Search

Objectives: To determine if management of ureteric stones in the UK changed during the coronavirus disease 2019 (COVID‐19) pandemic and whether this affected patient outcomes. Patients and methods: We conducted a multicentre retrospective study of adults with computed tomography‐confirmed ureteric stone disease at 39 UK hospitals during a pre‐pandemic period (23/3/2019–22/6/2019) and a period during the pandemic (the 3‐month period after the first severe acute respiratory syndrome coronavirus‐2 case at individual sites). The primary outcome was success of primary treatment modality, defined as no further treatment required for the index ureteric stone. Our study protocol was published prior to data collection. Results: A total of 3735 patients were included (pre‐pandemic 1956 patients; pandemic 1779 patients). Stone size was similar between groups (P > 0.05). During the pandemic, patients had lower hospital admission rates (pre‐pandemic 54.0% vs pandemic 46.5%, P < 0.001), shorter mean length of stay (4.1 vs 3.3 days, P = 0.02), and higher rates of use of medical expulsive therapy (17.4% vs 25.4%, P < 0.001). In patients who received interventional management (pre‐pandemic 787 vs pandemic 685), rates of extracorporeal shockwave lithotripsy (22.7% vs 34.1%, P < 0.001) and nephrostomy were higher (7.1% vs 10.5%, P = 0.03); and rates of ureteroscopy (57.2% vs 47.5%, P < 0.001), stent insertion (68.4% vs 54.6%, P < 0.001), and general anaesthetic (92.2% vs 76.2%, P < 0.001) were lower. There was no difference in success of primary treatment modality between patient cohorts (pre‐pandemic 73.8% vs pandemic 76.1%, P = 0.11), nor when patients were stratified by treatment modality or stone size. Rates of operative complications, 30‐day mortality, and re‐admission and renal function at 6 months did not differ between the data collection periods. Conclusions: During the COVID‐19 pandemic, there were lower admission rates and fewer invasive procedures performed. Despite this, there were no differences in treatment success or outcomes. Our findings indicate that clinicians can safely adopt management strategies developed during the pandemic to treat more patients conservatively and in the community. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the long‐term oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU) and the impact of diagnostic ureteroscopy (URS) on survival outcomes. Materials and Methods: A retrospective analysis of all consecutive patients undergoing RNU for suspected UTUC at a UK tertiary referral centre from a prospectively maintained database was conducted. The primary outcome measures were 5‐ and 10‐year cancer‐specific survival (CSS). The secondary outcomes were: overall survival (OS), recurrence‐free survival (RFS), impact of prior diagnostic URS on OS, CSS and intravesical RFS (intravesical‐RFS), and predictors of intravesical recurrence. Statistical analysis was performed in R using the 'survminer' and 'survival' packages. The Kaplan–Meier method was used to calculate survival functions and these were expressed in graphical form. Uni‐/multivariate survival analyses were performed using the Cox proportional hazard regression model. Statistical significance in this study was set at P < 0.05. Results: A total of 422 patients underwent RNU with confirmed UTUC. The median (interquartile range) follow‐up of patients with confirmed UTUC was 9.2 (5.6–12.7) years. The 5‐ and 10‐year CSS rates were 70.5% (95% confidence interval [CI] 65.9–74.9) and 67.1% (95% CI 62.4–71.6), respectively. OS (HR 1.04 [95% CI 0.78–1.38]; P = 0.46) and CSS (HR 0.96 [95% CI 0.68–1.34]; P = 0.81) were similar in the diagnostic URS and the direct RNU cohorts. intravesical RFS was superior for the direct RNU cohort (HR 1.94 [95% CI 1.19–3.17]; P = 0.008). In multivariate analysis, prior URS, T2 stage, proximal ureter tumour and bladder cancer history were predictors of metachronous bladder recurrence. Conclusion: This single‐centre retrospective cohort study reports the long‐term oncological outcomes of RNU with a median follow‐up of 9.2 years, serving as a reference standard in counselling patients undergoing RNU. Stage and grade of the RNU specimen were the only two studied factors that appeared to adversely impact long‐term CSS and OS. Our results suggest that the risk of intravesical recurrence is increased nearly twofold in patients who have undergone diagnostic URS prior to RNU. Prior URS, however, does not appear to adversely impact long‐term CSS and OS. The authors suggest that a risk‐stratified approach be adopted, wherein diagnostic URS is offered only in equivocal cases. [ABSTRACT FROM AUTHOR]

Objective: To develop and evaluate an assessment tool for endourological skills during simulation including cystoscopy, ureteroscopy (URS) and transurethral resection (TUR) procedures. Methods: We designed a Global Assessment of Urological Endoscopic Skills (GAUES) tool, comprised of nine endourology task‐specific and two global‐rating skills items. The tool was developed through two rounds of the Delphi process. The GAUES tool was used to assess acquisition of URS and TUR skills of novices (Year 2 core surgical trainees, CT2) and intermediate level trainees (residents at the start of the UK higher surgical training programme in Urology, Speciality Trainee Year 3, ST3) at the Urology Simulation Boot Camp (USBC) between 2016 and 2018. Validity was evaluated by comparing scores between trainees with different levels of urological experience. Inter‐rater reliability was also assessed. Results: We evaluated 130 residents, 52% of trainees were at an intermediate stage of training and 39% were novices. In all, 9% of the anonymous forms were missing demographics. The completion rate of the GAUES tool during the USBC for URS and TUR was 85% and 89%, respectively. Our analysis demonstrated a significant difference in all domains between intermediates and novices at assessment in URS, except for one domain more suited to clinical assessment (P = 0.226). There was excellent intraclass correlation (ICC) overall between the two experts' judgements, ICC = 0.841 (95% confidence interval 0.767–0.893; P < 0.001, n = 88). Conclusions: We have developed the novel GAUES tool for cystoscopic, URS and TUR skills. Overall, we demonstrated good face, content and construct validity and excellent reliability, suggesting that the GAUES tool can be useful for endourological skills assessment. [ABSTRACT FROM AUTHOR]

Background: Open surgery for abdominal aortic aneurysms in the UK is usually performed via a midline transperitoneal incision. However, the left retroperitoneal (RP) approach may be beneficial for juxtarenal abdominal aortic aneurysms and certain physiological reasons. One potential disadvantage is that the left kidney usually requires mobilization anteromedially risking injury to the renal tract and possibly the ureter. Methods: In this retrospective study, the time of onset, clinical presentation and treatment of left renal tract complications are scrutinized and discussed. Reasons for open aortic surgery as opposed to endovascular repair being undertaken were documented. Also, the aortic cross‐clamp positions and type of reconstruction were examined. Results: A total of 208 patients underwent RP aortic surgery for aneurysmal disease. The aortic cross‐clamp positions were infrarenal in 115 (55%), suprarenal in 78 (38%) and supra‐superior mesenteric artery or supracoeliac in 15 (7%). Two percent (4/208) sustained ureteric complications and all occurred in the upper third of the left ureter. The time of onset of symptoms ranged from 2 to 14 days post‐operatively with a median of 3.5. Clinical signs were non‐specific including pyrexia, tachycardia and flank pain. Conclusion: Ureteric complications following left RP aortic surgery is uncommon and usually occurs in the upper third of the renal tract. Trauma appears to be the most common cause, although ureteric ischaemia can occur but presents later particularly in those with comorbidities. [ABSTRACT FROM AUTHOR]

Objectives: To compare the total cost of a treatment strategy starting with ureteroscopy (URS) vs a strategy starting with extracorporeal shockwave lithotripsy (ESWL). Methods: For ureteric stones of <10 mm, URS or ESWL are the main treatment options that are considered. Although the interventions differ, the goal of the interventions is to achieve a stone‐free status. A systematic review and meta‐analysis undertaken as part of the National Institute for Health and Care Excellence (NICE) guideline on 'Renal and ureteric stones: assessment and management' identified URS as more effective, in terms of getting people stone free, but has a higher probability of re‐admission and adverse events (AEs) that contributes to downstream resource use. ESWL is initially less costly, but lower effectiveness means a greater need for repeat or ancillary procedures in order to get a patient stone free. Given these trade‐offs between benefits and costs, a cost analysis of URS and ESWL was undertaken as part of the NICE guideline, using evidence from the literature of effectiveness, re‐admission and AEs. The NICE guideline meta‐analysis showed a lot of heterogeneity and differences in how outcomes were reported between studies. The costing analysis, therefore only used studies where: (i) patients were rendered stone free, and (ii) where effectiveness, was based on the first‐line (initial) procedures. Exploratory quality adjusted life year (QALY) work was also undertaken to identify the QALY and quality of life (QoL) differences required for the most expensive intervention to be cost effective, based on the assumption that the difference in effectiveness between the initial procedures would be the main source of the QALY gain between the two strategies. Results: The URS strategy was more costly overall than the ESWL strategy (incremental cost of £2387 [pounds sterling]). Sensitivity analysis varying the initial effectiveness of ESWL treatment (between the base case value of 82% and 40%) showed that URS would still be a more costly strategy even if the initial session of ESWL only had a success probability of 40%. A two‐way sensitivity analysis as part of the exploratory QALY work showed that ESWL would have to have very low effectiveness and people would have to wait for further treatment for many weeks (following a failed ESWL treatment) for there to be feasible QoL gains to justify the additional cost of the URS strategy. Conclusions: ESWL is less effective at initial stone clearance and therefore requires more ancillary interventions than URS. However, the magnitude of the difference in costs means URS is unlikely to be cost effective intervention at a population level for first‐line treatment, implying ESWL should be the first choice treatment. [ABSTRACT FROM AUTHOR]

Purpose: To report the outcomes of paediatric ureteroscopy (URS) for stone disease from a specialist endourology centre in the UK. Ureteroscopy for management of stone disease has increased worldwide and is now being done more commonly in the paediatric age group. Methods: Data were analysed retrospectively from a database maintained between April 2010 and May 2018. Consecutive patients ≤ 16 years of age undergoing semi-rigid or flexible URS for stone disease were included. Stone size and stone-free rate (SFR) were routinely assessed using an ultrasound (USS) and/or plain KUB XR. Complications were graded according to the Clavien–Dindo classification and recorded within 30 days post-procedure and readmissions within 90 days after the procedure were also captured. Results: Over the 8-year period between April 2010 and April 2018, 81 patients with a mean age of 8.8 years (range 18 months–16 years) and a male to female ratio 1:1.1 underwent 102 procedures (1.28 procedure/patient to be stone free). Of the 81 patients, 29 (35.8%) had comorbidities, with 26 (32%) having multiple comorbidities. The mean (± SEM) single and overall stone size was 9.2 mm (± 0.48, range 3–30 mm) and 11.5 mm (± 0.74, range 4–46 mm) respectively, with 22 (27.1%) having multiple stones. Thirty-five (34.7%) had stent in situ pre-operatively. The stone location was in the ureter (26.6%), lower pole (35.4%), and renal pelvis (16.5%), with 22/81(27%) having multiple stones and 21/102 (20.5%) where a ureteral access sheath (UAS) was used. With a mean hospital stay of 1.2 days, the initial and final SFR was 73% and 99%, respectively, and 61/102 (60%) had ureteric stent placed at the end of the procedure. While there were no intra-operative complications, the readmission rate was less than 1% and there were only three early complications recorded. This included a case each of prolonged admission for pain control (grade I), urinary retention (grade II) and post-operative sepsis requiring a brief ITU admission (grade IV). Conclusion: Our study demonstrates that in appropriate setting a high stone-free rate can be achieved with minimal morbidity for paediatric patients. There is potentially a need to factor the increasing role of URS in future paediatric urolithiasis guidelines. [ABSTRACT FROM AUTHOR]

Few studies show that 'emergency extracorporeal shockwave lithotripsy (eESWL)' reduces the incidence of ureteroscopy in patients with ureteric calculi. We assess success of eESWL and look to study and identify factors which predict successful outcome. We retrospectively studied patients presenting with their first episode of ureteric colic undergoing eESWL (within 72 h of presentation) over a 5-year period. Patient's age, gender, stone size and location, time between presentation and ESWL, number of shock waves and ESWL sessions, and Hounsfield units (HU) were recorded. 97 patients (mean age 40 years; 76 males, 21 females) were included. 71 patients were stone free after eESWL (73.2 %) (group 1) and 26 patients failed treatment and proceeded to ureteroscopy (group 2). The two groups were well matched for age and gender. Mean stone size in group 1 and 2 was 6.4 mm and 7.7 mm, respectively, ( p = 0.00141). Stone location was 34, 21, and 16 in upper, middle and lower ureter in group 1 compared to 11, 5, and 10 in group 2, respectively. Mean HU in group 1 was 480 and 612 in group 2 ( p value 0.0036). In group 2, significantly, more patients received treatment after 24 h compared with group 1 (38 vs 22.5 %). The number of shock waves, maximal intensity, and ESWL sessions were not significantly different in the two groups. No complications were noted. eESWL is safe and effective in patients with ureteric colic. Stone size and Hounsfield units are important factors in predicting success. Early treatment (≤24 h) minimizes stone impaction and increases the success rate of ESWL. [ABSTRACT FROM AUTHOR]

The article discusses a study conducted to provide demographics of patients undergoing Ureteroscopy (URS) stone surgery and its outcome in Great Britain. It also examines complication rates for patients undergoing URS as well as use of different treatment modalities and peri-operative practices. The study found that overall stone clearance rate for URS procedures to be 78%.