Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 1 of 16
1
Contemporary practice patterns in the management of acute obstructing ureteral stones Sri Sivalingam, Ian M Stormont, Stephen Y Nakada.
Department of Urology, University of Wisconsin Hospitals and Clinics, Madison, WI
Corresponding author: Sri Sivalingam, MD Glickman Urological Institute Cleveland Clinic Email: [email protected] Key Words: Ureteral calculi; renal colic; ureteroscopy; SWL; percutaneous; stent Word Count Abstract: 248 Text: 1486
Page 1 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 2 of 16
2 ABSTRACT:
OBJECTIVES: To elucidate current practice patterns amongst endourological society members for acutely obstructing ureteral stones requiring intervention.
METHODS: A practice pattern survey was sent to members of the endourological society using Survey Monkey. The following question stem was given: “Patient presents to the Emergency Room (ER) with acute renal colic and intractable pain, no signs of infection and no pyuria. Stone is obstructing, and causing intractable pain; thus observation or Medical Expulsive Therarpy (MET) is not appropriate”. A follow-up stem was provided for specific scenarios: “Calculus measuring x mm at x location. What is your preferred management option?” The options given for immediate management included Shock Wave Lithotripsy (SWL), Ureteroscopy (URS), stent placement or percutaneous management.
RESULTS: Four hundred sixteen complete responses of approximately 2000 were received. There was a significant difference in management choice based on stone location (P 20mm and in distal calculi (FIGS 2 & 3). In all scenarios except large proximal stones however, URS remained the preferred choice. It was interesting to note that most respondents offered immediate surgical management rather than stent placement in the acute setting. Despite the perceived theoretical advantage to stent placement and deferred surgery, our survey indicates that most urologists attempt immediate URS to treat the offending stone. This is perhaps a reflection of improved endoscopic equipment which facilitates URS in an acute setting. Additionally, there is recent evidence supporting immediate URS in an emergency setting to be safe and efficacious compared to delayed treatment
9,10 11
. Regarding stent placement, the impact of
pre-operative stenting has shown equivocal results, with some studies showing no clear advantage 12, while others show a significant benefit 13 14. A limitation of this study is the relatively low response rate of 21% (416 participants); we suspect that many of the listed emails within the endourological society’s directory are duplicate and potentially outdated.
Nonetheless, among
the 416 respondents, significant noteworthy trends were observed. This assessment of the emergency management of ureteral calculi when intervention is needed is encouraging, given that the management choices of respondents are consistent with the evidence based recommendations of the current ureteral stone guidelines.
Page 9 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 10 of 16
10
CONCLUSION Our survey indicates strong concordance with the ureteral stone guidelines in the practices of Endourology society members.
Our survey
suggests that endourologists may prefer immediate over delayed treatment for acutely obstructed ureteral stones.
Further studies are needed to assess
outcomes and complications of each approach.
Page 10 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 11 of 16
11 REFERENCES 1.
2.
3. 4. 5.
6.
7. 8. 9.
10.
11.
12.
13.
14.
Stamatelou KK, Francis ME, Jones CA, Nyberg LM, Curhan GC. Time trends in reported prevalence of kidney stones in the United States: 19761994. Kidney Int. 2003;63(5):1817-1823. Skolarikos A, Laguna MP, Alivizatos G, Kural AR, de la Rosette JJ. The role for active monitoring in urinary stones: a systematic review. J Endourol. 2010;24(6):923-930. Brown J. Diagnostic and treatment patterns for renal colic in US emergency departments. Int Urol Nephrol. 2006;38(1):87-92. Pearle MS, Calhoun EA, Curhan GC, Project UDoA. Urologic diseases in America project: urolithiasis. J Urol. 2005;173(3):848-857. Saigal CS, Joyce G, Timilsina AR, Project UDiA. Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management? Kidney Int. 2005;68(4):1808-1814. Sivalingam S, Tamm-Daniels I, Nakada SY. Office-based ureteral stent placement under local anesthesia for obstructing stones is safe and efficacious. Urology. 2013;81(3):498-502. Scales CD, Krupski TL, Curtis LH, et al. Practice variation in the surgical management of urinary lithiasis. J Urol. 2011;186(1):146-150. Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. J Urol. 2007;178(6):2418-2434. Guercio S, Ambu A, Mangione F, Mari M, Vacca F, Bellina M. Randomized prospective trial comparing immediate versus delayed ureteroscopy for patients with ureteral calculi and normal renal function who present to the emergency department. J Endourol. 2011;25(7):11371141. Al-Ghazo MA, Ghalayini IF, Al-Azab RS, et al. Emergency ureteroscopic lithotripsy in acute renal colic caused by ureteral calculi: a retrospective study. Urol Res. 2011;39(6):497-501. Sarica K, Tanriverdi O, Aydin M, Koyuncu H, Miroglu C. Emergency ureteroscopic removal of ureteral calculi after first colic attack: is there any advantage? Urology. 2011;78(3):516-520. Shields JM, Bird VG, Graves R, Gómez-Marín O. Impact of preoperative ureteral stenting on outcome of ureteroscopic treatment for urinary lithiasis. J Urol. 2009;182(6):2768-2774. Netsch C, Knipper S, Bach T, Herrmann TR, Gross AJ. Impact of preoperative ureteral stenting on stone-free rates of ureteroscopy for nephroureterolithiasis: a matched-paired analysis of 286 patients. Urology. 2012;80(6):1214-1219. Chu L, Sternberg KM, Averch TD. Preoperative stenting decreases operative time and reoperative rates of ureteroscopy. J Endourol. 2011;25(5):751-754.
Page 11 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 12 of 16
12
Abbreviations:
URS – Ureteroscopy
SWL – Shock wave lithotripsy
ER – Emergency Room
MET – Medical Expulsive Therapy
NT – Nephrostomy Tube
SFR – Stone Free Rate
Page 12 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 13 of 16
13
Figure 1 – Preferred management choice catagorized by stone size and location
Page 13 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 14 of 16
14
Figure 2 – Treatment preference categorized by stone size
Page 14 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 15 of 16
15
Figure 3 – Treatment Preference categorized by stone location
Page 15 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 16 of 16
16 Table 1 – Treatment preferences among members of the Endourological society for acutely obstructing ureteral calculi, grouped by stone size and location.
Proximal
Mid
Distal
Stone size
URS
SWL
STENT
NT
5
42.8%
40.9%
16.1%
0
10
40.6%
38.9%
16.8%
3.6%
15
42.3%
19.7%
20.2%
17.8%
20
25.2%
10.8%
20%
44%
ALL
37.7%
27.6%
18.3%
16.4%
5
69.0%
18.5%
12.3%
0
10
70.2%
15.4%
13.5%
1.0%
15
69.5%
9.9%
18.3%
2.4%
20
63.7%
6%
21.6%
8.7%
ALL
68.1%
12.5%
16.4%
3.1%
5
82%
11.1%
7.0%
0
10
85.8%
6.3%
7.7%
0.2%
15
83.2%
2.9%
13.2%
0.7%
20
80%
2.9%
15.6%
1.4%
ALL
82.8%
5.8%
10.9%
0.6%
Page 16 of 16
Page 1 of 16
1
Contemporary practice patterns in the management of acute obstructing ureteral stones Sri Sivalingam, Ian M Stormont, Stephen Y Nakada.
Department of Urology, University of Wisconsin Hospitals and Clinics, Madison, WI
Corresponding author: Sri Sivalingam, MD Glickman Urological Institute Cleveland Clinic Email: [email protected] Key Words: Ureteral calculi; renal colic; ureteroscopy; SWL; percutaneous; stent Word Count Abstract: 248 Text: 1486
Page 1 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 2 of 16
2 ABSTRACT:
OBJECTIVES: To elucidate current practice patterns amongst endourological society members for acutely obstructing ureteral stones requiring intervention.
METHODS: A practice pattern survey was sent to members of the endourological society using Survey Monkey. The following question stem was given: “Patient presents to the Emergency Room (ER) with acute renal colic and intractable pain, no signs of infection and no pyuria. Stone is obstructing, and causing intractable pain; thus observation or Medical Expulsive Therarpy (MET) is not appropriate”. A follow-up stem was provided for specific scenarios: “Calculus measuring x mm at x location. What is your preferred management option?” The options given for immediate management included Shock Wave Lithotripsy (SWL), Ureteroscopy (URS), stent placement or percutaneous management.
RESULTS: Four hundred sixteen complete responses of approximately 2000 were received. There was a significant difference in management choice based on stone location (P 20mm and in distal calculi (FIGS 2 & 3). In all scenarios except large proximal stones however, URS remained the preferred choice. It was interesting to note that most respondents offered immediate surgical management rather than stent placement in the acute setting. Despite the perceived theoretical advantage to stent placement and deferred surgery, our survey indicates that most urologists attempt immediate URS to treat the offending stone. This is perhaps a reflection of improved endoscopic equipment which facilitates URS in an acute setting. Additionally, there is recent evidence supporting immediate URS in an emergency setting to be safe and efficacious compared to delayed treatment
9,10 11
. Regarding stent placement, the impact of
pre-operative stenting has shown equivocal results, with some studies showing no clear advantage 12, while others show a significant benefit 13 14. A limitation of this study is the relatively low response rate of 21% (416 participants); we suspect that many of the listed emails within the endourological society’s directory are duplicate and potentially outdated.
Nonetheless, among
the 416 respondents, significant noteworthy trends were observed. This assessment of the emergency management of ureteral calculi when intervention is needed is encouraging, given that the management choices of respondents are consistent with the evidence based recommendations of the current ureteral stone guidelines.
Page 9 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 10 of 16
10
CONCLUSION Our survey indicates strong concordance with the ureteral stone guidelines in the practices of Endourology society members.
Our survey
suggests that endourologists may prefer immediate over delayed treatment for acutely obstructed ureteral stones.
Further studies are needed to assess
outcomes and complications of each approach.
Page 10 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 11 of 16
11 REFERENCES 1.
2.
3. 4. 5.
6.
7. 8. 9.
10.
11.
12.
13.
14.
Stamatelou KK, Francis ME, Jones CA, Nyberg LM, Curhan GC. Time trends in reported prevalence of kidney stones in the United States: 19761994. Kidney Int. 2003;63(5):1817-1823. Skolarikos A, Laguna MP, Alivizatos G, Kural AR, de la Rosette JJ. The role for active monitoring in urinary stones: a systematic review. J Endourol. 2010;24(6):923-930. Brown J. Diagnostic and treatment patterns for renal colic in US emergency departments. Int Urol Nephrol. 2006;38(1):87-92. Pearle MS, Calhoun EA, Curhan GC, Project UDoA. Urologic diseases in America project: urolithiasis. J Urol. 2005;173(3):848-857. Saigal CS, Joyce G, Timilsina AR, Project UDiA. Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management? Kidney Int. 2005;68(4):1808-1814. Sivalingam S, Tamm-Daniels I, Nakada SY. Office-based ureteral stent placement under local anesthesia for obstructing stones is safe and efficacious. Urology. 2013;81(3):498-502. Scales CD, Krupski TL, Curtis LH, et al. Practice variation in the surgical management of urinary lithiasis. J Urol. 2011;186(1):146-150. Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. J Urol. 2007;178(6):2418-2434. Guercio S, Ambu A, Mangione F, Mari M, Vacca F, Bellina M. Randomized prospective trial comparing immediate versus delayed ureteroscopy for patients with ureteral calculi and normal renal function who present to the emergency department. J Endourol. 2011;25(7):11371141. Al-Ghazo MA, Ghalayini IF, Al-Azab RS, et al. Emergency ureteroscopic lithotripsy in acute renal colic caused by ureteral calculi: a retrospective study. Urol Res. 2011;39(6):497-501. Sarica K, Tanriverdi O, Aydin M, Koyuncu H, Miroglu C. Emergency ureteroscopic removal of ureteral calculi after first colic attack: is there any advantage? Urology. 2011;78(3):516-520. Shields JM, Bird VG, Graves R, Gómez-Marín O. Impact of preoperative ureteral stenting on outcome of ureteroscopic treatment for urinary lithiasis. J Urol. 2009;182(6):2768-2774. Netsch C, Knipper S, Bach T, Herrmann TR, Gross AJ. Impact of preoperative ureteral stenting on stone-free rates of ureteroscopy for nephroureterolithiasis: a matched-paired analysis of 286 patients. Urology. 2012;80(6):1214-1219. Chu L, Sternberg KM, Averch TD. Preoperative stenting decreases operative time and reoperative rates of ureteroscopy. J Endourol. 2011;25(5):751-754.
Page 11 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 12 of 16
12
Abbreviations:
URS – Ureteroscopy
SWL – Shock wave lithotripsy
ER – Emergency Room
MET – Medical Expulsive Therapy
NT – Nephrostomy Tube
SFR – Stone Free Rate
Page 12 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 13 of 16
13
Figure 1 – Preferred management choice catagorized by stone size and location
Page 13 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 14 of 16
14
Figure 2 – Treatment preference categorized by stone size
Page 14 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. Page 15 of 16
15
Figure 3 – Treatment Preference categorized by stone location
Page 15 of 16
Journal of Endourology Contemporary practice patterns in the management of acute obstructing ureteral stones (doi: 10.1089/end.2014.0681) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Page 16 of 16
16 Table 1 – Treatment preferences among members of the Endourological society for acutely obstructing ureteral calculi, grouped by stone size and location.
Proximal
Mid
Distal
Stone size
URS
SWL
STENT
NT
5
42.8%
40.9%
16.1%
0
10
40.6%
38.9%
16.8%
3.6%
15
42.3%
19.7%
20.2%
17.8%
20
25.2%
10.8%
20%
44%
ALL
37.7%
27.6%
18.3%
16.4%
5
69.0%
18.5%
12.3%
0
10
70.2%
15.4%
13.5%
1.0%
15
69.5%
9.9%
18.3%
2.4%
20
63.7%
6%
21.6%
8.7%
ALL
68.1%
12.5%
16.4%
3.1%
5
82%
11.1%
7.0%
0
10
85.8%
6.3%
7.7%
0.2%
15
83.2%
2.9%
13.2%
0.7%
20
80%
2.9%
15.6%
1.4%
ALL
82.8%
5.8%
10.9%
0.6%
Page 16 of 16
