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Pain is the leading cause of unplanned emergency department visits and readmissions after ureteroscopy, making postoperative analgesic stewardship a priority given the current opioid epidemic. We conducted a double-blinded, randomized controlled trial, with noninferiority design, comparing nonsteroidal anti-inflammatory drugs to opiates for postoperative pain control in patients undergoing ureteroscopy for urolithiasis.Patients were randomized and blinded to either oxycodone (5 mg) or ketorolac (10 mg), taken as needed, with 3 nonblinded oxycodone rescue pills for breakthrough pain. Primary study outcome was visual analogue scale pain score on postoperative days 1-5. Secondary outcomes included medication utilization, side effects, and Ureteral Stent Symptom Questionnaire scores.A total of 81 patients were included (43 oxycodone, 38 ketorolac). The 2 groups had comparable patient, stone, and perioperative characteristics. No differences were found in postoperative pain scores, study medication or rescue pill usage, or side effects. Higher maximum pain scores on days 1-5 (p0.05) and higher questionnaire 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 (mean±SD 1.3±1.3 vs 2.3±2.6, p=0.02). There was no difference in unscheduled postoperative physician encounters.This is the first double-blinded randomized controlled trial comparing nonsteroidal anti-inflammatory drugs and opiates post-ureteroscopy, and demonstrates noninferiority of nonsteroidal anti-inflammatory drugs 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-ureteroscopy, justifying continued investigation into reducing postoperative opiate prescriptions.

OBJECTIVE: To delineate the role of the urinary metabolome in the genesis of urinary stone disease (USD). METHODS: Untargeted metabolomics was utilized in comparative analyses of calcium-based stones (CBS) and spot urine samples from patients with a history of USD with or without urinary stone activity based on radiologic imaging. Stone and urine metabolomes were stratified by composition and radiographic stone-activity, respectively. Additionally, we quantified highly abundant metabolites that were present in either calcium oxalate (CaOx) or calcium phosphate (CaPhos) stones and also significantly enriched in the urine of active stone formers (SF) compared to non-active SF. These data were used to delineate either a direct involvement of urinary metabolites in lithogenesis or the passive uptake of biomolecules within the stone matrix. RESULTS: Urinary metabolomes were distinct based on radiographic stone-activity and the 2 types of CBS. Stratification by radiologic stone activity was driven by the enrichment of 14 metabolites in the urine of active SF that were also highly abundant in both CaOx and CaPhos stones, indicative of a potential involvement of these metabolites in lithogenesis. Using the combination of these 14 metabolites in total, we generated a model that correctly classified patients as either active vs non-active SF in a prospectively recruited cohort with 73% success. CONCLUSION: Collectively, our data suggest specific urinary metabolites directly contribute to the formation of urinary stones and that active SF may excrete higher levels of lithogenic metabolites than non-active patients. Future studies are needed to confirm these findings and establish the causative mechanisms associated with these metabolites.

Purpose:Electronic patient portals can be beneficial in providing direct engagement and clarity to avoid unnecessary extra provider encounters. In this study we assessed whether portal usage among ...

Background: Vaginal calculi are rare and can grow quite large if they remain undetected. Vaginal stones are caused by the pooling of urine in the vagina and can be classified as either primary or secondary, depending on the absence or presence, respectively, of a nidus. Primary stones without any urethrovaginal or vesicovaginal fistula are even more uncommon but appear to be more commonly reported in incontinent women with significant physical disabilities. Case Presentation: We present a case of an ∼11 cm primary vaginal stone in a 61-year-old woman with cerebral palsy. This was removed using a nephroscope and an endoscopic ultrasonic lithotrite through the vaginal introitus with subsequent analysis demonstrating a struvite stone composition. Conclusion: This case is unique not only for the large size of the calculi but also for our less invasive approach, using a nephroscope and endoscopic ultrasonic lithotrite to fragment and remove the stone. We hope that this report will assist other providers in the timely and accurate diagnosis and treatment of future vaginal stone patients.

INTRODUCTION AND OBJECTIVE:The American Urological Association guidelines recommend peri-procedural antibiotics for percutaneous nephrolithotomy (PCNL), yet it is not clear which is superior. Given...

INTRODUCTION AND OBJECTIVE:Patients with nephrolithiasis are engaged in shared decision making to determine the most suitable treatment option. This process is inherently accompanied by decisional ...

INTRODUCTION AND OBJECTIVE:Nephrolithiasis is a cause of significant morbidity in patient populations with musculoskeletal abnormalities, spinal cord injury, and multiple sclerosis often requiring ...

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 o...

Objective To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists. Methods Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns. Results As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked “What is most challenging about HoLEP in current practice?” common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm). Conclusion With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.

Introduction: We sought to assess the accuracy of using stone volume (SV) estimated with a software algorithm as a predictor for stone passage in a trial of medical expulsive therapy (MET). Methods: We identified patients with ureteral stones discharged from the ER on MET. Patients with infection, non-ureteral stones, or needing immediate surgical intervention were excluded. For each stone, longest dimension (LD) was recorded and SV was estimated by a computed tomography (CT)-based region growing (RG) algorithm and standard ellipsoid formula (EF). Stone passage within 30 days was assessed via electronic chart and followup phone call. Results: Fifty-one patients were included for analysis (53±16.7 years, 24% female). The mean LD was 4.85±2.02 mm. The mean SV was similar by EF and RG (0.051±0.057cm3 vs. 0.049± 0.052 cm3; p=0.28). Thirty-three (65%) patients passed their stone, while 18 (35%) did not. The mean LD for passed stones vs. failed passage was 4.1±1.7 mm vs. 6.2±1.8 mm (p=0.0002); the mean EF volume was 0.028±0.035 cm3 vs. 0.093±0.066 cm3 (p=0.00007); and the mean volume by RG was 0.028±0.027cm3 vs. 0.088±0.063 cm3 (p=0.00005). Conclusions: The clinical utility of using SV estimated by software algorithm as a predictor for success of MET has not previously been examined. We demonstrate that spontaneously passed stones had a significantly smaller volume than those requiring intervention. Further prospective studies are needed to validate these findings and establish volume thresholds for probability of stone passage.

Author(s): Fedrigon, Donald; Alshara, Luay; Monga, Manoj | Abstract: 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 l 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.

INTRODUCTION AND OBJECTIVE:Recurrence of urinary stone disease (USD) is typically assessed through imaging, which can expose patients to unhealthy levels of radiation. We aimed to use the urinary m...

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.

Studies indicate that with a safety wire in the ureter, an increased amount of force is necessary to advance ureteral access sheaths up to the proximal ureter. Theoretically, the compression of the ureter with the wire could lead to an increase in number and severity of ureteral injuries secondary to placement of a sheath. This prospective study aims to evaluate if there is a correlation between the use of a safety wire and ureteral injury from sheath placement by evaluating the location of the wire in relation to the injury after ureteroscopy.Fifty-nine consecutive patients underwent ureteroscopy for upper tract urinary stone disease. A 12/14 French ureteral access sheath was used with a safety wire in place. Ureteroscopy during withdrawal of the sheath was video recorded and reviewed by a blinded observer. Visible ureteral injuries were graded per the Traxer ureteral injury scale and the proximity of the wire to the injury was noted.Thirty-one of 59 patients (52.4%) had a ureteral injury secondary to access sheath placement. Eighteen (30.5%) injuries were low-grade, 13 (22.0%) were high-grade (grade 2 and 3) and there were no grade 4 injuries. A total of 10 (32.3%) injuries occurred on the same side as the wire while 67.7% were on the contralateral side of the ureter. Of the injuries that occurred on the same side as the wire, 80% were grade 1 injuries and 2 (20%) were grade 3. Statistical analysis did not show a significant relationship between high/low injury grade and side of injury (p value = 0.088). This suggests that there is no association of between the safety wire and development of high injury.There is no association between the location of the safety wire and ureteral injury if injury occurs during the placement of a ureteral access sheath. This suggests that the use of a safety wire does not add significant morbidity to the procedure.

Introduction: We aimed to characterize current practice patterns among endourologists on medical expulsive therapy (MET) for treatment of ureteral calculi.Methods: An online survey was administered to Endourological Society members. Respondents’ MET usage, index case management, and awareness of recent guidelines and literature were compared based on international status, practice setting, interval since training, and endourological fellowship training.Results: Of the 237 complete responses, 65% were international, 61% were academic, 66% had >10 years in practice, and 71% were endourology fellowship-trained. MET was used by 88%, with no differences between international, academic, practice length, and fellowship-trained groups. MET was used more frequently for