Search

Background: Studies assessing the stone-free rate (SFR) after ureteroscopy are limited to expert centers with varied definitions of stone free. Real-world data including community practices related to surgeon characteristics and outcomes are lacking., Objective: To evaluate the SFR for ureteroscopy and its predictors across diverse surgeons in Michigan., Design, Setting, and Participants: We assessed the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry for patients with renal or ureteral stones treated with ureteroscopy between 2016 and 2021 who had postoperative imaging., Outcome Measurements and Statistical Analysis: Stone free was defined as no fragments on imaging reports within 60 d entered by independent data abstractors. Factors associated with being stone free were examined using logistic regression, including annual surgeon volume. We then assessed variation in surgeon-level SFRs adjusted for risk factors., Results and Limitations: We identified 6487 ureteroscopies from 164 surgeons who treated 2091 (32.2%) renal and 4396 (67.8%) ureteral stones. The overall SFRs were 49.6% (renal) and 72.7% (ureteral). Increasing stone size, lower pole, proximal ureteral location, and multiplicity were associated with not being stone free. Female gender, positive urine culture, use of ureteral access sheath, and postoperative stenting were associated with residual fragments when treating ureteral stones. Adjusted surgeon-level SFRs varied for renal (26.1-72.4%; p < 0.001) and ureteral stones (52.2-90.2%; p < 0.001). Surgeon volume was not a predictor of being stone free for renal stones. Limitations include the lack of imaging in all patients and use of different imaging modalities., Conclusions: The real-world complete SFR after ureteroscopy is suboptimal with substantial surgeon-level variation. Interventions focused on surgical technique refinement are needed to improve outcomes for patients undergoing ureteroscopy and stone intervention., Patient Summary: Results from a diverse group of community practicing and academic center urologists show that for a large number of patients, it is not possible to be completely stone free after ureteroscopy. There is substantial variation in surgeon outcomes. Quality improvement efforts are needed to address this., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: AUA stone management guidelines recommend stenting duration following ureteroscopy be minimized to reduce morbidity; stents with extraction strings may be used for this purpose. However, an animal study demonstrated that short dwell time results in suboptimal ureteral dilation, and a pilot clinical study showed this increases postprocedure events. Using real-world practice data we examined stent dwell time after ureteroscopy and its association with postoperative emergency department visits., Materials and Methods: We used the Michigan Urological Surgery Improvement Collaborative registry to identify ureteroscopy and stenting procedures (2016-2019). Pre-stented cases were excluded. Stenting cohorts with and without strings were analyzed. Using multivariable logistic regression we evaluated the risk of an emergency department visit occurring on the day of, or day after, stent removal based on dwell time and string status., Results: We identified 4,437 procedures; 1,690 (38%) had a string. Median dwell time was lower in patients with a string (5 vs 9 days). Ureteroscopy in younger patients, smaller stones, or renal stone location had a higher frequency of string use. The predicted probability of an emergency department visit was significantly greater in procedures with string, compared to without string, when dwell times were less than 5 days ( P < .01) but were not statistically significant after., Conclusions: Patients who had ureteroscopy and stenting with a string have short dwell times. Patients are at increased risk of a postoperative emergency department visit around the time of stent removal if dwell time is ≤4 days. We recommended stenting duration of at least 5 days in nonpre-stented patients.

Introduction: Despite AUA guidelines providing criteria for ureteral stent omission after ureteroscopy for nephrolithiasis, stenting rates in practice remain high. Because pre-stenting may be associated with improved patient outcomes, we assessed the impact of stent omission vs placement in pre-stented and non-pre-stented patients undergoing ureteroscopy on postoperative health care utilization in Michigan., Methods: Using the MUSIC (Michigan Urological Surgery Improvement Collaborative) registry (2016-2019), we identified pre-stented and non-pre-stented patients with low comorbidity undergoing single-stage ureteroscopy for ≤1.5 cm stones with no intraoperative complications. We assessed variation in stent omission for practices/urologists with ≥5 cases. Using multivariable logistic regression, we evaluated whether stent placement in pre-stented patients was associated with emergency department visits and hospitalizations within 30 days of ureteroscopy., Results: We identified 6,266 ureteroscopies from 33 practices and 209 urologists, of which 2,244 (35.8%) were pre-stented. Pre-stented cases had higher rates of stent omission vs non-pre-stented cases (47.3% vs 26.3%). Among the 17 urology practices with ≥5 cases, stent omission rates in pre-stented patients varied widely (0%-77.8%). Among the 156 urologists with ≥5 cases, stent omission rates in pre-stented patients varied substantially (0%-100%); 34/152 (22.4%) never performed stent omission. Adjusting for risk factors, stent placement in pre-stented patients was associated with increased emergency department visits (OR 2.24, 95% CI:1.42-3.55) and hospitalizations (OR 2.19, 95% CI:1.12-4.26)., Conclusions: Pre-stented patients undergoing stent omission after ureteroscopy have lower unplanned health care utilization. Stent omission is underutilized in these patients, making them an ideal group for quality improvement efforts to avoid routine stent placement after ureteroscopy.

Introduction and Objective: Shared decision making is recommended to guide medical/surgical treatment strategies. We aimed at developing a surgical decision aid (SDA) facilitating decision making between ureteroscopy (URS) or shockwave lithotripsy (SWL) in patients with symptomatic nephrolithiasis. Methods: The SDA scope was identified through discussions with patients and urologists in the Michigan Urological Surgery Improvement Collaborative (MUSIC). A steering committee of patient advocates, MUSIC coordinating center, content experts, biostatisticians, and urologists was formed. Content domains were assessed through best available evidence and content experts. For content validation we anonymously surveyed 35 MUSIC urologists. Content validity ratios (CVR), numeric value indicating degree of expert validity, were calculated. Face validation interviews were conducted with patient advocates. Results: The SDA prototype using descriptive plain language and pictorial information was designed for nephrolithiasis patients, candidates for SWL or URS. It first provides patients procedural education whereas the second section informs urologists of patient goals. Six content domains were chosen: anesthesia type, effectiveness, number of procedures, risk, pain, and recovery. Overall, 91.4% and 85.7% of MUSIC urologists indicated that each section accomplished their goals, respectively. Anesthesia received an unacceptable CVR. High levels of face validation overall were reported with unacceptable scoring for anesthesia and recovery. Conclusions: We developed an SDA facilitating treatment choice between SWL and URS with promising content and face validity. Agreement and contradiction between anesthesia type and recovery validation results indicate the importance of shared decision making and the need for a validated SDA. Future work should focus on the SDAs value and opportunities for refinement in practice.

Background: Unplanned hospitalization following ureteroscopy (URS) for urinary stone disease is associated with patient morbidity and increased healthcare costs. To this effect, AUA guidelines recommend at least a urinalysis in patients prior to URS. We examined risk factors for infection-related hospitalization following URS for urinary stones in a surgical collaborative., Methods: Reducing Operative Complications from Kidney Stones (ROCKS) is a quality improvement (QI) initiative from the Michigan Urological Surgery Improvement Collaborative (MUSIC) consisting of academic and community practices in the State of Michigan. Trained abstractors prospectively record standardized data elements from the health record in a web-based registry including patient characteristics, surgical details and complications. Using the ROCKS registry, we identified all patients undergoing primary URS for urinary stones between June 2016 and October 2017, and determined the proportion hospitalized within 30 days with an infection-related complication. These patients underwent chart review to obtain clinical data related to the hospitalization. Multivariable logistic regression analysis was performed to determine risk factors for hospitalization., Results: 1817 URS procedures from 11 practices were analyzed. 43 (2.4%) patients were hospitalized with an infection-related complication, and the mortality rate was 0.2%. Median time to admission and length of stay was 4 and 3 days, respectively. Nine (20.9%) patients did not have a pre-procedure urinalysis or urine culture, which was not different in the non-hospitalized cohort (20.5%). In hospitalized patients, pathogens included gram-negative (61.5%), gram-positive (19.2%), yeast (15.4%), and mixed (3.8%) organisms. Significant factors associated with infection-related hospitalization included higher Charlson comorbidity index, history of recurrent UTI, stone size, intra-operative complication, and procedures where fragments were left in-situ., Conclusions: One in 40 patients are hospitalized with an infection-related complication following URS. Awareness of risk factors may allow for individualized counselling and management to reduce these events. Approximately 20% of patients did not have a pre-operative urine analysis or culture, and these findings demonstrate the need for further study to improve urine testing and compliance.

Objective: To understand patient and practice-level factors impacting postoperative imaging use after ureteroscopy (URS) for urinary stone disease., Methods: The Michigan Urological Surgery Improvement Collaborative's Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) initiative is a consortium of 52 urologists from 11 practices in Michigan. From June 2016 to July 2017, we prospectively collected clinical data for patients undergoing URS for stone treatment by MUSIC ROCKS participants. We measured the proportion of these patients who underwent US, AXR, and/or CT within the first 60 days after their procedure. We then assessed variation in the use of post-URS imaging according to patient characteristics and across MUSIC ROCKS practices., Results: During the 13-month study period, we identified 2850 patients who were treated with URS for stone disease. Overall, only 47.6% of these patients underwent postoperative imaging. AXR was the most common modality used (55.0% of patients), followed by US (21.9%) and CT (11.1%). As shown in the Figure, use of post-URS imaging varied widely across participating practices (23.7%-73.6%; P <.01). Imaging receipt did not differ by patient age, gender, or insurance status. However, patients with more comorbidities, renal stones and those with larger stones were more likely to receive post-URS imaging (P <.05 for each comparison)., Conclusion: Fewer than half of patients in Michigan undergo postoperative imaging after URS for stone disease. Moreover, there is substantial variation across providers in post-URS imaging use. These findings help identify opportunities to improve the quality of care for patients with urinary stone disease in the State., (Copyright © 2019. Published by Elsevier Inc.)