Edmonds, Victoria S

Introduction: Ureteral stones are a common cause of emergency presentations. Definitive stone removal at the index encounter can reduce delays and repeat interventions. It is unknown whether fellowship-trained endourologists are more likely to perform definitive management than general/other subspecialist urologists. This multicenter retrospective cohort study evaluated the influence of endourology subspecialty training on the choice between upfront definitive stone treatment and initial ureteral decompression at first presentation. Patients managed with medical expulsive therapy alone were not included. Methods: Adults (≥18 years) presenting at 2022 to seven North American academic centers with symptomatic, noninfected, computed tomography-confirmed ureteral stones were included. Patients with infection, sepsis, positive nitrites, or intraoperative pyelonephritis were excluded from the study. Variables included demographics, stone size and location, subspecialty of the on-call urologist, and management type (definitive [ureteroscopy or shockwave lithotripsy] vs deferred [(initial stent]). Multivariate logistic regression was used to identify the predictors of definitive treatment. Results: Among the 395 patients, 190 (48.0%) underwent definitive management and 205 (52.0%) underwent deferred treatment. Distal stones were treated definitively more often than proximal stones were (51.1% vs 36.6%). An endourologist was on call for 150 encounters (38.0%); 64.7% of these patients received definitive treatment, compared with 38.0% under general/other subspecialist urologists. On multivariate analysis, endourologist on-call remained independently associated with definitive management (odds ratio [OR] 3.46, 95% confidence interval [CI] 2.19–5.47, p < 0.0001), as did distal stone location (OR: 2.46, 95% CI: 1.21–5.00, p = 0.013). Severe complications are rare, and none of the patients developed sepsis. Conclusions: Endourologists were more than three times more likely to perform definitive interventions for symptomatic, noninfected ureteral stones at initial presentation. Subspecialty expertise and timely operative access enable safe, efficient, single-stage management.

Clinical History: A 60-year-old female was found to have a 2 cm Ureteropelvic junction (UPJ) stone in an ectopic right pelvic kidney while undergoing evaluation for gross hematuria. She had no prior stone history and normal renal function. Physical Exam: Physical exam was unremarkable. Computed tomography (CT) Urogram revealed a medial, pelvic kidney with overlying bowel and posterior, tortuous ureter. Renal vein ran longitudinally along the anterior surface of the kidney. Diagnosis: A 2 cm UPJ stone in an ectopic right pelvic kidney. Intervention: Given tortuosity of the ureter and overlying bowel precluded an endoscopic approach, we proceeded with robotic-assisted pyelolithotomy. 1 An open-ended ureteral catheter was advanced to allow for distension of the renal pelvis. After placing robotic trocars, peritoneum and Gerota’s fascia were dissected off the anterior surface of the kidney. Robotic Potts were used to enter the renal pelvis. No stone was visible, thus antegrade ureteroscopy was performed through a robotic port, demonstrating an impacted 2 cm lower pole stone. We performed antegrade ureteroscopy, laser lithotripsy, and basket-extraction. A robotic suction arm was employed to remove remaining dust. A double-J ureteral stent was placed antegrade, and pyelotomy was closed in a running fashion. Follow-Up/Outcomes: The patient had an uneventful postoperative course and CT at 6 weeks demonstrated no residual stone. Laparoscopic or robotic-assisted pyelolithotomy demonstrates higher stone free rates in pelvic kidneys compared with endoscopic treatment (97.2% vs 65.9%–84.9%). 2 However, surgical approach should be decided based on patients’ anatomy, stone density and location, and surgeon experience. Author Disclosure Statement: The authors have no conflicts of interest to disclose. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: Music was obtained from www.pixabay.com and is no copyright music, free for use. Exact Runtime of video: 5 min 00 sec.