Brenton Winship

Psychiatric Diagnoses and Other Factors Associated with Emergency Department Return within 30 Days of Ureteroscopy

Purpose: Emergency department visits after ureteroscopy are costly and inconvenient. To better understand those at risk we aimed to identify patient demographic, medical and surgical factors associated with 30-day emergency department presentation following ureteroscopy for urolithiasis with particular attention to those with a history of a psychiatric diagnosis. Materials and Methods: We retrospectively reviewed 1,576 cases (1,395 adults) who underwent stone related ureteroscopy during 3 years at a total of 2 hospitals. We collected patient demographics, medical history and operative details. The primary outcome was return to the emergency department within 30 days of ureteroscopy. Logistic regression was performed to examine factors associated with emergency department presentation. Results: Of the patients 613 (43.9%) had a history of psychiatric diagnosis. Of those with ureteroscopy encounters 12.6% returned to the emergency department within 30 days of ureteroscopy, including 58.8% with a history of psychiatric diagnosis. On multivariable analysis variables associated with emergency department return included a history of psychiatric diagnosis (OR 1.57, p = 0.012), uninsured status (OR 2.46, p = 0.001) and a stone only in the kidney (OR 1.76, p = 0.022). Patients who returned to the emergency department had had more emergency department visits in the year prior to surgery (OR 1.40, p <0.001). On univariable analysis older patients and those with longer operative time were more frequently admitted from the emergency department (OR 1.03, p = 0.002 and OR 1.96, p = 0.03. respectively) while uninsured patients were admitted less frequently (OR 0.19, p = 0.013). No difference was noted in admissions between those with a psychiatric diagnosis and all others (60.7% vs 55.8%, p = 0.48). Conclusions: We identified factors associated with emergency department return after ureteroscopy, including a history of psychiatric diagnosis, uninsured status and emergency department visits in the year before surgery. These patients may benefit from targeted interventions to help avoid unnecessary emergency department visits.

In Vitro Comparison of a Novel Single Probe Dual-Energy Lithotripter to Current Devices

PURPOSEnThe LithoClast Trilogy is a novel single probe, dual-energy lithotripter with ultrasonic (US) vibration and electromagnetic impact forces. ShockPulse and LithoClast Select are existing lithotripters that also use a combination of US and mechanical impact energies. We compared the efficacy and tip motion of these devices in an in vitro setting.nnnMATERIALS AND METHODSnBegostones, in the ratio 15:3, were used in all trials. Test groups were Trilogy, ShockPulse, Select ultrasound (US) only, and Select ultrasound with pneumatic (USP). For clearance testing, a single investigator facile with each lithotripter fragmented 10 stones per device. For drill testing, a hands-free apparatus with a submerged balance was used to apply 1 or 2u2009lbs of pressure on a stone in contact with the device tip. High-speed photography was used to assess Trilogy and ShockPulses probe tip motion.nnnRESULTSnSelect-USP was slowest and Trilogy fastest on clearance testing (pu2009<u20090.01). On 1u2009lbs drill testing, Select-US was slowest (pu2009=u20090.001). At 2u2009lbs, ShockPulse was faster than Select US (pu2009=u20090.027), but did not significantly outpace Trilogy nor Select-USP. At either weight, there was no significant difference between Trilogy and ShockPulse. During its US function, Trilogys maximum downward tip displacement was 0.041u2009mm relative to 0.0025u2009mm with ShockPulse. Trilogy had 0.25u2009mm of maximum downward displacement during its impactor function while ShockPulse had 0.01u2009mm.nnnCONCLUSIONSnSingle probe dual-energy devices, such as Trilogy and ShockPulse, represent the next generation of lithotripters. Trilogy more efficiently cleared stone than currently available devices, which could be explained by its larger probe diameter and greater downward tip displacement during both US and impactor functions.

Dusting Efficiency of the Moses Holmium Laser: an Automated in vitro Assessment

INTRODUCTIONnMoses technology is a novel Holmium:YAG laser system designed to minimize stone retropulsion and improve stone ablation when the laser is not in direct contact with the stone. Our aim was to assess the efficiency of Moses technology relative to short- and long-pulse lithotripsy using an automated in vitro dusting model of stone comminution.nnnMETHODSnAll tests were conducted using a Lumenis Pulse 120H Holmium:YAG laser with a 365u2009μm Moses D/F/L fiber. Hard (15:3) and soft (15:6) Begostones mimicking calcium oxalate monohydrate and uric acid stones, respectively, were used. To assess ablation efficiency and fiber tip degradation, a dusting model was employed: the laser was moved by a three-dimensional positioning system in a spiral motion across a flat Begostone surface submerged in water. Ablation efficiency was measured as stone mass loss after 4u2009kJ of energy delivery. Fiber tip degradation was measured at 1u2009kJ intervals. Comparative trials with short pulse, long pulse, Moses contact, and Moses distance settings were completed with the laser tip positioned at 0, 1, and 2u2009mm distances from the stone at energy settings of 0.4u2009J delivered at 70u2009Hz.nnnRESULTSnIn our dusting model, stone ablation was significantly greater the closer the laser was to the stone. On hard stones, pulse type did not have a significant impact on ablation at any distance. On soft stones at 0u2009mm, Moses contact produced the greatest ablation, significantly greater than long pulse (pu2009<u20090.05). At 1u2009mm, Moses distance produced significantly greater ablation than all other settings (pu2009=u20090.025) and was as effective as long or short pulse at 0u2009mm. At 2u2009mm distance, no pulse type demonstrated significantly different ablation. Fiber tip degradation was minimal and not significant between settings.nnnCONCLUSIONSnMoses technology delivers greater ablation of soft stones when in contact and 1mm from the stone surface.

Let’s get to the point: Comparing Insertion Characteristics and Scope Damage of Flat-tip and Ball-tip Holmium Laser Fibers

INTRODUCTIONnA ball-tip holmium laser fiber (TracTip; Boston Scientific) has been developed to theoretically reduce damaging friction forces generated within a ureteroscope working channel. We compared the insertional forces and damage with a ureteroscope inner lining when inserting standard flat-tip and ball-tip laser fibers.nnnMATERIALS AND METHODSnA standard ureteroscope channel liner was placed in a 3D-printed plastic mold. Molds were created at four angles of deflection (30°, 45°, 90°, and 180°) with a 1u2009cm radius of curvature. New 200u2009μm ball-tip (TracTip; Boston Scientific) and 200u2009μm flat-tip (Flexiva; Boston Scientific) laser fibers were advanced through the liner using a stage controller. A strain gauge was used to measure force required for insertion. Each fiber was passed 600 times at each angle of deflection. The ureteroscope liner was changed every 150 passes. Leak testing was performed every 50 passes or when the insertional force increased significantly to assess damage to the liner.nnnRESULTSnAt all deflection angles, the average insertional force was significantly lower with the ball-tip laser fibers compared with flat-tip laser fibers (pu2009<u20090.001). All trials with the ball-tip lasers were completed at each angle without any leaks. Two of four trials using flat-tip fibers at 45° deflection caused liner leaks (at 91 and 114 passes). At 90° deflection, all flat-tip trials caused liner leaks on first pass. The 180° trials could not physically be completed with the flat-tip laser fiber. Within the flat- and ball-tip groups, an increasing amount of force was needed to pass the fiber as the degree of deflection increased (pu2009<u20090.001).nnnCONCLUSIONSnThe ball-tip holmium laser fiber can be safely passed through a deflected ureteroscope without causing liner perforation. The standard flat-tip fiber requires greater insertion force at all angles and can cause the ureteroscope liner to leak if it is deflected 45° or more.