Unsuccessful Medical Expulsive Therapy: A Cost to Waiting?

Clinical, Diagnostic, and Metabolic Characteristics Associated with Nephrolithiasis in the Black Women's Health Study

Background/Objectives: Nephrolithiasis (kidney stones) is a frequently occurring urologic condition resulting in significant patient morbidity and healthcare costs. Despite the higher prevalence of metabolic risk factors for nephrolithiasis among Black women, there have been few epidemiologic studies of kidney stones focusing on this group. Methods: We describe demographic and health characteristics, diagnostics, and metabolic profiles of US Black women with self-reported kidney stones. The women were participants in the Black Women's Health Study (BWHS), a large prospective cohort of US Black women (median age 38 years) begun in 1995. Results: Among the 2750 BWHS participants who completed an online supplemental questionnaire assessing urologic health, 201 women reported nephrolithiasis. Of this number, 62% had completed ≥ 16 years of education, and 82% reported access to health care. Overall, 39% reported experiencing ≥ 2 stones in their lifetime, and 29% required surgery to treat the condition. Thirty-two percent reported having completed a metabolic evaluation, while 70% had undergone a CT scan to diagnose nephrolithiasis. The frequency of metabolic evaluation increased with the number of metabolic components reported: 3% (0 components) to 43% (3-4 components). Conclusions: Our findings are consistent with reports of lower rates of metabolic evaluation among Black patients despite their having multiple risk factors for nephrolithiasis. Further study is needed to identify the barriers and facilitators of metabolic and diagnostic workup of nephrolithiasis in Black women.

Work absence and productivity loss of patients undergoing a trial of spontaneous passage for ureteral stones

Patients with ureteral stones are often managed with a spontaneous trial of passage. While cost effective, the current literature has not examined the effects of a trial of passage on patients' work productivity. In this study, we aim to characterize work absence and productivity losses in a cohort of patients undergoing a trial of passage for ureteral stones. Actively employed patients aged 18 to 64 and discharged from Duke emergency departments without surgical intervention for ureteral stones ≤ 10 mm were contacted by phone four weeks after their presentation. Participants completed the Institute for Medical Technology Assessment Productivity Cost Questionnaire which assesses three domains: absenteeism - missed work; presenteeism -productivity when returning to work; and unpaid work - assistance with household work. Linear regression associated demographic and stone factors with productivity losses.109 patients completed the survey. In total, 67% of patients missed work, 46% had decreased productivity when returning to work, and 55% required assistance with unpaid work. 59% of patients with stones ≤ 5 mm missed work versus 84% with stones > 5 mm (p = 0.009). African American race (coefficient 23.68, 95% confidence interval 2.24-45.11, p = 0.031), first-time stone formers (coefficient 20.28, 95% confidence interval 2.50-38.07, p = 0.026), and patients with stones > 5 mm (coefficient 25.34, 95% CI 5.25-45.44, p = 0.014) were associated with increased productivity losses. The majority of patients miss work while undergoing a trial of passage and many have decreased productivity when returning to work. This information may help counsel patients in emergency departments, especially first-time stone formers, and prevent return visits.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

The Development of an Artificial Intelligence Model Based Solely on Computer Tomography Successfully Predicts Which Patients Will Pass Obstructing Ureteral Calculi

OBJECTIVE

To improve upon prior attempts to predict which patients will pass their obstructing ureteral stones, we developed a machine learning algorithm to predict the passage of obstructing ureteral stones using only the CT scan at a patient's initial presentation.

METHODS

We obtained Institutional Review Board approval to conduct a retrospective study by extracting data from all patients with an obstructing 3-10 mm ureteral stone. We included patients with sufficient data to be categorized as having either passed or failed to pass an obstructing ureteral stone. We developed a 3D-convolutional neural network (CNN) model using a dynamic learning rate, the Adam optimizer, and early stopping with 10-fold cross-validation. Using this model, we calculated the area under the curve (AUC) and developed a model confusion matrix, which we compared with a model based only on the largest dimension of the stone.

RESULTS

A total of 138 patients met inclusion criteria and had adequate images that could be preprocessed and included in the study. Seventy patients failed to pass their ureteral stones, and 68 patients passed their stones. For the 3D-CNN model, the mean AUC was 0.95 with an overall mean sensitivity of 95% and mean specificity of 77%, which outperformed the model based on stone-size.

CONCLUSION

The 3D-CNN model predicts which patients will pass their obstructing ureteral stones based on CT scan alone and does not require any further measurements. This can provide useful clinical information which may help obviate the need for a delay in care for patients who inevitably require surgical intervention.

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage

OBJECTIVES

To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease.

METHODS

We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP.

RESULTS

We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant.

CONCLUSION

Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease

PURPOSE

Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery.

MATERIALS AND METHODS

A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery.

RESULTS

Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression.

CONCLUSIONS

Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.

Beyond medical expulsive therapy: evolution to supported stone passage for ureteric stones

OBJECTIVE

To evaluate the impact of removing tamsulosin from standardized ureteric stone clinical protocols on rate of stone surgery.

PARTICIPANTS AND METHODS

We conducted a single-centre, comparison of all patients with unilateral, <1 cm ureteric stones presenting to a stone clinic after discharge from the emergency department during consecutive years. In the initial year, patients were initially offered medical expulsive therapy (MET) with tamsulosin. In the subsequent year, the protocol was modified to focus on symptom control without tamsulosin; this was termed 'supported stone passage' (SSP). The primary outcome was rate of stone surgery within 90 days of the initial clinic encounter.

RESULTS

Among 723 patients (360 MET, 363 SSP), the rate of attempted stone passage increased from 65% to 74%, between the initial and the subsequent year (P < 0.016). Tamsulosin prescription in patients to attempting stone passage decreased from 84% to 13% (P < 0.001). In patients attempting stone passage, the rate of stone surgery was 26% in the METand 19% in the SSP group (P = 0.066). The overall surgery rate decreased from 51% in the MET group to 40% in the SSP group (P = 0.003). Multivariable analysis, controlling for age, sex and stone burden, did not demonstrate a difference in either rate of attempting to pass stones or in rate of failure of passage according to care protocol. We were unable to demonstrate an independent effect of tamsulosin on failure of passage. Overall, surgical intervention was less likely in the SSP phase than in the MET phase, with an odds ratio of 0.64 (confidence interval) 0.44-0.91; P = 0.013).

CONCLUSIONS

Removing tamsulosin from clinical protocols did not impair stone passage in patients attempting to pass stones.