Impact of gender on success and complication rates after ureteroscopy

Ureteroscopy for urolithiasis in bedridden patients: it is feasible and acceptable

PURPOSE

To investigate the safety of transurethral ureteroscopy (URS) for urolithiasis in bedridden patients and to identify bedridden patient-specific risk factors for postoperative complications.

METHODS

The patients who underwent URS for urolithiasis were divided into bedridden patients and good performance status (PS) patients, and the groups were compared regarding their clinical characteristics and postoperative complications. A multivariable logistic regression analysis was performed to evaluate independent predictors of postoperative febrile urinary tract infection (fUTI).

RESULTS

A total of 1626 patients were included, 276 in the bedridden patient group, and 1350 in the good PS patient group. The bedridden patient group had a significantly higher age and higher proportion of females and had multiple comorbidities. In 77 patients (27.9%), 88 postoperative complications developed for the bedridden patient group. Clavien-Dindo grade III or IV complications were observed in only 8 patients. No grade V complications were observed. The most common complication was fUTI. The frequency of fUTI with grade III or IV for the bedridden patient group (2.2%) was higher compared with the good PS patient group (0.5%), but the difference was not statistically significant (p = 0.13). Bedridden patient-specific risk factors for fUTI included female sex, diabetes mellitus, cerebrovascular comorbidities, lower extremity contracture, and prolonged operative time.

CONCLUSION

URS for urolithiasis is a feasible and acceptable procedure in bedridden patients, despite the moderate rate of postoperative complications. The identified risk factors provide a framework for risk stratification and individualized care in this unique patient population.

Does gender influence retrograde intrarenal surgery (RIRS) outcomes? Data from the Flexible Ureteroscopy Outcomes Registry (FLEXOR)

INTRODUCTION AND OBJECTIVES

As well established flexible ureteroscopy (RIRS). There is still no evidence if gender can have any influence on the outcomes and complication when performing. This study aims to evaluate the role that gender has in performing flexible ureteroscopy from a large series of patients.

METHODS

This study retrospectively analyzed patients who underwent RIRS for renal stones from January 2018 to August 2021 within the multicentric FLEXOR registry. Demographics, stone characteristics, perioperative findings, results and complications were analyzed and compared between gender groups.

RESULTS

A total of 6669 patients were included, 66.1% were male and 33.9% were female. Stone characteristics was comparable between groups. Female patients had significant higher fever and positive urine culture rates (12% vs. 8% and 37% vs. 34%). Also, females had a slight longer hospital stay (3.8 vs. 3.5 days; P < 0.001) and more residual fragments after the procedure (23.03% vs. 20.97 (P = 0.032). Overall complications were slightly significantly higher in women (15.74% vs. 14% (P = 0.042)) mainly at the expense of fever rates (6.9% vs. 5.7%) whereas the risk of sepsis was similar in both groups. A multivariate analysis showed that larger stone size, multiple and lower pole stones seem to have a negative impact in the incidence of residual stones and complications.

CONCLUSION

Our real life global study reflects that female gender may have a correlation with a slightly increased residual fragment rate and overall low grade complications. However, women can safely be treated with RIRS with no increased the rate of sepsis with appropriate care.

Single-dose fosfomycin could prevent infectious complications after retrograde intrarenal surgery: A prospective study

BACKGROUND

In this study, we aimed to show the protective effect of a single-dose Fosfomycin from infective complications against the standard usage of cephalosporine before retrograde intrarenal surgery.

MATERIAL

A total of 186 patients who underwent retrograde intrarenal surgery between 2020 and 2021, included the study. Patients were divided into two groups: group 1(n=49), patients who received an oral dose of 3g Fosfomycin tromethamine powder administered 4-6h before the operation; and group 2 (n=137): patients who received Cephalosporin 30min before surgery and an additional dose 6h after surgery.

RESULTS

The median age and stone size were significantly higher in the cephalosporin group (P=0.006 and P=0.008, respectively). There was no statistically significant difference between the groups in terms of postoperative fever and postoperative UTI (P=0.408 and P=0.438). Additionally, no patient developed sepsis. and no adverse event was seen in either group. Preoperative urinary tract infection (UTI) and previous Extracorporeal Shock Wave lithotripsy (ESWL) were independent risk factors and increased postoperative infectious complications (O.R. 2.929 95% C.I. 0.723, P<0.001, and O.R. 2.860 95% C.I. 0.985, P=0.004, respectively).

CONCLUSION

Infectious is still one of the important complications after RIRS, and preoperative UTI is an independent risk factors for infections. Fosfomycin monotherapy could be sufficient and is also effective in patients with preoperative culture positive.

Safety and efficacy of ureteroscopy for urolithiasis in octogenarians

OBJECTIVE

To examine the safety and efficacy of ureteroscopy (URS) for urolithiasis in octogenarians, and identify preoperative risk factors for the incidence of postoperative complications.

METHODS

The patients who underwent URS for urolithiasis were divided into octogenarians and younger patients (age: <80 years), and the groups were compared regarding their clinical characteristics, intraoperative and postoperative complications, and stone-free rate. The predictors of postoperative complications were evaluated using logistic regression models.

RESULTS

A total of 1207 patients were included, 166 in the octogenarian patient group and 1041 in the younger patient group. The proportion of female patients (p < 0.001), American Society of Anesthesiologists (ASA) score (p < 0.001), rate of preoperative pyelonephritis (p < 0.001), and diabetes mellitus (p = 0.003) were higher in the octogenarian group. No statistically significant differences were found between the two groups regarding stone size, location, and intraoperative complications. Postoperative complications, which reached a significant difference, were observed in 34 (20.5%) octogenarians and 117 (11.2%) younger patients (p = 0.002). However, age itself was not significantly associated with postoperative fever, the most frequent postoperative complication, in multivariate analysis. Female sex, ASA score of ≥3, history of diabetes mellitus, and prolonged operative time (≥120 min) were the significant predictors of fever. The stone-free rate in the octogenarian group was superior to that in the younger patient group (80.1% vs. 70.6%, respectively; p = 0.035).

CONCLUSION

Our results suggest that URS for urolithiasis can be safely and effectively applied to octogenarians in selected cases.

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

OBJECTIVES

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Gender Differences in Kidney Stone Disease (KSD): Findings from a Systematic Review

Purpose of Review

The prevalence of kidney stones is rising and historically carries a preponderance for males. However, recent evidence has questioned whether this gender gap is closing. The aim of this systematic review was to examine this further as well as evaluate possible underlying causes.

Recent Findings

Recent evidence confirms the disparity in kidney stone disease between genders is closing. In the modern era, the rise in prevalence among females has been greater, especially in adolescence. Quality of life is also more adversely affected by kidney stone events among females who are also more likely to develop sepsis after endourological surgery. Males, however, are more likely to present with stone events during periods of high ambient temperatures

Summary

Recent literature demonstrates a temporal change in the disease burden of KSD among men and women. The latter, especially adolescent females, are more likely to develop KSD in their lifetime compared to previous eras. Determining causation is complex and continued research is warranted.

Ureteroscopy-assisted puncture for ultrasonography-guided renal access significantly improves overall treatment outcomes in endoscopic combined intrarenal surgery

OBJECTIVES

To assess the impact and availability of ureteroscopy-assisted puncture for percutaneous renal access during ultrasonography-guided miniaturized (mini)-endoscopic combined intrarenal surgery for large volume renal and/or proximal ureteral stones.

METHODS

We conducted a multi-institutional retrospective cohort study for urolithiasis treatment. Data from a total of 313 patients who underwent mini-endoscopic combined intrarenal surgery to treat renal and/or ureteral stones between January 2016 and April 2020 were collected. We compared the outcomes between ultrasonography-guided mini-endoscopic combined intrarenal surgery with and without ureteroscopy-assisted puncture (ureteroscopy-assisted puncture(+) group [n = 126] and ureteroscopy-assisted puncture(-) group [n = 187] group, respectively). The primary outcome was requirement for additional surgical intervention. Secondary outcomes were stone-free rate, complications and total procedure, fluoroscopy, hospital stay, and postoperative ureteral stent placement durations.

RESULTS

The ureteroscopy-assisted puncture(+) group had a lower additional surgical intervention rate and a higher stone-free rate immediately after and 3 months after surgery than the ureteroscopy-assisted puncture(-) group (5.6% vs 19.7%, P < 0.001; 82.5% vs 65.8%, P = 0.001; 59.5% vs 44.6%, P = 0.011). The median total procedure, fluoroscopy, and postoperative ureteral stent placement durations were 18 min, 3 min, and 5 days shorter, respectively, in the ureteroscopy-assisted puncture(+) group. Multivariate analyses showed that ureteroscopy-assisted puncture was associated with a decreased risk of additional surgical intervention (odds ratio 0.31, P = 0.011) and postoperative infection (odds ratio 0.34, P = 0.003) and decreased total procedure (estimate = -11 min; P = 0.011), fluoroscopy (estimate = -3 min; P = 0.034), and postoperative ureteral stent placement (estimate = -8 days; P = 0.011) durations. Female patients and those with smaller stone volumes or without hydronephrosis were identified as ideal ureteroscopy-assisted puncture candidates.

CONCLUSIONS

Ureteroscopy-assisted puncture during mini-endoscopic combined intrarenal surgery could provide favorable surgical outcomes, especially in female patients without collecting system obstruction.

The Impact of Race and Gender on 30-Day Urologic Surgery Complications

OBJECTIVE

To assess the effect of race and gender on complications after urologic surgeries.

MATERIALS AND METHODS

The American College of Surgeons' National Surgical Quality Improvement Program data was utilized for patients undergoing urologic surgeries. Patient demographics and comorbidities were analyzed. Postoperative complications occurring in a 30-day postoperative period were noted and classified per the Clavien-Dindo classification.

RESULTS

From 2008-2018, 284,050 patients underwent urologic surgery. The majority were men (80%) and identified as non-Hispanic white (80%). Complications occurred in 12%, including 9% minor, 5% major, and mortality in 0.6%. Univariate analysis found female gender, non-Hispanic black and Native American race, and patient comorbidities (hypertension, diabetes, heart failure, lung disease, chronic kidney disease) to be associated with increased risk of complications. Female gender remained a significant predictor on multivariable logistic regression, and Hispanic race was found to be an independent negative predictor of postoperative complications, although these results did not appear clinically significant. On exclusion of gender-specific urologic surgeries, female gender was associated with higher likelihood of minor complications, but male gender was associated with higher likelihood of major complications or mortality.

CONCLUSION

Race was not associated with postoperative complication rate. Patient comorbidities are associated with an increased risk of 30-day postoperative complications. Females were more likely to have minor and males were more likely to major complications. Optimizing patient comorbidities preoperatively is key to improving postoperative outcomes.

Predictors and Strategies to Avoid Mortality Following Ureteroscopy for Stone Disease: A Systematic Review from European Association of Urologists Sections of Urolithiasis (EULIS) and Uro-technology (ESUT)

CONTEXT

While kidney stone disease is common and ureteroscopy (URS) is perceived as minimally invasive, there is mortality associated with treatment.

OBJECTIVE

The aim of this review was to ascertain the number of mortalities from URS for stone disease over the past three decades, identify relevant patient risk factors and predictors of mortality, and summarise the key recommendations so that similar instances can be avoided, and lessons can be learnt.

EVIDENCE ACQUISITION

A systematic literature search was conducted following Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) methodology for English-language article reporting on data from 1990 to December 2020. Data collated from each study included patient and stone characteristics, number of mortalities, and cause of death.

EVIDENCE SYNTHESIS

Fifteen studies met our inclusion criteria and revealed a total of 72 mortalities from ten countries. The age range of reported patients varied from 21 to 89 yr, with over 60% being above 65 yr of age and 97% with some comorbidity. Based on available data, death reports in females were three times more than those in males. The stone size ranged from 10 to 38 mm. Treatment of larger stones corresponded to a longer operative time, with procedural duration varying from 30 to 120 min. Of the reported causes of mortality in 42 patients, the aetiology was sepsis in over half of the patients, with other causes being cardiac-related, respiratory-related, multiorgan failure, and haemorrhagic complications.

CONCLUSIONS

Although the reported URS mortality rate seems to be low, there has been a rise in deaths over the past decade. Efforts must be made to have preoperative urine culture, and reduce operative time and stage procedures in patients with a large stone burden. Care must be taken in patients with robust preoperative assessment, intraoperative techniques, and postoperative monitoring for early detection of complications with interdisciplinary management of complex cases.

PATIENT SUMMARY

We reviewed the risk factors associated with postureteroscopy mortality and ways to minimise this. Evidence shows that although reported mortality remains low, there seems to be an increase in mortality in the past decade and urologists must remain vigilant of this.

Study of ureteral and renal morphometry on the outcome of ureterorenoscopic lithotripsy: The critical role of maximum ureteral wall thickness at the site of ureteral stone impaction

Purpose:

The purpose is to study the association of stone, ureteral, and renal morphometric parameters with the relevant outcome variables, i.e., complication rate, stone-free rate (SFR), and operating time of ureterorenoscopic lithotripsy. Although a safe procedure, it still occasionally has major complications. Computed tomography (CT) scan is often performed to diagnose ureteral calculi, providing opportunities for ureteral morphometry that may have a bearing on the outcome of the procedure.

Materials and Methods:

Ureteric, renal, and stone morphometric parameters were measured from CT of the abdomen and pelvis of the 110 patients with ureteral calculi who underwent ureteroscopic lithotripsy (URSL). Data were collected retrospectively in 25 patients and prospectively in 85 patients. Association of these parameters with the outcome variables of the procedure mentioned above was studied.

Results:

On univariate analysis, body mass index, stone size, and maximum ureteral wall thickness (MUWT) were found to have a significant association with URSL complications, SFR, and duration of surgery. On multivariable analysis, only MUWT was found to be an independent risk factor for URSL complications. In 90% of total patients with residual stones, MUWT was found to be >4.8 mm.

Conclusion:

Ureteral wall thickness of >4.8 mm is associated with prolonged duration of surgery and lower SFR. Patients with ureteral wall thickness of >4.8 mm at the site of ureteral stone who are planned for URSL must be counseled about the higher chances of residual stones and the need for additional procedure.

Risk Factors of Urinary Tract Infection After Ureteral Stenting in Patients with Renal Colic During Pregnancy

Introduction: To investigate risk factors associated with urinary tract infection (UTI), following ureteral stenting, for patients with renal colic during pregnancy. Patients and Methods: Patients with renal colic during pregnancy who underwent ureteral stenting in The First Affiliated Hospital of Guangzhou Medical University between 2009 and 2019 were examined retrospectively. Ureteral stenting patients who had UTIs after hospital discharge and before delivery were classified as the infected group. Multivariate logistic regression analysis was used to assess the risk factors associated with UTI after ureteral stenting. Results: A total of 102 patients were enrolled into the study. Mean age was 30 years (interquartile range [IQR]: 26-33 years) and mean gestation age was 22 weeks (IQR: 18-28 weeks). UTI occurred in 21 patients (20.6%). Compared with noninfected patients, infected patients had a higher rate of positive urine culture (52.4% vs 13.6%, p = 0.000), kidney stones ≥10 mm (81% vs 35.8%, p = 0.000), residual stones after ureteral stenting (71.4% vs 43.2%, p = 0.021), and different surgical indications and gestational ages (18 vs 23 weeks, p = 0.00). Multifactor analysis showed that gestational age, positive urine culture (odds ratio [OR] = 6.233, 95% confidence interval [CI]: 1.830-21.227), and stones ≥10 mm (OR = 0.124, 95% CI: 0.031-0.495) were independent risk factors for UTI after ureteral stenting in patients with renal colic. In the infection group, Escherichia coli was the most commonly found organism (47.4%). Conclusions: Gestational age, positive urine culture before surgery, and stone ≥10 mm were risk factors for UTI after ureteral stenting in pregnant patients with renal colic. E. coli was the main pathogen of UTI after this procedure. Preoperative anti-infection treatment needs to be based on drugs that are sensitive to E. coli.

Secondary signs on preoperative CT as predictive factors for febrile urinary tract infection after ureteroscopic lithotripsy

Background

Febrile urinary tract infection (UTI) is one of the most common complications after ureteroscopic lithotripsy (URS). We evaluated the effect of secondary signs on preoperative computed tomography (CT) for febrile UTI after URS.

Methods

In total, 182 patients who underwent URS for ureteral stones from January 2013 to December 2015 were retrospectively included in this study. These patients were divided into two groups according to the presence of postoperative febrile UTI after URS. We compared the clinical factors, stone factors, and secondary signs between the groups. Predictive factors for febrile UTI after URS were analyzed using a multivariate logistic regression model.

Results

Febrile UTI occurred in 26 of the 182 patients. In univariate analysis, presence of comorbid chronic kidney disease (CKD) and stone size were significantly different between UTI and non-UTI groups. Among secondary signs, presence of hydroureter, perinephric fat stranding, periureteral fat stranding, and tissue rim sign were significantly different between the groups. In multivariate logistic regression analysis, comorbid CKD, stone size, perinephric fat stranding, and tissue rim sign were independent predictive factors for febrile UTI after URS.

Conclusion

This study demonstrated that secondary signs including perinephric fat stranding and tissue rim sign on preoperative CT, CKD, and stone size are independent predictive factors for febrile UTI after URS.

New computed tomographic predictors of complicated perioperative course of 17.5F mini-percutaneous nephrolithotomy (mini-PNL)

PURPOSE

Radiological parameters predicting a postoperative stone-free status (SFS) or a complicated perioperative course of mini-PNL, are scarce. Our aim was to identify such factors for prone 17.5F mini-PNL.

METHODS

A monocentric cohort of 103 cases was retrospectively analysed for factors predicting SFS and relevant complications, i.e. Clavien-Dindo (CD) ≥ 2. Parameters measured on preoperative supine CT included maximal stone diameter, skin-to-stone distance (SSD), ideal tract length (ITL), access angle, minimal T12-Lower Kidney Pole distance (T12LP) and minimal Iliac Crest-Lower Kidney Pole distance (ICLP). Infundibulopelvic angle (IPA) was measured on intraoperative pyelography.

RESULTS

The median maximal stone diameter was lower in cases with postoperative SFS [16 mm (Min. 10; Max. 35) vs. 20 mm (Min. 6; Max. 85), p = 0.0052]. CD ≥ 2 was more frequent in cases with a bigger stone burden [19 mm (Min. 13; Max. 85) vs. 16 mm (Min. 6; Max. 49), p = 0.0056] and with the ribs in the access angle [7/23 (30.43%) vs. 8/76 (10.53%); p = 0.0454]. T12LP significantly differed in cases with and without CD ≥ 2 [80.48 mm (± 21.31) vs. 90.43 mm (± 19.42), p = 0.0397]; however, it had no influence on SFS (p > 0.05). SSD, ITL, IPA and ICLP were significant regarding neither SFS nor CD ≥ 2 prevalence (p > 0.05). Using multivariate logistic regression, T12LP was confirmed as an independent predictor on CD ≥ 2 prevalence.

CONCLUSIONS

Preoperative computed tomographic factors indicating elevated kidney position influence perioperative course of mini-PNL. T12LP and the presence of ribs in the access angle are, apart from stone diameter, the most useful indicators for cases at risk of CD ≥ 2.

Predictors of Urinary Infections and Urosepsis After Ureteroscopy for Stone Disease: a Systematic Review from EAU Section of Urolithiasis (EULIS)

PURPOSE OF REVIEW

To present the latest evidence related to the predictors of urinary tract infections (UTIs) and urosepsis after ureteroscopy (URS) for stone disease.

RECENT FINDINGS

Our review suggests that almost half of all post-URS complications are related to infectious complications although reported rates of urosepsis were low. The use of antibiotic prophylaxis, treatment of pre-operative UTI, and low procedural time seem to reduce this risk. However, the risk is higher in patients with higher Charlson comorbidity index, elderly patients, female gender, long duration of pre-procedural indwelling ureteric stents and patients with a neurogenic bladder and with high BMI. Infectious complications following ureteroscopy can be a source of morbidity and potential mortality. Although majority of these are minor, efforts must be taken to minimise them especially in high-risk patients. This includes the use of prophylactic antibiotics, limiting stent dwell and procedural time, prompt identification and treatment of UTI and urosepsis, and careful planning in patients with large stone burden and multiple comorbidities.

Sex differences in the therapy of kidney and ureteral stones

PURPOSE OF REVIEW

Better understanding of sex differences affecting urolithiasis may help us offer tailored treatment strategies to our patients.

RECENT FINDINGS

The incidence of urolithiasis is increasing and the male-to-female ratio has decreased from 3 : 1 to 1.3 : 1 between 1970 and 2000. In women, obesity has a larger effect on the risk of developing urolithiasis [odds ratio (OR) 1.35; 95% confidence interval (CI): 1.33-1.37] compared with men (OR 1.04; 95% CI: 1.02-1.06). Urolithiasis is a risk factor for coronary artery disease in men (risk ratio = 1.23; 95% CI: 1.02-1.49) and for stroke in women (risk ratio = 1.12; 95% CI: 1.03-1.21). Women tolerate cystoscopic stent removal and shock wave lithotripsy better than men. For shock wave lithotripsy menopaused women have reported lower visual analog scale scores than menstruating women (P < 0.001). Female sex was an independent predictor of stone impaction (OR 1.15; 95% CI: 1.03-1.27) and postoperative sepsis after ureteroscopy (OR 2.31; 95% CI: 1.14-4.37).

SUMMARY

The sex gap in urolithiasis is closing. The changing role of women in society and dietary habits can be responsible for this epidemiologic shift. Women show a higher threshold for pain during urologic procedures, but they suffer from infectious complications more than men. Urolithiasis is a risk factor for cardiovascular events in both sexes.

Assessment of Patient and Surgical Variables Including Residency Training Level on Adverse Events After Ureteroscopy for Ureteral Stones: A Multivariate Analysis

PURPOSE

With advances in technology, ureteroscopy (URS) is increasingly utilized for the management of urolithiasis. Previous studies have attempted to characterize the post-operative complication and readmission rates relative to the technical difficulty of the procedure. There is limited data exploring the resident level of training and its effect on adverse outcomes in these cases. We review our experience with URS to create a model to predict factors, including resident experience, that affect rates of post-operative complications.

MATERIALS AND METHODS

We reviewed ureteroscopies performed at our academic facility from January 2009 to December 2013. Ureteral-only stones were examined for demographics, stone characteristics, operative techniques, and resident training level. Post-operative adverse events requiring urology consultation, clinic or emergency department visits, hospital admission, prolonged post-operative hospitalization, or unplanned repeat surgery within 30 days of the procedure were identified and analyzed.

RESULTS

Four hundred seventeen cases of URS for ureteral-only stones were included for study. We identified 53 (12.7%) involving an unexpected post-operative course. Several logistic regression models were created to make a predictive model of adverse events. One model found only lack of stone clearance to be significant for increasing the likelihood of an adverse event. A second model determined that no residency year showed higher odds of adverse outcomes.

CONCLUSIONS

URS has increased in prevalence in recent years, but overall complication rates are low. Resident level of experience does not appear to impact adverse event rate. Stone clearance during initial surgery appears to be the most important in avoiding adverse events. Further expansion of the database over time will improve our ability to predict adverse outcomes in this common procedure.