Ureteroscopic Stone Treatment Research Articles

Preoperative urine culture with contaminants is not associated with increased risk for urinary tract infection after ureteroscopic stone treatment.

We aimed to assess whether the presence of contaminants in the pre-operative urine culture (preop-UC) predicts postoperative urinary tract infection (postop-UTI) in patients undergoing elective ureteroscopy with laser lithotripsy. A retrospective chart review was performed from 01/2019 to 12/2021 examining patients with unilateral stone burden ≤ 2cm who underwent ureteroscopy with laser lithotripsy and had a preop-UC within 3months. Positive, negative, contaminated, and polymicrobial definitions for UCs were established in accordance with current guidelines. Patients with positive and polymicrobial cultures were excluded. Postop-UTI was defined as the presence of urinary symptoms and a positive UC within 30days of the procedure. Multivariable logistic regression models were utilized to evaluate risk factors for contamination in the preop-UC and the risk of postop-UTI. A total of 201 patients met the inclusion-exclusion criteria. Preop-UC was negative in 153 patients and contaminated in 48 patients. Significant contaminant-related factors included female gender and increased BMI. Postop-UTI was diagnosed in 3.2% of patients with negative preop-UCs and 4.2% of patients with contaminants, with no difference between groups (p = 0.67). The regression model determined that the presence of contaminants in preop-UC failed to predict postop-UTI (OR 0.69, p = 0.64). The presence of contaminants in preop-UCs is not associated with an increased risk of postop-UTIs after ureteroscopy. Our study supports that contaminants in the preop-UC can be interpreted as a negative UC in terms of postop-UTI risk stratification. Preoperative antibiotics should not be prescribed for patients undergoing uncomplicated ureteroscopy for stone surgery in the setting of a contaminated preop-UC.

Ureteroscopic and Robot-Assisted Ureteroplasty with Buccal Mucosa Graft

Introduction and Objective: In this video we present a case of a ureteroscopic and robot-assisted redo ureteroplasty with buccal mucosa graft for a proximal ureteral stricture. Methods: Here, we present a case of 72-year-old female patient with a history of a right-sided proximal ureteral stricture after ureteroscopic stone treatment. For this stricture she underwent robotic end-to-end ureteroplasty. Two years later, she presented with recurrence of the stricture for which she underwent balloon dilatation and tandem stenting. Unfortunately, the stricture recurred rapidly. A redo ureteroplasty with buccal mucosa graft was planned. Results: Surgery and postoperative course were uneventful. Six weeks after surgery, the Double-J stent was removed and 4 months postoperatively, the patient is doing fine without evidence for recurrence of the ureteral stricture. Conclusions: The video illustrates how retrograde ureteroscopy in combination with FireFly fluorescence imaging can be a valuable contribution to identifying the ureter, which in redo cases is often surrounded by a lot of fibrotic tissue. Moreover, localization of the stricture site is facilitated by retrograde ureteroscopy. After onlay of the buccal mucosa graft, patency and watertightness of the ureteroplasty can easily be controlled. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. All authors declare no conflict of interest in connection with this video. Runtime of video: 3 mins 16 secs

Cost-utility analysis of shockwave lithotripsy vs ureteroscopic stone treatment in adults.

To assess the cost-effectiveness, resource use implications, quality-adjusted life-years (QALYs) and cost per QALY of care pathways starting with either extracorporeal shockwave lithotripsy (SWL) or with ureteroscopic retrieval (ureteroscopy [URS]) for the management of ureteric stones. Data on quality of life and resource use for 613 patients, collected prospectively in the Therapeutic Interventions for Stones of the Ureter (TISU) randomized controlled trial (ISRCTN 92289221), were used to assess the cost-effectiveness of two care pathways, SWL and URS. A health provider (UK National Health Service) perspective was adopted to estimate the costs of the interventions and subsequent resource use. Quality-of-life data were calculated using a generic instrument, the EuroQol EQ-5D-3L. Results are expressed as incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. The mean QALY difference (SWL vs URS) was -0.021 (95% confidence interval [CI] -0.033 to -0.010) and the mean cost difference was -£809 (95% CI -£1061 to -£551). The QALY difference translated into approximately 10 more healthy days over the 6-month period for the patients on the URS care pathway. The probabaility that SWL is cost-effective is 79% at a society's willingness to pay (WTP) threshold for 1 QALY of £30,000 and 98% at a WTP threshold of £20,000. The SWL pathway results in lower QALYs than URS but costs less. The incremental cost per QALY is £39 118 cost saving per QALY lost, with a 79% probability that SWL would be considered cost-effective at a WTP threshold for 1 QALY of £30 000 and 98% at a WTP threshold of £20 000. Decision-makers need to determine if costs saved justify the loss in QALYs.

Infection after ureteroscopy for ureteric stones: analysis of 71 305 cases in the Hospital Episode Statistics database.

To investigate the burden of infectious complications following ureteroscopy (URS) for ureteric stones on a national level in England using data from the Hospital Episodes Statistics (HES) data warehouse. A retrospective cohort was identified and followed up in HES during the period April 2013 to March 2020 for all procedure codes relating to ureteroscopic stone treatment (M27.1, M27.2, M27.3). Treatment episodes relating to the first URS ('index ureteroscopy') for each patient were further analysed. All subsequent admissions within 30 days were also captured. The primary outcome was diagnosis of urinary tract infection (UTI; including all codes relating to a UTI/sepsis within the first 30 days of index URS). Secondary outcomes were critical care attendance, attendance at the accident and emergency department (A&E) within 30 days, and mortality. A total of 71 305 index ureteroscopies were eligible for analysis. The median age was 55 years, and 81% of procedures were elective and 45% were undertaken as day-cases. At the time of index URS, 16% of patients had diabetes, 0.5% had coexisting neurological disease and 40% had an existing stent/nephrostomy. Overall, 6.8% of the cohort (n = 4822) had a diagnosis of UTI within 30 days of index URS (3.9% immediately after surgery). A total of 339 patients (0.5%) required an unplanned stay in critical care during their index URS admission; 8833 patients (12%) attended A&E within 30 days. Overall mortality was 0.18% (60 in-hospital, 65 within 30 days); 40 deaths (0.056%) included infection as a contributing cause of death. We present the largest series evaluating infectious complications after ureteroscopic stone treatment. The procedure is safe, with low inpatient infective complication and critical care admission rates.

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.

Do outcomes of ureteroscopic stone treatment vary with stone composition? A prospective analysis.

Urinary tract calculi are commonly treated with ureteroscopy and laser stone fragmentation (URSL). The composition of calculi depends on underlying patient factors. Stones associated with metabolic or infectious conditions are sometimes thought to be more difficult to treat. This analysis explores whether the composition of calculi impacts on stone-free and complication rates. A prospectively maintained database of patients undergoing URSL between 2012-2021 was used to explore records for patients with uric acid (Group A), infection (Group B) and calcium oxalate monohydrate (Group C) calculi. Patients who had undergone URSL to treat ureteric or renal calculi were included. Patient demographics, stone parameters and operative details were collected, with the principal outcomes being stone-free rate (SFR) and associated complications. A total of 352 patients were included (58 Group A, 71 Group B and 223 Group C patients) and had their data analysed. SFR was >90% for all three groups and a single Clavien-Dindo grade III complication was noted. No significant differences were found between the groups for complications, SFR and day case rates. This cohort of patients demonstrated that outcomes were similar for three different types of urinary tract calculi, which form for differing reasons. URSL appears to be an effective, safe treatment for all stone types with comparable results.

High- and Low-Power Laser Lithotripsy Achieves Similar Results: A Systematic Review and Meta-Analysis of Available Clinical Series.

Purpose: There is no clear evidence that high-power (HP) laser generators perform better than low-power (LP) ones in terms of lithotripsy outcomes. We aimed to perform a systematic review of literature to compare the efficacy outcomes of both HP and LP during ureteroscopic lithotripsy. Materials and Methods: A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting perioperative outcomes of HP and LP lithotripsy. Using the methodology recommended by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we identified 22 nonrandomized noncomparative retrospective studies published between 2015 and 2019 that were eligible for inclusion in this systematic review. Because of the lack of comparative studies, we decided to perform two separate meta-analytic syntheses for LP and HP studies, then we compared them using a Wald-type test. Results: Overall, the selected studies included 6403 patients. Study design, exposure assessment, selection criteria, and outcome of interest were heterogeneous. LP studies were more common (n = 17, 77%), whereas HP studies were more common in the latest inclusion period. Faster lithotripsy (32.9 minutes vs 63.9 minutes, p < 0.01) was observed in HP studies. However, stone volume resulted twofold higher (2604 mm3vs 1217 mm3, p = 0.048) in LP studies. Pooled stone-free rate was similar in both LP and HP studies, 81% and 82%, respectively, p > 0.05. No difference in complication rate was observed between the two groups, p = 0.12. Conclusions: HP laser lithotripsy appears to require shorter operative time, with similar stone-free and complication rates as compared with LP traditional lithotripsy. However, when taking into account stone burden, this advantage seems to be lost, or at least not to be comparable with what observed in laboratory studies. Because of the lack of high-level comparative evidence, further clinical studies are needed to elucidate the benefits of using HP laser generators during ureteroscopic stone treatment.

Infection-related hospitalization following ureteroscopic stone treatment: results from a surgical collaborative

BackgroundUnplanned hospitalization following ureteroscopy (URS) for urinary stone disease is associated with patient morbidity and increased healthcare costs. To this effect, AUA guidelines recommend at least a urinalysis in patients prior to URS. We examined risk factors for infection-related hospitalization following URS for urinary stones in a surgical collaborative.MethodsReducing Operative Complications from Kidney Stones (ROCKS) is a quality improvement (QI) initiative from the Michigan Urological Surgery Improvement Collaborative (MUSIC) consisting of academic and community practices in the State of Michigan. Trained abstractors prospectively record standardized data elements from the health record in a web-based registry including patient characteristics, surgical details and complications. Using the ROCKS registry, we identified all patients undergoing primary URS for urinary stones between June 2016 and October 2017, and determined the proportion hospitalized within 30 days with an infection-related complication. These patients underwent chart review to obtain clinical data related to the hospitalization. Multivariable logistic regression analysis was performed to determine risk factors for hospitalization.Results1817 URS procedures from 11 practices were analyzed. 43 (2.4%) patients were hospitalized with an infection-related complication, and the mortality rate was 0.2%. Median time to admission and length of stay was 4 and 3 days, respectively. Nine (20.9%) patients did not have a pre-procedure urinalysis or urine culture, which was not different in the non-hospitalized cohort (20.5%). In hospitalized patients, pathogens included gram-negative (61.5%), gram-positive (19.2%), yeast (15.4%), and mixed (3.8%) organisms. Significant factors associated with infection-related hospitalization included higher Charlson comorbidity index, history of recurrent UTI, stone size, intra-operative complication, and procedures where fragments were left in-situ.ConclusionsOne in 40 patients are hospitalized with an infection-related complication following URS. Awareness of risk factors may allow for individualized counselling and management to reduce these events. Approximately 20% of patients did not have a pre-operative urine analysis or culture, and these findings demonstrate the need for further study to improve urine testing and compliance

Ureteral Strictures Following Ureteroscopic Stone Treatment

Background and Purpose: Ureteral stricture is a rare, but serious complication following ureteroscopy (URS) for stones. The aim of this study was to investigate how many patients ended up with a ureteral stricture after URS at our hospital and how these were treated. We also wanted to identify potential risk factors for postendoscopic stricture formation. Materials and Methods: A retrospective evaluation of 1001 URSs for stone treatment at the day-case surgery unit between 2013 and 2018 was performed. Data on pretreatment status, the surgical procedure, and follow-up were recorded. Exact χ2 and independent samples t-tests were used comparing data among those who developed strictures and those who did not. Multiple logistic regression was performed analyzing risk factors for stricture formation. Results: In total, 1001 URSs were performed in 725 patients, 289 women and 436 men. Of these, 995 cases were eligible for analysis. At follow-up with CT after 3 months, 28 (3.0%) strictures were identified. Of these, 20 received endourologic treatment with balloon dilatation of which 15 (75%) were effective. Definitive treatment in the 13 patients with failed or unattempted endourologic treatment included nephrectomy, reconstructive surgery, permanent nephrostomy, or observation with no further treatment. In multiple regression analysis, use of ureteral access sheath (UAS; odds ratio [OR] 4.6, p = 0.011), ureteral perforation (OR 11.8, p < 0.0001), and surgical time >60 minutes (OR 5.7, p < 0.005) were found to be risk factors for stricture formation. Conclusion: Ureteral stricture is a rare complication of URS. Balloon dilatation should be the first line of treatment. Use of UAS, perforation, and excessive operating time were found to be risk factors for postendoscopic ureteral stricture formation. Special attention to these risk factors should be given to reduce the incidence of ureteral strictures.

Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment.

Flexible ureteroscopy is the keystone of modern kidney stone treatment. Although a simple surgical technique achieves good clinical results and a low complication rate, there are high demands on the surgeon's dexterity and ergonomic restrictions. Robotic-assisted flexible ureteroscopy (rfURS) could overcome these limitations. After 4years of use of rfURS at a tertiary stone center, performance factors were analyzed to define the role of rfURS in kidney stone management. A rfURS system was installed in August 2014 at the SLK Kliniken (Heilbronn, Germany). Treatment data of N = 240 consecutive patients undergoing rfURS were prospectively collected and analyzed. The patient cohort represents typical stone formers. N = 240 renal units containing 443 stones with an average stone load of 1798mm3 were treated. Surgical parameters as well as the peri- and postoperative complications were recorded, analyzed and compared to the current data in the literature. OR time 91min, stone treatment time 55min, stone treatment efficacy 33mm3/min; perioperative complications 5.4%; robot times: preparation 5min, docking 5min, console time to stone contact 6min, console time 75min; postoperative complications 6.7%; postoperative length of stay 1.5days; stone-free rate (residuals < 2mm) 90% and re-treatment rate 8.75%. This consecutive series represents real-life data about the utilization of rfURS. The detailed analysis of performance factors revealed the successful utilization of the first generation of robotic systems in endourologic stone surgery, and indicates that the robot performs comparably to conventional flexible URS. Optimal ergonomics maintain the surgeon's endurance in long-lasting surgeries.

A comparative study between a single dose pre-induction antibiotic versus continuous antibiotics to prevent urinary tract infection during ureteroscopy

Background and objective: This study aimed to evaluate the effect of adding postoperative antibiotics in reducing the incidence of symptomatic urinary tract infections following ureteroscopic stone treatment beyond the recommended preoperative dose. Methods: This prospective comparative study was conducted between March and November 2017. A total of 80 patients with preoperative negative urine cultures who underwent ureteroscopy were randomly allocated. All the patients received a single dose antibiotic before the induction of anesthesia, and a group of them also received postoperative antibiotics. The rate of symptomatic urinary tract infection was compared between the patients who received only preoperative antibiotics (group 1) and those who received pre- and postoperative antibiotics (group 2). Results: Eighty patients underwent ureteroscopy for stone treatment. The time to follow up was 4±2 weeks from ureteroscopy. Eleven (13.8%) patients in total developed urinary tract infections postoperatively, including five (12.5%) from group 1 and six (15%) from group 2, P = 0.74. In group 1, four patients presented with cystitis and one with sepsis; those patients with infections in group 2 presented with pyelonephritis (n=2) and cystitis (n=4). Risk factors such as preoperative stenting, nephrostomy tubes, and Foleys catheters did not differ between groups. Conclusion: The postoperative symptomatic urinary tract infection rate in this study (13.8%) is in agreement with previous reports. This study suggests that a single preoperative dose of antibiotics is sufficient, and additional postoperative antibiotics do not decrease infection rates after ureteroscopic stone treatment.

The effect of percutaneous nephrostomy implementation on the outcome of ureteroscopic stone treatment.

We aimed to investigate the effect of percutaneous nephrostomy (PCN) implementation on the second ureteroscopy (URS) outcomes after a failed URS. The data of four hundred forty-eight patients with an unsuccessful URS history were evaluated. Patients were divided into two groups; patients who underwent PCN before second URS (Group A) and patients who did not (Group B). We compared the stone access rate in the second URS between the two groups according to patient and stone characteristics and operative data. Then, group A was subdivided into two groups according to stone access as; access succeeded (Group A1) and access failed (Group A2). We also compared stone access rates between these two groups in terms of gender, age, body mass index, stone size, side, location, grade of hydronephrosis and PCN duration. All data were available immediately after surgery and obtained from patient files and the outcome assessment was performed during the study period. Stone access rate was higher in group A than group B (143/196 vs 41/252, P = .0018). Mean nephrostomy duration and mean hydronephrosis grade were significantly higher and mean stone size was significantly lower in group A1 than group A2 (18.74 vs 9.62 days, P < .001; grade 3.25 vs 1.21, P = .038; and 7.286 vs 12.631 mm P < .001, respectively). PCN is a favourable intervention after a failed URS and increases the success rate of the second operation with ease of implementation and minimal morbidity.

Smartphone-based stent tracking application for prevention of forgotten ureteral double-J stents: a prospective study.

ABSTRACTPurpose:Retained or forgotten ureteral stents (FUS) have a potential to cause significant morbidity as well as medico-legal issues and increased cost. We aimed to evaluate the efficacy and usefulness of smartphone-based Ureteral Stent Tracker (UST) application and compare the results with basic appointment card system to prevent FUS, prospectively.Materials and Methods:A total of 90 patients who underwent ureteroscopic stone treatment procedure with indwelling DJ stents were equally distributed into two groups. In group-1, patients were followed using UST application. In group-2, only appointment cards were given to the patients. Two groups were compared in terms of stent overdue times and complete lost to follow up rates.Results:Forty-four patients in group-1 and 43 patients in group-2 completed the study. Among patients, 22.7% in group-1 and 27.9% in group-2 did not return for the stent removal on the scheduled day. In group-1, these patients were identified using the UST and called for the stent removal on the same day. After 6 weeks of maximal waiting period, mean overdue times in group-1 and group-2 were 3.5 days and 20 days, respectively (p = 0.001). In group-2, 3 patients (6.9%) were lost to follow up, while in group-1, it was none (p = 0.001).Conclusions:We found that the patients who were followed by the smartphone-based UST application has less overdue times and lost to follow up cases compared to the basic appointment card system. The UST application easily follows patients with indwelling ureteral stents and can identify patients when overdue.

Risk Factors for Ureteral Damage in Ureteroscopic stone Treatment: Results of the German Prospective Multicentre Benchmarks of Ureterorenoscopic Stone Treatment-Results in Terms of Complications, Quality of Life, and Stone-Free Rates Project

Background: The Post-Ureteroscopic Lesion Scale (PULS) is a validated, standardised scale that classifies iatrogenic ureteral lesions during ureteroscopy (URS). Objective: To determine risk factors for the various PULS-grades caused by URS. Method: We prospectively investigated the independent influence of various risk factors in correlation with PULS-Grade 1+ and 2+ on 307 patients with ureterorenoscopic stone treatment from 14 German urologic departments. Results: The following are the outcomes of the study: 117 (38.4%) and 188 (61.6%) of the calculi (median stone size 6 mm) were found in the kidney or ureter; 70% and 82.4% underwent preoperative or postoperative ureteral stenting; 44.3 and 7.2% received laser or ballistic lithotripsy; 60% of the patients presented with PULS grade 1+ and 8% with PULS grade of 2+. Only intracorporal lithotripsy revealed a significant independent risk factor for PULS grade 1+ or 2+. Both laser and ballistic therapies raised the probability of PULS grade 1+ by the factors 3.6 (p < 0.001) and 3.9 (p = 0.021), respectively. The ORs in conjunction with PULS grade 2+ were 3.1 (p = 0.038) and 5.8 (p = 0.014) respectively. Neither endpoint exhibited a significant difference regarding the lithotripsic procedure (laser vs. ballistic). Conclusion: Intracorporal lithotripsy is associated with a significant increase in damage to the ureter; further research is needed to determine its long-term effects.

Outcomes of Elective Ureteroscopy for Ureteric Stones in Patients with Prior Urosepsis and Emergency Drainage: Prospective Study over 5 yr from a Tertiary Endourology Centre

BackgroundElective treatment of ureteric stones is needed after emergency drainage of urosepsis. ObjectiveWe wanted to look at the outcomes of elective ureteroscopic stone treatment in patients with prior sepsis and emergency drainage via retrograde ureteric stent (RUS) or percutaneous nephrostomy (PCN). Design, setting, and participantsData of all patients who underwent elective ureteroscopy (URS) for stone disease over 5 yr (March 2012–December 2016) were prospectively collected. InterventionElective URS following previous emergency RUS or PCN. Outcome measurements and statistical analysisOutcomes were collated for consecutive patients who underwent emergency drainage for urosepsis secondary to stone disease, followed by elective URS. Data was collected regarding patient demographics, stone parameters, and clinical outcomes. Statistical analysis was performed using SPSS version 24. Results and limitationsIn total, 76 patients underwent 82 elective procedures (six underwent bilateral URS) with a male to female ratio of 1:2 and a mean age of 57 yr. Emergency decompression was achieved via RUS in 63 (83%) and PCN in 13 (17%) patients. A positive urine culture on presentation was obtained in 26 (34%) patients, and 27 (36%) patients were admitted to the intensive care unit (ICU). The mean single and overall stone size was 8.6 (2–23) and 10.8 (2–32) mm, respectively. The mean operating time was 42 (5–129) min with stone-free rate (SFR) of 97% (n=74). There were three (4%) complications in total, of which two patients developed urinary tract infection needing intravenous antibiotics (Clavien II) and a third developed sepsis (Clavien IV) needing ICU admission. There was no difference in ureteroscopic lithotripsy outcomes (operative time, complications, or SFR) on comparing initial RUS or PCN, admission to ICU or ward, positive or negative urine culture result, presence of single or multiple stones, and between American Society of Anaesthesiologists (ASA) grade of patients. The ASA grade of patients was a significant predictor of day case procedures (p=0.001). ConclusionsElective URS achieved excellent outcomes in patients who previously presented with obstructing calculi and sepsis needing emergency decompression. Overnight inpatient admission was needed in some patients with a higher ASA grade. Patient summaryIn this report, we look at the outcomes of planned ureteroscopy procedures for stone disease in patients with previous urosepsis. These patients with previous emergency drainage for urosepsis had excellent outcomes from their planned ureteroscopic surgery. This information will help in preoperative patient optimisation and counselling.

Outcomes of Ureteroscopic Stone Treatment in Patients With Spinal Cord Injury

To evaluate the association of clinical factors on outcomes in patients with spinal cord injury (SCI) undergoing ureteroscopy. Immobility, recurrent urinary tract infection, and lower urinary tract dysfunction contribute to renal stone formation in patients with SCI. Ureteroscopy is a commonly utilized treatment modality; however, surgical complication rates and outcomes have been poorly defined. Evidence guiding safe and effective treatment of stones in this cohort remains scarce. Records were retrospectively reviewed for patients with SCI who underwent ureteroscopy for kidney stones from 1996 to 2014 at a single institution. Multivariate relationships were evaluated using a general estimating equation model. Forty-six patients with SCI underwent a total of 95 ureteroscopic procedures. After treatment, stone-free rate was 17% and 20% with <2-mm fragments. The complication rate was 21%. On multivariate analysis, SCI in cervical (C) levels was associated with higher risk of complications (C3: odds ratio [OR] 3.83, 95% confidence interval [CI] 2.17-6.98; C6: OR 3.83, 95% CI 1.08-13.53). American Spinal Injury Association Scale A classification was associated with a lower probability of stone-free status (OR 0.16, 95% CI 0.03-0.82). Patients averaged 2.2 procedures yet more procedures were associated with lower stone-free status (OR 0.83, 95% CI 0.03-0.32). Chronic obstructive pulmonary disease and bladder management modality were not associated with stone-free status or complications. In patients with SCI, higher injury level and complete SCI were associated with worse stone clearance and more complications. Stone-free rate was 17%. Overall, flexible ureteroscopy is a relatively safe procedure in this population. Alternative strategies should be considered after failed ureteroscopy.

A comparative study between a single dose pre-induction antibiotic versus continuous antibiotics to prevent urinary tract infection during ureteroscopy

Background and objective: This study aimed to evaluate the effect of adding postoperative antibiotics in reducing the incidence of symptomatic urinary tract infections following ureteroscopic stone treatment beyond the recommended preoperative dose. Methods: This prospective comparative study was conducted between March and November 2017. A total of 80 patients with preoperative negative urine cultures who underwent ureteroscopy were randomly allocated. All the patients received a single dose antibiotic before the induction of anesthesia, and a group of them also received postoperative antibiotics. The rate of symptomatic urinary tract infection was compared between the patients who received only preoperative antibiotics (group 1) and those who received pre- and postoperative antibiotics (group 2). Results: Eighty patients underwent ureteroscopy for stone treatment. The time to follow up was 4±2 weeks from ureteroscopy. Eleven (13.8%) patients in total developed urinary tract infections postoperatively, including five (12.5%) from group 1 and six (15%) from group 2, P = 0.74. In group 1, four patients presented with cystitis and one with sepsis; those patients with infections in group 2 presented with pyelonephritis (n=2) and cystitis (n=4). Risk factors such as preoperative stenting, nephrostomy tubes, and Foleys catheters did not differ between groups. Conclusion: The postoperative symptomatic urinary tract infection rate in this study (13.8%) is in agreement with previous reports. This study suggests that a single preoperative dose of antibiotics is sufficient, and additional postoperative antibiotics do not decrease infection rates after ureteroscopic stone treatment.

Ureteroscopic Stone Treatment

Renal and ureteral stone treatment has evolved from an open operation to being entirely endoscopic. Since the inception of the natural orifice treatment of stones, there have been many more advancements in multiple aspects of the case, including smaller scopes, higher-resolution imaging, and more powerful lasers. This technological evolution in ureteroscopic stone treatment has broadened its indication as a first-line therapy by helping to attenuate the learning curve and expedite stone fragmentation and extraction. This overview includes the evolution of ureteroscopic stone treatment; however, the majority is dedicated to reviewing equipment and operative techniques pertaining to ureteroscopic stone treatment of upper tract stones. This review contains 10 highly rendered figures, 5 tables, and 43 references Key words: holmium laser, kidney, lithotripsy, nephrolithiasis, ureter, ureteral stent, ureteroscopy

Ureteroscopic Laser Lithotripsy: A Review of Dusting vs Fragmentation with Extraction.

Ureteroscopic laser lithotripsy is becoming the most commonly utilized treatment for patients with urinary calculi. The Holmium:YAG (yttrium aluminum garnet) laser is integral to the operation and is the preferred flexible intracorporeal lithotrite. In recent years, there has been increasing interest in examining the effect of varying the laser settings on the effectiveness of stone treatment. Herein, we review the two primary laser treatment approaches: dusting and fragmentation with extraction. We reviewed PubMed and MEDLINE databases from January 1976 through January 2017. All authors participated in the development of consensus definitions of dusting and fragmentation with extraction. The review protocol adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology. When the Holmium:YAG laser is used to treat stones, there are two parameters that can be adjusted: power (J) and frequency (Hz). In one treatment paradigm, which became termed "fragmentation with extraction," laser settings that relied on high energy and low frequency were used. Another paradigm, which became termed "dusting," utilized low energy and high frequency settings, which had the effect of breaking off exceedingly small fragments from the stone. Both dusting and fragmentation with extraction approaches to ureteroscopic stone treatment are effective. In fact, there is little evidence that one approach is better than the other. However, each does have relative advantages and disadvantages, which should be considered. Although dusting tends to be associated with shorter procedure times and a lower risk of ureteral damage, this approach may place the patient at increased risk for future stone events should all of the resultant debris not be expelled from the collecting system. The active removal associated with fragmentation with extraction, in contrast, may provide for a more complete initial stone clearance.

MP75-03 UNPLANNED 30-DAY ENCOUNTERS AFTER URETERO-RENOSCOPY FOR UROLITHIASIS

You have accessJournal of UrologyStone Disease: Surgical Therapy VII1 Apr 2017MP75-03 UNPLANNED 30-DAY ENCOUNTERS AFTER URETERO-RENOSCOPY FOR UROLITHIASIS Kefu Du, Robert Wang, Joel Vetter, Alethea Paradis, Alana Desai, Robert Figenshau, and Ramakrishna Venkatesh Kefu DuKefu Du More articles by this author , Robert WangRobert Wang More articles by this author , Joel VetterJoel Vetter More articles by this author , Alethea ParadisAlethea Paradis More articles by this author , Alana DesaiAlana Desai More articles by this author , Robert FigenshauRobert Figenshau More articles by this author , and Ramakrishna VenkateshRamakrishna Venkatesh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2151AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While stone treatment by ureteroscopy is increasingly performed, it incurs frequent unplanned encounters. We aim to identify avoidable predictors to minimize 30-day encounters. METHODS We performed retrospective chart review on 157 patients who underwent ureteroscopy for urolithiasis between January and June 2016. Patient demographics, stone characteristics, operative details, and 30-day postoperative unplanned patient-initiated phone calls, emergency department (ED) visits, and readmissions were collected. Administrative patient phone calls were excluded. In order to obtain the most accurate ED and readmission rates, questionnaires were delivered to patients via telephone or email and supplemented chart review data. Fisher′s exact and Wilcoxon rank-sum tests were used for qualitative and quantitative variables, respectively. RESULTS There were 44 (28%) unplanned patient-initiated phone calls, 23 (14.6%) ED visits, and 8 (5.1%) readmissions postoperatively. The most common chief complaints and ED diagnoses are listed in Table 1. Factors associated with a higher rate of phone calls include first time stone procedure (37% vs 21%, p = 0.03), outpatient status (30% vs 0%, p = 0.02), intraoperative stent placement (31% vs 0%, p = 0.01), and stent removal at home (59% vs 29%, p = 0.01). Factors associated with increased rate of ED visits were first time stone procedure (23% vs 8%, p = 0.01) and ureteral access sheath usage (30% vs 12%, p = 0.02). Factors associated with a higher rate of readmissions were bilateral procedure (20% vs 3%, p = 0.01) and ureteral access sheath usage (15% vs 3%, p = 0.03). Interestingly, of the 16 patients who had no intraoperative stenting, none had unplanned phone call, ED visit or readmission. Stone number and location, operative time, Charleston comorbidity, and history of preoperative urinary tract infection were not significantly associated with postoperative encounters. CONCLUSIONS Pain, first time stone treatment, and presence of a ureteral stent were common reasons for postoperative encounters after ureteroscopy. Development of a clinical care pathway for ureteroscopic stone treatment including patient education and pain management may minimize these encounters and improve treatment quality and cost. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1004 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Kefu Du More articles by this author Robert Wang More articles by this author Joel Vetter More articles by this author Alethea Paradis More articles by this author Alana Desai More articles by this author Robert Figenshau More articles by this author Ramakrishna Venkatesh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...