The end of "Cutting for Stone"? Using the lithoclast trilogy for cystolitholapaxy on a 4 cm bladder stone per urethra.

We present a case of cystolitholapaxy using the LithoClast Trilogy lithotripter device per urethra via a rigid 26F nephroscope in a 36-year-old female with chondrodysplasia, paraplegia, contractures, and history of bladder augment managed with clean intermittent catheterization. The stone was 4cm in diameter with an average of 1300 Hounsfield Units, and composed of 45% calcium phosphate, 40% struvite, and 15% ammonium urate. Advantages include faster fragmentation time versus holmium laser, improved safety with suction extraction and improved vision, ability to treat larger stones endoscopically, and control of all variables by one surgeon with only a single foot pedal.

Preliminary Evidence of Decreased Disease-Specific Health-Related Quality of Life in Asymptomatic Stone Patients.

INTRODUCTION: Kidney stone patients have lower health-related quality of life (HRQOL) than nonstone formers. Among active stone patients (those with stones), those with symptoms have lower HRQOL than those without. However, little is known about whether asymptomatic stones affect patients' HRQOL. METHODS: A sample of asymptomatic stone formers was assembled by identifying patients who reported no symptoms on the disease-specific Wisconsin Stone Quality of Life (WiSQoL) questionnaire (n=351). Of these, 107 were identified (M:F 61:46; 53±17 years; BMI 29.5±7.6). Patients were mostly recurrent (78%), and 42% thought they had stones at the time of the WiSQoL questionnaire. Patients' WisQoL responses were compared by self-reported stone status (yes/no), actual stone status (yes/no, corroborated from imaging and medical records), age, gender, and duration of stones. RESULTS: Of patients reporting stones at the time of the questionnaire (42% of sample), 37 (82%) were correct about it. Of patients who reported not having stones (49% of sample), 29 (55%) were correct. WiSQoL results were lower (worse HRQOL) among patients with stones versus those without, regardless of whether they knew their actual stone status. CONCLUSIONS: Asymptomatic patients with current stones, whether they are aware of them or not, may have lower HRQOL. These results suggest that (a) some patients may not be fully aware of their stone-related symptoms or are better able to handle them than others, and (b) due to the potential impact on HRQOL, some patients may benefit from definitive knowledge of their stone status as this may inform decision-making for subsequent stone management.

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

PURPOSE: Ureteral stent discomfort is a significant postoperative problem for many 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. MATERIALS AND METHODS: A 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. RESULTS: A 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 31.9 kg/m(2) (p = 0.44) in monotherapy group 1 vs combination therapy group 2. Between the 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 of initial 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). CONCLUSIONS: Combination 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.

Shared Decision Making for Urolithiasis: The Use of a Patient Decision Making Aid.

INTRODUCTION: Patients desire an active role in health care decisions. We evaluated whether a patient decision making aid is useful when considering surgical treatment for urolithiasis. METHODS: Patients with a history of urolithiasis were recruited for study. They were asked to consider a hypothetical case of an asymptomatic 10 mm proximal ureteral stone for which elective surgical intervention was recommended. Shock wave lithotripsy and ureteroscopy were presented as potential options. A patient decision making aid was developed to explain and compare the options. A urologist presented the information to the patients, once using the patient decision making aid and then without the aid. We assessed participant satisfaction with each format, and invited comments about the aid and its content, design and clarity. RESULTS: Mean ± SD age of the 4 male and 10 female participants was 61 ± 9 years. Of the participants 86% found the patient decision making aid helpful but identified areas for improvement. Specifically, patients wanted more information on stent placement, stent discomfort, long-term effects and cost. Of the participants 79% reported that the aid improved their understanding of the treatment options compared to the session without the aid. While 8 of 14 participants preferred hearing surgeon recommendations, most still reported value in the patient decision making aid. CONCLUSIONS: Patient decision making aids are increasingly used in the management of several diseases and they require patient input into development. In our study the aid improved patient self-reported understanding of surgical options for ureteral stone removal. Notably, most participants still preferred to make decisions based on the surgeon recommendation. Modification of the patient decision making aid based on patient suggestions will enhance its usefulness and applicability in the clinical setting.

Flexible ureteroscopic laser lithotripsy for upper urinary tract stone disease in patients with spinal cord injury.

The objective of this study is to present the outcomes of flexible ureteroscopic laser lithotripsy (URS) for upper urinary tract stone disease in spinal cord injury (SCI) patients performed by a single surgeon. A retrospective analysis was performed for SCI patients treated with flexible URS for proximal ureter and kidney stone disease by a single surgeon between 2003 and 2013. Patient characteristics, operative outcomes, metabolic evaluation, and stone analyses were assessed in detail. A total of 27 URS procedures were performed for urolithiasis in 21 renal units of 19 patients. The mean age was 52.1 ± 15.6 years (16-72) and mean BMI was 29.2 ± 7.3 kg/m(2) (20-45.7). Etiology of SCI was trauma (n: 10), multiple sclerosis (n: 6), cerebrovascular accident (n: 1), or undetermined (n: 2). The mean stone size was 15.9 ± 8.6 (6-40) mm. In the 27 URS procedures, stones were located in the ureter (n: 5), the kidney (n: 14), and both areas (n: 8). Mean hospitalization time was 2.0 ± 2.4 (0-10) days. Postoperative complications were observed in 6 cases (22.2%). Three major complications included urosepsis (n: 1) and respiratory failure (n: 2), that were observed postoperatively and required admission to the intensive care unit. The 2 minor complications were hypotension, fever and UTI, and required medical treatment. Fourteen (66.6%) of the 21 renal units were stone free. Calcium phosphate carbonate (n: 9) and struvite (n: 5) were the primary stone compositions detected. Hypocitraturia (n: 6), hypercalciuria (n: 5), hypernaturia (n: 5), hyperoxaluria (n: 4), and hyperuricosuria (n: 1) were common abnormalities in 24-h urine analysis. Ureteroscopic laser lithotripsy can be an effective treatment modality for SCI patients with upper urinary tract calculi.

Does socioeconomic status, age, or gender influence appointment attendance and completion of 24-hour urine collections?

OBJECTIVE: To examine the association of age, gender, and socioeconomic status with appointment attendance and completion of 24-hour urine collections to identify patient characteristics associated with barriers to treatment. METHODS: A retrospective review was performed under institutional review board approval for new patients scheduled at a single metabolic stone clinic over a 1.5-year period. Postal codes were used to identify poverty and education levels using US Census Bureau data. We evaluated 3 years of adherence based on "no shows," percentage of stone clinic appointments attended, and percentage of 24-hour urine collections completed. Quintile analyses were used to further explore nonlinear data. RESULTS: A total of 447 patients were included (246 men and 201 women). Mean age was 49 ± 14.5 years. Younger age, areas of higher poverty, and areas of lower education were all weakly to moderately associated with increased "no show" rates and decreased clinic attendance. Men tended to not show for appointments more frequently than women (P = .043). When grouped by age groups, younger age was strongly correlated with decreased 24-hour urine collection completion (R = 0.75). When divided into age quintiles, relationships between "no shows" and clinic attendance were strengthened as they were when patients were divided into poverty quintiles. CONCLUSION: It is critical for providers to be aware of health disparities in medical stone management. Low education, high poverty, and younger age are associated with suboptimal evaluation follow-up. Of note, the lowest adherence was in younger patients, a population that requires the most urgent workup.

Do multiple ureteroscopies alter long-term renal function? A study using estimated glomerular filtration rate.

BACKGROUND AND PURPOSE: Although considered standard of care for symptomatic urolithiasis, few data are available that evaluate the effects of multiple ureteroscopies (URS) with laser lithotripsies on long-term renal function. We investigated this relationship in a population with preexisting mild to moderate kidney disease. Previous studies have been limited by estimates of glomerular filtration rate (eGFR) calculated from creatinine level during acute stone obstruction, and inclusion of patients with a history of other stone procedures, such as shockwave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). METHODS: Charts were reviewed for patients with a baseline eGFR below 90 mL/min/1.73 m(2) who underwent at least two URS for nephrolithiasis at our institution from 2004 to 2012. Patients undergoing SWL or PCNL at any point in their history were excluded. A total of 26 patients, with a mean of 2.3±0.6 URS procedures, were included. The eGFR was recorded at baseline before acute stone presentation and surgery, and at the last recorded follow-up visit. Stone location, total stone burden, and comorbidities were also recorded. RESULTS: The mean eGFR changed from 68.0±13.3 to 75.4±23.0 mL/min/1.73m(2) (mean increase of 10.1±25.0%; mean annual increase of 3.8±15.3%) over a mean follow-up period of 28.1 months (range 5-75 mos). There was no significant difference in eGFR change between patients with stones treated in the kidney alone vs the ureter and kidney combined (12.1% vs 8.3% mean increase; P=0.74). Age, presence of diabetes mellitus or hypertension, baseline creatinine level, total stone burden, and number of URS performed were not significantly associated with change in eGFR. CONCLUSIONS: Using eGFR measured before acute stone presentation, our results suggest that multiple ureteroscopies for stones are not detrimental to long-term renal function, even in patients with preexisting stage 2-3 chronic kidney disease.

Expanding endourology for biliary stone disease: the efficacy of intracorporeal lithotripsy on refractory biliary calculi.

BACKGROUND AND PURPOSE: We evaluated the efficacy of ureteroscopic therapy (electrohydraulic lithotripsy [EHL] and intraductal laser lithotripsy [ILL]) in patients with challenging biliary stones secondary to anatomic variations resulting from a previous surgical procedure, including liver transplantation. PATIENTS AND METHODS: A retrospective chart review was performed for all patients with previous surgical alteration of the gastrointestinal (GI) tract who underwent EHL or ILL via peroral or percutaneous access for choledocholithiasis by a single surgeon at our institution from 2000 to 2012. A database containing clinical and surgical variables was created, and long-term follow-up was conducted (3-138 months; median, 99 months). RESULTS: Thirteen patients (51.7±20.0 years; M:F, 10:3) in whom endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTHC), or both failed were identified. Failure of ERCP/PTHC was because of inaccessibility of the calculi in all cases. Stone clearance was achieved in 12/13 (93%) patients; 8/12 (62%) after one procedure, and 4/12 (31%) after two procedures. One patient with biliary cast syndrome needed four interventions over 9 years. Major complications were low, with only one patient with hypotension and cholangitis that resolved with 24 hours of administration of intravenous fluids and antibiotics. CONCLUSIONS: Both endoscopic and percutaneous lithotripsies are effective treatments for refractory biliary calculi resulting from the post-surgical GI tract. Although a staged second procedure may be necessary in patients with significant stone burden, this is significantly better than extensive open surgery.