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Ureteral stents are an invaluable tool for urologists but suffer from several drawbacks, including: limited durability due to stent encrustation, significant morbidity from bothersome urinary symptoms, pain and infection, risk of the forgotten stent and costly removal. This review highlights key advances in ureteral stent technology that seek to address these issues.Over the past 2 years clinical trials have brought ureteral stent technology aimed to reduce stent-associated morbidity closer to clinical application. Stent material and changes to stent design show promise in improving patient tolerability without increasing complications. Low-tech innovations such as magnetic and catheter snare removal may quickly reduce costs. Radical advances such as biodegradable stent materials remain in preclinical models but show promise for eliminating the need for stent removal.The ideal ureteral stent does not currently exist in clinical practice. This review highlights key studies that have advanced ureteral stent technology in the past 2 years.

OBJECTIVE To compare the health-related quality of life (HRQOL) of patients with residual fragments after surgical intervention for kidney stones to patients that are stone-free using the disease-specific Wisconsin stone quality of life (WISQOL) questionnaire. Kidney stones contribute to impaired HRQOL, which is increasingly recognized as an important healthcare outcome measurement. MATERIALS AND METHODS With institutional review board approval, 313 adult patients who underwent surgical intervention for kidney stones at 4 sites completed a WISQOL questionnaire. We retrospectively collected surgical data including presence of residual fragments on post-operative imaging. We calculated standardized WISQOL total and domain scores (0-100), which included items related to social functioning (D1), emotional functioning (D2), stone-related impact (D3), and vitality (D4). Scores were compared between patients with residual fragments to those who were stone-free after surgical intervention. RESULTS Demographics did not differ between groups, overall mean age 54.6 ± 13.5 and 55.4% female. There was no significant difference in total WISQOL score for patients with residual fragments (n = 124) compared to patients that were stone-free (n = 189), 110.5 ± 27.8 vs 115.4 ± 23.6 respectively, (P = .12). Interestingly, patients with residual fragments who underwent secondary surgery were found to have significantly lower total WISQOL score (88.4 ± 30.1 vs 116.6 ± 25.0, P CONCLUSION Stone-free status after surgical intervention is not associated with better HRQOL when compared with patients whose surgeries left residual fragments. Indeed, further surgical intervention on residual fragments to achieve stone-free status may actually result in worse HRQOL.

To evaluate the impact of chronic stone recurrence on an individual's quality of life using the validated Wisconsin Stone Quality of Life (WISQOL) questionnaire. We collected cross-sectional data on patients with kidney stones from 14 institutions in North America. A stone event was defined as renal colic, stone-related procedure or emergency department visit. The regression analyses using general linear models and pairwise comparison determined the impact of the number of stone events on quality of life. The median number of stone events among the 2205 patients who completed the questionnaire was 3 (IQR 1-6). The mean total score was 107.4 ± 28.7 (max 140 points). The number of lifetime stone events was an independent predictor of lower quality of life (p 0.001), specifically, score declined significantly beyond five events. Compared with patients who experienced a single stone event, there was a 0.4, 2.5, and 6.9 point decline in the adjusted mean WISQOL score after 2-5, 6-10, or 10 events, respectively. The cumulative number of lifetime stone events was associated with a lower quality of life when more than five stone events were occurred. These findings underscore the importance of efforts to determine the underlying metabolic etiology of urolithiasis in the recurrent stone former, and the institution of a regimen to place their stone disease in remission.

OBJECTIVE To build the Wisconsin Stone Quality of Life Machine-Learning Algorithm (WISQOL-MLA) to predict urolithiasis patients' health-related quality of life (HRQoL) based on demographic, symptomatic and clinical data collected for the validation of the Wisconsin Stone Quality-of-Life (WISQOL) questionnaire, an HRQoL measurement tool designed specifically for patients with kidney stones. MATERIAL AND METHODS We used data from 3206 stone patients from 16 centres. We used gradient-boosting and deep-learning models to predict HRQoL scores. We also stratified HRQoL scores by quintile. The dataset was split using a standard 70%/10%/20% training/validation/testing ratio. Regression performance was evaluated using Pearson's correlation. Classification was evaluated with an area under the receiver-operating characteristic curve (AUROC). RESULTS Gradient boosting obtained a test correlation of 0.62. Deep learning obtained a correlation of 0.59. Multivariate regression achieved a correlation of 0.44. Quintile stratification of all patients in the WISQOL dataset obtained an average test AUROC of 0.70 for the five classes. The model performed best in identifying the lowest (0.79) and highest quintiles (0.83) of HRQoL. Feature importance analysis showed that the model weighs in clinically relevant factors to estimate HRQoL, such as symptomatic status, body mass index and age. CONCLUSIONS Harnessing the power of the WISQOL questionnaire, our initial results indicate that the WISQOL-MLA can adequately predict a stone patient's HRQoL from readily available clinical information. The algorithm adequately relies on relevant clinical factors to make its HRQoL predictions. Future improvements to the model are needed for direct clinical applications.

Purpose: Metabolic syndrome (MetS) is a cluster of metabolic diseases that is linked to atherosclerotic cardiovascular disease. MetS has also been linked to increased nephrolithiasis. However, limi...

Objective To understand kidney stone patients’ experiences with increasing fluid intake, common barriers to adherence, and technology-mediated intervention techniques that may improve adherence in this population. Increasing fluid intake to produce at least 2.5 L of urine daily is a well-established preventive strategy to reduce the risk of kidney stones. Unfortunately, adherence with this well-known and inexpensive recommendation is commonly below 50%. Materials and Methods Patients with a history of kidney stones were recruited to participate in semistructured focus groups about their experiences with increasing fluid intake. Inductive content analysis was used to extract themes from focus group transcripts. Results Themes from discussions with 19 patients described current fluid intake strategies, barriers to increasing fluid intake, and desirable features in a digital tool for promoting fluid intake. Common barriers to increasing fluid intake included work habits, travel, leisure activities, forgetting to drink, limited access to water, and not feeling thirsty. Patients had tried to increase fluid intake using strategies such as carrying a water bottle, identifying contextual cues for drinking, self-monitoring fluid intake, and seeking social support. Patients expressed interest in wearing sensors to improve fluid intake if the sensor was aesthetically pleasing, had guaranteed benefit and was able to connect to existing devices. The most acceptable location to wear a sensor was as a wristband or bracelet. Conclusion The use of automated and semiautomated tracking technology in combination with evidence-based behavior change techniques should be explored in efforts to improve adherence to fluid intake recommendations.

Kidney stones are a source of significant morbidity which have been shown to negatively impact health related quality of life. We sought to understand the association between health related quality of life, socioeconomic status and race among patients with kidney stones.Patients with stones at a total of 11 stone centers across the United States completed the WISQOL (Wisconsin Stone Quality of Life questionnaire). The patient ZIP Code™ was used to estimate household income. A mixed effects regression model was constructed for analysis with ZIP Code as the random intercept.A total of 2,057 stone formers completed the WISQOL. Lower income was independently associated with significantly lower health related quality of life (β = 0.372, p = 0.014), as were nonwhite race (β = -0.299, p = 0.001), unemployed work status (β = -0.291, p = 0.008), female gender (β = -0.204, p0.001), body mass index greater than 40 kg/mLower income, nonwhite race and unemployed work status were independently associated with lower health related quality of life among patients with kidney stones. While clinical characteristics such as body mass and stone disease severity were also associated with health related quality of life, this study shows that socioeconomic factors are similarly important. Further research to understand the specific mechanisms by which socioeconomic status and race impact health may lend insight into methods to optimize clinical treatment of stone formers and patients with other chronic diseases.

INTRODUCTION The opioid epidemic is a growing problem in the United States. There is a high rate of opioid oversupply for treatment of symptomatic nephrolithiasis, partly due to patients being seen by multiple providers. In Pennsylvania, there are efforts to integrate a prescription drug monitoring program (PDMP) within the electronic medical record (EMR). The objectives of this study were to evaluate prescribing practices for opioids for symptomatic nephrolithiasis and the incidence of prescriptions not documented within the EMR.Adults who presented for treatment of symptomatic nephrolithiasis were sequentially evaluated from May - October 2017 at Penn State Milton S. Hershey Medical Center. With IRB approval, we evaluated opioids prescribed in the EMR, which was compared to the PDMP for each stone episode. We calculated daily morphine milligram equivalents (MME) and total MME available to patients.A total of 301 patients were identified (52% male) with a mean age of 50.0 +/- 16.7 years and 249 (83%) of patients were prescribed narcotics with an average of 226.8 +/- 232.2 MME for their stone episode. Of patients that were prescribed narcotics, 19% had additional narcotics prescribed to them that were not entered into the EMR and later identified using PDMP. The average additional opioid prescribed was 371.8 +/- 404.2 total MME.The majority of patients presenting with symptomatic nephrolithiasis were prescribed an opioid. Approximately one-fifth of patients were receiving opioids from other providers that were not documented in the EMR at the time of their opioid prescription. PDMP, or similar resources, should be utilized by providers to minimize opioid use and reduce oversupplying patients.

Obesity is a known risk factor for recurrent nephrolithiasis and it can be challenging to provide safe surgical intervention in the super obese population. Despite high weight limits on surgical beds, these often do not take into account positioning the patient on the end of the bed for dorsal lithotomy, which can risk an unsteady bed. In addition, depending on patient habitus the leg stirrups may not accommodate. There is limited literature that discusses the technical approach for positioning super obese patients in dorsal lithotomy when the weight limit approaches or exceeds the capacity of equipment available. In this article, we present a modified positioning technique to improve bed stability, which also provides an alternative if the patient's legs are not supported by available leg stirrups. From our experience, this modified dorsal lithotomy positioning for ureteroscopy is feasible and safe in patients with super obesity. Surgical intervention on this population requires appropriate planning and teamwork to ensure safe positioning.

Objective Kidney stones are painful and costly. Prevention guidelines emphasize a simple behavior change: increasing fluid intake and urine output. Unfortunately, adherence to those prevention guidelines is limited, and patients report forgetting or not being thirsty enough. This study evaluated the acceptability of using semiautomated tracking of fluid consumption to trigger just-in-time reminders to drink and increase the experienced automaticity of fluid intake. Method In a single-group trial, participants with a history of kidney stones (n = 31) used the sipIT digital tools (H2OPal connected water bottle, H2OPal mobile app for self-tracking, Fitbit smartwatch app for gesture detection) for 3 months. Results The semiautomated monitoring system detected 46,654 drinking events. From baseline to 1-month follow-up, the experienced automaticity of fluid intake increased significantly (d = 0.50) and remained elevated at 3-month follow-up (d = 0.64). A major barrier to adherence (lack of thirst) decreased from baseline to follow-ups. Retention rates and participant feedback indicated that this digital tool was acceptable to patients. Conclusion Semiautomated tracking of fluid consumption can be used to trigger just-in-time reminders. Based on this demonstration, the sipIT tools are ready for testing in a rigorous Phase II trial to evaluate efficacy for increasing fluid consumption and urine output as recommended for preventing the recurrence of kidney stones. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Introduction: Health-related quality of life (HRQOL) is decreased in patients with kidney stones at all stages of stone disease, even when asymptomatic. Stress is thought to contribute to HRQOL, although there has been minimal investigation into the effect of stress on stone-related quality of life (QOL). We used the Wisconsin Stone Quality of Life Questionnaire (WISQOL) to assess the relationship of stress to stone-related QOL in kidney stone patients. Methods: As part of the WISQOL Research Consortium, patients were approached in outpatient clinics and completed the WISQOL and the Perceived Stress Scale 10-item questionnaire (PSS-10). Patients with stones at enrollment were divided into those with symptoms and those without, while patients with no current stones formed another group. Questionnaire scores from each group were compared statistically and correlations between the groups were calculated. Results: Patients (n=704) were enrolled from six centers. The WISQOL successfully discriminated between patients with current stones and those without (p

INTRODUCTION AND OBJECTIVE:Urolithiasis is associated with a decreased health-related quality of life. The Wisconsin Stone Quality of Life (WISQOL) questionnaire is a validated instrument to evalua...

INTRODUCTION AND OBJECTIVE:Compliance with increasing fluid intake to produce at least 2.5L of urine daily for stone prevention is commonly below 50%. We previously identified patient interest in t...

Objective To evaluate kidney stone patients’ interest in lifestyle behavior modification and a variety of mobile health (mHealth) technologies to improve adherence to fluid consumption recommendations for the prevention of nephrolithiasis. Of particular interest was the acceptability of various intervention components for the design of a stone-specific mHealth technology. Materials and Methods Using a cross-sectional design, adult patients with a diagnosis of kidney stones (n = 94) were recruited from outpatient clinics to complete a three-part questionnaire. Results Patients reported being willing to make lifestyle changes to prevent kidney stones (97%). The majority of the patients recalled the recommendation to increase fluid intake (93%) but few monitored their daily fluid intake (30%). Most patients had never installed an app (95%) or owned a device (100%) to help with increasing fluid consumption, but believed an app or device could improve their adherence (72%) and would be interested in using an app or device (86%). The mHealth intervention components most widely perceived as useful included automated lapse detection with notifications, educational materials, self-monitoring tools, scheduler with prompts and/or reminders and/or notifications, connected water bottles and text message reminders to drink. Conclusion Patients are interested in lifestyle behavior change to prevent stones but technology has not been widely adopted to improve adherence to fluid intake recommendations for stone prevention. This study identified a number of viable mHealth intervention components that should be considered when designing a stone-specific mHealth technology to support adherence to increased fluid consumption recommendations.

Introduction: Urolithiasis causes a significant impact on health-related quality of life (HRQOL). Patients with kidney stones have high levels of stress and anxiety. Symptom resolution often requires treatment. Travel distance is a barrier to care but little is known about its effects on HRQOL. We hypothesize that increased distance to treatment site is associated with decreased HRQOL. Methods: Patients with a history of stones were enrolled at 11 tertiary centers as part of the QOL Stone Consortium of North America. HRQOL data were obtained using the Wisconsin Stone Quality of Life questionnaire (WISQOL). We calculated distance between patient and treatment site using national ZIP codes. We used linear models to evaluate the effect of distance on HRQOL, while also considering demographics data, stones/symptom status, and distance. Results: Of the 1676 enrolled patients, 52% were male, 86% non-Latino White, and the mean age was 53 years. Mean distance to treatment site was 63.3 km (range: 0–3774), with 74% reporting current stones and 45% current symptoms. WISQOL score and distance were negatively correlated for patients reporting current stones and symptoms (p=0.0010). Linear modelling revealed decreased WISQOL scores for patients with symptoms as distance increased from treatment site (p=0.0001), with a 4.7-point decrease for every 100 km traveled. Conclusions: Stone disease imposes significant burden on patients’ HRQOL due to a variety of factors. Patients with active stone symptoms report worse HRQOL with increased distance to their treatment site. Possible etiologies include travel burden, increased disease burden, decreased healthcare use, and delays in care.

Kidney stone formers have lower health related quality of life than nonstone formers. The North American Stone Quality of Life Consortium is a multicenter, longitudinal, prospective study of health related quality of life in patients with kidney stones using the WISQOL (Wisconsin Stone Quality of Life Questionnaire) with data on 2,052 patients from a total of 11 centers. This study is a subanalysis of cross-sectional data looking at the association of age, gender and race on health related quality of life of stone formers.We performed multivariable analyses of ordinal logistic regression analyses to determine the impact of age, gender and race on health related quality of life, adjusting for other baseline covariates. The proportional odds assumption of ordinal logistic regression was checked. Total score and scores on 4 subdomains (social functioning, emotional functioning, stone related impact and vitality) were included.Median total score for all patients was 80.4. On multivariable analysis older patients had a significantly higher total health related quality of life score than younger patients (per 10-year increase OR 1.25, p0.0001). Male patients had higher scores than females (OR 1.56, p = 0.0003) and nonCaucasian patients had lower health related quality of life than nonLatino Caucasian patients (OR 0.63, p = 0.0045).Younger and female patients with kidney stones have lower health related quality of life than older and male patients, respectively. NonCaucasian patients with stones also have lower health related quality of life. The clinical impact of these findings might include future implications for patient counseling, including dietary and medical management of stone disease, and potential changes to the paradigm of the surgical management of stones.

INTRODUCTION AND OBJECTIVES:Compliance with increasing fluid intake to produce at least 2.5L of urine daily for stone prevention is commonly below 50%. We have previously shown that patients are interested in utilizing sensors to provide automated lapse detection in fluid intake to improve adherence to recommendations. Wrist-worn inertial sensors can detect drinking behavior with accelerometers and gyroscopes. The purpose of this study was to devise a protocol to test the ability of a wrist sensor to refine the detection of drinking behavior in everyday activities and to evaluate the recruitment process for future clinical trials.METHODS:Patients with kidney stones were recruited to participate in the 70-minute lab sessions. Wrist sensors were worn bilaterally and participants were videotaped performing a variety of daily activities, including drinking from various vessels.RESULTS:36 patients with a history of kidney stones were enrolled to participate out of a total of 56 who were eligible. Six participa...

Over the last decade, advances in mobile technologies have enabled the development of intelligent systems that attempt to recognize and model a variety of health-related human behaviors. While automated dietary monitoring based on passive sensors has been an area of increasing research activity for many years, much less attention has been given to tracking fluid intake. In this work, we apply an adaptive segmentation technique on a continuous stream of inertial data captured with a practical, off-the-shelf wrist-mounted device to detect fluid intake gestures passively. We evaluated our approach in a study with 30 participants where 561 drinking instances were recorded. Using a leave-one-participant-out (LOPO), we were able to detect drinking episodes with 90.3% precision and 91.0% recall, demonstrating the generalizability of our approach. In addition to our proposed method, we also contribute an anonymized and labeled dataset of drinking and non-drinking gestures to encourage further work in the field.

To determine the extent to which validated techniques for behavior change have been infused in commercially available fluid consumption applications (apps).Coders evaluated behavior change techniques represented in online descriptions for 50 fluid consumption apps and the latest version of each app.Apps incorporated a limited range of behavior change techniques (20% of taxonomy). The number of techniques varied by operating system but not as a function of whether apps were free or paid. Limitations include the lack of experimental evidence establishing the efficacy of these apps.Patients with urolithiasis can choose from many apps to support the recommended increase in fluid intake. Apps for iOS devices incorporate more behavior change techniques compared to apps for the Android operating system. Free apps are likely to expose patients to a similar number of techniques as paid apps. Physicians and patients should screen app descriptions for features to promote self-monitoring and provide feedback on discrepancies between behavior and a fluid consumption goal.

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.

We evaluated the use of periureteral injection of botulinum toxin type A (Botox(®), BTX-A) to facilitate passage of ureteral stones in a porcine model. We believe that reducing detrusor muscle tone around the intramural ureter may facilitate passage of ureteral stones through the ureterovesical junction.With complete Institutional Animal Care and Use Committee approval, artificial stones (BegoStone plus) were placed by retrograde ureteroscopy into the proximal ureter using fluoroscopic guidance using an in-vivo porcine model. Six animals underwent periureteral BTX-A injection 30 U/mL to three locations around the ureteral orifice, and six animals were in the control group undergoing periureteral injection of physiologic saline.There was a significant decrease in time to stone passage in the BTX-A group compared with the control group, 2.6 ± 1.3 vs 6.8 ± 2.9 days, respectively (p = 0.018). None of the animals had evidence of vesicoureteral reflux postprocedure (N = 0/12).Preliminary results suggest that periureteral injection of BTX-A facilitates ureteral stone passage in this model. BTX-A may provide a simple, office-based endoscopic treatment option for ureteral stones. Further studies would be necessary to evaluate its efficacy in humans compared with traditional medical expulsive therapy.

INTRODUCTION AND OBJECTIVE:The Wisconsin Stone Quality of Life (WISQOL) questionnaire, a quality of life (QOL) measurement tool designed specifically for kidney stone patients was recently validate...

There are no current guidelines on the optimal management of asymptomatic renal stones. This review summarizes the current literature, focusing on more recent studies that have been done to grow the body of evidence on this topic. Recent studies have found that stone size is a significant predictor of need for future surgical intervention, with > 7 mm for pediatric population and > 4 mm for residual fragments after both PNL and ureteroscopy (URS). The role of URS has been better defined with a recent RCT concluding that URS and SWL had comparable outcomes for an asymptomatic lower pole stone

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.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.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).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.

Objective To evaluate the use of percutaneous nephrolithotomy (PNL) and technical approach in the super obese population (body mass index [BMI] ≥ 50). Materials and Methods We performed a retrospective review of 31 consecutive PNL cases with a BMI > 50 from a single surgeon (SYN) from 1995 to 2013. Procedures were performed in the prone position, and upper pole access was used. Operative time, length of hospital stay, stone burden, complication rates, and stone-free rates were measured. Results Of the 31 patients who underwent PNL (age 51.2 ± 12; 71% female), the mean BMI was 59.1 ± 6 kg/m2 (range 50.4-71.7 kg/m2). Mean stone burden was 3.8 cm ± 2. The majority of patients (90.3%) had an upper pole puncture site for access with an operative time of 122.1 ± 75 minutes. The technique was similar to non-obese patients; however, there was a need for extra-long instrumentation. The overall stone-free rate was 71%, with utilization of a second-look PNL in 11 cases. The complication rate, Clavien grade 3 or higher, was 9.7% (3 of 31). Conclusion PNL is technically feasible, safe, and effective in patients with a BMI ≥ 50. The complication rate, length of hospital stay, and stone-free rate with use of second-look PNL in super obese patients are comparable to severely obese patients. Intervention should not be automatically ruled out or delayed based on the patient's BMI alone.

Cystinuria is a rare cause of urolithiasis. Affected patients have an earlier onset and more aggressive disease than patients with other stone etiologies. We assessed the health-related quality of life (HRQOL) of cystine stone-forming patients using the disease-specific Wisconsin Stone Quality of Life questionnaire (WISQOL).Cystine patients treated in our stone clinics (n = 12) completed the WISQOL; information about medical and stone histories was gathered. Patients were matched with noncystine stone formers (n = 12) for gender, age, and comorbidities. In addition, a second control group (n = 90), also from our institution and consisting of mixed calcium stone formers, was included. WISQOL responses were compared between groups.Cystine patients had significantly lower total WISQOL scores than noncystine patients. Compared with noncystine stone formers, cystine stone formers also had lower HRQOL scores for subscales (domains) related to social impact, emotional impact, disease impact, and vitality (p ≤ 0.04 for all). On specific items, cystine patients reported significantly more sleep problems (p = 0.02), more bother with nocturia (p = 0.03), and feeling tired or fatigued (p = 0.02). Among those with current stones, cystine patients scored lower than noncystine patients for total score and in two of four domains.Using a stone-specific questionnaire, patients with cystine stones have lower HRQOL compared with noncystine stone formers. Identifying and addressing specific areas of decrement in patients with cystine stones may improve disease management and patients' HRQOL.

INTRODUCTION AND OBJECTIVES: We evaluated the use of periureteral injection of botulinum toxin type A (Botox , BTX-A) to facilitate passage of ureteral stones in a porcine model. We believe that reducing detrusor muscle tone around the intramural ureter may facilitate passage of ureteral stones through the ureterovesical junction. METHODS: With complete Institutional Animal Care and Use Committee approval, artificial stones (BegoStone plus) were placed by retrograde ureteroscopy into the proximal ureter using fluoroscopic guidance using an in vivo porcine model. Six animals underwent periureteral BTX-A injection 30 U / mL to 3 locations around the ureteral orifice and 6 animals were in the control group undergoing periureteral injection of normal saline. RESULTS: There was a significant decrease in time to stone passage in the BTX-A group compared to the control group, 2.6 1.3 vs. 6.8 2.9 days respectively (p1⁄4 0.018). None of the animals had evidence of vesicoureteral reflux post-procedure (N1⁄40/12). CONCLUSIONS: Preliminary results suggest periureteral injection of BTX-A facilitates ureteral stone passage in this model. BTX-A may provide a simple, office-based endoscopic treatment option for ureteral stones. Further studies would be necessary to evaluate its efficacy in humans as compared to traditional medical expulsive therapy.

OBJECTIVE To test the hypothesis that patients with bladder cancer who had evidence of lymphovascular invasion (LVI) in their transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens would have a worse prognosis and higher likelihood of clinical understaging, and to assess the effect of LVI discovered at RC on subsequent disease-related mortality, as the prognostic significance of LVI in TURBT or RC specimens of patients treated for urothelial carcinoma of the bladder is not completely established. PATIENTS AND METHODS We retrospectively reviewed the records of 163 patients with urothelial carcinoma of the bladder seen at our institution, and who had TURBT (69) or RC (94) between 1995 and 2005. We compared patients with LVI on TURBT and/or RC specimens to a group of controls who did not have LVI on TURBT (34) or RC (32). RESULTS Patients with LVI present in their TURBT specimen had a shorter disease-specific survival than those without LVI, with a 5-year survival of 33.6% vs 62.9% (log-rank test P = 0.027; hazard ratio 2.21). LVI at TURBT varied with clinical stage (P = 0.049). Patients with LVI and who were clinical stage I or II had lower survival than those without LVI (P = 0.049; hazard ratio 2.68). LVI did not affect survival among those with clinical stage III or IV (P = 0.29). There was a trend for patients with LVI at TURBT to be clinically understaged compared to those without LVI (75% vs 46%) but the difference was not significant (P = 0.086). Patients with LVI detected in their RC specimen were significantly more likely to have cancer recurrence than were those with no evidence of LVI (48% vs 19%, P = 0.006). For the RC group there was also a significant difference in survival distribution between patients with evidence of LVI vs those without (5-year survival 45.5% vs 78.4%, P = 0.017). Those with LVI were significantly more likely to die from the disease than those without LVI (P = 0.017; hazard ratio 2.92). CONCLUSIONS Our findings suggest that LVI is a histological feature that might be associated with a poorer prognosis in patients with urothelial carcinoma of the bladder. The presence of LVI in TURBT specimens predicts shorter survival for patients with stage I or II disease. The presence of LVI in RC specimens predicts recurrence of disease and shorter survival. Further studies are needed to determine whether this group of patients would benefit from early RC and/or perioperative chemotherapy to improve clinical outcomes.

Objectives To determine whether the severity of haematuria (microscopic or gross) at diagnosis influences the disease stage at presentation in patients diagnosed with bladder cancer. Patients and Methods We conducted a multi-institutional observational cohort study of patients who were newly diagnosed with bladder cancer between August 1999 and May 2012. We reviewed the degree of haematuria, demographic information, clinical and social history, imaging, and pathology. The association of haematuria severity with incident tumour stage and grade was evaluated using logistic regression. Results Patients diagnosed with bladder cancer presented with gross haematuria (GH; 1 083, 78.3%), microscopic haematuria (MH; 189, 13.7%) or without haematuria (112, 8.1%). High-grade disease was found in 64% and 57.1% of patients presenting with GH and MH, respectively, and severity of haematuria was not associated with higher grade disease. Stage of disease at diagnosis for patients presenting with MH was Ta/carcinoma in situ (CIS) in 68.8%, T1 in 19.6%, and ≥T2 in 11.6%. Stage of disease at diagnosis for patients presenting with GH was Ta/CIS in 55.9%, T1 in 19.6%, and ≥T2 in 17.9%. On multivariate analyses, GH was independently associated with ≥T2 disease at diagnosis (odds ratio 1.69, 95% confidence interval 1.05–2.71, P = 0.03). Conclusions Among patients with newly diagnosed bladder cancer, presentation with GH is associated with a more advanced pathological stage. Earlier detection of disease, before development of GH, could influence survival in patients with bladder cancer. Type of haematuria at presentation does not impact grade of disease.

Ureteral stricture is a late complication of ureteroscopy (URS) and can be challenging to treat stones when present concomitantly. Ureteral stones may fail to spontaneously pass secondary to a distally located ureteral stricture. Retrograde access may be difficult or unable to be obtained depending on the degree of the stricture and presence of stone impaction. This chapter will focus on the treatment options for a ureteral stone with a distal ureteral stricture.

The focus of this chapter is on the indications, technical considerations, and complications of ureteroscopy for both renal and ureteral calculi. When making decisions about treatment of both renal and ureteral calculi, it is important to take the following into consideration: probability of stone-free rate, need for additional procedures, and morbidity related to the treatment modality. We will discuss in detail the indications for each of the treatment modalities that are considered for both renal and ureteral calculi including: ureteroscopy (URS) with intracorporeal lithotripsy, extracorporeal shock wave lithotripsy (ESWL), and percutaneous nephrolithotomy (PCNL). Discussion will include treatment decisions based on the following stone characteristics: size, location, and Hounsfield unit (HU) density to suggest potential stone composition. During surgical planning, it is also important to consider the following patient characteristics: children, pregnancy, coagulopathies or bleeding disorders, and patient body habitus. In addition, we will discuss technical considerations including specifications of current available flexible ureteroscopes and lithotripters. The last section of the chapter will review the possible complications from ureteroscopy including: bleeding, infection, ureteral stent discomfort, ureteral injury, need for secondary treatment, renal damage, and ureteral stricture.