Contemporary Surgical Trends in the Management of Upper Tract Calculi

Oberlin, Daniel T.; Flum, Andrew S.; Bachrach, Laurie; Matulewicz, Richard S.; Flury, Sarah C.

doi:10.1016/j.juro.2014.09.006

Cited by 172 publications

(82 citation statements)

References 22 publications

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“…At the same time, urologists show a dramatic adoption of endo-DOI: 10.1159/000486345 scopic techniques for management of upper tract calculi over shockwave lithotripsy [7]. The utilisation of fluoroscopy during URS + LL adds to the total yearly effective radiation dose.…”

Section: Discussionmentioning

confidence: 99%

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics

et al. 2018

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Introduction and Objectives: Stone formers often have a chronic exposure to significant quantities of ionising radiation from radiological investigations and interventions. Predicting radiation exposure would allow the clinician to quantify expected cumulative radiation and find strategies to minimise exposure. We evaluated radiation exposure during ureteroscopy and laser lithotripsy (URS + LL) for a single stone episode and correlated the results to stone characteristics. Method: Data was collected retrospectively for all patients undergoing URS + LL in our institution over a 1 year period. Patients with multiple stones, staghorn stones or incomplete stone clearance were excluded to simplify the analysis. Patient characteristics, fluoroscopy data and stone characteristics were recorded. Results: We included 302 consecutive patients in the study. The majority of stones were located in the renal calyces/pelvis (54%) with the rest located in the upper (18%), middle (13%) and lower ureter (15%). Mean stone diameter was 9.9 mm (range 4–30 mm). Mean radiation exposure time during URS + LL was 44 s (range 12–119 s) with a mean total radiation exposure of 7.5 milligray (mGy; range 1.2–29.7 mGy). Renal stones were associated with 27% higher radiation exposure compared to ureteral stones (8.3 vs. 6.7 mGy; p = 0.02). There was a positive correlation between stone diameter and radiation exposure (Spearman’s correlation coefficient ρ = 0.28; p < 0.001). Stones with diameter greater than 10 mm were associated with 37% higher radiation exposure compared to smaller stones (9.1 vs. 6.6 mGy; p < 0.001). Conclusion: There is a direct correlation between stone burden, as well as location, and radiation exposure during URS + LL. Clinicians should consider strategies to reduce total radiation exposure in recurrent stone formers at risk of high radiation exposure by limiting screening time, using pulsed rather than continuous fluoroscopy, management with primary URS + LL, or using ultrasound guidance.

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Section: Discussionmentioning

confidence: 99%

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics

et al. 2018

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“…Randomized trials suggest that these two techniques are of similar efficacy, and therefore, guidelines endorse both as first-line options. However, SWL has been associated with an increased risk of hypertension (72), and emerging comparative effectiveness studies favor ureteroscopy (73), which is increasing in use (70,71,74). When patients undergo procedural interventions, a temporary ureteral stent is often placed to prevent ureteral obstruction and other adverse sequelae: in claims-based analyses, approximately 82% after ureteroscopy and 42% after SWL (75).…”

Section: Surgical Interventionmentioning

confidence: 99%

Urinary Stone Disease: Advancing Knowledge, Patient Care, and Population Health

Scales

Tasian

Schwaderer

et al. 2016

CJASN

137

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Expanding epidemiologic and physiologic data suggest that urinary stone disease is best conceptualized as a chronic metabolic condition punctuated by symptomatic, preventable stone events. These acute events herald substantial future chronic morbidity, including decreased bone mineral density, cardiovascular disease, and CKD. Urinary stone disease imposes a large and growing public health burden. In the United States, 1 in 11 individuals will experience a urinary stone in their lifetime. Given this high incidence and prevalence, urinary stone disease is one of the most expensive urologic conditions, with health care charges exceeding $10 billion annually. Patient care focuses on management of symptomatic stones rather than prevention; after three decades of innovation, procedural interventions are almost exclusively minimally invasive or noninvasive, and mortality is rare. Despite these advances, the prevalence of stone disease has nearly doubled over the past 15 years, likely secondary to dietary and health trends. The NIDDK recently convened a symposium to assess knowledge and treatment gaps to inform future urinary stone disease research. Reducing the public health burden of urinary stone disease will require key advances in understanding environmental, genetic, and other individual disease determinants; improving secondary prevention; and optimal population health strategies in an increasingly cost-conscious care environment.

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“…The European Association of Urology (EAU) guidelines recommend SWL as the first line management option for proximal ureteral stones <10mm, and an equivalent first line option to endourology for renal stones <20mm, proximal ureteral stones >10mm and distal ureteral stones <10mm [7]. In spite of this, reports indicate that the rate of SWL use has plateaued or decreased in recent years alongside a surge in the use of ureteroscopy with the holmium laser [8][9][10][11], and despite evidence suggesting similar success rates between management options [7]. The current evidence examining the use of SWL demonstrates wide variation in clinical outcomes, with overall stone free rates (SFRs) ranging from 40.2% to 96.8%, and is limited to studies reporting small cohorts or in which multiple models of SWL machine has been used [12].…”

Section: Introductionmentioning

confidence: 99%

Shock wave lithotripsy (SWL): outcomes from a national SWL database in New Zealand

Alexander

Gowland²,

Cadwallader

et al. 2016

BJU International

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ObjectivesTo present the national outcomes for New Zealand of over 9 000 stone cases treated with SWL at 21 centres over a 20 year period. Subjects/patients and methodsStone cases treated with SWL on board the Mobile Medical Technology (MMT) vehicle between 19 June 1995 and 1 December 2014 were identified, and data collection undertaken prospectively for patient, stone and treatment characteristics, and retrospectively for treatment outcomes. The primary outcome was treatment success, defined as complete stone clearance or clinically insignificant residual fragments (CIRFs) of ≤4mm. Secondary outcomes were stone free rate, complications and auxiliary procedures, and all statistical analyses were descriptive. Results9 538 stone cases (7 769 patients) were included. The overall, cumulative success rate was 58.7%; this included 45.1% that were stone free and 13.5% in which there were CIRFs ≤4mm. Success rates varied widely by stone size and location. Overall rates of urinary tract infection, perinephric haematoma, hospital admission and ureteral stent placement were 1.1%, 0.2%, 6.8% and 4.1%, respectively. Variations in SWL protocols across centres limits the overall reliability of our findings. ConclusionSWL remains a low morbidity management option requiring careful patient selection. This study provides valuable data for patient counseling and the formation of evidence based guidelines in SWL. The MMT SWL service has demonstrated that is it possible to deliver a high volume specialist stone service without requiring patients to travel further for treatment. KeywordsKidney stones, Nephrolithiasis, Lithotripsy IntroductionUrolithiasis comprises a significant and growing proportion of urological practice, with international epidemiological data demonstrating a global increase in its incidence and prevalence in recent decades [1][2][3]. This has important economic implications for healthcare services: a recent analysis estimated that the cost of stone disease will be >$5 billion per annum by 2030 in the USA [4]. Since its inception in the 1980s, shock wave lithotripsy (SWL) has become a well established treatment option for urolithiasis, demonstrating superior outcomes in morbidity and postoperative recovery than surgery, with relatively few contraindications [5,6]. The European Association of Urology (EAU) guidelines recommend SWL as the first line management option for proximal ureteral stones <10mm, and an equivalent first line option to endourology for renal stones <20mm, proximal ureteral stones >10mm and distal ureteral stones <10mm [7]. In spite of this, reports indicate that the rate of SWL use has plateaued or decreased in recent years alongside a surge in the use of ureteroscopy with the holmium laser [8][9][10][11], and despite evidence suggesting similar success rates between management options [7]. The current evidence examining the use of SWL demonstrates wide variation in clinical outcomes, with overall stone free rates (SFRs) ranging from 40.2% to 96.8%, and is limited to studies reporting small coho...

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Contemporary Surgical Trends in the Management of Upper Tract Calculi

Abstract: Junior and senior clinicians showed a dramatic adoption of endoscopic techniques. Treatment of upper tract calculi is an evolving field and provider specific attributes affect how these stones are treated.

Cited by 172 publications

References 22 publications

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics

Urinary Stone Disease: Advancing Knowledge, Patient Care, and Population Health

Shock wave lithotripsy (SWL): outcomes from a national SWL database in New Zealand

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