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Policastro C, Dispagna M, Smith G, Byler T, Wiener S. Factors associated with unplanned clinical encounters for ureteral stent-related symptoms. World J Urol 2024; 42:74. [PMID: 38324162 DOI: 10.1007/s00345-024-04768-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND, INTRODUCTION AND AIM Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters. METHODS AND MATERIALS Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS. RESULTS Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid use returned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002). CONCLUSION Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.
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Affiliation(s)
- Connor Policastro
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Mauro Dispagna
- School of Medicine, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Garrett Smith
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Timothy Byler
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Scott Wiener
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA.
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Verhovsky G, Rappaport YH, Zilberman DE, Neheman A, Zisman A, Gielchinsky I, Chertin L, Sabler IM. Tubeless Ureterorenoscopy-Our Experience Using a 120 W Laser and Dusting Technique: Postoperative Pain, Complications, and Readmissions. J Pers Med 2022; 12:1878. [PMID: 36579609 PMCID: PMC9699241 DOI: 10.3390/jpm12111878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction and Objective: Both double J-stent (DJS) and ureter catheter (UC) drainage represent routine practice following ureterorenoscopy. In select situations, a tubeless approach is possible and safe. In tubeless cases, we use a sheathless dusting technique with the Lumenis® MOSES Pulse™120 H Holmium: YAG laser. We evaluated these three drainage subgroups and compared postoperative pain, complications, and readmissions. Methods: A retrospective database of 269 consecutive patients who underwent primary ureterorenoscopy for the treatment of upper urinary tract stones between October 2018 and August 2019. The cohort was divided according to post-operative drainage as Tubeless, UC, and DJS. The decision on whether to perform post-operative drainage was by surgeon preference. Demographic and clinical parameters such as stone location, number, and burden, hydronephrosis grade, and postoperative complications (fever, acute renal failure, and the obstruction of the upper urinary tract by Stone Street) were assessed. Pain was assessed using a 0−10 Visual Analog Scale score (VAS) and the use of analgesics by dose/case in each group. Results: There were 70 (26%) tubeless, 136 (50%) UC, and 63 (24%) DJS cases. Patients drained with DJSs had a significantly higher stone burden, more severe obstruction, and prolonged operative time. Tubeless and UC-drained patients had the same stone characteristics with maximal diameters of 8.4 (6.1−12) mm and 8 (5.2−11.5) mm in comparison to the stented group, with 12 (8.6−16.6) mm, p < 0.01. The operation time was the longest in the stented group at 49 min (IQR 33−60) in comparison to the UC and tubeless groups at 32 min (23−45) and 28 min (20−40), respectively (p < 0.001). Auxiliary procedures were more prevalent in the stented group, but the overall stone-free rate was not significantly different, p = 0.285. Postoperative ER visits, readmissions, and complications were the highest in the UC-drained group, at 20% in the UC vs. 6% in the tubeless and 10% in the stented groups. Post-operative pain levels and analgesic use were significantly lower in the tubeless group with a significant reduction in opiate usage. Conclusions: A tubeless approach is safe in selected cases with fewer post-operative complications. While DJS should be considered in complex cases, UC may be omitted in straightforward cases since it does not appear to reduce immediate postoperative complications. Those fitted for tubeless procedures had improved postoperative outcomes, facilitating outpatient approach to upper urinary tract stone treatment and patient satisfaction.
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Affiliation(s)
- Guy Verhovsky
- Department of Urology, Shamir Medical Center, Assaf Harofeh Campus, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Urology, Shamir Medical Center, Assaf-Harofeh Zeriffin 7030000, Israel
| | - Yishai H. Rappaport
- Department of Urology, Samson Assuta Medical Center, Ashdod, the Goldman School of Medicine, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Dorit E. Zilberman
- Department of Urology, Sheba Medical Center, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Amos Neheman
- Department of Urology, Shamir Medical Center, Assaf Harofeh Campus, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Amnon Zisman
- Department of Urology, Shamir Medical Center, Assaf Harofeh Campus, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ilan Gielchinsky
- Department of Urology, Shamir Medical Center, Assaf Harofeh Campus, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Leon Chertin
- Department of Urology, Shamir Medical Center, Assaf Harofeh Campus, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Itay M. Sabler
- Department of Urology, Shamir Medical Center, Assaf Harofeh Campus, the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Harper JD, Desai AC, Antonelli JA, Tasian GE, Ziemba JB, Al-Khalidi HR, Lai HH, Maalouf NM, Reese PP, Wessells HB, Kirkali Z, Scales CD. Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS. BMC Urol 2022; 22:53. [PMID: 35387623 PMCID: PMC8988384 DOI: 10.1186/s12894-022-01004-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/10/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains. METHODS In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30. RESULTS The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability. CONCLUSIONS This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.
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Affiliation(s)
- Jonathan D. Harper
- grid.34477.330000000122986657Department of Urology, University of Washington School of Medicine, Seattle, WA 98195 USA
| | - Alana C. Desai
- grid.4367.60000 0001 2355 7002Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO USA
| | - Jodi A. Antonelli
- grid.267313.20000 0000 9482 7121Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Gregory E. Tasian
- grid.239552.a0000 0001 0680 8770Division of Pediatric Urology, Department of Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Justin B. Ziemba
- grid.411115.10000 0004 0435 0884Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Hussein R. Al-Khalidi
- grid.26009.3d0000 0004 1936 7961Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA
| | - H. Henry Lai
- grid.4367.60000 0001 2355 7002Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Anesthesiology, Washington University School of Medicine, St Louis, MO USA
| | - Naim M. Maalouf
- grid.267313.20000 0000 9482 7121Department of Internal Medicine, Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Peter P. Reese
- grid.25879.310000 0004 1936 8972Renal-Electrolyte and Hypertension Division, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA ,grid.25879.310000 0004 1936 8972Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Hunter B. Wessells
- grid.34477.330000000122986657Department of Urology, University of Washington School of Medicine, Seattle, WA 98195 USA
| | - Ziya Kirkali
- grid.419635.c0000 0001 2203 7304National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD USA
| | - Charles D. Scales
- grid.26009.3d0000 0004 1936 7961Departments of Surgery and Population Health Science, Duke Surgical Center for Outcomes Research, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA
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Lee JY, Andonian S, Bhojani N, Bjazevic J, Chew BH, De S, Elmansy H, Lantz-Powers AG, Pace KT, Schuler TD, Singal RK, Wang P, Ordon M. Canadian Urological Association guideline: Management of ureteral calculi - Abridged version. Can Urol Assoc J 2021; 15:383-393. [PMID: 34847343 PMCID: PMC8631858 DOI: 10.5489/cuaj.7652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jason Y. Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Naeem Bhojani
- Department of Urology, Université de Montréal, Montreal, QC, Canada
| | - Jennifer Bjazevic
- Division of Urology, Department of Surgery, Western University, London, ON, Canada
| | - Ben H. Chew
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shubha De
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Hazem Elmansy
- Urology, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | | | - Kenneth T. Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Trevor D. Schuler
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Rajiv K. Singal
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Peter Wang
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Michael Ordon
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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5
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Crivelli JJ, Maalouf NM, Paiste HJ, Wood KD, Hughes AE, Oates GR, Assimos DG. Disparities in Kidney Stone Disease: A Scoping Review. J Urol 2021; 206:517-525. [PMID: 33904797 PMCID: PMC8355087 DOI: 10.1097/ju.0000000000001846] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE We reviewed the available evidence regarding health disparities in kidney stone disease to identify knowledge gaps in this area. MATERIALS AND METHODS A literature search was conducted using PubMed®, Embase® and Scopus® limited to articles published in English from 1971 to 2020. Articles were selected based on their relevance to disparities in kidney stone disease among adults in the United States. RESULTS Several large epidemiological studies suggest disproportionate increases in incidence and prevalence of kidney stone disease among women as well as Black and Hispanic individuals in the United States, whereas other studies of comparable size do not report racial and ethnic demographics. Numerous articles describe disparities in imaging utilization, metabolic workup completion, analgesia, surgical intervention, stone burden at presentation, surgical complications, followup, and quality of life based on race, ethnicity, socioeconomic status and place of residence. Differences in urinary parameters based on race, ethnicity and socioeconomic status may be explained by both dietary and physiological factors. All articles assessed had substantial risk of selection bias and confounding. CONCLUSIONS Health disparities are present in many aspects of kidney stone disease. Further research should focus not only on characterization of these disparities but also on interventions to reduce or eliminate them.
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Affiliation(s)
- Joseph J Crivelli
- Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Naim M Maalouf
- Department of Internal Medicine and Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Henry J Paiste
- Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Kyle D Wood
- Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Amy E Hughes
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gabriela R Oates
- Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Dean G Assimos
- Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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6
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Reicherz A, Maas V, Reike M, Brehmer M, Noldus J, Bach P. Striking a balance: outcomes of short-term Mono-J placement following ureterorenoscopy. Urolithiasis 2021; 49:567-573. [PMID: 33847780 PMCID: PMC8560726 DOI: 10.1007/s00240-021-01264-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/27/2021] [Indexed: 01/02/2023]
Abstract
To evaluate factors affecting the outcomes of short-term Mono-J insertion for 6 h following ureteroscopic stone removal. Patients treated with a Mono-J for 6 h after ureterorenoscopy and stone removal were analysed. FaST 1 and 2 (Fast Track Stent Studies), two consecutive single academic centre studies, were conducted between August 2014 and April 2018. In each study, we randomized patients with renal or ureteral calculi to two groups before ureterorenoscopy. FaST 1 compared a Mono-J insertion for 6 h versus Double-J insertion for 3–5 days after ureterorenoscopy. FaST 2 compared a Mono-J insertion to a tubeless procedure in the same clinical setting. All patients were pre-stented for 3–5 days before URS. The study endpoint was stent-related symptoms as assessed by a validated questionnaire (USSQ). Results were stratified by clinical parameters, stone characteristics and operation details. 108 of 156 initially randomized patients undergoing ureterorenoscopy were included. USSQ scores covering the time 3–5 weeks after stone removal showed a significantly reduced urinary symptoms and pain index compared to the scores before ureterorenoscopy. USSQ results before and after stone removal did not correlate with stone size or operation time and did not differ significantly depending on stone localization, the treating endourologist, or ureterorenoscopic device used (p > 0.05). Six patients (5%) required reintervention. Following secondary ureterorenoscopy and ureteral drainage with a Mono-J for 6 h, quality of life is independent of stone size and localization, operation time, the treating endourologist, and the URS device used.
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Affiliation(s)
- Alina Reicherz
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| | - Verena Maas
- Department of Urology, Augusta Medical Center Bochum, University of Witten/Herdecke, Bochum, Germany
| | - Moritz Reike
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Mirco Brehmer
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Joachim Noldus
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Peter Bach
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
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7
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Wang R, Hu Y, Xie H, Xie L, Yang Y, Liu C. Novel Use of a Modified Triangular Prismatic Double-J Stent for 2- to 3-cm Renal Stones after One-Stage Retrograde Intrarenal Surgery. Urol Int 2021; 105:594-599. [PMID: 33744902 DOI: 10.1159/000512056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/04/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To initially evaluate the outcomes of the modified triangular prismatic double-J (DJ) stent in the management of 2- to 3-cm renal stones after one-stage retrograde intrarenal surgery (RIRS). METHODS Patients with 2- to 3-cm renal stones who underwent one-stage RIRS with indwelling DJ stents were retrospectively evaluated. Eighty-eight patients who were placed the triangular prismatic DJ stents and 64 patients who received standard DJ stents were randomly included. The clinical characteristics and intraoperative and postoperative outcomes of the 2 groups were compared and analyzed. RESULTS The 2 groups had similar baseline characteristics. The urinary symptom score and pain score did not differ between groups (p > 0.05). The residual fragments of the 2 groups were similar 1 day after operation (p = 0.134). There was no significant difference in residual fragments in the lower calyx between groups at the time of stent removal (p = 0.834). The patients in the modified group had better spontaneous passage of residual fragments in the nonlower calyx than those in the standard group during the 2 weeks with the stents (p = 0.005). Fewer patients in the modified group had residual fragments (>4 mm) in the nonlower calyx (p = 0.026) and ureter (p = 0.010) than the patients with standard stents at the time of stent removal. CONCLUSION The indwelling triangular prismatic DJ stent is a safe and efficient treatment method. Patients with these stents had better spontaneous residual fragment passage than those with the standard DJ stents.
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Affiliation(s)
- Rui Wang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yude Hu
- Department of Urology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Haijie Xie
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Linguo Xie
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yu Yang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Chunyu Liu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China,
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8
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Videourology Abstracts. J Endourol 2021. [DOI: 10.1089/end.2021.29107.vid] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Reicherz A, Maas V, Wenzel P, Dahlkamp L, Palisaar J, von Bodman C, Noldus J, Bach P. Transient stent placement versus tubeless procedure after ureteroscopy retrograde surgery stone extraction (Fast Track Stent study 2): A randomized prospective evaluation. Int J Urol 2020; 27:749-754. [PMID: 32974894 DOI: 10.1111/iju.14291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether in pre-stented patients undergoing ureteroscopic stone removal (ureteroscopy retrograde surgery) a tubeless procedure provides a better outcome compared with short-term (6 h) ureteral stenting using an external ureteral catheter. METHODS In this single academic center study (Fast Track Stent study 2), carried out between May 2016 and April 2018, 121 patients with renal or ureteral calculi were initially treated with double-J insertion. Before secondary ureteroscopy retrograde surgery, patients were prospectively randomized into two groups: tubeless versus ureteral catheter insertion for 6 h after ureteroscopy retrograde surgery. Exclusion criteria were acute urinary tract infection, solitary kidney or stone diameter >25 mm. Study end-points were stent-related symptoms assessed by a validated questionnaire (ureteral stent symptom questionnaire), administered both before and 4 weeks after surgery. Numerical ureteral stent symptom questionnaire scores were compared using the Mann-Whitney-U-test. The level of significance was defined as P < 0.05. RESULTS Ureteroscopy retrograde surgery procedures carried out by 13 surgeons resulted in >90% stone removal in all patients (n = 121), with a mean operation time of 19.9 versus 18.0 min for ureteral catheter versus tubeless, respectively (P = 0.37). Patient groups did not differ significantly in their ureteral stent symptom questionnaire scores (urinary index P = 0.24; pain index P = 0.35). Patients showed a significant preference for tubeless procedure over ureteral catheter reinsertion (Question GQ P < 0.0001). The reintervention rate was 13.3% for the tubeless procedure (n = 8) and 1.6% for the ureteral catheter group (n = 1), respectively (P = 0.034). CONCLUSIONS Short-term ureteral catheter and no stent insertion after ureteroscopy retrograde surgery stone extraction in pre-stented patients result in comparable quality of life. However, the reintervention rate is higher for tubeless procedures.
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Affiliation(s)
- Alina Reicherz
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Verena Maas
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Patricia Wenzel
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Lisa Dahlkamp
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Jüri Palisaar
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | | | - Joachim Noldus
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Peter Bach
- Department of Urology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
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10
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Nour HH, Kamel AI, Elmansy H, Badawy MH, Shabana W, Abdelwahab A, Elbaz A, Eleithy T, Rushdy M. Pneumatic vs laser lithotripsy for mid-ureteric stones: Clinical and cost effectiveness results of a prospective trial in a developing country. Arab J Urol 2020; 18:181-186. [PMID: 33029429 PMCID: PMC7473316 DOI: 10.1080/2090598x.2020.1749800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To compare the management of large ureteric stones (>10 mm) with ureterorenoscopy (URS) and laser or pneumatic lithotripsy, and their associated costs. Patients and methods Our prospective study followed the tenets of the Declaration of Helsinki and included 101 patients with large mid-ureteric stones eligible for URS and lithotripsy, and was conducted between January 2018 and August 2019. Patients were randomly divided into two groups: Group 1 had laser lithotripsy, while the Group 2 had lithotripsy using a pneumatic energy source. Results Operative time was significantly longer in cases using pneumatic lithotripsy (P < 0.001). The stone-free rate (SFR) on the first postoperative day was 94% and 92.5% for laser and pneumatic lithotripsy respectively, and there were no statistically significant differences in terms of early (day 1) or late (day 30) SFRs between the groups. Complications were classified according to the Clavien–Dindo Grading System, all complications were Grade <III, with no statistically significant difference between the groups (P = 0.742). The use of pneumatic lithotripsy had lower treatment costs. The number of auxiliary procedures required to reach a stone-free status was statistically equivalent in both groups. Conclusion The type of lithotripsy did not affect the SFR or complications. However, laser lithotripsy was much more expensive than pneumatic lithotripsy. Abbreviations KUB: plain abdominal radiograph of the kidneys, ureters and bladder; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: Ureterorenoscopy; US: ultrasonography
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Affiliation(s)
- Hani H Nour
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Ahmed I Kamel
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Hazem Elmansy
- Department of Urology, Thundar Bay Regional Health Sciences Center, Thunder Bay, ON, Canada
| | - Mohamad H Badawy
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Waleed Shabana
- Department of Urology, Zagazig University, Zagazig, Egypt
| | - Ayman Abdelwahab
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Ahmed Elbaz
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Tarek Eleithy
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
| | - Mamdouh Rushdy
- Department of Urology, Theodor Bilharz Research Institute, Giza, Egypt
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11
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MacCraith E, O'Kelly J, Ryan J, Forde JC, Cheema I, McLornan L, Davis NF. Predictors of emergency department attendance following ureterorenoscopy for urolithiasis. Ir J Med Sci 2020; 189:1445-1449. [PMID: 32239425 DOI: 10.1007/s11845-020-02221-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND We sought to determine the rate of emergency department (ED) attendance for complications after ureterorenoscopy (URS) for stone disease and to identify risk factors for ED attendance after URS. METHODS An analysis of all patients undergoing URS over 12 months at a single institution was performed. Patient demographics, preoperative and intraoperative variables associated with postoperative complications and subsequent ED attendance were collected. Logistic regression analyses were performed to determine predictors of URS complications presenting to ED. RESULTS In total, 202 ureteroscopies were performed on 142 patients for urolithiasis. The mean age was 50.73 ± 13.93 and 66% were male. The incidence of re-presentation to ED was 14.8% (n = 30). Patients presented with postoperative pain (n = 10; 4.95%), pyrexia (n = 9; 4.46%), urinary tract infection (UTI) (n = 7, 3.47%), haematuria (n = 3, 1.49%) and urosepsis (n = 1; 0.5%). Significant risk factors for ED attendance included preoperative stent dwell time > 30 days (P = 0.004), recently treated positive preoperative urine culture (P < 0.0001), stone size ≥ 13 mm (P = 0.043), stone location mid-ureter (P = 0.036) and female gender (P = 0.005). The following factors did not predict ED attendance, stent omission, access sheath utilization and operation duration. CONCLUSION Risk factors for ED attendance after URS include prolonged pre-stent dwell time, stone size ≥ 13 mm, treatment for a positive preoperative urine culture, mid-ureteric stone location and female gender. Urologists should be aware of these findings to decrease the risk of emergency re-presentation after elective URS surgery.
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Affiliation(s)
- Eoin MacCraith
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland.
| | - John O'Kelly
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
| | - James Ryan
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
| | - James C Forde
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
| | - Ijaz Cheema
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
| | - Liza McLornan
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
| | - Niall F Davis
- Department of Urology, Connolly Hospital, Blanchardstown, Dublin 15, Ireland
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13
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Khanna A, Fedrigon D, Monga M, Gao T, Schold J, Abouassaly R. Postoperative Emergency Department Visits After Urinary Stone Surgery: Variation Based on Surgical Modality. J Endourol 2019; 34:93-98. [PMID: 31691596 DOI: 10.1089/end.2019.0399] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction: Urinary stone disease is responsible for more than 1 million emergency department (ED) visits annually. There is increasing regulatory and cost pressure to reduce unplanned episodes of care, particularly after elective surgery. However, the frequency of ED visits in the early postoperative period after different modalities of stone surgery is not well characterized. We aimed at describing rates of postoperative ED visits after percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), and extracorporeal shockwave lithotripsy (SWL). Methods: The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) state databases for Florida (2010-2012), Iowa (2010-2012), California (2010-2011), and New York (2006-2012) were used to identify patients undergoing PCNL, URS, or SWL. The HCUP State Emergency Department Database was used to identify postoperative ED visits in the first 30 days after surgery. Rates of postoperative ED visits were compared across surgery types with chi-square and multivariate logistic regression. Results: A total of 321,899 patients undergoing stone surgery during the study period were identified, including 151,006 (46.9%) URS, 128,040 (39.8%) SWL, and 42,853 (13.3%) PCNL. PCNL had the highest rate of 30-day postop ED visits (13.2%), followed by URS (10.6%) and SWL (7.5%; p < 0.0001). On multivariate logistic regression adjusting for baseline clinical and sociodemographic characteristics, both PCNL (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.56-1.69) and URS (OR 1.33, 95% CI 1.30-1.37) were independently associated with increased risk of postop ED visit when compared with SWL. Conclusion: Among kidney stone surgeries, PCNL has the highest rate of 30-day postoperative ED visits, whereas SWL has the lowest. Postoperative ED visits are an important outcome for both patients and surgeons, and observed differences across surgical modalities should be incorporated into the preoperative shared decision-making process.
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Affiliation(s)
- Abhinav Khanna
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Donald Fedrigon
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manoj Monga
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tianming Gao
- Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
| | - Jesse Schold
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
| | - Robert Abouassaly
- Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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14
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Ordonez M, Hwang EC, Borofsky M, Bakker CJ, Gandhi S, Dahm P. Reprint - Ureteral stent vs. no ureteral stent for ureteroscopy in the management of renal and ureteral calculi: A Cochrane review. Can Urol Assoc J 2019; 14:61-68. [PMID: 31348748 DOI: 10.5489/cuaj.5957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to assess the effects of postoperative ureteral stent placement after uncomplicated ureteroscopy. METHODS We performed a comprehensive search with no restrictions on publication language or status up to February 1, 2019. We only included randomized trials. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the certainty of the evidence according to GRADE. RESULTS We included 23 studies with 2656 randomized patients. Primary outcomes: It is uncertain whether stenting reduces the number of unplanned return visits (very low certainty of evidence [CoE]). Pain on the day of surgery is probably similar (mean difference [MD] 0.32; 95% confidence interval (CI) -0.13-0.78; moderate CoE). Pain on postoperative days 1-3 may show little to no difference (standardized mean difference [SMD] 0.25; 95% CI -0.32-0.82; low CoE). It is uncertain whether stented patients experience more pain on postoperative days 4-30 (very low CoE). Stenting may result in little to no difference in the need for secondary interventions (risk ratio [RR] 1.15; 95% CI 0.39-3.33; low CoE). SECONDARY OUTCOMES We are uncertain whether stenting reduces the need for narcotics and reduces ureteral stricture rates up to 90 days (very low CoE). Rates of hospital admission may be slightly reduced (RR 0.70; 95% CI 0.32-1.55; low CoE). This review was limited to patients in whom ureteroscopy was deemed 'uncomplicated.' In addition, time intervals for the grouping for the reported degree of pain were established post-hoc. The CoE for most outcomes was rated as low or very low for methodological reasons. CONCLUSIONS Findings of this review illustrate the tradeoffs of risks and benefits faced by urologists and their patients when it comes to decision-making about stent placement after uncomplicated ureteroscopy for stone disease.
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Affiliation(s)
- Maria Ordonez
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
| | - Eu Chang Hwang
- Department of Urology, University of Minnesota, Minneapolis, MN, United States.,Department of Urology, Chonnam National University Medical School, Hwasun, South Korea.,Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
| | - Caitlin J Bakker
- Health Sciences Libraries, University of Minnesota, Minneapolis, MN, United States
| | | | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, MN, United States.,Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, United States
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15
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Southern JB, Higgins AM, Young AJ, Kost KA, Schreiter BR, Clifton M, Fulmer BR, Garg T. Risk Factors for Postoperative Fever and Systemic Inflammatory Response Syndrome After Ureteroscopy for Stone Disease. J Endourol 2019; 33:516-522. [DOI: 10.1089/end.2018.0789] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Amanda J. Young
- Biostatistics Core, Biomedical and Translational Informatics Institute, Geisinger, Danville, Pennsylvania
| | - Korey A. Kost
- Phenomic Analytics and Clinical Data Core, Biomedical and Translational Informatics Institute, Geisinger, Danville, Pennsylvania
| | | | - Marisa Clifton
- Department of Urology, Geisinger, Danville, Pennsylvania
| | | | - Tullika Garg
- Department of Urology, Geisinger, Danville, Pennsylvania
- Department of Epidemiology and Health Services Research, Geisinger, Danville, Pennsylvania
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Kang C, Shu X, Herrell SD, Miller NL, Hsi RS. Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy. J Endourol 2019; 33:480-485. [PMID: 30618280 PMCID: PMC7366266 DOI: 10.1089/end.2018.0796] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: Kidney stone formers are at risk for opioid dependence. The aim of this study is to describe opiate exposure and determine predictors of prolonged opiate use among kidney stone formers after surgery. Materials and Methods: A retrospective review was performed among patients who underwent ureteroscopy for upper tract stone disease. Prescription data were ascertained from a statewide prescribing database. Demographic data and surgical factors were collected from the electronic medical record. Predictors of additional postsurgery prescriptions filled within 30 days and persistent opiate use 60 days after ureteroscopy were determined. Results: Among 208 patients, 127 (61%) had received preoperative opiate prescriptions within 30 days before surgery. Overall, 12% (n = 25) of patients required an additional opiate prescription within 30 days after ureteroscopy, and 7% (n = 14) of patients continued to use opiate medications more than 60 days postoperatively. Patients continuing to use opiates long-term were not chronic opiate users. For both outcomes, preoperative opiate exposure, including number of prescriptions, days prescribed, and unique providers had significant associations (all p < 0.05). Additionally, younger age (p = 0.049) was associated with obtaining an additional opiate prescription within 30 days. Lower BMI (p = 0.02) and higher ASA score (p = 0.03) were predictors of continued opiate use more than 60 days after ureteroscopy. Conclusions: The majority of stone formers have had opiate exposure before surgery, often from multiple providers. Approximately 1 in 8 stone formers who undergo ureteroscopy require additional opiate prescriptions within 30 days. A small but significant population receive opiates beyond the immediate postoperative period.
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Affiliation(s)
- Caroline Kang
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xiang Shu
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - S. Duke Herrell
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicole L. Miller
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan S. Hsi
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
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Ordonez M, Hwang EC, Borofsky M, Bakker CJ, Gandhi S, Dahm P. Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi. Cochrane Database Syst Rev 2019; 2:CD012703. [PMID: 30726554 PMCID: PMC6365118 DOI: 10.1002/14651858.cd012703.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ureteroscopy combined with laser stone fragmentation and basketing is a common approach for managing renal and ureteral stones. This procedure is associated with some degree of ureteral trauma. Ureteral trauma may lead to swelling, ureteral obstruction, and flank pain and may require subsequent interventions such as hospital admission or secondary ureteral stent placement. To prevent such issues, urologists often place temporary ureteral stents prophylactically, but the value of doing so remains unclear. OBJECTIVES To assess the effects of postoperative ureteral stent placement after uncomplicated ureteroscopy. SEARCH METHODS We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Google Scholar, and Web of Science), trials registries, other sources of grey literature, and conference proceedings, up to 01 February 2019. We applied no restrictions on publication language or status. SELECTION CRITERIA We included trials in which researchers randomised participants undergoing uncomplicated ureteroscopy to placement of a ureteral stent versus no ureteral stent. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach. MAIN RESULTS Primary outcomesStenting may slightly reduce the number of unplanned return visits (16 trials with 1970 participants; very low CoE), but we are very uncertain of this finding.Pain on the day of surgery as measured on a visual analogue scale (scale 0 to 10; higher values reflect more pain) is probably similar (mean difference (MD) 0.32 higher, 95% confidence interval (CI) 0.13 lower to 0.78 higher; 4 trials with 346 participants; moderate CoE). Pain on postoperative days 1 to 3 may show little to no difference (standardised mean difference (SMD) 0.25 higher, 95% CI 0.32 lower to 0.82 higher; 8 trials with 683 participants; low CoE). On postoperative days 4 to 30, stented participants may experience more pain (8 trials with 903 participants; very low CoE), but we are very uncertain of this finding.Stenting may result in little to no difference in the need for secondary interventions (risk ratio (RR) 1.15, 95% CI 0.39 to 3.33; 10 studies with 1435 participants; low CoE); this corresponds to three more interventions per 1000 participants (95% CI 13 fewer to 48 more).Secondary outcomesStenting may reduce the need for narcotics (7 trials with 830 participants; very low CoE), but we are very uncertain of this finding.Rates of urinary tract infection (UTI) up to 90 days are probably not substantially different (RR 0.94, 95% CI 0.59 to 1.51; 10 trials with 1207 participants; moderate CoE); this corresponds to three fewer infections per 1000 participants (95% CI 23 fewer to 29 more).Ureteral stricture rates up to 90 days may be slightly reduced (14 trials with 1625 participants; very low CoE), but we are very uncertain of this finding.Rates of hospital admission may be slightly reduced (RR 0.70, 95% CI 0.32 to 1.55; 13 studies with 1647 participants; low CoE). This corresponds to 15 fewer admissions per 1000 participants (95% CI 33 fewer to 27 more). AUTHORS' CONCLUSIONS Findings of this review illustrate the trade-offs of risks and benefits faced by urologists and their patients when it comes to decision-making about stent placement after uncomplicated ureteroscopy for stone disease. We noted that both desirable and undesirable effects were small in absolute terms, with findings based mostly on low and very low CoE. The main issues reducing our confidence in research findings were study limitations (mostly risk of performance and detection bias) and imprecision. We were unable to conduct any of the preplanned subgroup analyses, in particular those based on stone size, stone location, and use of ureteral dilation, which may be important effect modifiers. Given the importance of this question, higher-quality and sufficiently large trials are needed to better inform decision-making.
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Affiliation(s)
- Maria Ordonez
- University of MinnesotaDepartment of Urology420 Delaware Street SE, MMC 394MinneapolisMinnesotaUSA
| | - Eu Chang Hwang
- Chonnam National University Medical School, Chonnam National University Hwasun HospitalDepartment of UrologyHwasunKorea, South
| | - Michael Borofsky
- University of MinnesotaDepartment of Urology420 Delaware Street SE, MMC 394MinneapolisMinnesotaUSA
| | - Caitlin J Bakker
- University of MinnesotaHealth Sciences Libraries303 Diehl Hall, 505 Essex Street SEMinneapolisMinnesotaUSA55455
| | | | - Philipp Dahm
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
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Li JK, Teoh JY, Ng CF. Updates in endourological management of urolithiasis. Int J Urol 2018; 26:172-183. [PMID: 30575154 DOI: 10.1111/iju.13885] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/21/2018] [Indexed: 12/23/2022]
Abstract
Urinary stone disease, or urolithiasis, is a very common disease with increasing prevalence and incidence. With the advancement of endoscopic techniques, the treatment outcomes of ureteroscopy (or transureteral lithotripsy) and percutaneous nephrolithotomy are continuously improving. In recent years, there have been many new developments in the field, including new endoscopy design, more effective auxiliary tools, improvement in treatment protocols, introduction of robotic technology, combining both ureteroscopy and percutaneous nephrolithotomy (endoscopic combined intrarenal surgery or transureteral lithotripsy-assisted percutaneous nephrolithotomy), improvement in laser technology, and so on. All these new inputs will further improve the treatment efficacy and safety of the procedures, thus benefiting our patients. In the present review, we briefly go through the main steps of ureteroscopy and percutaneous nephrolithotomy, with a concise description and application of these new advances.
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Affiliation(s)
- Joseph Km Li
- S. H. Ho Urology Center, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jeremy Yc Teoh
- S. H. Ho Urology Center, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chi-Fai Ng
- S. H. Ho Urology Center, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
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