Emergent versus delayed lithotripsy for obstructing ureteral stones: a cumulative analysis of comparative studies

Urgent ureterorenoscopy as a primary treatment for ureteral stone: why not?

To evaluate the feasibility of urgent ureteroscopy (uURS) and elective ureteroscopy (eURS) in the management of patients with renal colic due to ureteral stones. Patients who were operated for ureteral stones between September 2020 and March 2022 were determined retrospectively. The patients who were operated within the first 24 h constituted the uURS group, while the patients who were operated after 24 h were classified as eURS. No limiting factors such as age, gender and concomitant disease were determined as inclusion criteria. Patients with bilateral or multiple ureteral stones, bleeding diathesis, patients requiring emergency nephrostomy or decompression with ureteral JJ stent, and pregnant women were not included. The two groups were compared in terms of stone-free rate, complications, and overall outcomes. According to the inclusion-exclusion criteria, a total of 572 patients were identified, including 142 female and 430 male patients. There were 219 patients in the first group, the uURS arm, and 353 patients in the eURS arm. The mean stone size was 8.1 ± 2.6. The stone-free rate was found to be 87.8% (502) in general, and 92 and 85% for uURS and eURS, respectively. No major intraoperative or postoperative complications were observed in any of the patients. Urgent URS can be performed effectively and safely as the primary treatment in patients with renal colic due to ureteral stones. In this way, the primary treatment of the patient is carried out, as well as the increased workload, additional examination, treatment and related morbidities are prevented.

Cost-effectiveness of quality improvement intervention to reduce time between CT-detection and ureteroscopic laser fragmentation in acute symptomatic ureteric stones management

OBJECTIVE

To prospectively assess clinical and cost effectiveness of emergency ureteroscopic laser fragmentation of urinary stones causing symptoms or obstruction.

PATIENTS AND METHODS

100 consecutive patients with an average (median) age 55.6 (57.5) years and average (median) stone size of 8.2 mm (± 7 mm) between October 2018 and December 2021 who underwent emergency ureteroscopy and laser fragmentation formed the study cohort as part of a clinical service quality improvement. Primary outcome was single procedure stone-free rate and cost-effectiveness. The secondary outcomes were complications, re-admission and re-intervention. A decision analysis model was constructed to compare the cost-effectiveness of emergency ureteroscopy with laser fragmentation (EUL) and emergency temporary stenting followed by delayed ureteroscopy with laser fragmentation (DUL) using our results and success rates for modelling.

RESULTS

Single procedure stone-free rates (SFR) for EUL and DUL were 85%. The re-intervention rate, re-admission and complication rates of the study cohort (EUL) were 9%, 18%, and 4%, respectively, compared to 15%, 20%, and 5%, respectively for the control cohort (DUL). The decision analysis modelling demonstrated that the EUL treatment option was more cost-efficient, averting £2868 (€3260) per patient for the UK health sector. Total cost of delayed intervention was £7783 (€8847) for DUL in contrast to £4915 (€5580) for EUL.

CONCLUSIONS

Implementation of quality improvement project based on a reduction in CT detection-to-laser fragmentation time interval in acute ureteric obstruction or symptoms caused by stones had similar clinical effectiveness compared to delayed ureteroscopic management, but more cost-effective.

Comparison of immediate versus post-stenting ureteroscopy for ureteral stones treatment

Ureteroscopy is a highly effective treatment for ureteral stones, characterized by a high stone-free rate and a low need for re-treatment. Ureteral stent placement can improve the insertion of the ureteral access sheath and ureteroscope but may be associated with higher morbidity prior to and after ureteroscopy. The study aimed to compare immediate versus post-stenting ureteroscopy for ureteral stone treatment in terms of operative time, intra- and post-operative complications, length of hospital stay, and stone-free rate. This prospective study involved 126 patients with ureteral stones divided into two groups: the post-stenting ureteroscopy group (PS-URS), who underwent primary ureteral stenting by double J followed by delayed ureteroscopy, and the immediate ureteroscopy group (I-URS), who underwent immediate ureteroscopy without previous stenting. Sixty-six patients were included in the PS-URS group and 60 patients in the I-URS group. Results were comparable, with no significant differences between both groups. The mean operative time was 33.77±3.51 minutes for the PS-URS group and 34.60±2.01 minutes for the I-URS group. The average length of hospital stay was 0.84±2.55 days for PS-URS and 0.92±1.96 days for I-URS patients. The stone-free rate was 97% in the PS-URS group and 95% in the I-URS group. The overall complication rate was 4.5% versus 5% in the PS-URS and I-URS groups, respectively, with all complications being minor and managed effectively. Immediate ureteroscopy is a safe and relevant operative approach for ureteral stones, with comparative results for post-stenting delayed ureteroscopy.

Practice patterns and outcomes of urgent versus elective ureteroscopy in a statewide surgical collaborative

PURPOSE

Urgent indications for nephrolithiasis treatment include obstruction with intractable pain or renal impairment without untreated infection. Patients and hospitals may benefit from urgent primary ureteroscopy. We aimed to examine variation in urgent ureteroscopy utilization and associated outcomes.

METHODS

Using Reducing Operative Complications from Kidney Stones (ROCKS), we identified all ureteroscopy's between 2016 and 2019. Cases were classified by acuity (elective versus urgent). We assessed practice/urologist variation in urgent ureteroscopy performance. We characterized patients demographic, operative and outcomes data, making bivariate comparisons with elective ureteroscopy to understand implications of urgent surgery. We performed multilevel modeling to understand factors associated with unplanned healthcare encounters after urgent ureteroscopy.

RESULTS

12,859 cases were identified from 33 practices and 204 urologists, 10,854 (84.4%) elective and 2005 (15.6%) urgent. Urgent ureteroscopy was performed on younger patients (53 vs 57, p < 0.001), with higher rates of ureteral stones (72.8% vs 56.8%, p < 0.001). Urgent ureteroscopy rates varied widely by practice (2-70%) and urologist (0-98%). Urgent ureteroscopy had higher stenting rates (77.4% vs 72.5%, p < 0.001), stone free rates (66% vs 58.4%, p < 0.001), and postoperative ED visits (11% vs 7.2%, p < 0.001). There were no differences in intraoperative complications or unplanned hospitalizations. Factors predictive of ED visits in urgent ureteroscopy included concomitant ureteral/renal stone location (OR = 1.53, CI = 1.05-2.23, p = 0.035).

CONCLUSIONS

In Michigan elective ureteroscopy is performed 5 times more frequently than urgent ureteroscopy with wide variation. Urgent ureteroscopy demonstrated low morbidity. Urgent ureteroscopy produced modestly higher stone free rates with a slightly increased frequency of unscheduled ED visits particularly for ureteral stones.

Development and validation of a predictive model for treatment outcome after emergency extracorporeal shockwave lithotripsy in patients with symptomatic ureteral stones during the COVID-19 pandemic: in a large prospective cohort

The predictors of treatment outcome after emergency extracorporeal shockwave lithotripsy (SWL) are not well characterized. Therefore, based on a large prospective cohort, we aimed to develop and validate a nomogram for predicting treatment outcome after emergency SWL in patients with symptomatic ureteral stones. The development cohort included 358 patients with symptomatic ureteral stones who underwent emergency SWL between June 2020 and August 2021 in our hospital. One hundred and twenty-nine patients with symptomatic ureteral stones participated in the validation cohort from September 2021 to April 2022. The data were prospectively recorded. The backward stepwise selection was applied using the likelihood ratio test with Akaike's information criterion as the stopping rule. The efficacy of this predictive model was assessed concerning its clinical usefulness, calibration, and discrimination. Finally, 15.6% (56/358) of patients in the development cohort and 14.0% (18/129) of those in the validation cohort suffered from stone-free failure after emergency SWL. We identified four predictors for stone-free failure: stone size, stone density, skin to stone distance (SSD), and degree of hydronephrosis. This model showed good discrimination with an area under the receiver operating characteristic (AUROC) curves of 0.935 (0.899-0.971) and good calibration (P = 0.059). The decision curve analysis showed that the model was clinically valuable. In this large prospective cohort, we found that stone size, stone density, SSD, and degree of hydronephrosis were predictors of treatment outcome after emergency SWL. This nomogram will be helpful in preoperative risk stratification to provide individualized treatment recommendations for each patient. Furthermore, early identification and appropriate management of patients may increase the success rate of emergency SWL during the COVID-19 pandemic.

Predictors of successful emergency shock wave lithotripsy for acute renal colic

The role of emergency shockwave lithotripsy (SWL) in persistent pain control in patients with ureteral stones is not well established. The aim of this study is to evaluate efficacy as well as the predicting variables for successful early SWL patients with symptomatic ureteral stones. Eighty-six patients with a persistent renal colic secondary to single ureteral stone (6–12 mm) were prospectively enrolled in this study. SWL was performed within 24 h of the onset of flank pain. Pain control and stone-free rate after emergency SWL session were 58.1% and 44.2%, respectively. Seven patients required post-SWL ureteroscopy and ureteral stent placement for uncontrolled pain. The overall 3-month stone-free rate after SWL monotherapy was 83.7%. On multivariate analysis, predictors for pain relief after emergency SWL were lower Hounsfield (HU) stone density, mild hydronephrosis (HN) at presentation and presentation during the first colic episode. Lower HU stone density was the single predictor of successful stone clearance after single emergency SWL session on multivariate analysis. In conclusion, early SWL is feasible and effective in management of ureteral stones presented by renal colic with low HU.

Consensus Statement on Urinary Stone Treatment During A Pandemic: A Delphi Process from the Endourological Society TOWER Research Initiative

INTRODUCTION

The COVID-19 pandemic has had a significant impact on the care of patients with urolithiasis. Recommendations and prioritization of endourologic surgical procedures vary among regions and a comprehensive overall international directive is needed. We used the Delphi method to obtain international consensus on managing urolithiasis patients during the pandemic.

METHODS

A three-round Delphi process was used to elicit expert consensus (53 global key opinion leaders within the Endourological Society from 36 countries) on an extensive survey on management of endourologic patients in a pandemic. Questions addressed general management, inpatient and outpatient procedures, clinic visits, follow-up care and best practices for suspension and resumption of routine care.

RESULTS

Consensus was achieved in 64/84 (76%) questions. Key consensus findings included: consultations should be delivered remotely when possible. Invasive surgical procedures for urolithiasis patients should be reserved for high-risk situations (infection, renal failure, etc.). To prevent aerosolization, spinal anesthesia is preferred over general, whenever feasible. Treatment of asymptomatic renal stones should be deferred. Primary definitive treatment of obstructing or symptomatic stones (both renal and ureteral) is preferred over temporizing drainage. Extracorporeal shock wave lithotripsy should be continued for obstructive ureteral stones. There was consensus on treatment modalities and drainage strategies depending on location and size of the stone.

CONCLUSION

International endourologist members of the Endourological Society participated in this Delphi initiative to provide expert consensus on management of urolithiasis during a pandemic. These results can be applied currently and during a future pandemic.

Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct?

PURPOSE

To describe the change in upper urinary tract stone management in Germany over a 14-year period.

METHODS

Using remote data processing we analyzed the nationwide German billing data from 2006 to 2019. To analyze the clinics' case numbers and regional trends, we used the reimbursement.INFO tool based on standardized quality reports of all German hospitals. To also cover shock wave lithotripsy (SWL) as an outpatient procedure, we analyzed the research database of the Institute for Applied Health Research with a representative anonymous sample of 4 million insured persons.

RESULTS

The number of inpatient interventional therapies for upper tract urolithiasis in Germany increased from 70,099 cases in 2006 to 94,815 cases in 2019 (trend p < 0.0001). In-hospital SWL declined from 41,687 cases in 2006 to 10,724 cases in 2019 (decline of 74%; trend p < 0.0001). The percentage of SWL as an outpatient procedure increased between 2013 and 2018 from 36 to 46% of all performed SWL, while total SWL case numbers declined. Contrarily, the number of ureteroscopies increased from 32,203 cases in 2006 to 78,125 cases in 2019 (increase of 143%; trend p < 0.0001). The number of percutaneous nephrolithotomy also increased from 1673 cases in 2006 to 8937 in 2019 (increase of 434%; trend p < 0.0001).

CONCLUSION

We observed an increase in interventional therapy for upper tract urolithiasis in Germany with a dramatic shift from SWL to endoscopic/percutaneous treatment. These changes may be attributed to enormous technological advances of the endoscopic armamentarium and to reimbursement issues.

Association between time to lithotripsy and stone-free rate in patients with ureteral stones undergoing shock wave lithotripsy

Early shock wave lithotripsy is associated with higher stone-free rate compared to delayed treatment of ureteral stones, but may constitute overtreatment because ureteral stones can pass spontaneously. We studied the association between time to treatment and stone-free rate in patients with ureteral stones to determine optimal shock wave lithotripsy timing. We retrospectively analyzed 537 patients undergoing shock wave lithotripsy for ureteral stones. Patients were divided into five groups according to time from onset of symptoms to lithotripsy—urgent (0–3 days), early (4–30 days), late (31–60 days), long-delayed lithotripsy (≥ 61 days), and asymptomatic. Stone-free rates were compared among groups. Mean age and stone size were 55.6 ± 13.1 years and 7.48 ± 3.29 mm, respectively. Mean number of shock wave lithotripsy sessions and stone-free rate were 1.37 and 91.6%, respectively, in the overall population. Stone-free rates were 95.2%, 96.8%, 91.3%, 86.3%, and 82.7% in urgent, early, late, long-delayed lithotripsy, and asymptomatic groups, respectively. Long-delayed lithotripsy and asymptomatic groups had significantly more lithotripsy sessions and lower stone-free rate, compared to urgent and early lithotripsy groups. In multivariate analysis, time to lithotripsy [long-delayed lithotripsy (odds ratio: 0.273, p = 0.004) and asymptomatic nature (odds ratio: 0.236, p = 0.002)] and age (odds ratio: 0.959, p = 0.003) independently affected stone-free rate. In conclusion, time to lithotripsy is a strong predictive factor for stone-free status following shock wave lithotripsy. Urgent shock wave lithotripsy did not improve stone-free rate if performed within 1 month. However, time to shock wave lithotripsy > 2 months reduced likelihood of stone-free status.

Immediate Shockwave Lithotripsy vs Delayed Shockwave Lithotripsy After Urgent Ureteral Stenting in Patients with Ureteral or Pyeloureteral Urolithiasis: A Matched-Pair Analysis

Introduction: The most common cause of acute renal colic is a ureteral obstruction caused by ureterolithiasis. Urgent intervention is often necessary due to intractable pain. Early extracorporeal shockwave lithotripsy (SWL) as an alternative treatment option to ureteral stenting becomes forgotten in times of rising ureterorenoscopy. However, definitive guidelines are lacking, in which urgent treatment should be preferred in the absence of signs of infection. Therefore, we assessed efficacy and safety of early SWL (eSWL) to secondary SWL (sSWL) after urgent ureteral stenting. Patients and Methods: One hundred four patients treated between January 2015 and November 2017 for obstructive ureterolithiasis were matched regarding stone size, stone localization, and assigned to group eSWL (n = 52) or group sSWL (n = 52). The eSWL group received shock waves (without prior ureteral stenting) and sSWL group ureteral stenting within 48 hours from diagnosis. Thereafter, patients in group sSWL were treated with shock waves for a median of 23 ± 14.6 days after ureteral stenting. Stone-free rates, complication rates, and reintervention rates were assessed. Univariable and multivariable logistic regression was applied to find predictors of outcomes in the two treatment groups. Results: Overall, there was no statistically significant difference between both groups regarding stone-free rate and complication rate. Reinterventions were more often addressed for patients in group sSWL (p = 0.05). eSWL was significantly superior to sSWL regarding stone-free rates for stones between 6 and 9 mm (p = 0.04). At the multivariable multinomial logistic regression none of the two treatment modalities was associated with better outcomes. A body mass index ≥30 was associated with a reduced 6-week stone-free status (p = 0.04), whereas stones ≥8 mm were associated with an increased need of reintervention (p = 0.04). Conclusion: eSWL seems to be an effective and safe emergency procedure compared with sSWL after urgent stenting within 6 weeks and should be considered as a treatment option in patients without absolute indications for immediate ureteral drainage. Clinical trial registration number: 2019-00155.

Small-tract percutaneous nephrolithotomy for an elderly female with renal and ureteral stones complicated by pyogenic kidney

Percutaneous nephrolithotomy (PCNL) is feasible in the extremely elderly patients. However, there were higher rate of complications and longer hospitalizations. The case presented is a 95-year-old female who was admitted to the hospital and was diagnosed with multiple stones in the right kidney and upper ureter with right renal effusion and infection, urosepsis, and chronic bronchitis. After sufficient preoperative preparation, small-tract PCNL under vacuum suctioning was performed using the left lateral position under combined lumbar spinal and epidural anesthesia. The patient recovered and was discharged smoothly on schedule. Good clinical and social effects have achieved.

Comparison of Primary and Delayed Ureteroscopy for Ureteric Stones: A Prospective Non-Randomized Comparative Study

BACKGROUND

Primary ureteroscopy (P-URS) has been shown to be as safe and as efficacious as preoperative stent insertion followed by a delayed ureteroscopy (D-URS). However, studies are of limited patient cohort.

METHODS

A prospective study comparing P-URS and laser fragmentation for ureteric stones to those who received a stent insertion followed by D-URS and stone fragmentation.

RESULTS

A total of 367 consecutive patients were included. P-URS was conducted on 235 patients and D-URS on 132 patients. There was no overall difference between patient or stone demographics between the 2 groups, although there were more proximal ureteric and pelvi-ureteric junction stones in the preoperative stent group. The mean operative times were comparable with a stone free rate of 97 and 94% in the preoperative stent and no-stent groups, respectively. The overall complication rates were comparable.

CONCLUSION

The current study provides evidence for the feasibility, safety, and efficacy of P-URS for ureteric calculi in a publicly funded healthcare setting with results comparable to those patients with a preoperative stent and delayed procedure. Therefore, cumulatively, P-URS could lead to less hospitalization, length of stay, stent-related morbidity, and ultimately will be more cost-effective.

Emergency vs elective ureteroscopy for a single ureteric stone

Objective

To compare emergency with elective ureteroscopy (URS) for the treatment of a single ureteric stone.

Patients and methods

The files of adult patients with a single ureteric stone were retrospectively reviewed. Patients with fever or turbid urine on passage of the guidewire beside the stone underwent ureteric stenting or nephrostomy drainage. Patients who underwent URS were included and divided into two groups: the emergency (EM) Group, those who presented with persistent renal colic and underwent emergency URS within 24 h; and the elective (EL) Group, who underwent elective URS after ≥14 days of diagnosis. Patients with ureteric stents were excluded. The technique for URS was the same in both groups. Safety was defined as absence of complications. Efficacy was defined as the stone-free rate after a single URS session.

Results

From March 2015 to September 2018, 179 patients (107 in the EM Group and 72 in the EL Group) were included. There were significantly more hydronephrosis and smaller stones in the EM Group (P = 0.002 and P = 0.001, respectively). Laser disintegration was needed in more patients in the EL Group (83% vs 68%, P = 0.023). Post-URS ureteric stents were inserted in more patients in the EM Group (91% vs 72%, P = 0.001). Complications were comparable for both groups (4.2% for EL and 5.6% for EM, P = 0.665). Stone-free rates were also comparable (93% in the EL Group and 96% in the EM Group, P = 0.336).

Conclusions

Emergency URS can be as safe and effective as elective URS for the treatment of a single ureteric stone if it is performed in patients without fever or turbid urine.

Abbreviations: EL Group: elective group; EM Group: emergency group; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; MET: medical expulsive therapy; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy

Extracorporeal shock-wave lithotripsy: is it still valid in the era of robotic endourology? Can it be more efficient?

PURPOSE OF REVIEW

The aim of the article is to evaluate the actual role of extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis based on the new developments of flexible ureterorenoscopy (FURS) and percutaneous nephrolithotomy (PCNL).

RECENT FINDINGS

In Western Europe, there is a significant change of techniques used for treatment of renal stones with an increase of FURS and a decrease of ESWL. The reasons for this include the change of indications, technical improvement of the endourologic armamentarium, including robotic assistance. Mostly relevant is the introduction of digital reusable and single-use flexible ureterorenoscopes, whereas micro-PCNL has been abandoned. Some companies have stopped production of lithotripters and novel ideas to improve the efficacy of shock waves have not been implemented in the actual systems. Promising shock-wave technologies include the use of burst-shock-wave lithotripsy (SWL) or high-frequent ESWL. The main advantage would be the very fast pulverization of the stone as shown in in-vitro models.

SUMMARY

The role of ESWL in the management of urolithiasis is decreasing, whereas FURS is constantly progressing. Quality and safety of intracorporeal shock-wave lithotripsy using holmium:YAG-laser under endoscopic control clearly outweighs the advantages of noninvasive ESWL. To regain ground, new technologies like burst-SWL or high-frequent ESWL have to be implemented in new systems.

Socioeconomic Disparities in the Acute Management of Stone Disease in the United States

INTRODUCTION

Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality.

MATERIALS AND METHODS

The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared.

RESULTS

We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients.

CONCLUSION

Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.