ureteroscopic stone procedures monthly. Routine postoperative imaging was obtained by 48% of participants as follows: US (47%), KUB (17%), CT (4%), IVP (2%), and KUB + US (30%). Urologists who did not routinely image patients were more concerned about cost (55% Vs. 25%, p= <.0001), radiation exposure (69% vs. 44%, p= <.0001), and diagnostic inaccuracy of US (57% vs. 44%, p= <0.02). These urologists were also less likely to have completed an Endourology fellowship (7% vs. 23%, p= <.0001). The most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median 5, IQR 1), residual stones (median 5, IQR 1), ureteral perforation (median 5, IQR 2), and presence of a solitary kidney (median 4.5, IQR 2). CONCLUSIONS Currently, about 50% of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. Imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever. Factors discouraging routine imaging & expectations of future change Routine imaging Non-routine imaging p-value Cost of imaging 38 (25%) 93 (55%) .0001 Access to imaging 19 (13%) 11 (7%) .0610 Radiation Hazards 66 (44%) 116 (70%) .0001 Accuracy of ultrasound 66 (44%) 96 (57%) .0192 Anticipate Change of Practice 16 (11%) 13 (8%) .3918 Guideline Importance 94 (62%) 95 (57%) .3006 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e119-e120 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohamed Omar More articles by this author Hemant Chaparala More articles by this author Manoj Monga More articles by this author Sri Sivalingam More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparación entre cirugía retrógrada intrarrenal y litotricia extracorpórea para el tratamiento de la litiasis de polo inferior renal de hasta 15 mm. Estudio prospectivo aleatorizado

IntroductionExtracorporeal Shock Wave Lithotripsy (ESWL) is currently the recommended treatment for intra-renal calculi smaller than 2cm. However the low Stone Free Rate (SFR) in lower pole calculi gives rise to new techniques, such us retrograde intrarenal surgery (RIRS), for improve the surgery outcomes. ObjectiveTo compare the efficacy of a treatment with ESWL with RIRS, in terms of SFR after surgery, in patients with kidney stones up to 15mm in the lower pole. Material and methodsA prospective study was carried out in order to assess the results of ESWL and RIRS in patients with lower pole stones less than 15mm. Among a total of 55 patients, 31 were underwent to ESWL (Group 1) and the remaining 24 to RIRS (Group 2). Clinical data recorded, including general characteristics of each patient, were: calculi size, side, operative time, complications according to Clavien scale, SFR and the presence of residual fragments at 2 months post-treatment assessed by a CT scan. STATA 11 was used to perform the statistical analysis. ResultsThere were no differences for general descriptors among groups with the exception of a significantly longer operative time for RIRS. The rates of SFR and residual fragments lesser than 3mm. were lower in the RIRS group than in ESWL ones. RIRS also showed a lower rate of clinically significant fragments (0% vs 42.3%. P<.05). In the subgroup of patients with stones between 10/15mm RIRS showed higher SFR (75% vs. 41.2%) and a lower rate of stones>3mm (0% vs. 58.8%), being statistically significant (P<.05). Clavien III or higher complications were not reported in any of the groups. ConclusionsIn the treatment of lower pole stone RIRS has the same results than ESWL in terms of SFR. Regarding absence of a clinically significant residual fragment, RIRS was superior to ESWL. A bigger sample size is required in order to confirm this results.

Calculating the Number of Shock Waves, Expulsion Time, and Optimum Stone Parameters Based on Noncontrast Computerized Tomography Characteristics

To define the parameters that accompanied a successful extracorporeal shock wave lithotripsy (ESWL), namely the number of shock waves (SWs), expulsion time (ET), mean stone density (MSD), and the skin-to-stone distance (SSD). A total of 368 patients diagnosed with renal calculi using noncontrast computerized tomography had their MSD, diameter, and SSD recorded. All patients were treated using a Siemens lithotripter. ESWL success meant a stone-free status or presence of residual fragments <3 mm, ET was the time in days for the successful clearance of stone fragments. Correlation was performed between the stone characteristics, number of SWs, and ET. Two multiple regression analysis models defined the number of SWs and ET. Two receiver operating characteristic curves plotted the best MSD cutoff value and optimum SSD for a successful ESWL. Three hundred one patients were ESWL successes. A significant positive correlation was elicited between number of SWs and stone diameter, density and SSD; between ET and stone diameter and density. Multiple regressions concluded 2 equations: Number of SWs = 265.108 + 5.103 x1 + 22.39 x2 + 10.931 x3 ET (days) = -10.85 + 0.031 x1 + 2.11 x2 x1 = stone density (Hounsfield unit [HUs]), x2 = stone diameter (mm), and x3 = SSD (mm). Receiver operating characteristic curves demonstrated a cutoff value of ≤ 934 HUs with 94.4% sensitivity and 66.7% specificity and P = .0211. The SSD curve showed that a distance ≤ 99 mm was 85.7% sensitive, 87.5% specific, P <.0001. Stone disintegration is not recommended if MSD is >934 HUs and SSD >99 mm. The required number of SWs and the expected ET can be anticipated.

Emergency versus elective ureteroscopic treatment of ureteral stones

This retrospective study investigates the role of the emergency ureteroscopic (URS) approach in the definitive treatment of ureteric stones. We reviewed all patients admitted for ureteric stones from May 2003 to December 2010. Those who underwent URS stone treatment were selected and stratified into emergency (EMG) and elective groups (ELG). Emergency URS is defined as URS being performed within 24 hours of admission to the emergency room. The main indication for emergency treatment was refractory ureteric colic in spite of narcotic analgesia. Both groups were statistically compared in terms of their patient-, stone- and outcome-related variables. The overall success rate was defined by the clearance of the stone and/or presence of residual fragments (<3 mm) at the end of 4-week follow-up period. In total, 903 patients were suitable for analysis with 244 and 659 patients in the EMG and ELG, respectively. Age, sex and comorbidities were comparable in both groups. Average ages were 43.4 ± 15.31 and 45.6 ± 13.24 years among EMG and ELG, respectively. Stones had an average size of 0.92 ± 0.49 (in the EMG group) and 0.96 ± 0.53 cm (in the ELG group). We found that 61.1% and 65.7% of stones were distally located in the EMG and ELG, respectively. EMG had a longer operative time (69 ± 21.03 vs. 57 ± 13.45 minutes) with comparable average hospital stays (1.9 days). Intra-operative double-J stents or ureteric catheter insertion was noted in 72.5 and 67.7% of EMG and ELG, respectively. The overall complication rates were reported in 13.1% in EMG and 14.4% in ELG. A higher rate of ureteric injuries (early and late) was documented in the EMG group (7% vs. 5.6%). Most of these injuries were minor and manageable without additional procedure and/or general anesthesia. Success was achieved in 90.6% and 91.8% of the EMG and ELG groups, respectively. With recent advances in technology, the growing trend toward one-stage definitive treatment, patient acceptability and rising concerns over financial aspects, emergency URS treatment of ureteric stones is evolving as a standard initial management option.

Heterogeneity in the Reporting of Disease Characteristics and Treatment Outcomes in Studies Evaluating Treatments for Nephrolithiasis

There is no standardization in the nephrolithiasis literature regarding preoperative or postoperative evaluation of patients who are undergoing treatment for stone disease. This may hinder comparisons of efficacy of different treatment modalities. We evaluated heterogeneity in the literature of preoperative and postoperative evaluations of patients who were undergoing surgical treatment for nephrolithiasis. A systematic PubMed search was performed for 2006 to 2008 using search terms kidney stones, ureteral stones, nephrolithiasis, ureterolithiasis, ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL). Articles that evaluated treatment outcomes were included, and information regarding preoperative and postoperative evaluation was collected. One hundred and fifty-four studies were included. Preoperative stone burden was evaluated using CT (42), ultrasonography (US) (42), plain radiography of the kidneys, ureters, and bladder (KUB) (92), multiple modalities (52), and no mention (45). Stone burden was reported as maximum diameter (105), surface area (32), volume (6), other (1), and no mention (10). Treatment modalities included URS (46), PCNL (71), SWL (50), and multiple modalities (9). Postoperative imaging included CT (37), US (67), KUB (115), multiple modalities (70), other (11) and no mention (19). Radiographic outcomes included strict stone free (114) and presence of residual fragments (RF) (64). There was wide variation in the size of RF reported (<1 mm through <7 mm). "Stone free" included the presence of RF in 18 studies. Treatment "success" was defined to include RF of various sizes. Reported clinical outcomes included stone-related events (46) and surgery (90). There is extensive variability in the reporting of preoperative disease characteristics and postoperative outcomes in studies that evaluate treatments for nephrolithiasis. Standardization of these criteria is essential for more meaningful comparisons of treatment modalities and outcomes for different disease subgroups.

Lithoclast® master in intracorporeal lithotripsy during percutaneous nephrolithotomy: Our experience

Background: This study was carried out to compare the efficacy of Lithoclast® Master with pneumolithotriptor during percutaneous nephrolithotomy (PNL) in the treatment of renal staghorn calculi. Methods: In this prospective study, 60 patients suffering from partial or complete staghorn renal stones were included. Patients were divided randomly in two groups: Groups I and II and underwent PNL for removal of stones. In Group I patients, standard pneumolithotriptor and in Group II, Lithoclast® Master was used for stone fragmentation. The patients were evaluated for rate of fragmentation/clearance, presence of residual fragments by KUB radiograph/ultrasound. Result was analyzed by Chi-square test. Result: The rate of fragmentation using Swiss Lithoclast® Master was more effective and quicker in comparison to standard pneumolithotriptor. The average time taken for fragmentation and clearance in Group I using pneumolithotriptor was 65 minutes, whereas it was 58 minutes using Lithoclast® Master, which was statistically significant ( p < 0.01). Only 4% patients had significant residual fragments (> 4mm) in Group II and 16 (53%) patients in Group I, which was significant (p < 0.01). The complications in both the modalities were insignificant; one (1.33%) patient had bleeding and three (10%) patients had urine leak in Group I; whereas three(10%) patients had bleeding and five (16.7%) urine leak in Group II. Conclusion: Lithoclast® Master is an effective intracorporeal lithotripter during percutaneous nephrolithotomy in the treatment of renal staghorn calculi for stone fragmentation/clearance with minimal residual fragments and complications.