First name
Gregory
Middle name
E
Last name
Tasian

Title

Risk Factors for Increased Stent-Associated Symptoms Following Ureteroscopy for Urinary Stones: Results from STENTS.

Year of Publication

2023

Number of Pages

101097JU0000000000003183

Date Published

01/2023

ISSN Number

1527-3792

Abstract

PURPOSE: The STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment.

MATERIALS AND METHODS: This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days (POD) 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms (SAS).

RESULTS: A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in SAS on POD 1. While pain intensity decreased ∼50% from POD 1 to POD 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity(p=0.004). Having chronic pain conditions(p<0.001), prior severe stent pain(p=0.021), and depressive symptoms at baseline(p<0.001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of SAS.

CONCLUSIONS: In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (e.g., age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of SAS.

DOI

10.1097/JU.0000000000003183

Alternate Title

J Urol

PMID

36648152

Title

Comparative effectiveness of high-power holmium laser lithotripsy for pediatric patients with kidney and ureteral stones.

Year of Publication

2022

Number of Pages

463.e1-463.e8

Date Published

08/2022

ISSN Number

1873-4898

Abstract

BACKGROUND: The comparative effectiveness of high-power laser technology for kidney stone surgery in pediatric patients is poorly understood. We compared outcomes for the 120 W Holmium:yttrium-aluminum-garnet (Ho:YAG) laser with MOSES technology to 30 W Ho:YAG laser for pediatric patients undergoing ureteroscopy with laser lithotripsy for kidney and ureteral stones.

OBJECTIVE: We evaluated the outcomes of the new MOSES laser technology as compared to low-power Ho:YAG lasers commonly used for kidney stone treatment in the pediatric population.

METHODS: We performed a retrospective cohort study of 131 consecutive patients aged 1-18 years who underwent ureteroscopy and laser lithotripsy for renal and ureteric calculi at a large freestanding children's hospital between 2013 and 2020. The primary outcome was the efficiency quotient, which incorporates stone clearance, auxiliary procedures, and retreatment rates. Outcomes were compared between groups using Chi-square or Fisher's exact tests and multivariable regression. A sensitivity analysis was performed extending the age limit to ≤21 years.

RESULTS: Outcomes are summarized in the table below. Median age of the cohort was 14 years with 53% of patients being female. MOSES laser had a higher efficiency quotient and was associated with a lower odds of post-operative emergency department visits (OR 0.2, 95% CI 0.0-1.0; p = 0.047). Operative time was similar. In the sensitivity analysis of patients ≤21 years, the statistical significance with fewer emergency department visits was lost and the efficiency quotient was lower.

DISCUSSION: Our results show that stone clearance is similar between the 120 W MOSES and 30 W Ho:YAG lasers. However, there are indications that high-power laser lithotripsy is more efficient due to fewer auxiliary procedures and a reduction in retreatment. In addition, higher power lasers were associated with fewer emergency department visits. The benefits appear to be greater among children ≤18 years. These exploratory findings are important for pediatric patients due to the requirement for general anesthesia for each procedure and their associated impact on children and their caregivers.

CONCLUSIONS: High-power laser lithotripsy may be more efficient than lower power laser lithotripsy, which is driven by the fewer auxiliary procedures and reduction in retreatment particularly among youth ≤18 years old.

DOI

10.1016/j.jpurol.2022.05.022

Alternate Title

J Pediatr Urol

PMID

35715329

Title

Comparative effectiveness of high-power holmium laser lithotripsy for pediatric patients with kidney and ureteral stones.

Year of Publication

2022

Date Published

06/2022

ISSN Number

1873-4898

Abstract

BACKGROUND: The comparative effectiveness of high-power laser technology for kidney stone surgery in pediatric patients is poorly understood. We compared outcomes for the 120 W Holmium:yttrium-aluminum-garnet (Ho:YAG) laser with MOSES technology to 30 W Ho:YAG laser for pediatric patients undergoing ureteroscopy with laser lithotripsy for kidney and ureteral stones.

OBJECTIVE: We evaluated the outcomes of the new MOSES laser technology as compared to low-power Ho:YAG lasers commonly used for kidney stone treatment in the pediatric population.

METHODS: We performed a retrospective cohort study of 131 consecutive patients aged 1-18 years who underwent ureteroscopy and laser lithotripsy for renal and ureteric calculi at a large freestanding children's hospital between 2013 and 2020. The primary outcome was the efficiency quotient, which incorporates stone clearance, auxiliary procedures, and retreatment rates. Outcomes were compared between groups using Chi-square or Fisher's exact tests and multivariable regression. A sensitivity analysis was performed extending the age limit to ≤21 years.

RESULTS: Outcomes are summarized in the table below. Median age of the cohort was 14 years with 53% of patients being female. MOSES laser had a higher efficiency quotient and was associated with a lower odds of post-operative emergency department visits (OR 0.2, 95% CI 0.0-1.0; p = 0.047). Operative time was similar. In the sensitivity analysis of patients ≤21 years, the statistical significance with fewer emergency department visits was lost and the efficiency quotient was lower.

DISCUSSION: Our results show that stone clearance is similar between the 120 W MOSES and 30 W Ho:YAG lasers. However, there are indications that high-power laser lithotripsy is more efficient due to fewer auxiliary procedures and a reduction in retreatment. In addition, higher power lasers were associated with fewer emergency department visits. The benefits appear to be greater among children ≤18 years. These exploratory findings are important for pediatric patients due to the requirement for general anesthesia for each procedure and their associated impact on children and their caregivers.

CONCLUSIONS: High-power laser lithotripsy may be more efficient than lower power laser lithotripsy, which is driven by the fewer auxiliary procedures and reduction in retreatment particularly among youth ≤18 years old.

DOI

10.1016/j.jpurol.2022.05.022

Alternate Title

J Pediatr Urol

PMID

35715329

Title

Automated Machine Learning Segmentation and Measurement of Urinary Stones on CT Scan.

Year of Publication

2022

Date Published

07/2022

ISSN Number

1527-9995

Abstract

OBJECTIVES: To evaluate the performance of an engineered machine learning algorithm to identify kidney stones and measure stone characteristics without the need for human input.

METHODS: We performed a cross-sectional study of 94 children and adults who had kidney stones identified on non-contrast CT. A previously developed deep learning algorithm was trained to segment renal anatomy and kidney stones and to measure stone features. The performance and speed of the algorithm to measure renal anatomy and kidney stone features were compared to the current gold standard of human measurement performed by 3 independent reviewers.

RESULTS: The algorithm was 100% sensitive and 100% specific in detecting individual kidney stones. The mean stone volume segmented by the algorithm was smaller than that of human reviewers and had moderate overlap (Dice score: 0.66). There was substantial variation between human reviewers in total segmented stone volume (Jaccard score: 0.17) and volume of the single largest stone (Jaccard score: 0.33). Stone segmentations performed by the machine learning algorithm more precisely approximated stone borders than those performed by human reviewers on qualitative assessment.

CONCLUSION: An engineered machine learning algorithm can identify and characterize stones more accurately and reliably than humans, which has the potential to improve the precision and efficiency of assessing kidney stone burden.

DOI

10.1016/j.urology.2022.07.029

Alternate Title

Urology

PMID

35908740

Title

Variation in care between pediatric and adult patients presenting with nephrolithiasis to tertiary care pediatric emergency departments in the United States (2009-2020).

Year of Publication

2022

Date Published

07/2022

ISSN Number

1873-4898

Abstract

BACKGROUND: Individuals with nephrolithiasis frequently present to the Emergency Department (ED). Safety and quality principles are often applied in pediatric EDs to children presenting with nephrolithiasis, such as limiting ionizing radiation exposure and opioid analgesics. However, it is unknown whether pediatric EDs apply these same principles to adult patients who present with nephrolithiasis. We hypothesized that adult patients would be associated with higher use of radiation-based imaging and opioid analgesics.

OBJECTIVE: To assess variations in diagnostic and treatment interventions and hospital utilization between pediatric and adult patients presenting to the pediatric ED with nephrolithiasis.

STUDY DESIGN: A retrospective cohort study was conducted, examining outcomes for pediatric (<18-years-old) versus adult (≥18-years-old) patients in 42 pediatric EDs from 2009 to 2020 using the Pediatric Health Information System (PHIS) database. Patients with an ICD-9/10 principal diagnosis code of nephrolithiasis with no nephrolithiasis-related visits within the prior 6 months were included. Primary outcomes were imaging, medications, and surgical interventions. Secondary outcomes were hospital admissions, 90-day ED revisits, and 90-day readmissions. Generalized linear mixed models with random effects were used to adjust for confounding and clustering.

RESULTS: In total, 16,117 patients with 17,837 encounters were included. Most hospitals were academic (95.2%), and a plurality were located in the South (38.1%). Most patients were <18-years-old (84.4%, median (interquartile range): 15 (12-17)-years-old), female (57.9%), and White (76.3%), and 17.1% were Hispanic/Latino. Most had no complex chronic conditions (89.2%) and no chronic disease per pediatric medical complexity algorithm (51.5%). For the primary outcome, adults, relative to pediatric patients, who presented to the pediatric ED with nephrolithiasis had higher adjusted odds of receiving computerized tomography (CT) scans (Odds Ratio [OR] 1.43 [95% Confidence Interval [CI] 1.29-1.59]) and opioid analgesics (OR 1.45 [95%CI 1.33-1.58]) (Summary Figure). Secondary outcomes showed that adults, relative to pediatric patients, had lower adjusted odds of hospital admissions, 90-day ED revisits, and 90-day readmissions.

DISCUSSION: Our results suggest that certain pediatric safety and quality principles, such as limiting ionizing radiation exposure and opioid analgesic prescriptions, are not being equally applied to pediatric and adult patients who present to pediatric EDs with nephrolithiasis. The mechanism of these findings remains to be elucidated.

CONCLUSIONS: Variations in care for individuals with nephrolithiasis reflect an opportunity for quality improvement in pediatric EDs and inform work exploring optimal care pathways for all patients presenting to the pediatric ED with nephrolithiasis.

DOI

10.1016/j.jpurol.2022.07.005

Alternate Title

J Pediatr Urol

PMID

35945144

Title

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS.

Year of Publication

2022

Number of Pages

53

Date Published

2022 Apr 06

ISSN Number

1471-2490

Abstract

<p><strong>BACKGROUND: </strong>Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains.</p>

<p><strong>METHODS: </strong>In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30.</p>

<p><strong>RESULTS: </strong>The median age was 44&nbsp;years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5&nbsp;mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2&nbsp;days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability.</p>

<p><strong>CONCLUSIONS: </strong>This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.</p>

DOI

10.1186/s12894-022-01004-9

Alternate Title

BMC Urol

PMID

35387623

Title

The Impact of Sex and Gender on Clinical Care and Research Design in Nephrolithiasis.

Year of Publication

2021

Number of Pages

54-57

Date Published

2021 05

ISSN Number

1527-9995

Abstract

<p>Although classically a disease of male preponderance, scrutiny of the available data on&nbsp;nephrolithiasis&nbsp;reveals substantial epidemiological discrepancies between males and females, suggesting sex-based&nbsp;pathophysiology&nbsp;underlying this disease.&nbsp;Furthermore, sex-based differences may exist in underlying urinary risk factors, presentation, and treatment response. Recognizing these differences will be essential to further understand the multitude of etiologies of kidney stone disease and aid in developing appropriately designed comparative effectiveness trials.</p>

DOI

10.1016/j.urology.2020.04.089

Alternate Title

Urology

PMID

32387245

Title

Laser access and utilization preferences for pediatric ureteroscopy: A survey of the Societies of Pediatric Urology.

Year of Publication

2021

Date Published

2021 Oct 18

ISSN Number

1911-6470

Abstract

<p><strong>INTRODUCTION: </strong>We sought to evaluate laser access and practice variability for pediatric ureteroscopy (URS) across the Societies of Pediatric Urology (SPU) to identify opportunities and barriers for future technology promulgation and evidence dissemination.</p>

<p><strong>METHODS: </strong>A 25-question survey was sent electronically to members of the SPU. The questionnaire assessed surgeon and hospital characteristics, treatment preferences based on an index case, and information about available laser units. Descriptive and comparative statistical analyses were performed to assess patterns of care and laser accessibility across the SPU.</p>

<p><strong>RESULTS: </strong>A total of 105 of 711 (15%) recipients responded. Seventy-seven respondents (73%) reported laser ownership, which was associated with greater after-hours laser access (87% vs. 13%, p&lt;0.01). Fifty-eight individuals provided additional laser specifications, of whom 21 (36%) used a high-power laser unit (&gt;60 W). Standard-power lasers were used more frequently in free-standing children's hospitals, as compared to those working within a larger hospital complex (75% vs. 50%, p=0.049). Variation existed in treatment preferences with respect to dusting (33, 34%), fragmentation (18, 19%), or a hybrid approach (46 respondents, 48%). Stone clearance was the most important consideration irrespective of treatment choice.</p>

<p><strong>CONCLUSIONS: </strong>Variability in surgical preferences and accessibility to laser units exist across pediatric urologists who performing URS. Laser ownership and access to newer technologies vary across practices and may influence treatment options. Understanding access to laser technology will be important when considering opportunities for surgical optimization to improve patient outcomes through future studies.</p>

DOI

10.5489/cuaj.7326

Alternate Title

Can Urol Assoc J

PMID

34672934

Title

Early-Onset Kidney Stone Disease-Consequences and Opportunities.

Year of Publication

2021

Date Published

2021 Sep 07

ISSN Number

2168-6211

DOI

10.1001/jamapediatrics.2021.2966

Alternate Title

JAMA Pediatr

PMID

34491264

Title

Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media.

Year of Publication

2021

Number of Pages

860-861

Date Published

2021 Aug 26

ISSN Number

1533-4406

DOI

10.1056/NEJMc2109725

Alternate Title

N Engl J Med

PMID

34437792

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