Best of AUA 2014: Stone Disease/Endourology

July 10, 2014

Matthew D. Dunn, MD, presents the take home messages on stone disease/endourology from the AUA annual meeting in Orlando, FL.

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• A review of American Board of Urology case logs for 2003 to 2012 showed that 54.2% of 441,162 procedures for upper tract urinary calculi were managed ureteroscopically, 41.3% by extracorporeal shock wave lithotripsy (SWL), and 4.5% by PCNL.

• Erythropoietin increased recovery of ureteral peristalsis in a murine model of obstructive uropathy.

• Human macrophages facilitate kidney stone clearance.

• Balance between the activation of inflammatory macrophages and suppression of anti-inflammatory macrophages may play an important role in kidney stone formation, and these markers may have potential as biomarkers to reflect urinary stone risk.

• Reusable laser fibers cleaved with various tools showed significant variability in power output and light dispersion.

• Various studies of ball-tipped lasers found degradation at high-energy settings, comminution efficiency similar to standard fiber, less ureteroscope damage, and potential cost savings.

• At 16-month median follow-up, a study of 230 metallic stents in 86 patients with chronic ureteral obstruction showed 24% failure rate and average lifespan of 7.4 months but greater durability compared with polymer stents.

• Analysis of analgesic use, complications, and stone-free rates following upper-pole percutaneous nephrolithotomy (PCNL) showed no differences between upper- and lower-pole access with respect to overall complications or analgesic requirements but superior stone-free rate for upper-pole procedures.

• A study of 50 cases of outpatient PCNL showed no major complications or deaths, leading to the conclusion that the procedure is safe in highly selected patients.

• Imaging evaluation 4 to 6 weeks after stent removal showed hydronephrosis rates of 2.4% after ureteroscopy and 5.7% after PCNL but with spontaneous resolution in most cases.

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• A randomized trial of initial ultrasound versus computed tomography imaging for suspected nephrolithiasis in 2,759 patients at 15 emergency departments showed no difference in serious adverse events, pain at 3 or 7 days, return to emergency department, or hospitalization at 3, 7, or 180 days according to whether patients had ultrasound evaluation by an emergency physician or radiologist or had abdominal CT as initial study.

• A study of the comparative effectiveness of shock wave lithotripsy and ureteroscopy showed a retreatment rate of 11% with SWL and <1% for ureteroscopy in almost 48,000 procedures.

• A comparison of cost-effectiveness of ureteroscopic laser lithotripsy versus shock wave lithotripsy for renal calculi showed single-procedure stone-free rates of 95% for URS and 55% for SWL (p<.001).

• A study of the economic impact of ureteroscope repairs showed 20 device repairs cost $115,000, which contributed to a negative net margin (–$455/case) for 11 inpatient procedures, whereas a positive margin was maintained for outpatient procedures ($659/case), resulting in a net positive margin of $594/case.

• A 2-day preoperative course of antibiotics before PCNL is as effective as a 7-day course, but there was no overall consensus on extended-course antibiotics aside from reserving treatment for carefully selected patients.

• Non-obese patients treated with potassium citrate (Urocit-K) are more likely to develop brushite stones, whereas no obese patient developed a brushite stone after treatment with potassium citrate.

• Bisphosphonate treatment not only improved bone mineral density but also reduced urolithiasis recurrence in Japanese men with osteoporosis.

• A phase II, placebo-controlled trial of a multi-herbal therapy for stone disease was associated with a significantly higher expulsion rate (p<.03), significantly smaller stone size (p<.02), and significantly less pain (p<.001), although the mechanism of action remains unknown.UT

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