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BackgroundPostoperative opioid prescribing has been linked with persistent opioid use. Ureteroscopy (URS) is a common urologic procedure and a potential area to focus on opioid reduction. We aim to characterize international practice patterns of opioid prescribing post URS and what measures may decrease the need for opioid prescription.MethodsWe developed a survey directed to members of the Endourological Society. The survey queried the frequency of opioid prescribing post URS, challenges when opioids are not prescribed, and measures thought to reduce the need for opioids.ResultsWe received 159 responses with the majority reported practicing urology for >20 years (37.1%), and performing 10-20 ureteroscopies/month (45.3%). Forty-one percent were from the United States (US) and Canada. Sixty-six percent completed a fellowship, 84% in endourology. Twenty-six percent prescribe opioids more than half the time and the majority do so less than 10% of the time (61.6%). Thirty-eight percent had no challenges when opioids were omitted. Measures felt to decrease the need for opioids were preoperative counseling, nonsteroidal anti-inflammatory drugs use, and use of adjunct medications. After adjusting for location and type of practice, endourology fellowship completion, years of practice, and number of ureteroscopies/month, we found that respondents from the US and Canada were more likely to prescribe opioids more than half the time post URS compared to respondents from the rest of the world [odds ratio (OR): 87.5, P50% of the time post URS. Most important factors felt to reduce opioid prescription post URS were preoperative counseling, nonsteroidal anti-inflammatory drugs use. US and Canadian urologists were more likely to prescribe opioids >50% of the time post URS compared to the rest of the world. We believe best practice guidelines should be considered by the American and Canadian Urological Associations to address post URS opioid prescribing.

Background: The odds of nephrolithiasis increase with more metabolic syndrome (MetS) traits. We evaluated associations of metabolic and dietary factors from urine studies and stone composition with MetS traits in a large cohort of stone-forming patients., Methods: Patients >18 years old who were evaluated for stones with 24-hour urine collections between July 2009 and December 2018 had their records reviewed retrospectively. Patient factors, laboratory values, and diagnoses were identified within 6 months of urine collection and stone composition within 1 year. Four groups with none, one, two, and three or four MetS traits (hypertension, obesity, dyslipidemia, and diabetes) were evaluated. Trends across groups were tested using linear contrasts in analysis of variance and analysis of covariance., Results: A total of 1473 patients met the inclusion criteria (835 with stone composition). MetS groups were 684 with no traits, 425 with one trait, 211 with two traits, and 153 with three or four traits. There were no differences among groups for urine volume, calcium, or ammonium excretion. There was a significant trend ( P <0.001) for more MetS traits being associated with decreasing urine pH, increasing age, calculated dietary protein, urine uric acid (UA), oxalate, citrate, titratable acid phosphate, net acid excretion, and UA supersaturation. The ratio of ammonium to net acid excretion did not differ among the groups. After adjustment for protein intake, the fall in urine pH remained strong, while the upward trend in acid excretion was lost. Calcium oxalate stones were most common, but there was a trend for more UA ( P <0.001) and fewer calcium phosphate ( P =0.09) and calcium oxalate stones ( P =0.01) with more MetS traits., Conclusions: Stone-forming patients with MetS have a defined pattern of metabolic and dietary risk factors that contribute to an increased risk of stone formation, including higher acid excretion, largely the result of greater protein intake, and lower urine pH., Competing Interests: J. Asplin is currently employed by Litholink Corporation, has ownership interest in LabCorp, and other interests in/relationships with Oxalosis and Hyperoxaluria Foundation Scientific Advisory Committee. All remaining authors have nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)

Purpose: Renal colic is common and CT (computerized tomography) is frequently utilized when the diagnosis of kidney stone is suspected. CT is accurate, but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting., Materials and Methods: In conjunction with the ACEP (American College of Emergency Physicians®) E-QUAL (Emergency Quality Network) we formed a nine-member panel with three physician representatives each from the ACEP, the ACR® (American College of Radiology) and the AUA (American Urological Association). A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios., Results: From an initial search yielding 6,337 records there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%) and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%) with ultrasound in 9 (31%) and no further imaging needed in 13 (45%)., Conclusions: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.

Introduction: Renal colic is commonly seen in the emergency department (ED), where the focus is on diagnosis and symptom control. Educational materials are sometimes provided upon discharge, however, no standard content has been established. We characterized the educational materials given to patients reporting to EDs in different regions across the U.S. for symptomatic kidney stones, specifically evaluating disease-specific information, symptom management, prevention strategies including dietary recommendations (DRs), and patient follow up plans., Materials and Methods: Generic discharge instructions for patients presenting to EDs with renal colic were obtained from community hospitals and academic medical centers between October 2016 and November 2017. Hospitals were called directly. If the same discharge instructions were used by more than one hospital, each was included in our analysis. We assessed the different types of information provided with a focus on stone prevention and DRs by characterizing them into specific nutritional categories., Results: Of 266 hospitals contacted, 79 provided discharge instructions. Of these, 51 (65%) provided some information on diet. While most recommended higher fluid intake, almost 40% endorsed unnecessary fluid restrictions. Recommendations to reduce protein and oxalate intake were common, but erroneous information for both was given. Nearly 1 in 5 EDs recommended lower calcium intake. Less than 30% of EDs mentioned that stones can have different composition or causes. Less than 30% referenced consultation with a registered dietitian nutritionist (RDN) or that dietary approaches to stone prevention are optimally individualized. Only 9 summaries recommended urologic follow up., Conclusions: Many ED discharge materials contain DRs for stone prevention. These recommendations can be inaccurate and/or inappropriate. Advice on diet and stone prevention is more appropriately addressed in the outpatient setting when more data (stone composition, serum and urine parameters) and expert consultants are available.

Introduction: To identify factors associated with stone composition in patients undergoing percutaneous nephrolithotomy (PCNL)., Material and Methods: A retrospective analysis of patients who underwent PCNL at two academic institutions between 2002 and 2014. Stone composition, stone characteristics based on non-contrast computer tomography (NCCT), patient demographics, and the S.T.O.N.E nephrolithometry scores were compared. Stones were characterized as either infection or metabolic. Metabolic stones were classified as calcium phosphate-containing and all others., Results: A total of 192 renal units underwent PCNL. Retrieved stones were found to be 75% (144) metabolic and 25% (48) infection by stone analysis. Of the metabolic stones, 51% (73) were phosphate-containing calculi. Overall, infection stones were found to have a significantly higher S.T.O.N.E nephrolithometry score than metabolic stones (9.2 versus 8.1, p < 0.001). Average Hounsfield units (HU) were significantly lower in infection stones (765 versus 899, p < 0.05). Sixty-three percent of patients with infection stones were female as compared to 46% of patients with metabolic stones. Patients with phosphate-containing stones in the metabolic group were significantly more likely to be female (56% versus 35%, p < 0.01), younger (mean 49 versus 60 years of age, p < 0.02), and have lower BMI's (30 versus 32, p < 0.02) compared with other metabolic stones., Conclusions: Patient demographics including age, sex and BMI differ between patients with phosphate and non-phosphate containing metabolic stones. Higher S.T.O.N.E nephrolithometry scores were found in infection stones. These findings may serve as useful tools in the identification of stone compositions that are being seen more frequently in large and complicated stones undergoing PCNL.

Percutaneous nephrolithotomy (PCNL) is the standard treatment for patients with large stone burdens, but can be associated with significant complications. Flexible ureteroscopy is an alternative approach that is less invasive, but often requires multiple procedures. Typically, many factors play a role in the decision to perform PCNL or ureteroscopy. The challenge is that it is difficult to predict which stone burdens will be able to be cleared ureteroscopically. We describe our approach using initial prone ureteroscopy with the transition to standard prone PCNL if required.