Publications by authors named "Manoj Monga"

351 Publications

SKOPE - Study of Ketorolac vs Opioid for Pain after Endoscopy: A Double-Blinded Randomized Control Trial in Patients Undergoing Ureteroscopy.

J Urol 2021 Apr 5:101097JU0000000000001772. Epub 2021 Apr 5.

Cleveland Clinic- Glickman Urological & Kidney Institute.

Purpose: Pain is the leading cause for unplanned emergency department visits and readmissions after ureteroscopy (URS), making post-operative analgesic stewardship a priority given the current opioid epidemic. We conducted a double-blinded, randomized controlled trial (RCT), with non-inferiority design, comparing nonsteroidal anti-inflammatory drugs (NSAIDs) to opiates for postoperative pain control in patients undergoing URS for urolithiasis.

Materials And Methods: Patients were randomized and blinded to either oxycodone (5mg) or ketorolac (10mg), taken as needed, with 3 non-blinded oxycodone rescue pills for breakthrough pain. Primary study outcome was visual analog scale pain score on post-operative days 1-5. Secondary outcomes included medication utilization, side effects, and Ureteral Stent Symptoms Questionnaire (USSQ) scores.

Results: Eighty-one patients were included (43 oxycodone, 38 ketorolac). The two groups had comparable patient, stone, and perioperative characteristics. No differences were found in post-operative pain scores, study medication or rescue pill usage, or side effects. Higher maximum pain scores on days 1-5 (p<0.05) and higher USSQ score (28.1 vs 21.7, p=0.045) correlated with analgesic usage, irrespective of treatment group. Patients receiving ketorolac reported significantly fewer days confined to bed (1.3±1.3 vs 2.3±2.6, p=0.02). There was no difference in unscheduled post-operative physician encounters.

Conclusions: This is the first double-blinded RCT comparing NSAIDs and opiates post-URS and demonstrates non-inferiority of NSAIDs in pain control with similar efficacy, safety profile, physician contact and notably, earlier convalescence compared to the opioid group. This provides strong evidence against routine opioid use post-URS, justifying continued investigation into reducing post-operative opiate prescriptions.
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http://dx.doi.org/10.1097/JU.0000000000001772DOI Listing
April 2021

Predictive factors for spontaneous stone passage in diabetic patients with acute ureteric colic.

Chin Med J (Engl) 2021 Apr 1. Epub 2021 Apr 1.

Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA Department of Urology, University of California, San Diego, CA, USA.

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http://dx.doi.org/10.1097/CM9.0000000000001456DOI Listing
April 2021

Standardization of microbiome studies for urolithiasis: an international consensus agreement.

Nat Rev Urol 2021 Mar 29. Epub 2021 Mar 29.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

Numerous metagenome-wide association studies (MWAS) for urolithiasis have been published, leading to the discovery of potential interactions between the microbiome and urolithiasis. However, questions remain about the reproducibility, applicability and physiological relevance of these data owing to discrepancies in experimental technique and a lack of standardization in the field. One barrier to interpreting MWAS is that experimental biases can be introduced at every step of the experimental pipeline, including sample collection, preservation, storage, processing, sequencing, data analysis and validation. Thus, the introduction of standardized protocols that maintain the flexibility to achieve study-specific objectives is urgently required. To address this need, the first international consortium for microbiome in urinary stone disease - MICROCOSM - was created and consensus panel members were asked to participate in a consensus meeting to develop standardized protocols for microbiome studies if they had published an MWAS on urolithiasis. Study-specific protocols were revised until a consensus was reached. This consensus group generated standardized protocols, which are publicly available via a secure online server, for each step in the typical clinical microbiome-urolithiasis study pipeline. This standardization creates the benchmark for future studies to facilitate consistent interpretation of results and, collectively, to lead to effective interventions to prevent the onset of urolithiasis, and will also be useful for investigators interested in microbiome research in other urological diseases.
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http://dx.doi.org/10.1038/s41585-021-00450-8DOI Listing
March 2021

Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomized, double-blinded, placebo-controlled trial.

BJU Int 2021 Feb 25. Epub 2021 Feb 25.

Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Objectives: To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones who have undergone percutaneous nephrolithotomy (PCNL).

Material And Methods: In a randomized, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomized (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236.

Results: The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%, relative risk: 0.21, 95% confidence interval (CI): 0.03-0.76; P = 0.033, number-needed-to-treat: 12). Patients randomized to the tranexamic acid group showed higher immediate and three-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [95% CI]: 2.37 [1.15-4.87], P = 0.019, and 46.2% vs 28.1%, odds ratio [95% CI]: 2.20 [1.20-4.02], P = 0.011, respectively). Faster hemoglobin recovery was demonstrated by patients in the tranexamic group (mean, 21.3 days, P = 0.001). No statistical differences were found in operative time and complications between groups.

Conclusions: Tranexamic acid administration is safe and reduces the need for blood transfusion by five times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contributes to better stone clearance rate and faster hemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.
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http://dx.doi.org/10.1111/bju.15378DOI Listing
February 2021

Stent duration and increased pain in the hours after ureteral stent removal.

Can J Urol 2021 Feb;28(1):10516-10521

Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.

INTRODUCTION To assess the relationship between pain after ureteral stent removal and patient and procedural factors.

Materials And Methods: A validated survey designed to assess the relationship between quality of life and treatment decisions in kidney stone disease was randomly distributed to patients with a history of a ureteral stent in seven medical centers across North America participating in an endourology research collaborative between July 2016 and June 2018. The primary outcome was increased pain after ureteral stent removal. Statistical analyses were performed using Chi-square and multiple logistic regression.

Results: A total of 327 surveys were analyzed. Twenty seven percent of patients reported increased pain in the hours after ureteral stent removal. Patients with a stent ≤ 7 days were significantly more likely to experience pain after stent removal compared to those with a stent > 7 days (33.3% versus 22.8%, p = 0.04). Female gender (OR: 2.41, 95% CI: 1.42-4.10) was associated with increased pain after stent removal, while increasing age was inversely associated (OR: 0.52, 95% CI: 0.36-0.74). After adjustment, patients with a stent > 7 days were significantly less likely to report pain in the hours after removal (OR: 0.59, 95% CI: 0.35-0.99).

Conclusions: Approximately one in four patients will experience increased pain after ureteral stent removal. Female patients, younger patients, and patients with a stent ≤ 7 days were more likely to experience an increase in pain immediately following stent removal. Understanding factors associated with post-stent removal pain may be helpful in counseling patients at high risk stent removal morbidity.
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February 2021

Combined top-down approach with low-power thulium laser enucleation of prostate: evaluation of one-year functional outcomes.

World J Urol 2021 Jan 2. Epub 2021 Jan 2.

Urology Department, University of California, San Diego, CA, USA.

Objectives: To evaluate the safety and efficacy of combined top and down low power thulium laser enucleation of the prostate (ThuLEP).

Patients And Methods: Between May 2017 and May 2019, after institutional board review approval, successfully consented patients underwent combined top and down low power ThuLEP. We used a 30 -W Thulium laser with a 550 μm laser fiber and a 26 Fr continuous flow resectoscope. We collected data related to prostate size, enucleation time, morcellation time, perioperative complications, and early outcomes.

Results: Sixty patients underwent combined Top and down low power ThuLEP with mean age 67 ± 8. Acute urine retention was the main indication for surgery in 22% of patients, while the remaining had mean IPPS score 26 ± 3. The mean prostate volume was 102 ± 25 ml and the mean Qmax was 6 ± 2 ml/sec. Mean operative time was 103 ± 25 min, while; mean enucleation time was 80 ± 12 min, and mean morcellation time was 17 ± 6 min. The mean enucleated prostate volume was 73 ± 16 g and the mean hemoglobin drop was 1 ± 0.2 mg/dl. There was no need for blood transfusion and the mean hospital stay was 18 ± 4 h and catheters were removed on discharge. The 1st visit was at one month, and we observed significant mean Qmax improvement18 ± 5 ml/s. Our results showed no significant change of IIEF-5 score at 12-month follow-up compared to baseline.

Conclusion: Low-power Thulium enucleation with a combined top and down technique provided a safe and efficacious outcome, that may reduce strenuous wrist flexion and eliminate the need for high-power Thulium laser device.
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http://dx.doi.org/10.1007/s00345-020-03538-9DOI Listing
January 2021

A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium.

J Urol 2020 Dec 28:101097JU0000000000001582. Epub 2020 Dec 28.

UC San Diego Health, San Diego, California.

Purpose: Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy.

Materials And Methods: Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay.

Results: A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group.

Conclusions: Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.
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http://dx.doi.org/10.1097/JU.0000000000001582DOI Listing
December 2020

High pressure endoscopic irrigation: impact on renal histology.

Int Braz J Urol 2021 Mar-Apr;47(2):350-356

Glickman Urological and Kidney Institute Cleveland Clinic Foundation - Urology, Cleveland, Ohio, United States.

Purpose: High intra-renal pressures during flexible ureteroscopy have been associated with adverse renal tissue changes as well as pyelovenous backflow. Our objective was to investigate the effect of various intra-renal pressures on histologic changes and fluid extravasation during simulated ureteroscopy.

Materials And Methods: Twenty-four juvenile pig kidneys with intact ureters were cannulated with an Olympus flexible ureteroscope with and without a ureteral access sheath and subjected to India ink-infused saline irrigation for 30 minutes at constant pressures ranging from sphygmomanometer settings of 50mm, 100mm and 200mmHg. Renal tissue samples were collected, processed and stained, and were evaluated by a blinded pathologist for depth of ink penetration into renal parenchyma as a percentage of total parenchymal thickness from urothelium to renal capsule.

Results: The mean percentage of tissue penetration for kidneys with ink present in the cortical tubules at sphygmomanometer pressure settings of 50, 100, and 200mm Hg without a ureteral access sheath was 33.1, 31.0 and 99.3%, respectively and with ureteral access sheath was 0, 0 and 18.8%, respectively. Overall, kidneys with an access sheath demonstrated a smaller mean tissue penetration among all pressure compared to kidneys without a sheath (6.3% vs. 54.5%, p=0.0354). Of kidneys with sheath placement, 11% demonstrated any ink compared to 56% of kidneys without sheath placement.

Conclusions: Pressurized endoscopic irrigation leads to significant extravasation of fluid into the renal parenchyma. Higher intra-renal pressures were associated with increased penetration of irrigant during ureteroscopy in an ex-vivo porcine model.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.0248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857762PMC
March 2020

The role of laser in percutaneous surgery. Is this the best option for this approach?

Arch Esp Urol 2020 Oct;73(8):753-766

Department of Urology. Glickman Urological and Kidney Institute. Cleveland Clinic. Cleveland. OH.

Holmium laser has been established asthe gold-standard for the ureteroscopic management of urinary stone disease. However the role of laser inpercutaneous nephrolithotomy (PCNL) varies, as multiple energy sources and lithotripters are available. Currently, lasers are becoming more relevant with the development of several miniaturized PCNL techniques. The purpose of this article is to review the role of laser in percutaneous renal surgery, and whether or not it is the best option for this approach. Discussion points include: the history and background of lasers in urologic surgery, PCNL and its outcomes in the literature, the positives and negatives of lasers versus other lithotripters in several different PCNL techniques, emerging laser technology such as thulium fiber laser, the use of lasers in establishing percutaneous renal access, and laser's role in non-stone percutaneous renal surgery.
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October 2020

Urolithiasis in complicated inflammatory bowel disease: a comprehensive analysis of urine profile and stone composition.

Int Urol Nephrol 2021 Feb 11;53(2):205-209. Epub 2020 Sep 11.

Department of Urology, University of California, 200 W. Arbor Drive, MC8897, San Diego, CA, 92103-8897, USA.

Purpose: To evaluate the impact of extensive surgery on urine profile, serum exams and stone composition of complicated IBD patients.

Methods: Patients with IBD and a history of total proctocolectomy (TPC) with fecal diversion (end ileostomy or ileal pouch anal anastomosis-IPAA) were selected. Only patients with at least one complete 24-h urine profile were included. A case-control study was performed selecting patients with kidney stone disease in a random way who had also at least on complete 24-h urine profile. Case and controls were matched for age, gender, and body mass index (BMI). Groups were compared to urine profile, serum exams and stone composition.

Results: Sixty-eight patients were enrolled in this study, 34 patients with IBD who underwent TPC and had diagnosis of kidney stones and 34 matched patients with only kidney stones. IBD patients had a significantly lower urine volume, urine citrate and urine sodium. Regarding serum exams, only serum bicarbonate was statistically significant lower. In both groups, calcium oxalate stone was the most common.

Conclusion: Patients with IBD with TPC and kidney stones have a low urine volume and low urine citrate as main risk factors for kidney stone formation. As seen in the general population, calcium oxalate is the most common stone composition.
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http://dx.doi.org/10.1007/s11255-020-02649-xDOI Listing
February 2021

Can CT-Based Stone Impaction Markers Augment the Predictive Ability of Spontaneous Stone Passage?

J Endourol 2021 Apr 27;35(4):429-435. Epub 2020 Oct 27.

Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

A number of clinical and radiological predictors of either stone impaction or ureteral stone passage (SP) have been proposed. We aimed at identifying the key predictors of successful SP by using readily available CT-based tools/measurements. Patients presenting to the emergency department from February 2017 to February 2018 with an acute unilateral ureteral stone confirmed on non-contrast CT and managed conservatively were followed for SP. Patients with renal impairment, sepsis or requiring emergent intervention were excluded. Patients were followed at 1 month to confirm SP (stone collection/repeat imaging) or failure of passage. The CT variables analyzed included: Stone factors [location, size, volume, HU density (HUD)], impaction factors [ureteral HUD above and below the stone, maximal ureteral wall thickness (UWT) at the stone site, contralateral UWT, and ureteral diameter above and below the stone]. Binary logistic regression analysis was performed to identify predictors of SP. Forty-nine patients met study inclusion criteria, of whom 32 (65.3%) passed the stone without further intervention. Patients with successful passage were more likely to have smaller, lower volume and less dense stones located in the distal ureter ( < 0.01). Lower ureteral HUD below the stone, lower maximal UWT, and lower ureteral diameter above the stone were associated with successful passage ( < 0.01). On multivariable logistic regression analysis, only maximal UWT at the stone site was a significant independent predictor of SP outcome ( = 0.01). Youden's criterion identified 2.3 mm as the optimal UWT cut-off point, which will accurately predict SP with 82.4% sensitivity and 87.5% specificity. Maximal UWT at the stone site was the most significant predictor of successful passage in acute unilateral ureteral stones, with an optimal cut-off point of 2.3 mm. Further prospective studies are needed to accurately predict spontaneous SP.
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http://dx.doi.org/10.1089/end.2020.0645DOI Listing
April 2021

Ureteral Diameter as Predictor of Ureteral Injury during Ureteral Access Sheath Placement.

J Urol 2021 Jan 27;205(1):159-164. Epub 2020 Jul 27.

Department of Urology, University of California-San Diego, San Diego, California.

Purpose: We determined the association between ureteral diameter and ureteral injury during ureteral access sheath placement.

Materials And Methods: Patients were prospectively enrolled in the study from July 2014 to September 2015. All patients underwent preoperative noncontrast computerized tomography and had a 12Fr to 14Fr ureteral access sheath placement without pre-stenting. A measurement of proximal ureteral diameter was carried out by 2 urologists and 1 radiologist. Ureteral wall injuries were evaluated by 2 endourologists using the 5-grade classification.

Results: A total of 68 patients were included and the overall success rate for sheath placement was 94.1% (64). Among this group 46 patients (71.9%) had evidence of any type of injury to the ureter wall and the rate of high grade injuries was 26.1% (12). The ureteral diameter of patients who had a high grade injury was significantly smaller compared to those with low grade injuries (mean±SD 3.29±0.46 mm vs 4.5±0.97 mm, p <0.001). On multivariate analysis narrower proximal ureteral diameter was associated with a higher risk of high grade ureteral injury (OR 2.8, 95% CI 1.9-3.4, p <0.001), regardless of age, gender, body mass index, and middle and distal ureteral diameter.

Conclusions: The proximal ureteral diameter is associated with high grade ureteral injury. A smaller ureteral diameter increases the risk and the severity of ureteral injury. Therefore, preoperative measurement of the ureteral diameter is recommended for ureteral access sheath placement to predict the risk of ureteral injury.
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http://dx.doi.org/10.1097/JU.0000000000001299DOI Listing
January 2021

Long-term ureteroscopic management of upper tract urothelial carcinoma: 28-year single-centre experience.

Jpn J Clin Oncol 2021 Jan;51(1):130-137

Innovation Center Okayama for Nanobio-Targeted Therapy, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.

Background: Long-term survival outcomes of patients who undergo endoscopic management of non-invasive upper tract urothelial carcinoma remain uncertain. The longest mean follow-up period in previous studies was 6.1 years. This study reports the long-term outcomes of patients with upper tract urothelial carcinoma who underwent ureteroscopic ablation at a single institution over a 28-year period.

Methods: We identified all patients who underwent ureteroscopic management of upper tract urothelial carcinoma as their primary treatment at our institution between January 1991 and April 2011. Survival outcomes, including overall survival, cancer-specific survival, upper-tract recurrence-free survival and renal unit survival, were estimated using Kaplan-Meier methodology.

Results: A total of 15 patients underwent endoscopic management, with a mean age at diagnosis of 66 years. All patients underwent ureteroscopy, and biopsy-confirmed pathology was obtained. Median (range; mean) follow-up was 11.7 (2.3-20.9, 11.9) years. Upper tract recurrence occurred in 87% (n = 13) of patients. Twenty percent (n = 3) of patients proceeded to nephroureterectomy. The estimated cancer-specific survival rate was 93% at 5, 10, 15 and 20 years. Estimated overall survival rates were 86, 80, 54 and 20% at 5, 10, 15 and 20 years. Only one patient experienced cancer-specific mortality. The estimated mean and median overall survival times were 14.5 and 16.6 years, respectively. The estimated mean cancer-specific survival time was not reached.

Conclusions: Although upper tract recurrence is common, endoscopic management of non-invasive upper tract urothelial carcinoma provides a 90% cancer-specific survival rate at 20 years in selected patients.
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http://dx.doi.org/10.1093/jjco/hyaa132DOI Listing
January 2021

Outcomes of Conservative Management of Splenic Injury Incurred During Percutaneous Nephrolithotomy.

J Endourol 2020 Aug 15;34(8):811-815. Epub 2020 Jun 15.

Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.

Splenic injury is a rare complication after left-sided percutaneous nephrolithotomy (PCNL). Although initial observation is often espoused, the natural history of nonoperative conservative management is not well established and the implications of splenic injury are not fully defined in this context. We sought to describe outcomes of conservative management of splenic injury incurred at PCNL. We performed a multi-institutional retrospective review of individual patients who underwent PCNL complicated by trans-splenic nephrostomy access injury. Demographic info, intraoperative data, management strategies, and outcomes were reviewed. Nine patients suffered splenic injury after left PCNL. All patients had supracostal upper pole access under fluoroscopic guidance. Splenic injury was identified by computed tomography (CT) in the eight of nine (89%) who had imaging on first postoperative day. All eight patients were managed conservatively with nephrostomy dwell time of 2-21 days, one of whom (11%) required blood transfusion. The remaining patient (11%)-who had tubeless PCNL without postoperative imaging presented 5 days postoperatively with a delayed bleed and underwent emergent splenectomy. Seven of the nine (78%) were managed nonoperatively and without need for transfusion or embolization. The majority of patients incurring splenic injury during PCNL can be managed conservatively with maintenance of nephrostomy tube for ≥2 days. Consequences of unrecognized splenic injury may include splenic bleed and may prompt transfusion and/or splenectomy, underscoring role of routine postoperative CT to allow timely diagnosis, particularly in those undergoing upper pole supracostal left-sided percutaneous renal access.
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http://dx.doi.org/10.1089/end.2020.0076DOI Listing
August 2020

Predictive Factors for Kidney Stone Recurrence in Type 2 Diabetes Mellitus.

Urology 2020 Sep 25;143:85-90. Epub 2020 Apr 25.

Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Department of Urology, UCSD, San Diego, CA. Electronic address:

Objective: To determine the predictive factors for kidney stone recurrence in type 2 diabetic patients.

Methods: A retrospective cohort study was conducted from 2013 to 2019 by using the database of diabetic patients diagnosed with kidney stone disease. The patients were divided into 2 groups according to stone disease status: recurrent stone and nonrecurrent stone. Baseline characteristics were compared and logistic regression was done to assess which variables could predict a stone recurrence.

Results: There were 1617 type 2 diabetic patients with kidney stone disease, 1244 (77%) did not have a stone recurrence and 373 (23%) had a stone recurrence. Of these patients with recurrent stone, 40% had asymptomatic stones, 43% visited emergency department, and 45% required a surgical intervention. Median time to recurrence was 64 months. Multivariable analysis revealed that body mass index (odds ratios [OR] 1.032, 95% confidence interval [CI] 1.016-1.047), urine pH (OR 0.500, CI 0.043-0.581), HbA1c (OR 1.186, CI 1.012-1.277), diabetic neuropathy (OR 1.839, CI 1.413-2.392), diabetic retinopathy (OR 1.690, CI 1.122-2.546), insulin as well as potassium citrate therapy (OR 0.611, CI 0.426-0.87), and stone with calcium oxalate and uric acid composition (OR 1.955, CI 1.420-2.691 and OR 2.221, CI 1.249-3.949, respectively) are significant predictors for stone recurrence.

Conclusion: The severity of diabetes and stone composition are strong predictors for stone recurrence in type 2 diabetic patients, while HbA1c and urine pH are important modifiable factors.
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http://dx.doi.org/10.1016/j.urology.2020.04.067DOI Listing
September 2020

Percutaneous Nephrolithotomy in Horseshoe Kidneys: Results of a Multicentric Study.

J Endourol 2020 Jun 22. Epub 2020 Jun 22.

Glickman Urological and Kidney Institute, Cleveland, Ohio, USA.

To report the outcomes of percutaneous nephrolithotomy (PCNL) in horseshoe kidneys (HSK) in 12 institutions worldwide and evaluate the impact of patient position during operation. We carried out a retrospective analysis of PCNL procedures performed between 2008 and 2018 in patients with HSK. Pre-, peri-, and postoperative data were collected, and a subgroup analysis was performed according to patient position. Success was defined as an absence of >4-mm fragments. Values of  < 0.05 were considered significant. We analyzed 106 procedures. The transfusion, complication, and immediate success rates (ISRs) were 3.8%, 17.5%, and 54.7%, respectively. The final success rate (FSR) increased to 72.4% after a mean of 0.24 secondary procedures. Logistic regression showed that higher body mass index (BMI) and stone size were significantly associated with residual fragments ≥4 mm. Sixty-seven patients (63.2%) were treated in prone and 39 (36.8%) in supine position. The prone group had a significantly higher BMI than the supine group (30.1 27.7,  = 0.024). The transfusion, complication, and ISRs between the prone and supine groups were 4.5% 2.6% ( = 0.99), 16.9% 18.4% ( = 0.99), and 52.5% 69.2% ( = 0.151), respectively. Surgical time was significantly longer in the prone group (126.5 100 minutes,  = 0.04). Upper pole was the preferred access in 80.3% of the prone group and 43.6% of the supine group ( < 0.001). The prone group had significantly more Clavien 2 complications than the supine ( = 0.013). The FSR in the prone and supine groups increased to 66.1% and 82.1% after 0.26 and 0.21 secondary procedures, respectively. No complications higher than Clavien 3 occurred. PCNL in patients with HSK is safe and effective with a low complication rate. Higher BMI and stone size negatively impacted outcomes. Supine PCNL may be an option for treating kidney stones in patients with HSK.
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http://dx.doi.org/10.1089/end.2020.0128DOI Listing
June 2020

The use of outpatient opioid medication for acute renal colic and ureteral stents: Insights from a multi-institutional patient survey
.

Clin Nephrol 2020 Jun;93(6):269-274

Aims: To investigate the main reasons for use of opioids during acute episodes of renal colic and for ureteral stent symptoms post-operatively.

Material And Methods: A survey assessing the impact of decreased quality of life and use of opioid pain medication was distributed to patients with a history of ureteral stent at seven academic centers between July 2016 and June 2018.

Results: A total of 365 surveys were completed. Opioid use for stone (63.9%) and stent-related pain (39.0%) was common among respondents. When assessing whether patients used more opioids for stone or stent-related pain, 47.7% reported using more for stone pain while 15.0% reported using more for stent pain. 22.6% of patients required opioids for stent-related pain and not stone pain. Increasing patient age was found to be negatively associated with using opioids for stent-related pain (OR: 0.4, 95% CI: 0.3 - 0.6). Increasing age was also found to be negatively associated with opioid use for stone pain (OR: 0.6, 95% CI: 0.4 - 0.8). Patients with a greater number of prior stones had 3.2 times the odds of using opioids for stone pain, in our adjusted model (95% CI: 2.1 - 4.7).

Conclusion: Patients with more prior stone episodes are more likely to have used opioids for their most recent episode. Although ureteral stents have been shown to be associated with a decreased quality of life, we showed that the use of opioids for stent-related pain is less than that for stone pain. Younger patients are less likely to tolerate a stent without opioid analgesics.
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http://dx.doi.org/10.5414/CN109991DOI Listing
June 2020

Staghorn renal stones: what the urologist needs to know.

Int Braz J Urol 2020 Nov-Dec;46(6):927-933

Stevan B, Streem Center for Endourology & Stone Disease, Glickman Urological & Kidney Institute, The Cleveland Clinic, Cleveland, OH, USA.

Patients with staghorn renal stones are challenging cases, requiring careful preoperative evaluation and close follow-up to avoid stone recurrence. In this article we aim to discuss the main topics related to staghorn renal stones with focus on surgical approach. Most of staghorn renal stones are composed of struvite (magnesium ammonium phosphate) and are linked to urinary tract infection by urease-producing pathogens. Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice. Gold standard surgical technique is the percutaneous nephrolithotomy (PCNL). In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative. Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone. PCNL can be performed in supine or prone position according to surgeon's experience. Tranexamic acid can be used to avoid bleeding. To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option. Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure. The main goals of treatment are stone-free status, infection eradication, and recurrence prevention. Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.99.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527092PMC
January 2021

Comparison of automated irrigation systems using an in vitro ureteroscopy model.

Int Braz J Urol 2020 May-Jun;46(3):390-397

Cleveland Clinic, Glickman Kidney & Urological Institute, Cleveland, OH, USA.

Introduction: Two automated irrigation systems have been released for use during endoscopic procedures such as ureteroscopy: the Cogentix RocaFlow® (CRF) and Thermedx FluidSmart® (TFS). Accurate pressure control using automated systems may help providers maintain irrigation pressures within a safe range while also providing clear visualization. Our objective was to directly compare these systems based on their pressure accuracy, pressure-flow relationships, and fluid heating capabilities in order to help providers better utilize the temperature and pressure settings of each system.

Materials And Methods: An in vitro ureteroscopy model was used for testing, consisting of a short semirigid ureteroscope (6/7, 5F, 31cm Wolf 425612) connected to a continuous digital pressure transducer (Meriam m1550). Each system pressure output and flow-rate, via 100mL beaker filling time, was measured using multiple trials at pressure settings between 30 and 300mmHg. Output fluid temperature was monitored using a digital thermometer (Omega DP25-TH).

Results: The pressure output of both systems exceeded the desired setting across the entire tested range, a difference of 15.7±2.4mmHg for the TFS compared to 5.2±1.5mmHg for the CRF (p < 0.0001). Related to this finding, the TFS also had slightly higher flow rates across all trials (7±2mL/min). Temperature testing revealed a similar maximum temperature of 34.0⁰C with both systems, however, the TFS peaked after only 8 minutes and started to plateau as early as 4-5 minutes into the test, while the CRF took over 18 minutes to reach a similar peak.

Conclusions: Our in vitro ureteroscopy testing found that the CRF system had better pressure accuracy than the TFS system but with noticeably slower fluid heating capabilities. Each system provided steady irrigation at safe pressures within their expected operating parameters with small differences in performance that should not limit their ability to provide steady irrigation at safe pressures.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2019.0230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7088507PMC
August 2020

Ergonomics and musculoskeletal symptoms in surgeons performing endoscopic procedures for benign prostatic hyperplasia.

Ther Adv Urol 2020 Jan-Dec;12:1756287220904806. Epub 2020 Feb 20.

Glickman Urological & Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.

Background And Purpose: Benign prostatic hyperplasia (BPH) is the most common urologic disorder affecting older men, necessitating medical or surgical intervention. Limited data exists regarding the effect these surgeries have on the endourologist's musculoskeletal system following the surgery because of the required difficult posture, prolonged procedures, repetitive movements, and the settings of an adjustable visual display terminal workstation. The aim of our study was to survey the prevalence and possible causes of musculoskeletal disorders among endourologists performing transurethral resection of the prostate (TURP) or laser prostatectomy using either holmium laser enucleation or thulium laser enucleation.

Materials And Methods: An email inviting all members of the Endourological Society to participate in the survey was sent. The questionnaire included different demographic and practice characteristics, with concern regarding performing either TURP or laser prostatectomy and the incidence and type of musculoskeletal incidents following these surgeries. All responses were collected by a commercially available internet based survey host (www.surveymonkey.com) over a period of 6 weeks.

Results: Of the 121 complete responses, 84 (69%) of endourologists complained of a musculoskeletal disorder following TURP or laser prostatectomy. The most frequent complaint was for neck (64%), followed by back (57%), shoulder (48%), hand (40%), and elbow (18%). The average prostate volume turned out to be the most compelling predictor for musculoskeletal disorder occurrence with an average prostate volume of 76 g operated on by the complaining group compared with 59 g in the noncomplaining group. Those with more severe symptoms were linked to a mean prostate size of 80 g (60-146) and constantly complained of shoulder, neck, or back trouble compared with the less-severely complaining group.

Conclusions: A high prevalence of musculoskeletal complaints among urologists performing endourologic prostatectomy was confirmed and was found to be proportionally related to the size of the prostate. The integration of an ergonomic specialist inside the operation room to watch and correct the surgeon's position during endourologic procedures may reduce the endourologist's exposure to these occupational hazards.
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http://dx.doi.org/10.1177/1756287220904806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036503PMC
February 2020

The cost of operating room delays in an endourology center.

Can Urol Assoc J 2020 Jul;14(7):E304-E308

Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH, United States.

Introduction: This study sought to characterize delays and estimate resulting costs during nephrolithiasis surgery.

Methods: Independent observers documented delays during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures. Fifty index cases over a period of three months was considered sufficient to observe the generalizable trends. Operating room staff, excluding the surgeons, were blinded. Time-related metrics and delays preventing case progression were recorded using a smartphone-accessible data-collection instrument. Delays were categorized as: 1) missing equipment; 2) missing personnel; 3) equipment malfunction; or 4) delay due to case complexity. The first two categories were regarded as preventable and the latter two non-preventable.

Results: Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean cumulative delay per case was 3.5±3.2 minutes. Pre-start delays (n=17) were 4.5±3.5 minutes on average while intraoperative delays (n=39) were 3.1±2.9 minutes (p=0.167). Delays were evenly spread among the four categories. Thirty-one (55%) delays were preventable (mean 3.7±3.2 minutes) while 25 (45%) were non-preventable (mean 3.2±3.2 minutes) (p=0.58). This translates to $137 per case in preventable costs.

Conclusions: Preventable operative delays are encountered frequently in nephrolithiasis surgery, translating to significant additional charges and costs. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency in endourological surgeries. Key limitations are the observational nature of the study and sample size.
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http://dx.doi.org/10.5489/cuaj.6099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337710PMC
July 2020

Same sized three-way indwelling urinary catheters from various manufacturers present different irrigation and drainage properties.

Ther Adv Urol 2020 Jan-Dec;12:1756287219889496. Epub 2020 Jan 9.

Hospital Israelita Albert Einstein, São Paulo, Brazil.

Background: The three-way indwelling urinary catheter (IUC) is used for continuous bladder irrigation and is considered the cornerstone for clinical treatment of patients with macroscopic hematuria. Although there seems to be a logical relationship between catheter size and efficacy of irrigation and drainage, we often observe relevant variations in these parameters between different brands of catheters available on the market. The aim of this study was to compare the mechanical properties of different models of latex and silicone three-way catheters in an setting that resembles clinical use.

Methods: Three different three-way catheters were evaluated: Gold Silicone-Coated Rusch (Model A), 100% Silicone Rusch (Model B) and X-Flow Coloplast (Model C). Irrigation channel, drainage channel, and overall cross-sectional areas were all digitally measured. Irrigation and drainage channel flow rates were measured and correlated with their corresponding catheter cross-sectional area values.

Results: Different catheter models of the same caliber have different internal irrigation port diameters, internal drainage port diameters and internal cuff port diameters. The Model C IUC internal irrigation port diameter is significantly larger than models A and B. When flows were evaluated, we found that in the same model, the increase in caliber of the IUC was related to an increased drainage flow, but not to an increased irrigation flow.

Conclusion: Precise measurements of the internal architecture of the three-way catheter, rather than relying on the caliber itself, could assist surgeons in choosing the best product for each specific patient, while minimizing complications.
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http://dx.doi.org/10.1177/1756287219889496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952853PMC
January 2020

Nephrolithiasis and Polycystic Ovary Syndrome: A Case-Control Study Evaluating Testosterone and Urinary Stone Metabolic Panels.

Adv Urol 2019 17;2019:3679493. Epub 2019 Oct 17.

Cleveland Clinic, Glickman Urological & Kidney Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Introduction: Both elevated testosterone and polycystic ovary syndrome (PCOS) have been speculated as possible risk factors for kidney stone formation; however, the details of this potential relationship with regards to 24-hour urine metabolic panels and stone composition have not previously been characterized.

Methods: A total of 74 PCOS patients were retrospectively identified and matched with a cohort of female stone formers at a 3 : 1 ratio (by age and BMI). All patients had 24-hour urinary metabolic panels and stone compositions. These groups were compared using Pearson chi-square and Student -tests. Additionally, the PCOS group was differentiated based on free testosterone using multivariate analysis.

Results: The case-control cohort showed that PCOS patients had significantly lower sodium excretion (=0.015) and hypernatriuria rates (28.9% vs 50.9%, =0.009). The PCOS-testosterone cohort demonstrated that high testosterone patients had significantly higher citrate values (=0.041) and significantly lower odds of hypocitraturia (36.7% vs 54.2%, OR = 0.2, =0.042). The high testosterone group also had higher sodium excretion (=0.058) with significantly higher odds of having hypernatriuria (40.0% vs 13.6%, OR = 13.3, =0.021). No significant patterns were revealed based on stone composition analysis.

Conclusions: Compared to healthy stone formers, PCOS patients did not demonstrate significant differences in 24-hour urine and stone composition values. Elevated free testosterone in PCOS patients has a significant association with higher urinary citrate and sodium values: findings that in and of themselves do not confirm the hypothesized increased risk of stone formation. This patient cohort may provide deeper insight into the interplay between androgens and stone formation; however, further study is needed to fully characterize the possible relationship between PCOS and stone formation.
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http://dx.doi.org/10.1155/2019/3679493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854272PMC
October 2019

Postoperative Emergency Department Visits After Urinary Stone Surgery: Variation Based on Surgical Modality.

J Endourol 2020 01 18;34(1):93-98. Epub 2019 Dec 18.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.

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). 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. 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%;  < 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. 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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http://dx.doi.org/10.1089/end.2019.0399DOI Listing
January 2020

Renal Stone Features Are More Important Than Renal Anatomy to Predict Shock Wave Lithotripsy Outcomes: Results from a Prospective Study with CT Follow-Up.

J Endourol 2020 01 21;34(1):63-67. Epub 2019 Nov 21.

Division of Urology, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Lower pole kidney stones have been associated with poor shock wave lithotripsy (SWL) outcomes because of its location. However, the real impact of collecting system anatomy on stone clearance after SWL is uncertain. There is a lack of prospective well-controlled studies to determine whether lower pole kidney stones have inferior outcomes than nonlower pole kidney stones when treated with SWL. We prospectively evaluated patients with a single kidney stone of 5-15 mm undergoing SWL from June 12 through January 19. All patients were subjected to computed tomography before and 3 months after the procedure. Demographic data (age, gender, and body mass index), stone features (stone size, stone area, stone density, and stone-skin distance-SSD), and collecting system anatomy (infundibular length and width, and infundibulopelvic angle) were recorded. Outcomes (fragmentation and stone clearance rates) were compared between lower pole and nonlower pole cases. Then, a multivariate analysis including all variables was performed to determinate which parameters significantly impact on SWL outcomes. One hundred and twenty patients were included in the study. Mean stone size was 8.3 mm and mean stone density was 805 Hounsfield units. Overall stone fragmentation, success, and stone-free rates were 84.1%, 64.1%, and 34.1%, respectively. There were no significant differences in stone fragmentation (76.0% 71.4%;  = 0.624), success rate (57.6% 53.3%;  = 0.435), and stone-free rate (40.2% 35.7%;  = 0.422) in the lower nonlower pole groups, respectively. On multivariate analysis, only stone density ( < 0.001) and SSD ( = 0.006) significantly influenced fragmentation. Stone size ( = 0.029), stone density ( = 0.002), and SSD ( = 0.049) significantly influenced kidney stone clearance. Stone size, stone density, and SSD impact on SWL outcomes. Lower pole kidney stones have similar fragmentation and stone clearance compared with nonlower pole kidney stones.
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http://dx.doi.org/10.1089/end.2019.0545DOI Listing
January 2020

Defining Dysbiosis for a Cluster of Chronic Diseases.

Sci Rep 2019 09 9;9(1):12918. Epub 2019 Sep 9.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

The prevalence of many chronic diseases has increased over the last decades. It has been postulated that dysbiosis driven by environmental factors such as antibiotic use is shifting the microbiome in ways that increase inflammation and the onset of chronic disease. Dysbiosis can be defined through the loss or gain of bacteria that either promote health or disease, respectively. Here we use multiple independent datasets to determine the nature of dysbiosis for a cluster of chronic diseases that includes urinary stone disease (USD), obesity, diabetes, cardiovascular disease, and kidney disease, which often exist as co-morbidities. For all disease states, individuals exhibited a statistically significant association with antibiotics in the last year compared to healthy counterparts. There was also a statistically significant association between antibiotic use and gut microbiota composition. Furthermore, each disease state was associated with a loss of microbial diversity in the gut. Three genera, Bacteroides, Prevotella, and Ruminococcus, were the most common dysbiotic taxa in terms of being enriched or depleted in disease populations and was driven in part by the diversity of operational taxonomic units (OTUs) within these genera. Results of the cross-sectional analysis suggest that antibiotic-driven loss of microbial diversity may increase the risk for chronic disease. However, longitudinal studies are needed to confirm the causative effect of diversity loss for chronic disease risk.
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http://dx.doi.org/10.1038/s41598-019-49452-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733864PMC
September 2019

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices.

Int Braz J Urol 2019 Jul-Aug;45(4):658-670

Seção de Endourologia da Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brasil.

Purpose: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes.

Materials And Methods: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included.

Results: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition.

Conclusions: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837614PMC
September 2019

Ureteral Stent Placement During Shockwave Lithotripsy: Characterizing Guideline Discordant Practice.

Urology 2019 Nov 21;133:67-71. Epub 2019 Jun 21.

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH.

Objective: To describe utilization patterns of ureteral stent placement during extracorporeal shockwave lithotripsy (ESWL).

Methods: The Healthcare Cost and Utilization Project State Inpatient and Ambulatory Surgery Databases for Florida (2010-2012), Iowa (2010-2012), California (2010-2011), and New York (2006-2012) were used to identify patients undergoing ESWL with or without concomitant ureteral stent placement. Multivariate logistic regression was used to identify factors associated with ureteral stent placement. Postoperative ER visits and reoperation were compared between groups with multivariate logistic regression.

Results: A total of 128,040 patients undergoing ESWL during the study period were identified. Concomitant ureteral stent placement during ESWL was performed in 20,800 (16.2%) cases. Stent placement was more common among older patients (odds ratio [OR] 1.003 per year, 95% confidence interval 1.002-1.004) and those with greater comorbidity burden (OR 1.10, 1.09-1.11), but also among those with higher income (OR 1.13, 1.08-1.19) and private insurance (OR 1.05, 1.01-1.10). Patients undergoing concomitant ureteral stent placement had higher rates of 30-day postoperative ER visits (8.9% vs 7.3%, P<.0001) and 90-day reoperation (13.4% vs 8.2%, P<.0001) compared to patients undergoing ESWL alone.

Conclusion: A significant portion of patients treated with ESWL undergo concomitant ureteral stent placement, despite clinical guidelines over the last 2 decades discouraging this practice. Use of ureteral stent during ESWL appears driven by both clinical and nonclinical factors. Ureteral stent placement confers no perceivable advantage in postoperative ER visits or reoperation after ESWL based on administrative data from the Healthcare Cost and Utilization Project.
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http://dx.doi.org/10.1016/j.urology.2019.06.015DOI Listing
November 2019