Spontaneous Passage Research Articles

Factors related to the spontaneous passage of common bile duct stones through the papilla: a single-center retrospective cohort study.

ObjectiveCommon bile duct (CBD) stones can spontaneously pass through the papilla. This study explored factors associated with stone passage by comparing differences in the clinical features of stones retained in the CBD and excreted stones.MethodsData were retrospectively collected for all patients who were hospitalized in our center between March 2016 and May 2021 with clinical, laboratory, or imaging evidence of CBD stones. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were classified into two groups: group A (stones extracted by ERCP, n = 86) and group B (stones discharged before ERCP, n = 15). Demographic data, biochemical and radiological findings were compared between the groups.ResultsStone size (0.82 vs. 0.33 cm), and levels of total bilirubin (58.2 vs. 28.8 μmol/L), gamma-glutamyl transpeptidase (416.7 vs. 193.9 U/L), alkaline phosphatase (191.9 vs. 123.1 U/L), carbohydrate antigen 19-9 (603.7 vs. 37.2 U/mL), and α-L-fucosidase (37.4 vs. 22.6 U/L) were significantly higher in group A than in group B. Logistic regression analyses showed that stone size was the only factor significantly associated with spontaneous passage of CBD stones.ConclusionsCBD stones less than 0.33 cm in size may be self-expelled through the papilla.

Endourological treatment for lumbar ureteral stones. What are the benefits of flexible ureterorenoscopy?

Introduction and objectivesCurrently, there are no established criteria regarding treatment for lumbar ureteral stones. The objective of this work is to present our results in the endourological treatment of this pathology, analyzing the variables associated with the use of the flexible ureterorenoscope. Material and methodsRetrospective review of 103 patients who underwent retrograde URS with semi-rigid or flexible ureterorenoscope. Proximal location: L2–L3. Medial location: L4–L5. Semirigid URS was the initial treatment, with conversion to flexible URS when it was required to complete the procedure. Success was defined as absence of residual fragments (6 weeks). Demographic, surgical, immediate postoperative variables, and those related to the stone, were analyzed. Their correlation with the use of the flexible ureterorenoscope was evaluated. ResultsMean age: 57.2 years (SD 15.6); there were 73 men (70.9%). Stone size: 8 mm (range 4–30; IQR 4.5). Proximal location: 58 (56.3%). Previous JJ: 44.7%. Previous nephrostomy: 10.7%. Semirigid URS with conversion to flexible URS: 51 (49.5%). Impacted stones: 28.2%. Intraoperative complications: 2 (1.9%). Postoperative JJ: 84.5%. Immediate postoperative complications: 23 (22.3%) (Clavien-Dindo I–II: 91.3%). Postoperative ureteral stricture: 5.8%. Success: 88.4%. Residual fragments: 12 (11.7%). Spontaneous passage: 6 (50%). Greater performance of flexible URS in proximal ureteral stones (p = 0.001) of more than 11 mm (p = 0.02) in univariate analysis, and in proximal stones [OR 3.5; 1.5–8.1; p = 0.004] in multivariate analysis. ConclusionsEndourological treatment obtained a high success rate in our sample. Size greater than 11 mm and proximal ureteral location in univariate and multivariate analysis, respectively, behaved as predictors of flexible URS.

Relative benefits of extracorporeal shockwave lithotripsy (ESWL) compared to observation in acute renal colic

Miss Catherine Lovegrove1,2Mandy Spencer1Prof Ben Turney1,2Ms Naomi Neal1
 1 Department of Urology, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK2 University of Oxford Nuffield Department of Surgical Sciences, Oxford, Oxfordshire, UK
 
 Background NICE guidance recommends patients with renal colic be offered surgical treatment, including extracorporeal shockwave lithotripsy (ESWL), within 48 hours if pain is uncontrolled or stones unlikely to pass. We compared outcomes for ureteric stone passage after ESWL with those of observation to ascertain the relative benefits of ESWL.
 Methods We collected data on stone location, size and number of ESWL treatments required prospectively over 18 months. Stone passage was confirmed radiologically. Data were compared with MIMIC, a multi-centre collaborative study examining spontaneous stone passage after observation alone.
 Results 166 patients had ESWL for ureteric stones. Median size was 6.5mm (IQR 5.0-8.0mm). 57.2% (N=95) were proximal stones. Smaller stones required fewer treatments (P=0.003). Patients with a ureteric stone <5mm required median 1.0 ESWL treatments (IQR 1.0-2.0). Ureteric stones 5-7mm had median 1.0 treatments (IQR 1.0-2.0) and stones >7mm median 2.0 treatments (IQR 1.0-2.0). Compared to MIMIC, patients with ESWL for stones <5mm were 11% more likely to achieve stone clearance (100.0% vs 89.0%, P=0.001). ESWL for 5-7mm stones had 28.1% greater clearance compared to observation (77.1% vs. 49.0%, P<0.001) and ESWL for stones >7mm 21% greater likelihood of clearance (50.0% vs. 29.0%, P<0.001). Proximal ureteric stones were 16.4% more likely to pass with ESWL than observation (68.4% vs 52%, P=0.02). Distal stones showed similar passage with ESWL (77.5%) and observation (83.0%), P=0.43.
 Conclusions Proximal ureteric stones and those >5mm stones benefit most from ESWL. Results aid identification of patients whose stones are less likely to pass and warrant urgent review to consider ESWL.

327 Relative Benefits of Extracorporeal Shockwave Lithotripsy (ESWL) Compared to Observation in Acute Renal Colic

Abstract Aim NICE guidance recommends patients with renal colic be offered surgical treatment, including extracorporeal shockwave lithotripsy (ESWL), within 48 hours if pain is uncontrolled or stones unlikely to pass. We compared outcomes for ureteric stone passage after ESWL with those of observation to ascertain the relative benefits of ESWL. Method We collected data on stone location, size, and number of ESWL treatments required prospectively over 18 months. Stone passage was confirmed radiologically. Data were compared with MIMIC, a multi-centre collaborative study examining spontaneous stone passage after observation alone. Results 166 patients had ESWL for ureteric stones. Median size was 6.5mm (IQR 5.0-8.0mm). 57.2% (N = 95) were proximal stones. Smaller stones required fewer treatments (P = 0.003). Patients with a ureteric stone <5mm required median 1.0 ESWL treatments (IQR 1.0-2.0). Ureteric stones 5-7mm had median 1.0 treatments (IQR 1.0-2.0) and stones >7mm median 2.0 treatments (IQR 1.0-2.0). Compared to MIMIC, patients with ESWL for stones <5mm were 11% more likely to achieve stone clearance (100.0% vs 89.0%, P = 0.001). ESWL for 5-7mm stones had 28.1% greater clearance compared to observation (77.1% vs. 49.0%, P < 0.001) and ESWL for stones >7mm 21% greater likelihood of clearance (50.0% vs. 29.0%, P < 0.001). Proximal ureteric stones were 16.4% more likely to pass with ESWL than observation (68.4% vs 52%, P = 0.02). Distal stones showed similar passage with ESWL (77.5%) and observation (83.0%), P = 0.43. Conclusions Proximal ureteric stones and those >5mm stones benefit most from ESWL. Results aid identification of patients whose stones are less likely to pass and warrant urgent review to consider ESWL.

Foreign body in esophagus: Case report.

Introduction and importanceThe ingestion of foreign bodies is a frequent cause of consultation in the emergency department, especially in pediatric and elderly patients.Case presentationWe present the case of a 48-year-old male patient who arrived to the emergency department with dysphagia after food intake. The diagnosis is confirmed by simple neck tomography. After a failed endoscopy, he underwent surgery, with subsequent resolution of the condition.DiscussionThe diagnosis is based on the clinical history, physical examination and is supported by extension studies such as radiography, tomography and/or endoscopy, this last one being also therapeutic.ConclusionAlthough in most cases there is a spontaneous passage through the gastrointestinal tract, there is the possibility of requiring endoscopy (reported success greater than 95% of cases) or surgical treatment.

The high rate of spontaneous migration of small size common bile duct stones may allow a significant reduction in unnecessary ERCP and related complications: results of a retrospective, multicenter study.

Common bile duct stones (CBDS) can spontaneously migrate through the duodenal papilla. In this case, ERCP could be unnecessary and a significant rate of complications could be avoided. In this study, we aim at retrospectively evaluating the rate of spontaneous stone passage in patients with an imaging diagnosis of CBDS and at analysing the factors associated to spontaneous stone migration. We conducted a retrospective multi-centre analysis of patients undergoing ERCP for CBDS in a 12-month period. 1016 patients with CBDS were analysed. In all patients CBDS was diagnosed with adequate imaging methods performed prior to ERCP. ERCPs with failed biliary cannulation were excluded. Data regarding patients' characteristics, imaging findings and ERCP procedure were analysed. 1016 patients with CBDS undergoing ERCP were analysed (male sex 43.3%; mean age 69.9 ± 16.5years). Diagnosis of CBDS was obtained by EUS in 415 patients (40.8%), MR in 343 (33.8%), CT in 220 (21.7%), and US in 38 (3.7%). No stones were found at ERCP in 179 patients (17.6%), in 14 (6.2%) when ERCP was performed within 6h from imaging study, in 114 (18.5%) between 7h and 7days, in 32 (24.6%) between 8 and 29days, and in 19 (43.2%) after 30days. The rate of unnecessary ERCP occurred significantly more frequently in patients in whom imaging methods demonstrated either sludge or ≤ 5mm CBDS (29.9 vs. 8.3%; p < 0.001). Spontaneous migration of small CBDS is a frequent event, and ≤ 5mm size and a delay in ERCP > 7days represent predictive factors for it. We suggest that CBDS ≤ 5mm should not undergo immediate removal and this fact would allow reducing the rate of unnecessary ERCP with their related complications. Prospective studies are needed to confirm these results and demonstrate the safety of a conservative management in this setting.

MP18-02 EVALUATING SPONTANEOUS STONE PASSAGE RATES DURING THE COVID-19 PANDEMIC

INTRODUCTION AND OBJECTIVE: During the COVID-19 pandemic our institution limited elective surgery including management of kidney stones. Additionally, patients themselves were reluctant to pursue elective surgery. This presented us a unique opportunity to reassess the natural history of symptomatic nephrolithiasis given potentially prolonged periods of conservative management. METHODS: A retrospective review was performed of patients presenting to the emergency room (ER) with flank pain secondary to nephrolithiasis from March to April of 2020 (COVID peak period of elective surgery limitations), and a comparative cohort from March and April 2019. Assessed outcomes included definitive stone treatment at initial presentation to the ER, rate of spontaneous stone passage, and time to elective surgery from initial ER presentation. Chi-square or Mann-Whitney U tests were utilized for dependent binary variables and continuous variables, respectively. A Kaplan Meier analysis was used to demonstrate differences in time to elective surgery between the two eras. RESULTS: Baseline characteristics did not differ between groups (Table). Patients discharged from the ER were more often offered medical expulsive therapy (71.6% vs 55.0%, p=0.026) during the COVID era. The rate of surgical stone management or stent placement at initial presentation did not differ, however, discharged patients waited longer from initial ER presentation to elective surgery (55.3 vs 33.1 days, p=0.02). Spontaneous stone passage rates were similar between groups despite the delay, and similar stone location and stone size between eras. CONCLUSIONS: During the height of the COVID pandemic, ER patients with symptomatic stones had similar characteristics at presentation but were more often offered MET. Spontaneous stone passage during the pandemic was no different than in 2019, despite a significant difference in time to elective surgery from initial presentation to the ER with flank pain .

PD14-02 PROGRAM-ESTIMATED STONE VOLUME IS BEST PREDICTOR OF SPONTANEOUS PASSAGE FOR ACUTE NEPHROLITHIASIS

INTRODUCTION AND OBJECTIVE:In patients presenting with acute nephrolithiasis, stone burden is an important predictor of spontaneous passage (SP) and therefore guides management discussions, especia...

The Role of Procalcitonin and Other Markers of Inflammation in Predicting Spontaneous Passage of Ureteral Stones

The Role of Procalcitonin and Other Markers of Inflammation in Predicting Spontaneous Passage of Ureteral Stones

Prediction of the ureteric stone outcome by CT scan

Background and objective: Urolithiasis is prevalent in both developed and developing countries, which is attributed to changes in lifestyles. Management of ureteric stones is highly dependent on their characteristics such as volume, size, and density which can be determined based on the images obtained from CT scan. The present study was carried out to examine the association between the final outcomes of the stones and different stone parameters specified by CT scan. Methods: The present prospective cross-sectional study consisted of 100 patients who had been referred to the Radiology Department of Rizgary and Erbil Teaching Hospitals in Erbil, Kurdistan Region, Iraq, over six months in 2019 to undergo abdominal CT scan with clinical suspicion of ureteric stones. All patients underwent non-contrast MDCT scan, and the CT images were evaluated for the presence of ureteric stone, site of the stone, side, diameter in three planes, volume, and density. The outcome of the stone was correlated with each above variables. Results: Ureteric stones were more prevalent among the young and middle age group (25-64 years) with an approximate male-to-female ratio of 3.34:1. There were significant associations between stone outcomes (i.e. spontaneous passage or need for intervention) and the stone characteristics including volume (P &lt;0.001), density (P &lt;0.001)site (upper, mid and lower ureter) (P = 0.02), anteroposterior diameter (P &lt;0.001), transverse diameter (P = 0.006), and superior inferior diameter (P &lt;0.001). Conclusion: Upon the significant correlation between the spontaneous passage of ureteric stones and their characteristics (i.e., volume, density, site, anteroposterior diameter, transverse diameter, and superior inferior diameter), it is highly recommended that all patients with urolithiasis undergo CT scan examination in order to make the proper decision regarding stone management. Keywords: Ureteric stones; CT scan; Stone characteristics; Spontaneous passage.

Tratamiento endourológico de la litiasis ureteral lumbar. ¿Qué aporta la ureterorrenoscopia flexible?

Introduction and objectivesCurrently, there are no established criteria regarding treatment for lumbar ureteral stones. The objective of this work is to present our results in the endourological treatment of this pathology, analyzing the variables associated with the use of the flexible ureterorenoscope. Material and methodsRetrospective review of 103 patients who underwent retrograde URS with semi-rigid or flexible ureterorenoscope. Proximal location: L2-L3. Medial location: L4-L5. Semirigid URS was the initial treatment, with conversion to flexible URS when it was required to complete the procedure. Success was defined as absence of residual fragments (6 weeks). Demographic, surgical, immediate postoperative variables, and those related to the stone, were analyzed. Their correlation with the use of the flexible ureterorenoscope was evaluated. ResultsMean age: 57.2 years (SD 15.6); there were 73 men (70.9%). Stone size: 8mm (range 4-30; IQR 4.5). Proximal location: 58 (56.3%). Previous JJ: 44.7%. Previous nephrostomy: 10.7%. Semirigid URS with conversion to flexible URS: 51 (49.5%). Impacted stones: 28.2%. Intraoperative complications: 2 (1.9%). Postoperative JJ: 84.5%. Immediate postoperative complications: 23 (22.3%) (Clavien-Dindo I-II: 91.3%). Postoperative ureteral stricture: 5.8%. Success: 88.4%. Residual fragments: 12 (11.7%). Spontaneous passage: 6 (50%). Greater performance of flexible URS in proximal ureteral stones (P=0.001) of more than 11mm (P=0.02) in univariate analysis, and in proximal stones [OR 3.5; 1.5-8.1; P=0.004] in multivariate analysis. ConclusionsEndourological treatment obtained a high success rate in our sample. Size greater than 11mm and proximal ureteral location in univariate and multivariate analysis, respectively, behaved as predictors of flexible URS.

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.

Spontaneous Passage of a Long Nail through the Gastrointestinal Tract of a 2-year old Child: A Case Report

Swallowing of foreign body is a common problem in children. Although most foreign bodies in the gastrointestinal tract will pass spontaneously, passage of sharp and pointed object such as a long nail is unusual. We report a case of a 2-year old female who swallowed a 3-inch nail and passed the nail per rectum spontaneously without problems while preparations were being made for the removal of the nail. The rarity of this event makes it worthy of being reported.

Clinical and Radiological Predictors of Early Intervention in Acute Ureteral Colic.

PurposeAcute ureteric colic (AUC) is generally one of the most common reasons for emergency department attendance. Expectant management is recommended in non-complicated ureteral calculi. However, data regarding the optimal duration of observation or indications of early intervention (EI) are not well understood. This article describes the clinical and radiological factors that promote EI in AUC.Patients and MethodsThis was an observational and retrospective cohort study. Patients with AUC diagnosed based on non-contrast computerized tomography (NCCT) between 2019 and 2020 were enrolled in the study. These patients were classified into two main categories: spontaneous passage of stone (SSP) and EI. In addition, a comparative analysis was performed to identify clinical and radiological variables that promote EI.ResultsOne-hundred and sixty-one patients were included. High WBCs are associated with a significant increase in EI. Forty-three percent (n=37) of patients with serum WBCs higher than 10 had an EI, while 23% had SSP (n=17;p<0.001). High CRP level is also significantly associated with EI (n=36; 86%; p<0.001). Upper and middle ureteral calculi are statistically associated with EI (n=54; 62%) in comparison to the SSP cohort (n=22; 30%;p<0.001). EI is also linked to the maximal length of ureteric calculi (MCL) of 9 mm (6–13mm), and HU density of stone of 700 (430–990) H.U (p<0.001). Ureteric stone volume of 0.2 (0.06–0.3) cm3 is significantly associated with EI (p<0.001). Ureteral wall thickness of 3 (2–3 mm), the presence of extrarenal pelvis (n=20; 23%), and AP diameter of renal pelvis 18 (13–28 mm) are all significantly associated with a higher rate of EI (p<0.001). Multiple binary logistic regression analysis showed that MCL is the strongest predictor of EI.ConclusionMCL is an independent and robust predictor of EI in AUC. Biochemical variables and radiological characteristics can also act as an adjunct to promote EI.

Current Trends in the Use of Adrenoblockers in Urology: What Has Been Changed

The main indications and practical features of the use of α1-blockers (AB) in urology are analyzes in the article. Studies show that AB usually reduce IPSS by about 30–40% and increase Qmax by about 20–25%. Recently, there have been changes in the AB usage. They are increasingly used for other indications than the treatment of benign prostatic hyperplasia. This is the restoration of urination after urinary retention and in case of urolithiasis to improve the spontaneous passage of stones through the ureters (including women), although these indications are not officially approved. In addition, AB is increasingly being prescribed by physicians of various specialties (such as general practitioners or emergency physicians) rather than just urologists. The development and implementation of a system of sustained release of tamsulosin has improved its tolerability by reducing the side effects on the cardiovascular system and expanded the possibilities of its use. High-quality generic tamsulosin preparations (such as Tamsin Forte) with a sustained release system can be a worthy alternative to the original drugs.

Does volume matter? Incorporating estimated stone volume in a nomogram to predict ureteral stone passage.

Recent studies have shown that software-generated 3D stone volume calculations are better predictors of stone burden than measured maximal axial stone diameter. However, no studies have assessed the role of formula estimated stone volume, a more practical and less expensive alternative to software calculations, to predict spontaneous stone passage (SSP). We retrospectively included patients discharged from our emergency department on conservative treatment for ureteral stone (≤10 mm). We collected patient demographics, comorbidities, and laboratory tests. Using non-contrast computed tomography (CT) reports, stone width, length, and depth (w, l, d, respectively) were used to estimate stone volumes using the ellipsoid formula: V=ϖ*l*w*d*0.167. Using a backward conditional regression, two models were developed incorporating either estimated stone volume or maximal axial stone diameter. A receiver operator characteristic (ROC) curve was constructed and the area under the curve (AUC) was computed and compared to the other model. We included 450 patients; 243 patients (54%) had SSP and 207 patients (46%) failed SSP. The median calculated stone volume was significantly smaller among patients with SSP: 25 (14-60) mm3 vs. 113 (66-180) mm3 (p<0.001). After adjusting for covariates, predictors of retained stone included: neutrophil to lymphocyte ratio (NLR) ≥3.14 (odds ratio [OR] 6, 95 % confidence interval [CI] 3.49-10.33), leukocyte esterase (LE) >75 (OR 4.83, 95% CI 2.12-11.00), and proximal stone (OR 2.11, 95% CI 1.16-3.83). For every 1 mm3 increase in stone volume, the risk of SSP failure increased by 2.5%. The model explained 89.4% (0.864-0.923) of the variability in the outcome. This model was superior to the model including maximal axial diameter (0.881, 0.847-0.909, p=0.04). We present a nomogram incorporating stone volume to better predict SSP. Stone volume estimated using an ellipsoid formula can predict SSP better than maximal axial diameter.

A case report of spontaneous passage of large (&gt;1.5 cm) common bile duct calculi (4 in number) through faeces

Gallbladder (GB) stones are commonly associated with common bile duct stones (CBDS). While they may remain asymptomatic, some may present with symptoms like biliary colic, jaundice and cholecystitis. Most of these stones in the CBD, if small, pass through faeces. Passing larger stones through faeces is relatively rare and if it does occur, is usually associated with fatal complications like acute pancreatitis. The authors reported a case wherein symptomatic large CBD stones were spontaneously passed through faeces and the patient was relieved of the symptoms and did not suffer any further complications. Choledocholithiasis is usually managed by endoscopic retrograde cholangiopancreatography or by laparoscopic or open choledocholithotomy. Spontaneous passage of small CBD and GB calculi through faeces although common is associated often with the development of pancreatitis. Passage of large CBD calculi (size &gt;1.5 cm) through faeces is rarely seen.

Editorial Comment.

You have accessJournal of UrologyReview Article1 Sep 2021Editorial CommentThis article comments on the following:Natural History of Post-Treatment Kidney Stone Fragments: A Systematic Review and Meta-Analysisis a letter which has replyReply by Authors Roger L. Sur Roger L. SurRoger L. Sur Department of Urology, University of California San Diego Comprehensive Kidney Stone Center, San Diego, California More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001836.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Caveat emptor: Leaving fragments behind is problematic. This systematic meta-analysis by Brain et al clearly states that the urologist’s advice that “those little fragments left behind shouldn’t be a problem” is a black pearl. They report data from 18 studies that the larger the fragment (>4 mm), the greater the risk of needing a subsequent intervention. But even smaller fragments (<4 mm) carry this risk. Furthermore, we also now know that regardless of the procedure (shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy), residual fragments can cause downstream problems for patients. Not only is the chance of intervention proportional to size, but the risk can be as high as 38%–88% for up to 4 years—and since it was not studied, this risk potentially extends beyond 4 years. However, the authors also report that size of fragment did not predict risk of 1) spontaneous passage or 2) “progression” (composite definition including “stone growth,” “symptoms,” “complications”). And although stone size did not predict spontaneous passage or progression, small stones (<4 mm) still posed risk from 2%–79%—ie there was large variation even in small residual fragments. This study also places a disclaimer that not all studies used postoperative computerized tomography and therefore the true rate of residual fragments is likely underreported. This fact underscores the importance of the patient understanding their risk might be higher if ultrasound or plain film are used.1 All told, this Level 1a study now clearly re-emphasizes what Dr. Ralph Clayman has been saying all along: let’s stop the use of “clinically insignificant residual fragment” and reserve the term “stone-free” for no residual fragments on postoperative computerized tomography.2,3

Emergent urinary decompression in acute stone-related urinary obstruction: A systematic review and meta-analysis

Introduction: Emergent urinary decompression through percutaneous nephrostomy (PCN) or ureteric stent (URS) remains a mainstay in the management of urethral calculi-related obstruction with associated signs of infection or renal injury. Available evidence has shown similar performance, and current guidelines endorse both treatment strategies. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria up until August 2020. Studies included data on stone size and location, operative time, complications, length of stay, analgesic consumption, quality of life (QoL), and clinical outcomes between URS and PCN. Results: Ten studies with a total population of 772, of which 420 were treated with URS and 352 with PCN, were included. No statistical difference in operative time between both techniques was found. Nevertheless, length of stay in PCN was longer than in USR, with a mean difference of −1.87 days ((95% CI −2.69 to −1.06), Z=4.50, p=0.00001). No differences were found in the time to normalization of temperature or white blood cell counts. There were no significant differences in success rates, with an overall odds ratio (OR) of 0.60 ((95% CI 0.26 to −1.40), Z=1.17, p=0.24), or spontaneous passage after emergent drainage between groups. Complication rates ranged from 5% to 25% in URS and from 0% to 38% in PCN. In the studied population, out of the 157 patients from four studies describing complications, only 5% of URS procedures presented complications compared to 2% in PCN, showing a relatively low complication rate for either group (OR=2.07 (95% CI 0.89–4.84), Z=1.68, p=0.09). Differences in QoL were not significant. Conclusion: Both methods are equally effective, with no clear advantage for PCN over URS. Level of evidence: IV

Recurrent Nephrolithiasis in a Patient With Hypercalcemia and Normal to Mildly Elevated Parathyroid Hormone

A 42-year-old man was referred to our stone clinic for recurrent episodes of symptomatic nephrolithiasis. Spontaneous stone passages occurred at the ages of 25, 40, and 42 years with one need for endoscopic stone removal. Calculi were composed of 100% calcium oxalate monohydrate. The patient had not taken any medication or supplements. Increased fluid intake was the only intervention for stone prevention. Metabolic work-up at presentation revealed mild hypercalcemia and normal to mildly elevated intact parathyroid hormone, even after repletion with oral 25-hydroxyvitamin D.