Single Ureteral Stone Research Articles

Comparison of ureteral stone measurements for predicting the efficacy of a single session of extracorporeal shockwave lithotripsy: one-, two-, and three-dimensional computed tomography measurements.

The objective of this study was to compare the value of one-, two- and three-dimensional computed tomography (CT) measurements for predicting the efficacy of a single session of extracorporeal shock wave lithotripsy (ESWL) in patients with a single ureteral stone. A total of 165 patients were included based on the inclusion and exclusion criteria. Different models were constructed using a combination of patients' clinical data and measurements obtained by manual sketching and automated extraction software. Multivariate logistic regression was used to develop the models. Receiver operating characteristic curves were used to assess the performance of the models. There was good interobserver agreement for all measurements in different dimensions (P < 0.001). We also found that hydronephrosis, the largest diameter, the largest area, volume, and mean CT value were significantly greater in the failure group than in the success group (P < 0.01). Furthermore, all sizes and CT measurement values were found to be independent predictors for predicting efficacy after one session of ESWL (P < 0.05). In addition, the multivariate logistic analysis showed that the area under the curve (AUC) for two-dimensional and three-dimensional measurements was superior to that of one-dimensional measurement (P < 0.01). However, when size alone was included as a measurable predictor, there was no significant difference in the AUC among the one-, two-, and three-dimensional measurements (P > 0.05). In summary, after adjusting for clinical data, two- and three-dimensional measurements combining ureteral stone size and CT values were found to be the best predictors of ESWL efficacy, and software-based three-dimensional measurements should be considered to avoid interobserver variability in clinical practice.

Robot-assisted transurethral holmium ureterolithotripsy

Introduction. Currently, transurethral laser ureterolithotripsy is the standard treatment for ureteral stones. It allows you to achieve complete stone fragmentation in one-stage. We were interested in the possibility of performing ureterolithotripsy using a robotic assistant. In fact, robotic systems in medicine and surgery are becoming more and more relevant every year.Objective. To evaluate the possibilities of robot-assisted transurethral laser ureterolithotripsy, to study its effectiveness and duration in comparison with holmium lithotripsy in standard surgery, as well as to conduct a study and expert evaluation of the symptoms of surgeon fatigue in standard lithotripsy and robot-assisted lithotripsy.Materials &amp; methods. The study was conducted in 2022 and consisted of two stages. The first stage involved the development and testing of a robotic lithotripsy technique using simulators, including the author's fixation device for the ureteroscope. This device allowed to tightly fix the instrument in the "robotic arm", while maintaining the full range of necessary movements. During the second stage (clinical), the results of holmium ureterolithotripsy in standard and robotic surgeries were studied. Patients with ureterolithiasis were divided into two groups: 14 patients — standard lithotripsy and 13 patients — robotic assisted lithotripsy. The selection criteria were the presence of a single ureteral stone accessible to a semi-rigid ureteroscope.Results. According to the results of the study, robot-assisted transurethral holmium ureterolithotripsy has the greatest advantages in terms of the fatigue indicators of the surgeon during surgery. So, no significant difference was found in fragmentation time (1 gram of stone). In standard ureterolithotripsy this indicator was 63.8 min/g, and in robot-assisted ureterolithotripsy it was 57.8 min/g (p &lt; 0.1). When comparing the surgeon's fatigue scores, a significant difference between the two groups was determined. Thus, during standard surgery, the surgeon rated the shoulder numbness score at 3.50 points, while during robot-assisted surgery at 0.17 points (p &lt; 0.01).Conclusion. The study showed that transurethral contact laser ureterolithotripsy with the use of robotic assistant does not increase the surgery time, but the surgeon's fatigue factor is significantly reduced. This may indirectly contribute to reducing the risk of intra- and postoperative complications.

Outcomes of primary ureteroscopic lithotripsy: The role of maximum ureteral wall thickness at the site of stone impaction.

To verify if the maximum thickness of the ureteral wall at the stone site (m-UWT) can affect the outcomes of primary retrograde ureteroscopic lithotripsy (P-URSL) within a single-center dataset. We retrospectively reviewed data on 354 consecutive URSL performed from January 2020 to May 2022 at "Fondazione Poliambulanza" in Brescia (Italy). We included patients older than 18 years who underwent URSL for a single ureteral stone with a maximum diameter ranging from 5 to 10 mm. Patients with anatomical abnormalities, a positive preoperative urinary culture, or without a NCCT performed during the acute event were excluded. Patients were treated in an emergency setting (P-URSL within 48 h from the diagnosis of acute ureteral colic) or in a delayed one (D-URSL after a period of maximum 90 days of ureteral double-j stenting). For the resulting 139 patients we recorded demographic, clinical and stone-related features and perioperative data. We processed these data by univariate and multivariate analysis, and with a logistic regression analysis. Of the 139 included procedures, 63 were P-URSL and 76 D-URSL. At the univariate analysis we found that stone diameter (OR 0.845, p = 0.017), stone volume (OR 0.023, p = 0.001), stone density (OR 0.998, p = 0.000) and m-UWT (OR 0.499, p = 0.013) are predictors of P-URSL. Stone density (OR 0.998, p = 0.002) is an independent predictor of P-URSL at the multivariate analysis. At a logistic regression analysis, a distal ureteric position (OR 0.189, p = 0.014), stone diameter (OR 1.289, p = 0.006), and m-UWT (OR 2.297, p = 0.02) were found to be statistically significant predictors of incomplete stone clearance in patients undergoing P-URSL. m-UWT is the only predictor of short-term postoperative adverse events in patients undergoing P-URSL (OR 3.386, p < 0.001). From a descriptive analysis, it emerged that an increased m-UWT (>2 mm) significantly correlates to an endoscopic finding of ureteritis' signs and to an increase in operative time, hospital stay and post-procedural stenting time. A m-UWT greater than 2 mm also correlates with a lower stone free rate (SFR) and with a significant increase in both short and long-term postoperative complications. Our study confirmed a connection between m-UWT and poor endoscopic findings, as well as a direct correlation with the main morphometric parameters of the stone and finally with the outcomes of P-URSL itself. Further studies are necessary to validate our results, so that m-UWT might be routinely considered a useful tool in the decision-making process for P-URSL.

Primary impact of simultaneous use of double devices through one-working channel when performing flexible ureteroscope with ureteral access sheath for single ureteral stone: In bench and retrospective clinical study.

This study aimed to compare the simultaneous use of two devices versus a single device through a single working channel in flexible ureteroscopy using a ureteral access sheath for single ureteral stones. In a bench study, the time to (i) set laser fiber, (ii) exchange laser fiber and nitinol basket through working channel, and (iii) pull out the device from working channel were measured 10 times in each step. In a clinical study, 156 patients who underwent flexible ureteroscopy with a ureteral access sheath for a ureteral stone in middle and upper ureter between April 2019 and November 2021 were assessed. One device was used at a time for 79 patients (S-Group) and two were simultaneously used for 77 (D-Group). Surgical outcomes and complications were compared. In the bench study, the mean time to change from laser fiber to basket and from basket to laser fiber through the working channel were 26.1 ± 3.7 s and 23.6 ± 2.0 s (p = 0.084), respectively, which were significantly longer than the laser setup time (p < 0.001). In the clinical study, although the stone-free rate was not significantly different between the groups (S-Group 89.8%, D-Group 93.5%; p = 0.412), the median operation time was significantly shorter (p < 0.001) and the rate of postoperative stenting was significantly lower (p = 0.002) in the D-Group. There were no significant between-group differences in intra- and post-operative complications. The simultaneous use of two devices through a single working channel is safe and could help save the time needed to exchange the laser fiber and nitinol basket.

Predictors of successful emergency shock wave lithotripsy for acute renal colic

The role of emergency shockwave lithotripsy (SWL) in persistent pain control in patients with ureteral stones is not well established. The aim of this study is to evaluate efficacy as well as the predicting variables for successful early SWL patients with symptomatic ureteral stones. Eighty-six patients with a persistent renal colic secondary to single ureteral stone (6–12 mm) were prospectively enrolled in this study. SWL was performed within 24 h of the onset of flank pain. Pain control and stone-free rate after emergency SWL session were 58.1% and 44.2%, respectively. Seven patients required post-SWL ureteroscopy and ureteral stent placement for uncontrolled pain. The overall 3-month stone-free rate after SWL monotherapy was 83.7%. On multivariate analysis, predictors for pain relief after emergency SWL were lower Hounsfield (HU) stone density, mild hydronephrosis (HN) at presentation and presentation during the first colic episode. Lower HU stone density was the single predictor of successful stone clearance after single emergency SWL session on multivariate analysis. In conclusion, early SWL is feasible and effective in management of ureteral stones presented by renal colic with low HU.

Characterizing patients with multiple same-sided ureteric stones.

Patients presenting with multiple same-sided ureteric stones (MSSUS) are a unique population with nuanced prognostic and treatment considerations, which have yet to be characterized in the literature. Therefore, our purpose was to examine outcomes of patients with MSSUS vs those with single ureteric stones (SUS). A retrospective review of prospectively collected patients included adults (> 18yo) with [Formula: see text] 2 ipsilateral ureteral stones without prior treatment for their current stone burden. A historical comparison group was used as a control population. Univariate logistic regression analyses and descriptive statistics were performed with SPSS® 20.0 (p < 0.05). Seventy-nine MSSUS patients were compared to 101 SUS patients. MSSUS patients had 2.21 [Formula: see text] 0.66 ureteric stones and had significantly smaller lead stones (MSSUS 6.4mm vs SUS 7.2mm, p = 0.03). MSSUS patients were more likely to have had prior stones (66 vs 42%) and 5.9 times more likely to have had prior stone procedures. Conservative management was successful in 30% MSSUS vs 19% SUS (p = 0.073), and there were no differences in resolution time (p = 0.44). For patients proceeding to intervention, (MSSUS n = 52, SUS n = 78), ureteroscopy was performed on 58% MSSUS vs 51% SUS patients (p = 0.302), and shockwave lithotripsy in 10% MSSUS vs 26% SUS (p = 0.01). MSSUS were more likely to spontaneously pass a stone prior to planned intervention (OR = 41.1; 95% CI = 12.0-140.7; p = 0.0001). MSSUS patients are more likely recurrent stone formers with extensive stone histories and current stone burdens. Conservative management appears as successful between groups, with no difference in resolution time. When employed, ureteroscopy outcomes do not different between cohorts.

Shockwave lithotripsy compared with ureteroscopic stone treatment for adults with ureteric stones: the TISU non-inferiority RCT.

Urinary stone disease affects 2-3% of the general population. Ureteric stones are associated with severe pain and can have a significant impact on a patient's quality of life. Most ureteric stones are expected to pass spontaneously with supportive care; however, between one-fifth and one-third of patients require an active intervention. The two standard interventions are shockwave lithotripsy and ureteroscopic stone treatment. Both treatments are effective, but they differ in terms of invasiveness, anaesthetic requirement, treatment setting, number of procedures, complications, patient-reported outcomes and cost. There is uncertainty around which is the more clinically effective and cost-effective treatment. To determine if shockwave lithotripsy is clinically effective and cost-effective compared with ureteroscopic stone treatment in adults with ureteric stones who are judged to require active intervention. A pragmatic, multicentre, non-inferiority, randomised controlled trial of shockwave lithotripsy as a first-line treatment option compared with primary ureteroscopic stone treatment for ureteric stones. Urology departments in 25 NHS hospitals in the UK. Adults aged ≥ 16 years presenting with a single ureteric stone in any segment of the ureter, confirmed by computerised tomography, who were able to undergo either shockwave lithotripsy or ureteroscopic stone treatment and to complete trial procedures. Eligible participants were randomised 1 : 1 to shockwave lithotripsy (up to two sessions) or ureteroscopic stone treatment. The primary clinical outcome measure was resolution of the stone episode (stone clearance), which was operationally defined as 'no further intervention required to facilitate stone clearance' up to 6 months from randomisation. This was determined from 8-week and 6-month case report forms and any additional hospital visit case report form that was completed by research staff. The primary economic outcome measure was the incremental cost per quality-adjusted life-year gained at 6 months from randomisation. We estimated costs from NHS resources and calculated quality-adjusted life-years from participant completion of the EuroQol-5 Dimensions, three-level version, at baseline, pre intervention, 1 week post intervention and 8 weeks and 6 months post randomisation. In the shockwave lithotripsy arm, 67 out of 302 (22.2%) participants needed further treatment. In the ureteroscopic stone treatment arm, 31 out of 302 (10.3%) participants needed further treatment. The absolute risk difference was 11.4% (95% confidence interval 5.0% to 17.8%); the upper bound of the 95% confidence interval ruled out the prespecified margin of non-inferiority (which was 20%). The mean quality-adjusted life-year difference (shockwave lithotripsy vs. ureteroscopic stone treatment) was -0.021 (95% confidence interval 0.033 to -0.010) and the mean cost difference was -£809 (95% confidence interval -£1061 to -£551). The probability that shockwave lithotripsy is cost-effective is 79% at a threshold of society's willingness to pay for a quality-adjusted life-year of £30,000. The CEAC is derived from the joint distribution of incremental costs and incremental effects. Most of the results fall in the south-west quadrant of the cost effectiveness plane as SWL always costs less but is less effective. A limitation of the trial was low return and completion rates of patient questionnaires. The study was initially powered for 500 patients in each arm; however, the total number of patients recruited was only 307 and 306 patients in the ureteroscopic stone treatment and shockwave lithotripsy arms, respectively. Patients receiving shockwave lithotripsy needed more further interventions than those receiving primary ureteroscopic retrieval, although the overall costs for those receiving the shockwave treatment were lower. The absolute risk difference between the two clinical pathways (11.4%) was lower than expected and at a level that is acceptable to clinicians and patients. The shockwave lithotripsy pathway is more cost-effective in an NHS setting, but results in lower quality of life. (1) The generic health-related quality-of-life tools used in this study do not fully capture the impact of the various treatment pathways on patients. A condition-specific health-related quality-of-life tool should be developed. (2) Reporting of ureteric stone trials would benefit from agreement on a core outcome set that would ensure that future trials are easier to compare. This trial is registered as ISRCTN92289221. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 19. See the NIHR Journals Library website for further project information.

A novel model using computed tomography parameters to predict shock wave lithotripsy success in ureteral stones at different locations

ObjectiveTo combine non-contrast computerized tomography (NCCT)-based parameters with stone and patient characteristics that are already known to affect shock wave lithotripsy (SWL) success and assess this novel model’s effectiveness in predicting SWL success for single ureteral stones in different locations. Materials and methodsData of patients treated by SWL for a single ureteral stone between January 2017 and January 2019 were retrospectively reviewed. Demographic parameters of patients and stone characteristics were combined with NCCT-based parameters. NCCT-based parameters included the presence or absence of hydronephrosis, perinephric stranding, periureteral edema, diameter of the proximal ureter, ureteral wall thickness (UWT) at ureteral stone site. The logistic regression method was used for the development of a useful predictive model. Subsequently, the receiver operating curve was used to determine cut-off levels, and a scoring system was developed for prediction of SWL success. ResultsStone-free rate was 77,1% (267/346) in the entire cohort. Univariate analysis revealed that age, stone volume, density, perinephric stranding, diameter of proximal ureter, and UWT, were associated with SWL success. In multivariate analysis, proximal ureteral stone location, stone volume, density, and UWT were independent predictors of SWL success. The formula used during logistic regression analysis was: 1/[1 + exp {−8.856 + 0.008 (stone volume) + 0.002 (stone density) + 0.673 (UWT) + 1026 (proximal ureteral stone)}]. The scores of 0, 1, 2, 3 and 4 were associated with 97,8%, 83,4%, 60,8%, 33,2% and 11,1% success rates, respectively, in the prediction model based on these parameters. ConclusionWe conclude that our model can facilitate decision-making for SWL treatment of ureteral stones in different locations.

Modelo novedoso basado en los parámetros de la tomografía para predecir el éxito de la litotricia por ondas de choque en los cálculos ureterales de diferentes localizaciones

ObjectiveTo combine non-contrast computerized tomography (NCCT)-based parameters with stone and patient characteristics that are already known to affect shock wave lithotripsy (SWL) success and assess this novel model's effectiveness in predicting SWL success for single ureteral stones in different locations. Materials and methodsData of patients treated by SWL for a single ureteral stone between January 2017 and January 2019 were retrospectively reviewed. Demographic parameters of patients and stone characteristics were combined with NCCT-based parameters. NCCT-based parameters included the presence or absence of hydronephrosis, perinephric stranding, periureteral edema, diameter of the proximal ureter, ureteral wall thickness (UWT) at ureteral stone site. The logistic regression method was used for the development of a useful predictive model. Subsequently, the receiver operating curve was used to determine cut-off levels, and a scoring system was developed for prediction of SWL success. ResultsStone-free rate was 77,1% (267/346) in the entire cohort. Univariate analysis revealed that age, stone volume, density, perinephric stranding, diameter of proximal ureter, and UWT, were associated with SWL success. In multivariate analysis, proximal ureteral stone location, stone volume, density, and UWT were independent predictors of SWL success. The formula used during logistic regression analysis was: 1/[1+exp {-8.856+0.008(stone volume)+0.002 (stone density)+0.673 (UWT)+1026 (proximal ureteral stone)}]. The scores of 0, 1, 2, 3 and 4 were associated with 97,8%, 83,4%, 60,8%, 33,2% and 11,1% success rates, respectively, in the prediction model based on these parameters. ConclusionWe conclude that our model can facilitate decision-making for SWL treatment of ureteral stones in different locations.

Development and validation of a preoperative nomogram for predicting patients with impacted ureteral stone: a retrospective analysis

BackgroundTo develop and validate a practical nomogram for predicting the probability of patients with impacted ureteral stone.MethodsBetween June 2020 to March 2021, 214 single ureteral stones received ureteroscopy lithotripsy (URSL) were selected in development group. While 82 single ureteral stones received URSL between April 2021 to May 2021 were included in validation group. Independent factors for predicting impacted ureteral stone were screened by univariate and multivariate logistic regression analysis. The relationship between preoperative factors and stone impaction was modeled according to the regression coefficients. Discrimination and calibration were estimated by area under the receiver operating characteristic (AUROC) curve and calibration curve respectively. Clinical usefulness of the nomogram was evaluated by decision curve analysis.ResultsAge, ipsilateral stone treatment history, hydronephrosis and maximum ureteral wall thickness (UWTmax) at the portion of stone were identified as independent predictors for impacted stone. The AUROC curve of development and validation group were 0.915 and 0.882 respectively. Calibration curve of two groups showed strong concordance between the predicted and actual probabilities. Decision curve analysis showed that the predictive nomogram had a superior net benefit than UWTmax for all examined probabilities.ConclusionsWe developed and validated an individualized model to predict impacted ureteral stone prior to surgery. Through this prediction model, urologists can select an optimal treatment method and decrease intraoperative and postoperative complications for patients with impacted ureteral calculus.

MP65-02 STENT SYNDROME. DOES THE DIAMETER MATTER? RESULTS OF A PROSPECTIVE TRIAL

You have accessJournal of UrologyStone Disease: Surgical Therapy V (MP65)1 Sep 2021MP65-02 STENT SYNDROME. DOES THE DIAMETER MATTER? RESULTS OF A PROSPECTIVE TRIAL Pablo Contreras, María Florencia Frascheri, Nicolás Bonanno, Sofía Butori, Leandro Blas, and Carlos Ameri Pablo ContrerasPablo Contreras More articles by this author , María Florencia FrascheriMaría Florencia Frascheri More articles by this author , Nicolás BonannoNicolás Bonanno More articles by this author , Sofía ButoriSofía Butori More articles by this author , Leandro BlasLeandro Blas More articles by this author , and Carlos AmeriCarlos Ameri More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002105.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral catheter related symptoms may vary amongst people, depending on many factors. Our objective was to compare the symptoms produced by three different catheter diameters and the impact in the quality of life using a validated questionnaire. METHODS: Between June 2016 and February 2021 we conducted a prospective trial of 180 adults patients with a single ureteral stone who required an ureteral stent placement as a primary treatment. Patients were randomized 1:1:1 depending on catheter´s diameter: 4.7, 6 or 7 Fr, 60 patients in each group. A 26 cm Universa® stent was used in every cases. During the seventh and fourteenth day after the surgery, patients were requested to answer the ureteral stent symptoms questionnaire (USSQ). Results were compared using the unidirectional ANOVA test. RESULTS: The mean age was 48.3 years (±14.9), male/female relation was 2.37/1. Most of the patients referred pain: 93% claim being unable to live with symptoms, 47% could not engage in sexual activity and 70% would be very unhappy in case of requiring another stent again. After the statistical analysis, 4.7 Fr. stents produced significantly less urinary symptoms than 6 and 7 Fr. catheters. CONCLUSIONS: Ureteral catheter related symptoms deeply affected the quality of life in most cases. The 4,7 Fr. catheter produced significantly less urinary symptoms than 6 and 7 Fr. catheters. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1119-e1119 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pablo Contreras More articles by this author María Florencia Frascheri More articles by this author Nicolás Bonanno More articles by this author Sofía Butori More articles by this author Leandro Blas More articles by this author Carlos Ameri More articles by this author Expand All Advertisement Loading ...

PD26-08 IMPACT OF REVERSE TRENDELENBURG POSITION ON URETERAL STONE RETROPULSION: A PROSPECTIVE RANDOMIZED STUDY

You have accessJournal of UrologyStone Disease: Surgical Therapy III (PD26)1 Sep 2021PD26-08 IMPACT OF REVERSE TRENDELENBURG POSITION ON URETERAL STONE RETROPULSION: A PROSPECTIVE RANDOMIZED STUDY Johnathan Khusid, Harry Anastos, Ryan Chandhoke, Dara Lundon, Areeba Sadiq, Jake Bamberger, Blair Gallante, William Atallah, and Mantu Gupta Johnathan KhusidJohnathan Khusid More articles by this author , Harry AnastosHarry Anastos More articles by this author , Ryan ChandhokeRyan Chandhoke More articles by this author , Dara LundonDara Lundon More articles by this author , Areeba SadiqAreeba Sadiq More articles by this author , Jake BambergerJake Bamberger More articles by this author , Blair GallanteBlair Gallante More articles by this author , William AtallahWilliam Atallah More articles by this author , and Mantu GuptaMantu Gupta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002019.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Minimizing retropulsion may improve surgical efficiency during ureteroscopic lithotripsy. This study seeks to determine if reverse Trendelenburg (RT) positioning during ureteroscopic lithotripsy effects rates of stone retropulsion in patients with ureteral stones. METHODS: We prospectively recruited adult patients with radiographic evidence of a single ureteral stone and plans to undergo ureteroscopic lithotripsy. Patients were randomized to one of two positioning cohorts: standard supine dorsal lithotomy or dorsal lithotomy with RT position. In all cases in which retropulsion occurred, flexible ureteroscopy/pyeloscopy was performed to retrieve residual stone fragments. The primary endpoint of the study was any amount of stone retropulsion. Secondary endpoints were stone retropulsion into the kidney, stone free status, and post-operative hydronephrosis. RESULTS: To date, 91 patients have completed the study; 44 in the standard positioning group and 47 in the RT group. There were no significant differences between groups in age, gender, ASA score, BMI, stone location and stone composition at the time of ureteroscopy. In the RT group, retropulsion occurred significantly less often (9.0% of cases vs 63.8% of cases; odds ratio (OR) 0.06, p<0.001). Similarly, in the RT group, retropulsion to the kidney occurred less often (6.8% of cases vs 34% of cases; OR 0.15, p=0.001). Among the patients with adequate follow up imaging to assess for stone free status (74 patients) and hydronephrosis (65 patients), there were no significant differences between groups in the stone free status (94.9% of cases vs 88.6% of cases; p=0.364), or post-operative hydronephrosis (2.1% of cases vs 0% of cases; p=1.000). CONCLUSIONS: Reverse Trendelenburg positioning during ureteroscopic lithotripsy decreases both retropulsion in general, and retropulsion into the kidney. There was no significant impact on stone free status or post-operative hydronephrosis, which was likely secondary to our routine use of flexible ureteroscopy/pyeloscopy to retrieve any retropulsed fragments. The use of the RT position has the potential to decrease operative time, decrease the need for use of extra equipment, and potentially improve stone free rates in practice setting in which flexible ureteroscopes are not routinely available. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e440-e440 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Johnathan Khusid More articles by this author Harry Anastos More articles by this author Ryan Chandhoke More articles by this author Dara Lundon More articles by this author Areeba Sadiq More articles by this author Jake Bamberger More articles by this author Blair Gallante More articles by this author William Atallah More articles by this author Mantu Gupta More articles by this author Expand All Advertisement Loading ...

Long surgical waiting list times are associated with an increased rate of negative ureteroscopies.

Negative ureteroscopy (NURS) is "a ureteroscopy in which no stone is found during the procedure." We aimed to determine the association between the surgical waiting list time (WLT) and the NURS rate. We retrospectively analyzed all patients scheduled for ureteroscopy in our center between January 2017 and July 2019. The inclusion criterion was unilateral, semirigid ureteroscopy for a single ureteral stone; exclusion criteria were renal-only stones, incomplete ureteroscopy, and stones >10 mm. We analyzed age; gender; body mass index; stone size, density, and location; presence of a temporary double-J (DJ) stent; use of medical expulsive therapy; and WLT. Complications while waiting for surgery were also collected and analyzed. We included 219 patients, 41 (18.7%) of whom had NURS. The median WLT was 74 days (interquartile range [IQR] 45-127). Variables protective against NURS were large stone size (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.66-0.93), presence of a temporary DJ stent (OR 0.43, 95% CI 0.2-0.8), and radiopaque stones (OR 0.44, 95% CI 0.21-0.88). A long WLT ((≥60 days) increased the risk of NURS (OR 2.18, 95% CI 1.02-4.61). Complications requiring emergency department visits while waiting for surgery were documented in 58/137 (42.3%) patients with indwelling DJ stents; nonetheless, a WLT greater than the median was not associated with an increased risk of complications (p=0.38). Long WLT has an independent, direct, and linear correlation with NURS rates. Patients at higher risk of NURS, may be offered preoperative re-evaluation with a computed tomography scan in a resource-limited setting.

Shockwave Lithotripsy Versus Ureteroscopic Treatment as Therapeutic Interventions for Stones of the Ureter (TISU): A Multicentre Randomised Controlled Non-inferiority Trial

BackgroundRenal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways. ObjectiveTo report a pragmatic multicentre non-inferiority RCT comparing SWL with URS. Design, setting, and participantsThis trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention. Outcome measurements and statistical analysisThe primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned. Results and limitationsThe study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL. ConclusionsThis RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition. Patient summaryWe present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition.

‘Boxing in the corner’: A modified retrograde approach for the management of proximal ureteric stones of 1–2 cm

ABSTRACT Objectives: To study a modification to the conventional retrograde ureteroscopic approach for treating proximal ureteric stones of 1–2 cm; we intentionally push the stone from the proximal ureter into a favourable calyx then the flexible ureteroscope is used to fragment the trapped stone using laser lithotripsy (‘boxing in the corner’). Patients and methods: The study was conducted in a randomised prospective manner and included 100 patients who presented with a single proximal ureteric stone of 1–2 cm. We randomised the patients into two equal groups: Group A (50 patients) underwent the conventional retrograde technique (CRT) and Group B (50 patients) underwent the modified retrograde technique (MRT) with the primary intention of relocating the stone into a favourable calyx. Intended relocation of the proximal ureteric stone in the MRT group was achieved in a stepwise manner. All intraoperative parameters and postoperative outcomes were recorded and compared between the two groups. Results: There was no statistical significant difference in terms of the patients’ demographics and stone criteria between the two groups. The stone-free rate (SFR) was significantly higher in Group B (92%) compared to Group A (78%) (P = 0.049). Fluoroscopy time was significantly longer in Group B (P < 0.001), while operative time, lithotripsy time and hospital stay were comparable. There was no difference between the groups regarding complications. Conclusion: The MRT was found to be safe and more effective than the CRT for treating proximal ureteric stones of 1–2 cm, with a significantly higher SFR. Abbreviations CONSORT: Consolidated Standards of Reporting Trials; ESWL: extracorporeal shockwave lithotripsy; fURS: flexible ureteroscope; NCCT: non-contrast CT; SFR: stone-free rate; YAG: yttrium-aluminium-garnet

Emergency vs elective ureteroscopy for a single ureteric stone

ABSTRACT Objective To compare emergency with elective ureteroscopy (URS) for the treatment of a single ureteric stone. Patients and methods The files of adult patients with a single ureteric stone were retrospectively reviewed. Patients with fever or turbid urine on passage of the guidewire beside the stone underwent ureteric stenting or nephrostomy drainage. Patients who underwent URS were included and divided into two groups: the emergency (EM) Group, those who presented with persistent renal colic and underwent emergency URS within 24 h; and the elective (EL) Group, who underwent elective URS after ≥14 days of diagnosis. Patients with ureteric stents were excluded. The technique for URS was the same in both groups. Safety was defined as absence of complications. Efficacy was defined as the stone-free rate after a single URS session. Results From March 2015 to September 2018, 179 patients (107 in the EM Group and 72 in the EL Group) were included. There were significantly more hydronephrosis and smaller stones in the EM Group (P = 0.002 and P = 0.001, respectively). Laser disintegration was needed in more patients in the EL Group (83% vs 68%, P = 0.023). Post-URS ureteric stents were inserted in more patients in the EM Group (91% vs 72%, P = 0.001). Complications were comparable for both groups (4.2% for EL and 5.6% for EM, P = 0.665). Stone-free rates were also comparable (93% in the EL Group and 96% in the EM Group, P = 0.336). Conclusions Emergency URS can be as safe and effective as elective URS for the treatment of a single ureteric stone if it is performed in patients without fever or turbid urine. Abbreviations: EL Group: elective group; EM Group: emergency group; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; MET: medical expulsive therapy; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy

Prospective evaluation and classification of endoscopic findings for ureteral calculi

Difficulty in performing ureteroscopic lithotripsy (URSL) depends on endoscopic findings surrounding calculi. In this multicentre prospective cohort study of 185 patients with a single ureteral stone who underwent ureteroscopic lithotripsy registered in the SMART study between January 2014 and February 2017, we established a classification of endoscopic findings and analysed risk factors for ureteral changes. We evaluated endoscopic findings (oedema, polyps, ureteral mucosa-stone adherence, and distal ureteric tightness) based on the SMART classification. Operative time and ureteral injuries were significantly correlated with endoscopic finding grades. Multivariate analyses revealed that mucosa-stone adherence (MSA) was strongly affected by hydronephrosis grade (odds ratio, 12.4; p = 0.022) and the interval before surgery (odds ratio, 1.10; p = 0.012). The cutoff value for MSA was 98 days, with a predictive accuracy of 0.78. Risk factors for distal ureteric tightness were age (odds ratio, 0.96; p = 0.004) and early intervention (odds ratio, 0.90; p = 0.023). The cutoff value was 34 days, with a predictive accuracy of 0.72. In conclusion, appropriate intervention around 34 days (limited to 98 days) after symptom onset is necessary for treating ureteral calculi. Even if intervention passed 98 days post-symptom onset, staged URSL, alternative procedures, and detailed informed consent should be planned in advance, assuming strong MSA.

COMPARISON OF THE SUCCESS OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) WITH AND WITHOUT DJ STENTING IN PROXIMAL URETERIC STONE

BACKGROUND &amp; OBJECTIVE: There is disagreement in the use of ureteral double-J stent before the extracorporeal shock wave lithotripsy (ESWL), although most of the urologists suggest using stent in shock wave lithotripsy technique for stones bigger than 20mm, for preventing the risk of developing steinstrasse. To compare the success of ESWL with and without DJ stenting in proximal ureteric stone. METHODOLOGY: A total of 60 patients form both genders, between 15 to 55 years of age, with a single proximal ureteric stone, were included. Patients with solitary functioning kidney, multiple stones, pregnancy, pyonephrosis and sepsis were excluded. In Group-A, ESWL without DJ stenting was completed while in Group-B, ESWL with DJ stent placement was done. In all patients, at least 4 sessions were done fortnightly. Patients were followed regularly and final success was noted after one month of completion of ESWL sessions.&#x0D; RESULTS: The mean age was 36.85 ± 8.61 years. From 60 patients, 29 (48.33%) were men and 231 (51.67%) were women.Mean body mass index (BMI) was 28.30±2.20 kg/m . The average size of the stone was 12.47 ± 2.57 mm. Success (according to stone removal) of Group-A (ESWL without DJS) was seen in 26 (86.67%) patients while in Group-B (ESWL with DJS) was seen in 16 (53.33%) patients with P-value of 0.005. &#x0D; CONCLUSION: This study concluded that success (in terms of stone clearance) of extracorporeal shock wave lithotripsy (ESWL) without DJ stenting is higher compared to with DJ stenting in upper ureteric stone.

Negative-Pressure Ureteroscopic Holmium-YAG Laser Lithotripsy for Ureteral Stones

Objectives: The aim of this study was to describe a novel negative-pressure laser lithotripsy device to overcome the deficiencies of the conventional procedure. Patients and Methods: Between August 2018 and March 2019, 78 patients with a single ureteral stone underwent retrograde ureteroscopy with a Wolf 8F/9.8F rigid ureteroscope and a 200-μm holmium-YAG laser. The mean stone size was 11.8 mm, measured for the maximum length. The negative-pressure laser lithotripsy device consists of an F5 ureter catheter and a T joint. The closed tip of an F5 ureter catheter is cut off, and it is then inserted within one opening of the T joint. The 200-μm laser fiber is introduced into the ureteral catheter through the other opening of the T joint. The third opening of the T joint is connected to the negative-pressure pipe. The valve end of the Foley catheter is used for sealing the cap. Continuous suction and active irrigation throughout the lithotripsy could maintain adequate visibility. Results: All ureteroscopic procedures were successful. The negative-pressure device showed good stone retention capabilities, with no observed stone migration. We did not observe any major complications. The stone-free rate was 97.44% (76/78), demonstrated on plain radiography of the kidney-ureter-bladder on the first postoperative day. The stone-free rate after 1 month was 100%. Conclusions: The negative-pressure ureteroscopic lithotripsy is easy and safe management for the ureteral stones. It might reduce the risk of stone fragment retropulsion, improve surgical vision, shorten the operative time, and decrease the renal pelvic pressure.

Can serum procalcitonin levels be useful in predicting spontaneous ureteral stone passage?

BackgroundMedical expulsive therapy (MET) is recommended for ureteral stones when there is no indication for interventional treatment. Spontaneous passage (SP) may not always be perceived in patients undergoing MET. We aimed to demonstrate the effects of inflammatory factors on spontaneous ureteral stone passage in patients undergoing MET.MethodsOur study was conducted between August and November, 2016, in healthy volunteers and patients with a single distal ureteral stone between 5 and 10 mm in diameter and no indications for interventional therapy. Blood and urine samples from all patients and healthy volunteers were tested. The patients were followed up every 2 weeks for 1 month unless emergency situations appeared. Patients with stone-free status at follow-up were concluded to have achieved complete stone passage [SP(+)], and failure [SP(−)] was concluded if the patient had not passed the stone by the end of the study. Blood samples of the patients and the control group were analyzed, recording WBC (white blood cell), CRP (c-reactive protein), SED (sedimentation), MPV (mean platelet volume), NLR (neutrophil-to-lymphocyte ratio), and serum procalcitonin levels. Abnormalities in urine samples were recorded. All patients received diclofenac sodium 75 mg/day, tamsulosin 0.4 mg/day, and at least 3 l/day fluid intake. Patients were followed for a month with kidney, ureter, bladder (KUB) plain films, ultrasonography (USG), and unenhanced abdominal CT scans while undergoing MET. Comparative statistical analyses were performed between the SP(+) and SP(−) groups.ResultsThe procalcitonin levels of the SP(−) group were significantly higher (207 ± 145.1 pg/ml) than in the SP(+) group (132.7 ± 28.1 pg/ml) (p = 0.000). The leucocyturia rate of the SP(−) group was significantly higher than in the SP(+) group (p = 0.004). Based on the ROC curve analysis, 160 pg/ml (86.7% sensitivity, 70.8% specificity, p < 0.001; AUC: 0.788 95% CI (0.658–0.917) was identified as the optimal cut-off value for procalcitonin. In logistic regression analysis, a significant efficacy of procalcitonin and leucocyturia was observed in the univariate analysis on spontaneous passage. In the multivariate analysis, significant independent activity was observed with procalcitonin. (p < 0.05).ConclusionOur findings suggest that high procalcitonin levels and the presence of leucocyturia have a strong negative effect on SP of ureteral stones between 5 and 10 mm in diameter. This relationship can be explained by stone impaction, possibly caused by increased mucosal inflammation.