Margaret S. Pearle

2007 Guideline for the management of ureteral calculi.

TheAmericanUrologicalAssociationNephrolithiasis Clinical Guideline Panel was established in 1991. Since that time, the Panel has developed three guidelines on the management of nephrolithiasis, the most recent being a 2005 update of the original 1994 Report on the Management of Staghorn Calculi [1]. The European Association of Urology began their nephrolithiasis guideline project in 2000, yielding the publication of Guidelines on Urolithiasis, with updates in 2001 and 2006 [2]. While both documents provide useful recommendations on the management of ureteral calculi, changes in shock-wave lithotripsy technology, endoscope design, intracorporeal lithotripsy techniques, and laparoscopic expertise have burgeoned over the past five to ten years. Under the sage leadership of the late Dr. JosephW. Segura, the AUA Practice Guidelines Committee suggested to both the AUA and the EAU that they join efforts in developing the first set of internationally endorsed guidelines focusing on the changes introduced in ureteral stone management over the last decade. We therefore dedicate this report to the memory of Dr. Joseph W. Segura whose vision, integrity, and perseverance led to the establishment of the first international guideline project. This joint EAU/AUA Nephrolithiasis Guideline Panel (hereinafter the Panel) performed a systematic review of the English language literature published since 1997 and a comprehensively analyzed outcomes data from the identified studies. Based on their findings, the Panel concluded that when removal becomes necessary, SWL and ureteroscopy remain the two primary treatment modalities for the management of symptomatic ureteral calculi. Other treatments were reviewed, including medical expulsive therapy to facilitate spontaneous stone passage, percutaneous antegrade ureteroscopy, and laparoscopic and open surgical ureterolithotomy. In concurrence with the previously published guidelines of both organizations, open stone surgery is still considered a secondary treatment option. Blind basketing of ureteral calculi is not recommended. In addition, the Panel was able to provide some guidance e u r o p e a n u r o l og y 5 2 ( 2 0 0 7 ) 1 6 1 0 – 1 6 3 1

OPTIMAL METHOD OF URGENT DECOMPRESSION OF THE COLLECTING SYSTEM FOR OBSTRUCTION AND INFECTION DUE TO URETERAL CALCULI

PURPOSE We compare the efficacy of percutaneous nephrostomy with retrograde ureteral catheterization for renal drainage in cases of obstruction and infection associated with ureteral calculi. MATERIALS AND METHODS We randomized 42 consecutive patients presenting with obstructing ureteral calculi and clinical signs of infection (temperature greater than 38 C and/or white blood count greater than 17,000/mm.3) to drainage with percutaneous nephrostomy or retrograde ureteral catheterization. Preoperative patient and stone characteristics, procedural parameters, clinical outcomes and costs were assessed for each group. RESULTS Urine cultures obtained at drainage were positive in 62.9% of percutaneous nephrostomy and 19.1% of retrograde ureteral catheterization patients. There was no significant difference in the time to treatment between the 2 groups. Procedural and fluoroscopy times were significantly shorter in the retrograde ureteral catheterization (32.7 and 5.1 minutes, respectively) compared with the percutaneous nephrostomy (49.2 and 7.7 minutes, respectively) group. One treatment failure occurred in the percutaneous nephrostomy group, which was successfully salvaged with retrograde ureteral catheterization. Time to normal temperature was 2.3 days in the percutaneous nephrostomy and 2.6 in the retrograde ureteral catheterization group, and time to normal white blood count was 2 days in the percutaneous nephrostomy and 1.7 days in the retrograde ureteral catheterization group (p not significant). Length of stay was 4.5 days in the percutaneous nephrostomy group compared with 3.2 days in the retrograde ureteral catheterization group (p not significant). Cost analysis revealed that retrograde ureteral catheterization was twice as costly as percutaneous nephrostomy. CONCLUSIONS Retrograde ureteral catheterization and percutaneous nephrostomy effectively relieve obstruction and infection due to ureteral calculi. Neither modality demonstrated superiority in promoting a more rapid recovery after drainage. Percutaneous nephrostomy is less costly than retrograde ureteral catheterization. The decision of which mode of drainage to use may be based on logistical factors, surgeon preference and stone characteristics.

Climate-related increase in the prevalence of urolithiasis in the United States

An unanticipated result of global warming is the likely northward expansion of the present-day southeastern U.S. kidney stone “belt.” The fraction of the U.S. population living in high-risk zones for nephrolithiasis will grow from 40% in 2000 to 56% by 2050, and to 70% by 2095. Predictions based on a climate model of intermediate severity warming (SRESa1b) indicate a climate-related increase of 1.6–2.2 million lifetime cases of nephrolithiasis by 2050, representing up to a 30% increase in some climate divisions. Nationwide, the cost increase associated with this rise in nephrolithiasis would be

Management Of Ureteral Calculi: A Cost Comparison And Decision Making Analysis

0.9–1.3 billion annually (year-2000 dollars), representing a 25% increase over current expenditures. The impact of these changes will be geographically concentrated, depending on the precise relationship between temperature and stone risk. Stone risk may abruptly increase at a threshold temperature (nonlinear model) or increase steadily with temperature change (linear model) or some combination thereof. The linear model predicts increases by 2050 that are concentrated in California, Texas, Florida, and the Eastern Seaboard; the nonlinear model predicts concentration in a geographic band stretching from Kansas to Kentucky and Northern California, immediately south of the threshold isotherm.

Predictive value of kidney stone composition in the detection of metabolic abnormalities

PURPOSE We compared the cost of treatment strategies for ureteral calculi using a decision tree model. MATERIALS AND METHODS A comprehensive literature review was performed to determine the average success rate of each of 3 treatment modalities, namely observation, ureteroscopy and shock wave lithotripsy. Using these success rates decision analysis models were constructed using Data 3.5 software (TreeAge Software, Inc., Williamstown, Massachusetts) to estimate the cost of treatment and followup for each of the 3 treatments. One-way sensitivity analysis was performed to evaluate the effect of varying individual probabilities of success and costs, and 2-way sensitivity analysis was done to evaluate the model for a wide range of potential costs and success rates of ureteroscopy and shock wave lithotripsy. In addition, a table was constructed to enable individual surgeons and institutions to determine the cost impact of ureteroscopy and shock wave lithotripsy in their unique clinical scenarios. RESULTS Observation was the least costly pathway if no financial cost, such as emergency room visits, was incurred by failed observation. Ureteroscopy was less costly than shock wave lithotripsy for stones at all ureteral locations. A cost difference between the 2 modalities of approximately

PROSPECTIVE RANDOMIZED TRIAL COMPARING SHOCK WAVE LITHOTRIPSY AND URETEROSCOPY FOR MANAGEMENT OF DISTAL URETERAL CALCULI

1,440,

The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients.

1,670 and

Radiation Exposure in the Acute and Short-Term Management of Urolithiasis at 2 Academic Centers

1,750 was noted for proximal, mid and distal ureteral calculi, respectively. One-way sensitivity analysis showed that the cost of ureteroscopy would have to increase by more than

Complications of ureteroscopy

1,400,

NATURAL HISTORY OF RESIDUAL FRAGMENTS FOLLOWING PERCUTANEOUS NEPHROSTOLITHOTOMY

1,700 and