Sri Sivalingam

Does Combination Therapy with Tamsulosin and Tolterodine Improve Ureteral Stent Discomfort Compared with Tamsulosin Alone? A Double-Blind, Randomized, Controlled Trial

PURPOSEnUreteral stent discomfort is a significant postoperative problem forxa0many patients. Despite the use of narcotics and α-blockers patients often experience bothersome lower urinary tract symptoms and pain, which impair daily activities. We compared combination therapy with an α-blocker and an anticholinergic to monotherapy with an α-blocker.nnnMATERIALS AND METHODSnA double-blind, randomized, controlled trial was performed from December 2012 to April 2014. A total of 80 patients were randomized, including 44 to the combination group (tamsulosin 0.4 mg and tolterodine early release 4 mg) and 36 to the monotherapy group (tamsulosin 0.4 mg and placebo). Patients with preexisting ureteral stent placement or current anticholinergic therapy were excluded from study. Patients completed USSQ (Urinary Stent Symptom Questionnaire) before stent placement on the day of surgery, the day after stent placement, the morning of stent removal and the day after stent removal. The questionnaire included questions regarding urinary symptoms, general health, body pain, and work and sexual history.nnnRESULTSnA total of 80 patients (40 males and 40 females) were studied. Mean age was 51.5 vs 51.3 years (p = 0.95) and mean body mass index was 33.6 vs 31.9xa0kg/m(2) (p = 0.44) in monotherapy group 1 vs combination therapy group 2. Betweenxa0the 2 groups there was no significant difference in urinary symptoms, body pain and activities of daily living from baseline to just before stent removal (p = 0.95, 0.40 and 0.95, respectively). Although there was no difference between the groups, both showed improvement in urinary symptoms from the time ofxa0initial stent insertion to just prior to stent removal (difference -0.50 for combination therapy and -0.40 for monotherapy). The mean stent indwelling time of 9.6 and 8.7 days in the combination and monotherapy groups, respectively, did not differ (p = 0.67). On ANOVA it had no significant impact on results (p = 0.64).nnnCONCLUSIONSnCombination therapy with tamsulosin and tolterodine does not appear to improve urinary symptoms, bodily pain or quality of life in patients after ureteral stent placement for nephrolithiasis compared to tamsulosin alone. Both groups experienced worse urinary symptoms, pain and quality of life with a stent, suggesting that further research is necessary to improve stent discomfort.

Validation and Reliability of the Wisconsin Stone Quality of Life Questionnaire

Purpose: WISQOL (Wisconsin Stone Quality of Life questionnaire) is a disease specific, health related quality of life measure designed for patients who form kidney stones. The purpose of this study was to demonstrate the external and convergent validity of WISQOL and assess its psychometric properties. Materials and Methods: At the WISQOL creation site (development sample) and at 8 geographically diverse centers in the United States and Canada (consortium sample) patients with a history of kidney stones were recruited. Item response option variability, correlation patterns and internal consistency were compared between samples. Convergent validity was assessed by patients who completed both WISQOL and SF‐36v2® (36‐Item Short Form Health Survey, version 2). Results: Results were analyzed in 1,609 patients, including 275 in the development sample and 1,334 in the consortium sample. Response option variability patterns of all items were acceptable. Internal WISQOL consistency was acceptable. Intersample score comparisons revealed few differences. For both samples the domain‐total WISQOL score correlations exceeded 0.86. Item level analyses demonstrated suitable variation, allowing for discriminatory scoring. At the time that they completed WISQOL, patients with stones and stone related symptoms scored lowest for health related quality of life. Patients with stones but no symptoms and those with no stones scored higher. The convergent validity substudy confirmed the ability of WISQOL to identify stone specific decrements in health related quality of life that were not identified on SF‐36v2. Conclusions: WISQOL is internally consistent and discriminates among patients with different stone statuses and symptoms. WISQOL is externally valid across the North American population. It may be used for multicenter health related quality of life studies in kidney stone disease.

Shared decision making: why do patients choose ureteroscopy?

To evaluate patient’s characteristics that affects their decision on the management of asymptomatic renal calculi, and to determine the impact of anesthetic on the selection of shockwave lithotripsy (SWL). A survey was distributed to 100 patients in our multi-disciplinary stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8xa0mm lower pole stone and descriptions for managements options including active surveillance (annual radiography, 40xa0% chance of growthxa0>10xa0mm within 4xa0years, 20xa0% chance of passage), SWL under conscious sedation (65xa0% success rate), and URS (90xa0% success rate, with stent placement for 1xa0week). Patients were asked what was the most important variable impacting the choice of treatment. Patients preferred SWL (45xa0%) over URS (32xa0%) and active surveillance (23xa0%). Patients with a previous experience with URS were more likely to choose it again (pxa0=xa00.0433). Decisions were driven primarily by success rate (52xa0%), followed by risk of complications (29xa0%), postoperative pain (7xa0%) and others (12xa0%). Patients choosing URS had the highest magnitude of history of pain (pxa0=xa00.03) and were more likely to prioritize success (78xa0%) and less likely to prioritize surgical risk (13xa0%) or anticipated pain after surgery (0xa0%) (pxa0=xa00.01). Most (85xa0%) of the patients would rely on the physician’s recommendation for the treatment modality. Patients place differing value on risk versus success. As they rely heavily on the physician’s recommendation, it is important that their urologist determine whether risk or success is of highest priority for them to facilitate a shared medical decision.

Systemic Inflammatory Response Syndrome after Percutaneous Nephrolithotomy: A Randomized Single-Blind Clinical Trial Evaluating the Impact of Irrigation Pressure.

PURPOSEnWe evaluated the impact of intraoperative irrigation pressures on the risk of systemic inflammatory response after percutaneous nephrolithotomy.nnnMATERIALS AND METHODSnBetween January 2014 and March 2015, 90 patients with renal stones planned for percutaneous nephrolithotomy were randomized between low (80 mm Hg) and high (200 mm Hg) irrigation pressure. Patient demographics, perioperative outcomes and systemic inflammatory response incidence rates were compared using the chi-square and Wilcoxon signed rank tests.nnnRESULTSnMean patient age, gender, body mass index and other perioperative outcomes were similar in both arms. High pressure irrigation was associated with a higher risk of systemic inflammatory response syndrome (46%) compared to low pressure irrigation (11%, p=0.0002). On multivariate analysis only high irrigation pressure, paraplegia or neurogenic bladder and nonquinolone perioperative medication were predictive of postoperative systemic inflammatory response syndrome.nnnCONCLUSIONSnHigh pressure fluid irrigation fluid increases the risk of postoperative systemic inflammatory response syndrome after percutaneous nephrolithotomy.

Clinical Predictors of 30-Day Emergency Department Revisits for Patients with Ureteral Stones

PURPOSEnPatients with ureteral stones frequently present to the emergency department for an initial evaluation with pain and/or nausea. However, a subset of these patients subsequently return to the emergency department for additional visits. We sought to identify clinical predictors of emergency department revisits.nnnMATERIALS AND METHODSnWe reviewed emergency department visits at our institution with an ICD-9 diagnosis of urolithiasis and an associated computerized tomography scan between 2010 and 2013. Computerized tomography studies were independently reviewed to confirm stone size and location, and degree of hydronephrosis. The primary outcome was a second emergency department visit within 30 days of the initial visit for reasons related to the stone. Patient characteristics and stone parameters at presentation were recorded. Univariable and multivariable analyses were done to identify factors associated with emergency department revisits.nnnRESULTSnWe reviewed the records of 1,510 patients 18 years old or older who presented to the emergency department with a diagnosis of ureteral stones confirmed by computerized tomography. Of the patients 164 (11%) revisited the emergency department within 30 days. On multivariable analysis the presence of a proximal ureteral stone, age less than 30 years and the need for intravenous narcotics in the emergency department remained independently associated with an emergency department revisit.nnnCONCLUSIONSnYounger patients, those with proximal stones and those requiring intravenous narcotics for pain control are more likely to return to the emergency department. Consideration should be given for early followup or intervention for these patients to prevent costly emergency department returns.

Contemporary Imaging Practice Patterns Following Ureteroscopy for Stone Disease.

BACKGROUND AND PURPOSEnRoutine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. However, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. We sought to identify post-ureteroscopy imaging practices among experienced urologists.nnnMATERIALS AND METHODSnA REDcap questionnaire was sent to urologists in North America. The questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. Additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors influenced these preferences. The likelihood of altering clinical practice and the desire for specific imaging guidelines were also assessed. The interquartile range (IQR) was utilized as a measure of median consensus.nnnRESULTSnThree hundred twenty-two urologists completed the questionnaire. The mean number of years in practice was 18 ± 10; 82% of respondents performed more than five ureteroscopic stone procedures monthly. Routine postoperative imaging was obtained by 48% of participants as follows: ultrasound (US) (47%), kidneys, ureters, and bladder (KUB) (17%), CT (4%), intravenous pyelogram (IVP) (2%), and KUB+US (30%). Urologists who did not routinely image patients were more concerned about cost (55% vs 25%, p ≤ 0.0001), radiation exposure (69% vs 44%, p ≤ 0.0001), and diagnostic inaccuracy of US (57% vs 44%, p ≤ 0.02). These urologists were also less likely to have completed an endourology fellowship (7% vs 23%, p ≤ 0.0001). The most compelling predictors of obtaining postoperative imaging were postoperative pain and fever (median 5, IQR 1), residual stones (median 5, IQR 1), ureteral perforation (median 5, IQR 2), and presence of a solitary kidney (median 4.5, IQR 2).nnnCONCLUSIONSnCurrently, about 50% of urologists who regularly perform ureteroscopic stone procedures obtain postoperative imaging. Imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever.

Management of Ureteral Stent Discomfort in Contemporary Urology Practice

Introduction: Ureteral stents are used ubiquitously in routine urological practice, and despite their long‐standing clinical use, stent associated urinary symptoms and pain continue to be of significant concern for patients. Therefore, we reviewed contemporary randomized controlled trials and meta‐analyses investigating the alleviation of urinary stent symptoms. Methods: A thorough search of randomized controlled trials and meta‐analyses of pharmacotherapeutic means of alleviating urinary stent symptoms was conducted and reviewed. Efforts were made to evaluate the quality of studies based on methodology and tools used to assess symptoms. Results: Our search resulted in 16 published reports that fit our criteria. Of these randomized controlled trials 13 involved oral agents while 3 studies evaluated intravesical therapies. Specific pharmacological classes that were assessed included nonsteroidal anti‐inflammatory drugs, anesthetics, alpha‐antagonists, anticholinergics and paralytics. The majority of randomized controlled trials evaluated the role of alpha‐antagonists, which ultimately produced the most compelling evidence of a reduction in stent associated lower urinary tract symptoms and pain. The randomized controlled trials involving anticholinergic agents have produced inconsistent results. Conclusions: Stent associated symptoms are a significant source of dissatisfaction for patients undergoing urological procedures. Numerous agents have been studied and uroselective alpha‐antagonists have most consistently demonstrated a significant reduction in symptoms.

Mini versus Standard Percutaneous Nephrolithotomy: the impact of sheath size on intra-renal pelvic pressure and infectious complications in a porcine model

OBJECTIVEnTo determine how sheath and endoscope size affect intrarenal pelvic pressures and risk of postoperative infectious complications comparing Mini vs Standard percutaneous nephrolithotomy (PCNL).nnnMATERIALS AND METHODSnUropathogenic Escherichia coli were grown and 109 of them were instilled into the porcine renal pelvis through retrograde access for 1 hour. Percutaneous access utilized a 14/16F 20u2009cm ureteral access sheath for the Mini arm and a 30F sheath for the Standard arm. Nephroscopy was simulated utilizing either an 8/9.8F semirigid ureteroscope or 26F nephroscope for 1 hour while intrarenal pelvic pressure was continuously monitored. Blood and tissue cultures of kidney, liver, and spleen biopsies were plated and incubated and positive cultures were confirmed with polymerase chain reaction.nnnRESULTSnIntrapelvic pressures were higher in the Mini group, 18.76u2009±u20095.82u2009mm Hg vs 13.56u2009±u20095.82u2009mm Hg (pu2009<u20090.0001). Time spent above 30u2009mm Hg was greater in the Mini arm, 117.0 seconds vs 66.1 seconds (pu2009=u20090.0452). All pigs had positive kidney tissue cultures whereas spleen cultures were positive in 100% and 60% of pigs in the Mini and Standard arms, respectively (pu2009=u20090.0253); 90% and 30% had positive liver tissue culture in the Mini and Standard arms, respectively (pu2009=u20090.0062). Blood cultures were positive in 30% of pigs in the Mini arm compared with none in the Standard arm (pu2009=u20090.0603).nnnCONCLUSIONnMini-PCNL was associated with higher intrarenal pressures and higher risk of end organ bacterial seeding in the setting of an infected collecting system. This suggests a higher potential for infectious complications in a clinical setting.

Can a Simplified 12-Hour Nighttime Urine Collection Predict Urinary Stone Risk?

OBJECTIVEnTo determine if there is correlation between nighttime 12-hour and traditional 24-hour urine collection in regard to chemistry values and the supersaturations of calcium oxalate, calcium phosphate, and uric acid for the metabolic evaluation of nephrolithiasis.nnnMATERIALS AND METHODSnNinety-five patients were prospectively enrolled from 2013 to 2015. Patients >18 years of age who presented to a tertiary stone clinic and who would normally be counseled for 24-hour urine collection were eligible for the study. Participants completed 24-hour urine collections twice, with each divided into 2 separate 12-hour collections. Day-time collection began after the first morning void and continued for 12 hours. The night collection proceeded for the next 12 hours through the first morning void.nnnRESULTSnForty-nine 24-hour samples from 35 patients met inclusion criteria and were included in the analysis. Overall, there was strong correlation between the night 12-hour and the 24-hour urine collections with R2 ranging from 0.76 for pH to 0.96 for Citrate. In our analysis of variability, the nighttime 12-hour collection differed from the 24-hour collection by 30% in 1-9 patients (2.0%-18.4%) based on individual chemistry value. Diagnosis of underlying metabolic abnormalities was concordant in 92% of patients.nnnCONCLUSIONnA 12-hour nighttime collection has strong correlation with 24-hour urine collection. As such, simplifying the metabolic evaluation to a 12-hour overnight collection may be feasible-improving compliance and decreasing patient burden.

Patient Preference for Management of an Asymptomatic 15 mm Renal Calculus—Avoid Risk or Maximize Success?

Introduction: We evaluate patient preferences and the underlying factors determining decision making in the management of the asymptomatic 15 mm renal stone. Methods: A survey was randomly distributed to 106 patients at our multidisciplinary stone clinic. Patients were given a hypothetical scenario of a 15 mm renal stone, and were asked to choose among the 3 treatment options of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. The success rate, risk and morbidity associated with each treatment were provided to patients. Statistical analysis involved the Fisher exact and Wilcoxon signed rank tests. Analysis was performed using standard computer software with p <0.05 considered statistically significant. Results: A total of 103 patients completed our survey, and 58 (56%) chose ureteroscopy, 26 (25%) chose percutaneous nephrolithotomy and 19 (19%) preferred shock wave lithotripsy as the treatment option. Patients who selected shock wave lithotripsy were increasingly concerned with risk rather than success rate (74% vs 16%, respectively). In contrast, patients who selected percutaneous nephrolithotomy were more concerned with the success rate rather than risk (81% vs 7.5%, respectively). Rates of success and risk were given approximately equal importance by patients selecting ureteroscopy (40% vs 48%, respectively). Conclusions: Patients who choose percutaneous nephrolithotomy are primarily motivated by a desire to maximize success while the choice of shock wave lithotripsy is primarily motivated by a desire to minimize risks. The majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. Understanding the factors driving patient decision making would allow urologists to more effectively manage expectations and provide counseling.