Ojas Shah

Objective: To assess the effect of Moses™ 2.0 (Lumenis Be Ltd., Yokneam Illit, Israel; Boston Scientific, Marlborough, MA, USA) for lithotripsy of renal stones of 8–20 mm in diameter on operative time, surgeon workload, and retropulsion. Subjects/Patients and Methods: In our multicentre, randomised, double‐blind clinical trial, patients were randomised 1:1 to standard or Moses 2.0 laser lithotripsy and stratified by stone size. Patients and surgeons were blinded to laser modality. Primary outcomes were total operative time as well as surgeon workload assessed by the National Aeronautics and Space Administration‐Task Load Index (NASA‐TLX). Secondary outcomes were stone retropulsion evaluated by blinded video review and postoperative clinical outcomes. Linear regression modelling was used for analysis. Results: A total of 153 patients (79 Standard, 74 Moses 2.0) with similar clinical, stone, and operative characteristics were evaluated. There was no significant difference in operative times between the Standard and Moses 2.0 groups ( P = 0.73). Moses 2.0 was associated with lower effort, frustration, mental, physical, and temporal workload, as well as higher rated overall performance compared to the standard laser. Video review demonstrated no difference in rates of retropulsion ( P = 0.13). Complication rates (Standard: 13%; Moses 2.0: 10%) and stone‐free rates (Standard: 51%; Moses: 2.0 55%) were comparable. Conclusion: Our study evaluated the impact of Moses 2.0 technology on high‐powered renal stone dusting, constituting the largest double‐blind trial of its kind to date. There was insufficient evidence to suggest any difference in operative times or clinical outcomes when using Moses 2.0 compared to standard laser lithotripsy. Moses 2.0 was associated with reduced surgeon workload, which has implicit impact on surgeon wellness.

Computed tomography (CT) and ultrasound (US) are primary imaging modalities for evaluating flank pain and suspected nephrolithiasis in emergency departments (EDs). Prior evidence suggests that initial US instead of CT reduces radiation exposure without serious clinical consequences. We investigated trends in imaging employed for evaluating flank pain in United States EDs. ED encounters for flank pain were identified in the National Hospital Ambulatory Medical Care Survey (2014-2022). National estimates were generated via multistage survey weighting. Multivariate logistic regression models controlling for demographic and visit characteristics were used to calculate adjusted odds ratios (aORs) and α=0.01. Among an estimated 25.4 million ED encounters for flank pain, 24.2% resulted in a nephrolithiasis diagnosis. The annual rate of nephrolithiasis diagnoses was similar throughout the study period. Imaging utilization included CT-exclusive (53.3%), US-exclusive (5.6%), combined CT and US (4.6%), and neither CT nor US (36.4%) workups. CT-exclusive (aOR 1.050, p=0.009) and combined CT and US (aOR 1.175, p=0.001) workups increased over time, while encounters without imaging declined (aOR 0.945, p=0.006). US-exclusive workup remained constant over time. Revisit status (aOR: 0.447, p<0.001), Black race (aOR: 0.631, p=0.002), and care at teaching hospitals (aOR: 0.721, p=0.004) were significantly negatively associated with CT-exclusive workup. Younger age (aOR: 0.973, p<0.001) and care at teaching hospitals (aOR: 1.982, p=0.005) were significantly associated with US-exclusive workup. CT remains the predominant imaging modality for flank pain evaluation and has increased in use since 2014, while US-exclusive evaluation remains limited to select settings and patient populations.

A tri-layer ureteral stent with novel coating lining the inner and outer surfaces (Tria^™) was designed to reduce encrustation. We assessed technical success, complications, and patient symptoms in an international prospective stent registry conducted from 2020 to 2023. Outcomes included technical success, infections, and encrustation rates. Patient-reported PROMIS Pain Intensity (3a) and Pain Interference (6b) scores were obtained at time of index procedure, stent removal, and post-stent removal. Tria stents were compared to non-Tria stents grouped together. Of 359 total patients, 271 had a unilateral stent placed for stone management procedures. Tria vs. non-Tria groups were comparable in age (55.9y vs. 58.7y), gender (57.8% vs. 56.4% male), BMI (28.9 vs. 29.7 kg/m²), and stent indwell times (11.8 vs. 9.9 days). Pain interference scores (p = 0.025) were lower in patients with Tria stents, and pain intensity scores approached significance (p = 0.052). Non-Tria patients reported significantly larger decreases from the week prior to stent removal to post-stent removal in both domains (p = 0.0245, p = 0.0216). Infection (Tria 1.9% vs. non-Tria 3.4%, p = 0.45) and encrustation rates (Tria 1.3% vs. non-Tria 0%, p = 0.36) were both low and non-significantly different. Patients with Tria stents were more comfortable than non-Tria stents in the week prior to stent removal and post-stent removal visits.

Purpose: Elevated glycated hemoglobin A1c (HbA1c) has not been specifically evaluated as a risk factor for urosepsis after kidney stone procedures. Moreover, there are no current guidelines for perioperative HbA1c optimization, nor recommendations for the optimal timing to treat non-urgent kidney stones in the setting of poor glycemic control. We evaluated the association between perioperative HbA1c levels and sepsis risk after ureteroscopy with lithotripsy. Methods: Patients undergoing ureteroscopy with lithotripsy from January 2020 to June 2023 at a tertiary center were retrospectively reviewed. Postoperative sepsis was defined as Systemic Inflammatory Response Syndrome scores ≥2 within 30 days after ureteroscopy. The risk of sepsis at various HbA1c thresholds was evaluated via multivariate logistic regression. Results: A total of 1454 patients underwent ureteroscopy with lithotripsy, and 319 patients had HbA1c collected within 90 days of their procedures. The mean preoperative Charlson Comorbidity Index (CCI) score was 3.22 (±2.77). An increased risk of sepsis was observed among patients with HbA1c levels between 8.0% and 9.9% (odds ratio [OR] 4.42, p = 0.025) and ≥10% (OR 8.17, p = 0.003). Positive preoperative urine culture despite treatment (OR 4.53, p < 0.001) and higher CCI (OR 1.17, p = 0.045) were also associated with increased odds of sepsis. Conclusion: The odds of sepsis after ureteroscopy with lithotripsy follow a dose–response relationship with elevated perioperative HbA1c. These data underscore the clinical utility of incorporating HbA1c into preprocedural optimization and may justify certain patients to delay elective ureteroscopy to improve glycemic control before endourologic intervention.

Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.

Background: Updated in 2019, the American Urological Association’s (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized endourologists do not routinely follow the AUA’s statement on antibiotic use during PCNL and assessed their prescribing patterns. Methods: A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA’s recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. Results: A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data was predictive of following the AUA. 90.9% and 83.6% reported they have “never” used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤ 24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤ 24 hours of perioperative antibiotics while 20.4% begin antibiotics 7 or more days prior. Conclusions: Nearly half of respondents do not follow the AUA’s recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first line antibiotic choice for PCNL and their roles needs to be further evaluated as first line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

Introduction: Recent retrospective literature suggests that the quick sequential organ failure assessment scoring (qSOFA) tool is a potentially superior tool over use of the systemic inflammatory response syndrome criteria (SIRS) to predict septic shock after percutaneous nephrolithotomy (PCNL) surgery. Here we examine use of qSOFA and SIRS to predict septic shock within data series collected prospectively on PCNL patients as part of a greater study of infectious complications. Materials and methods: We performed a secondary analysis of two prospective multicenter studies including PCNL patients across nine institutions. Clinical signs informing SIRS and qSOFA scores were collected no later than post-operative day one. The primary outcome was sensitivity and specificity of SIRS and qSOFA (high risk score of greater-or-equal to 2 points) in predicting admission to the intensive care unit (ICU) for vasopressor support. Results: A total of 218 cases at nine institutions were analyzed. One patient required vasopressor support in the ICU. The sensitivity/specificity was 100%/72.4% (McNemar’s test p < 0.001) for SIRS and was 100%/90.8% (McNemar’s test p < 0.001) for qSOFA. Conclusion: Although PPV for both qSOFA and SIRS in prediction of post-PCNL septic shock is low, prospectively collected data demonstrates use of qSOFA may offer greater specificity than SIRS criteria when predicting post-PCNL septic shock.

Urinary stone disease is common and affects approximately 10% of the American adults. The role of diet in stone formation is well-recognized; however, the literature focus has been on dietary excess rather than micronutrient inadequacy. As patients with stones may be at risk for nutrient inadequacies, we investigated the role of micronutrient inadequacy in stone formation by performing a cross-sectional analysis of the National Health and Nutrition Examination Survey on adults who were not taking dietary supplements. Micronutrient intake was obtained from 24-h dietary recalls, and usual intake was calculated. Survey-weighted, adjusted logistic regression was used for an incident analysis on having any history of stones. An additional analysis on recurrent stone-formers was performed with the outcome being 2 or more stones passed. Finally, a sensitivity analysis using quasi-Poisson regression was performed with the outcome being number of stones passed. There were 9777 respondents representing 81,087,345 adults, of which 9.36% had a stone history. Our incident analysis revealed inadequate vitamin A intake to be associated with stone formation (OR 1.33, 95% CI: 1.03–1.71). Recurrent analysis did not find any significant associations, while our sensitivity analysis revealed inadequate vitamin A (IRR 1.96, 95% CI: 1.28–3.00) and pyridoxine (IRR 1.99, 95% CI: 1.11–3.55) to be associated with a higher number of recurrent stones. Hence, inadequate dietary intake of vitamin A and pyridoxine was associated with nephrolithiasis. Further research is needed to identify the roles of these micronutrients in stone-formers and the potential for evaluation and treatment.