INTRODUCTION:Our goal was to compare rates and risk factors for infection-related hospitalizations with and without ureteral access sheath (UAS) use during ureteroscopy (URS) for renal stones. METHODS:Using the Michigan Urological Surgery Improvement Collaborative clinical registry, we identified patients who underwent single-stage unilateral URS for renal stones. We assessed variation in UAS usage across practices and surgeons. We compared demographics of cases with and without UAS. Multivariable logistic regression was used to evaluate UAS use and clinical factors on 30-day infection-related hospitalization. RESULTS:Six thousand one hundred forty-two patients underwent URS by 233 urologists across 34 practices, and 152 (2.5%) had an infection-related hospitalization within 30 days. UAS was used in 59% of cases, with significant variation between practices (4.1%-99.5%, P < .001). Infection-related hospitalization was similar with (2.6%) and without (2.3%) UAS use (P = .5). On multivariable analysis, infection-related hospitalizations did not differ by UAS (odds ratio [OR] 0.8 [95% CI: 0.6-1.2]), but were associated with higher Charlson Comorbidity Index (CCI; CCI 1 vs 0, OR 1.9 [95% CI: 1.2-2.9]; CCI 2+ vs 0, OR 2.3 [95% CI: 1.4-3.6]), history of recurrent UTI (OR 2.4 [95% CI: 1.4-4.0]), larger stones (OR per 5 mm 1.1 [95% CI: 1.0-1.3]), and positive preoperative urinalysis and/or culture (OR 1.8 [95% CI: 1.2-2.7]). CONCLUSIONS:UAS use in URS for renal stones varies across Michigan and was not associated with lower infection-related hospitalization. Prospective studies on the implications of intrarenal pressure are needed.

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety III (PD62)1 May 2024PD62-09 REDUCING OPIOID UTILIZATION AFTER URETEROSCOPY IN A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE Russell Becker, Stephanie Daignault-Newton, Anthony Bonzagni, Golena Fernandez Moncaleano, Jerison Ross, Tudor Borza, Khurshid Ghani, Casey Dauw, and for the Michigan Urological Surgery Improvement Collaborative Russell BeckerRussell Becker , Stephanie Daignault-NewtonStephanie Daignault-Newton , Anthony BonzagniAnthony Bonzagni , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano , Jerison RossJerison Ross , Tudor BorzaTudor Borza , Khurshid GhaniKhurshid Ghani , Casey DauwCasey Dauw , and for the Michigan Urological Surgery Improvement Collaborative View All Author Informationhttps://doi.org/10.1097/01.JU.0001008656.89655.67.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Since its inception in 2016, the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) initiative has implemented multifaceted efforts to reduce postoperative opioid utilization after ureteroscopy, including patient education and standardized prescriber guidance for opioid-free multimodal pain management. Post-ureteroscopy opioid prescribing in Michigan fell dramatically from 2016-2021, yet it remains unknown whether this was the direct result of MUSIC ROCKS efforts, or larger national trends including increased public awareness of the opioid epidemic and regulatory changes which occurred over the same time period. METHODS: MUSIC ROCKS clinical registry data were used to tabulate post-ureteroscopy opioid urologist prescribing at time of ureteroscopy patterns from 2016-2021. These data were compared to Optum's Clinformatics Data Mart (CDM) administrative health claims for adult members and their dependents of large commercial and Medicare Advantage health plans. We identified patients who underwent ureteroscopy defined by CPT codes and calculated the proportion who had post-ureteroscopy opioid prescription fills within 14 days of surgery from their pharmacy claims defined by drug class and generic name. We report opioid fill rates within the state of Michigan and across the rest of the United States. The proportion of ureteroscopies with opioid prescriptions out of all ureteroscopies are reported by year for each cohort. RESULTS: The rate of postoperative opioid prescriptions after ureteroscopy in the MUSIC ROCKS collaborative declined sharply from 2016 to 2021 (86% to 20%) (Figure). This was also reflected in the CDM prescription fill claims for the state of Michigan (55% to 20%). By contrast, postoperative opioid fills across the remainder of the United States declined far more modestly over the same period (56% to 47%). CONCLUSIONS: Opioid prescribing after ureteroscopy in the state of Michigan declined sharply between 2016 and 2021. This decline occurred on a national scale over the same period but was far more modest in scale. This work demonstrates that dedicated efforts by large-scale quality improvement collaboratives such as MUSIC can drive meaningful changes in health care delivery. Download PPT Source of Funding: Blue Cross Blue Shield of Michigan © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e1289 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Russell Becker More articles by this author Stephanie Daignault-Newton More articles by this author Anthony Bonzagni More articles by this author Golena Fernandez Moncaleano More articles by this author Jerison Ross More articles by this author Tudor Borza More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

BackgroundUreteral stents are placed by urologists to ensure ureteral patency in the postoperative period following ureteroscopy to treat kidney stones, with the goal to reduce complications. However, ureteral stents themselves cause pain and urinary symptoms in many patients that can lead to morbidity. Professional society guidelines support stent omission after uncomplicated ureteroscopy, which represents most cases. Despite this, ureteral stents are utilized in more than 80% of all ureteroscopy procedures. One reason for guideline discordance is the low level of evidence supporting stent omission recommendations. Studies are inconclusive on whether stents increase pain and complications. A recent Cochrane review concluded higher quality and large trials are needed to inform decision-making. Furthermore, there is a lack of studies evaluating health-related quality of life (HRQOL), patient-reported outcomes (PROs), and unplanned healthcare utilization. Another factor is that prospective clinical trials are hindered by patient reluctance to be randomized to either stent placement or omission. The outcomes of patients who decline randomization have been ignored in trials, limiting the generalizability of the evidence.MethodsThrough collaboration with patient partners, we developed a pragmatic multi-center combined randomized and observational cohort study in a quality improvement collaborative. Patients will be prospectively enrolled into a randomized cohort in which assignment to ureteral stent omission (vs. placement) is determined in the operating room using a web-based randomization platform. Patients who decline randomization are invited to take part in an observational (real-world) cohort in which the determination of stent use is at the discretion of the urologist. Patients in both cohorts will complete preoperative and postoperative assessments of PROs including pain, urinary symptoms, interference with usual activities, time taken off work or school, and treatment satisfaction. Unplanned healthcare utilization within 30 days postoperatively will be assessed by review of the electronic health record. Severe adverse events will be recorded. A subgroup of patients and urologists will also participate in qualitative semi-structured interviews focusing on knowledge, preferences, and practice patterns regarding ureteral stenting. Interview transcripts will be thematically analyzed.DiscussionThis study is designed to evaluate the HRQOL and 30-day healthcare utilization of patients undergoing ureteral stent omission compared to stent placement following uncomplicated ureteroscopic treatment of upper urinary tract stones. Additionally, patient and urologist opinions and preferences related to ureteral stenting will be explored through qualitative interviews, with the aim of identifying key barriers and facilitators of practice change related to stenting practices.Trial registrationClinicalTrials.gov, NCT05866081. Registered on 19 May 2023.

You have accessJournal of UrologyBladder & Urothelial Upper Tract Oncology (V08)1 May 2024V08-09 MITOMYCIN-CONTAINING REVERSE THERMAGEL UGN-101 FOR UPPER TRACT UROTHELIAL CARCINOMA: RETROGRADE INSTILLATION IN CLINIC AND OUTCOMES Golena Fernandez Moncaleano, Nik B. Patel, Trudy Reicks, Russell E. N. Becker, Todd Morgan, Samuel Kaffenberger, Sapan Ambani, and Khurshid R. Ghani Golena Fernandez MoncaleanoGolena Fernandez Moncaleano , Nik B. PatelNik B. Patel , Trudy ReicksTrudy Reicks , Russell E. N. BeckerRussell E. N. Becker , Todd MorganTodd Morgan , Samuel KaffenbergerSamuel Kaffenberger , Sapan AmbaniSapan Ambani , and Khurshid R. GhaniKhurshid R. Ghani View All Author Informationhttps://doi.org/10.1097/01.JU.0001009440.59296.9f.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: UGN-101 was approved in 2020 for low-grade disease as adjuvant treatment provided as instillations into the kidney, for nephron preservation after endoscopic treatment. Treatment can be provided in the clinic using a retrograde approach, but the uptake is lower than antegrade instillation. There are concerns related to the risk of ureteral stenosis requiring stenting (49.3% - OLYMPUS trial). This video provides a step-by-step guide for UGN-101 retrograde instillation in clinic and informs on early outcomes from our center. METHODS: Following ureteroscopy and laser ablation, instillations with UGN-101 were performed in clinic under local anesthesia via flexible cystoscopy and a 7F custom designed ureteral catheter and injection gun. We reviewed (IRB approved) patients with low-grade disease undergoing UGN-101 between 01/2021-07/2023. Patients unable to tolerate a retrograde approach had antegrade instillation via nephrostomy. Induction of six-weekly instillation was provided followed by monthly maintenance if no adverse events and evidence of disease response. We assessed adverse events (AE) and cancer control outcomes. RESULTS: Steps for retrograde instillation include: 1) Flexible cystoscopy with guidewire access of ureter, 2) 7Fr ureteral catheter with molded Luer Lock port placement, 3) catheter visualization at the ureteropelvic junction through fluoroscopy, 4) Retrograde pyelogram to measure collecting system volume, 5) Withdrawal of UGN-101 into provided syringe, 6) Attachment to Uroject injection device 7) Syringe adaptor removal and connection to ureteral catheter 8) Slow injection with assessment of pain 9) Syringe and catheter removal.20 patients with a mean tumor burden of 1.67 cm (range 0.2-3.2), received at least one dose of UGN-101 of which 16 (80%) completed six instillations. 12 patients (60%) had a complete response (CR) after induction. 7 patients (35%) received at least one dose of monthly maintenance, of which 5 demonstrated durability of response. 6 patients (30%) had an AE related to the urinary system. Ureteral stents were placed in 5 patients for stenosis (25%); of which 4 were transient, with no subsequent obstruction. Only one patient (5%) required permanent stenting. CONCLUSIONS: UGN-101 instillation in clinic is easy to perform through a stepwise procedure. In this series, CR rates were similar to OLYMPUS trial. However, ureteral stenosis requiring stenting was lower than previously reported. Future research is needed to determine local factors contributing to these results at our center. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e559 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Golena Fernandez Moncaleano More articles by this author Nik B. Patel More articles by this author Trudy Reicks More articles by this author Russell E. N. Becker More articles by this author Todd Morgan More articles by this author Samuel Kaffenberger More articles by this author Sapan Ambani More articles by this author Khurshid R. Ghani More articles by this author Expand All Advertisement PDF downloadLoading ...

Introduction: Ureteral stents can cause significant patient discomfort, yet the temporal dynamics and impact on activities remain poorly characterized. We employed an automated tool to collect daily ecological momentary assessments (EMAs) regarding pain and the ability to work following ureteroscopy with stenting. Our aims were to assess feasibility and better characterize the postoperative patient experience. Materials and Methods: As an exploratory endpoint within an ongoing clinical trial, patients undergoing ureteroscopy with stenting were asked to complete daily EMAs for 10 days postoperatively or until the stent was removed. Questionnaires were distributed through text messages and included a pain scale (0-10) and a single item from the validated Patient-Reported Outcomes Measurement Information System Ability to Participate in Social Roles and Activities instrument, as well as days missed from work or school. Results: Among the first 65 trial participants, 59 completed at least 1 EMA (overall response rate 91%). Response rates were >85% for each time point through postoperative day (POD)10. Median respondent age was 58 years (interquartile range [IQR] 50-67), and 56% were female. Stones were 54% renal and 46% ureteral, with a median diameter of 9 mm (IQR 7-10). Median stent dwell time was 7 days (IQR 6-8). Pain scores were highest on POD1 (median score 4) and declined on each subsequent day, reaching a median score of 2 on POD5. Sixty-three percent of patients on POD1 reported that they had trouble performing their usual work at least sometimes, but by POD5, this was <50% of patients. Patients who work or attend school reported a median of 1 day missed (IQR 0-2). Conclusions: An automated daily EMA system for capturing patient-reported outcomes was demonstrated to be feasible with sustained excellent engagement. Patients with stents reported the worst pain and interference with work on POD1, with steady improvements thereafter, and by POD5, the majority of patients had minimal pain or trouble performing their usual work. This work is associated with a registered clinical trial [NCT05026710].

You have accessJournal of UrologyCME1 Apr 2023MP48-01 THE EFFECT OF OPIATES ON PATIENT REPORTED OUTCOMES AFTER URETEROSCOPY Andrew Higgins, Russell Becker, Stephanie Daignault-Newton, Golena Fernandez Moncaleano, John Ludlow, Hector Pimentel, Brian Seifman, David Wenzler, Bronson Conrado, Karla Witzke, and Khurshid Ghani Casey Dauw Andrew HigginsAndrew Higgins More articles by this author , Russell BeckerRussell Becker More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , John LudlowJohn Ludlow More articles by this author , Hector PimentelHector Pimentel More articles by this author , Brian SeifmanBrian Seifman More articles by this author , David WenzlerDavid Wenzler More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Karla WitzkeKarla Witzke More articles by this author , and Khurshid Ghani Casey DauwKhurshid Ghani Casey Dauw More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The outcomes of kidney stone surgery have long been focused on stone-free rates and safety, yet patient reported outcomes (PRO) are often lacking. In 2018 the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) group initiated a pain optimization pathway using an opioid-free multi-modal pain regimen. This has resulted in a decline in opioid prescription rates after ureteroscopy (86 to 19%). We used a comprehensive PRO system to understand the initiative’s impact on patients’ experiences of treatment pain and satisfaction. METHODS: MUSIC ROCKS instituted its patient-reported outcomes (PRO) program in 2020 which included an assessment of patient pain (PROMIS Pain Intensity short form and Pain Interference short form) and overall treatment satisfaction (ICIQ-S). This system is automated and distributes questionnaires preoperatively and at 7-10 days and 4-6 weeks following ureteroscopy (URS). We compared patients who were prescribed opiates after URS to those who were not. After adjusting for observed demographic differences (age, gender, pre-stent status, stone location/size, and preoperative pain), we evaluated PRO pain intensity and interference with linear mixed models. A clinically meaningful difference in PROMIS scores is 2.5-3.5 points. Treatment satisfaction scores were compared with Wilcoxon rank tests. RESULTS: A total of 292 patients completed all questionnaires (258 non-opioid and 34 opioid). There was no significant difference between non-opioid and opioid cohorts with regards to age (60 vs 59 years), gender (50 vs 53% male), pre-stenting status (76 vs 65%), stone location (64 vs 59% ureteral), and stone size (8.0 vs 7.2 mm). After adjustment, there was no significant difference in preoperative pain intensity scores between the groups at pre-URS (p=0.06), 7-10 days postop (p=0.87), and 4-6 weeks postop (p=0.99, Figure). Pain interference followed a similar pattern, with no significant differences observed at any timepoint. There was no difference in satisfaction scores, as measured both 7-10 days (p=0.46) and 4-6 weeks (p=0.47) after URS. CONCLUSIONS: Rates of opiate prescription have declined after URS in Michigan. Using a novel PRO system, we confirmed that utilization of opioid-free pathways has not resulted in increased pain nor decreased patient satisfaction. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e654 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Higgins More articles by this author Russell Becker More articles by this author Stephanie Daignault-Newton More articles by this author Golena Fernandez Moncaleano More articles by this author John Ludlow More articles by this author Hector Pimentel More articles by this author Brian Seifman More articles by this author David Wenzler More articles by this author Bronson Conrado More articles by this author Karla Witzke More articles by this author Khurshid Ghani Casey Dauw More articles by this author Expand All Advertisement PDF downloadLoading ...

In North America, ureteroscopy has become the most popular treatment modality for upper urinary tract urinary calculi. Herein we describe our technique for the treatment of renal stones with flexible ureteroscopy and high-power holmium laser lithotripsy. We discuss preoperative planning, intraoperative strategies, and laser settings for a high-frequency dusting technique with the goal to provide optimal patient outcomes.

Purpose: The ROCKS (Reducing Operative Complications from Kidney Stones) program in MUSIC (Michigan Urological Surgery Improvement Collaborative) was created to optimize ureteroscopy outcomes. Through data collection, distribution of reports, patient education, and standardization of medication, post-ureteroscopy emergency department visits in Michigan have declined. It is unclear whether this is because of statewide quality efforts or due to national trends. We therefore sought to understand emergency department visit rates in Michigan compared to a national data set. Materials and Methods: We compared the MUSIC ROCKS clinical registry in Michigan against a national cohort, Optum's de-identified Clinformatics Data Mart, from 2016-2021 (excluding Michigan). We identified patients who underwent ureteroscopy and the proportion who had a postoperative emergency department visit within 30 days. Emergency department rates were modeled over time, adjusting for age, gender, comorbidity, and ureteral stenting. Results: We identified 24,688 patients in MUSIC ROCKS and 99,340 in the Clinformatics Data Mart database who underwent ureteroscopy. The risk-adjusted emergency department visit rate in MUSIC ROCKS significantly declined over the study period (10.5% in 2016 to 6.9% in 2021, P < 0.001) while the mean emergency department visit rate in the Clinformatics Data Mart cohort was 9.9% and did not change over time (9.6% in 2016 to 10% in 2021). Comparing emergency department visits between the cohorts, the MUSIC ROCKS rate significantly declined relative to the Clinformatics Data Mart (P < 0.001) over the study period. Conclusions: Postoperative emergency department visit rates in Michigan have declined significantly after ureteroscopy since the establishment of MUSIC ROCKS. This decline outpaced national rates, providing evidence that systematic quality initiatives can improve urological care.

You have accessJournal of UrologyCME1 Apr 2023MP19-01 STONE LOCATION AND STENTING INFLUENCE PATIENT-REPORTED PAIN AND QUALITY OF LIFE AFTER URETEROSCOPY Russell E. N. Becker, Stephanie Daignault-Newton, Andrew M. Higgins, Mahin Mirza, Bronson Conrado, Golena Fernandez Moncaleano, Mahmoud Hijazi, Karla Witzke, Jeremy Konheim, Richard Sarle, Kandis Rivers, William W. Roberts, Khurshid R. Ghani, Casey A. Dauw, and for the Michigan Urological Surgery Improvement Collaborative Russell E. N. BeckerRussell E. N. Becker More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Andrew M. HigginsAndrew M. Higgins More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Mahmoud HijaziMahmoud Hijazi More articles by this author , Karla WitzkeKarla Witzke More articles by this author , Jeremy KonheimJeremy Konheim More articles by this author , Richard SarleRichard Sarle More articles by this author , Kandis RiversKandis Rivers More articles by this author , William W. RobertsWilliam W. Roberts More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Studies of ureteroscopy outcomes have historically centered on efficacy (stone-free rates) and safety (complications). However, the patient’s own subjective experience, including pain and health-related quality of life (HRQOL), are gaining recognition as additional important factors. Empirical data on these are severely lacking. We have previously reported that ureteral stent placement after ureteroscopy increases unplanned healthcare encounters. However, less is known about the impact of stent placement on HRQOL. METHODS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) group launched a patient-reported outcomes (PRO) program in 2021 which includes assessments of pain (PROMIS Pain Intensity and Pain Interference), lower urinary tract symptoms (LURN), and treatment satisfaction (ICIQ). This automated system distributes electronic questionnaires preoperatively and at 7-10 days and 4-6 weeks postoperatively. We compared postoperative day 7-10 (POD7) PROs for stented versus not stented patients based on stone location (renal versus ureteral) with linear regression models adjusting for preoperative score, age, gender, pre-stenting, and stone size. RESULTS: Clinical and PRO data were collected on 338 patients (64% ureteral, 36% renal stones). Overall 251 (74.3%) had a stent placed at the time of surgery. Stented patients had larger stones in both the ureteral (8 vs 6mm, p<0.001) and renal (10 vs 7mm, p<0.001) subgroups. Stent omission in patients with ureteral stones resulted in improved PROMIS Pain Interference (52.7 vs 57.4, p<0.01), PROMIS Pain Intensity (48.9 vs 53.6, p<0.01), LURN urinary symptoms (6.3 vs 10.3, p<0.001), and ICIQ treatment satisfaction (21.1 vs 18.5, p<0.01) at POD7 (Figure 1). For patients with renal stones, stent omission resulted in improved PROMIS Pain Interference (55.8 vs 61.1, p=0.02) and LURN urinary symptoms (6.9 vs 10.7, p<0.001), without significant differences in PROMIS Pain Intensity (52.9 vs 56.6, p=0.1) or ICIQ treatment satisfaction (20.0 vs 17.6, p=0.07). CONCLUSIONS: Stent omission at the time of ureteroscopy was associated with significantly better PROs at POD7 for patients with both ureteral and renal stones. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e264 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Russell E. N. Becker More articles by this author Stephanie Daignault-Newton More articles by this author Andrew M. Higgins More articles by this author Mahin Mirza More articles by this author Bronson Conrado More articles by this author Golena Fernandez Moncaleano More articles by this author Mahmoud Hijazi More articles by this author Karla Witzke More articles by this author Jeremy Konheim More articles by this author Richard Sarle More articles by this author Kandis Rivers More articles by this author William W. Roberts More articles by this author Khurshid R. Ghani More articles by this author Casey A. Dauw More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Introduction: We sought to examine the practice patterns of pain management in the emergency room (ER) for renal colic and the impact of opioid prescriptions on return ER visits and persistent opioid use.Methods: TriNetX is a collaborative research enterprise that collects real-time data from multiple health care organizations within the United States. The Research Network obtains data from electronic medical records and the Diamond Network provides claims data. We queried the Research Network for adults who visited the ER for urolithiasis, stratified by receipt of oral opioid prescriptions, to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use & GE;6 months from the initial visit. Propensity score matching was performed to control for confounders. The analysis was repeated in the Diamond Network as a validation cohort.Results: There were 255,447 patients in the research network who visited the ER for urolithiasis, of whom 75,405 (29.5%) were prescribed oral opioids. Black patients were less likely to receive opioid prescriptions than other races (p < 0.001). After propensity score matching, patients who were prescribed opioids had an increased risk of a return ER visit (RR 1.25, confidence interval [95% CI] 1.22-1.29, p < 0.001) and persistent opioid use (RR 1.12, 95% CI 1.11-1.14, p < 0.001) compared with patients who were not prescribed opioids. These findings were confirmed in the validation cohort.Conclusions: A significant proportion of patients presenting to the ER for urolithiasis receive opioid prescriptions, which carries a markedly increased risk of return ER visits and long-term opioid use.

You have accessJournal of UrologyCME1 Apr 2023PD28-08 URETEROSCOPY DUSTING VERSUS FRAGMENTATION/BASKETING FOR TREATING RENAL STONES: REAL WORLD UTILIZATION AND OUTCOMES Alex Zhu, Russell E.N. Becker, Andrew M. Higgins, Monica S. Van Til, Stephanie Daignault-Newton, Sung Yong Cho, Richard C. Sarle, Eric R. Stockall, Rabia Martin, Bronson Conrado, Golena Fernandez Moncaleano, Casey A. Dauw, Khurshid R. Ghani, and FOR the Michigan Urological Surgery Improvement Collaborative Alex ZhuAlex Zhu More articles by this author , Russell E.N. BeckerRussell E.N. Becker More articles by this author , Andrew M. HigginsAndrew M. Higgins More articles by this author , Monica S. Van TilMonica S. Van Til More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Sung Yong ChoSung Yong Cho More articles by this author , Richard C. SarleRichard C. Sarle More articles by this author , Eric R. StockallEric R. Stockall More articles by this author , Rabia MartinRabia Martin More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and FOR the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003313.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Dusting technique for ureteroscopy (URS) laser lithotripsy has become popular, but there remains a knowledge gap about how often it is performed compared to fragmentation with basketing. Prior studies of dusting vs. fragmentation/basketing are from expert single centers and may not reflect real-world practice. We assessed practice patterns and outcomes of the two techniques in Michigan. METHODS: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry, we identified all single-stage cases of URS laser lithotripsy performed for renal stones between 2016-2022. Data was collected by independent abstractors at each practice using standardized definitions. Stone-free rate (SFR) was defined as zero fragments on imaging reports (ultrasound, x-ray, CT scan) within 60 days. We assessed practice and urologist-level utilization of dusting vs. fragmentation/basketing. We compared characteristics of patients. Using multivariable regression we assessed the association of each technique with 30-day postoperative emergency department (ED) visits accounting for patient, stone, and surgical characteristics. RESULTS: Among 4,772 ureteroscopy procedures for renal stones performed by 230 surgeons across 34 practices, 2,838 (59%) were performed with a dusting technique. Significant variation in use of dusting was observed across practices (3-99%, p<0.001) and urologists (0-100%, p<0.001) (Figure 1). Utilization was greatest in larger practices. Dusting was used more frequently for larger stones (median [IQR]: 9mm [7-13] vs 8mm [6-11], p<0.001) and stones in multiple locations (30% vs. 20%, p<0.001). Ureteral access sheaths (55% vs 72%, p<0.001) and post-operative stents (79% vs 86%, p<0.001) were used less frequently with dusting. Post-operative imaging was performed in 48% of patients; SFR was lower with dusting (41% vs 57%, p<0.001). Dusting was associated with higher ED visits on multivariable analysis (OR 1.4, 95% CI 1.1-1.8, p=0.006). CONCLUSIONS: Six of ten patients with renal stones undergoing URS are treated with a dusting technique in Michigan. Our data suggests dusting is more frequently used in larger practices which could be related to access of high-power lasers. Real-world practice indicates dusting is associated with more post-operative ED visits. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e821 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alex Zhu More articles by this author Russell E.N. Becker More articles by this author Andrew M. Higgins More articles by this author Monica S. Van Til More articles by this author Stephanie Daignault-Newton More articles by this author Sung Yong Cho More articles by this author Richard C. Sarle More articles by this author Eric R. Stockall More articles by this author Rabia Martin More articles by this author Bronson Conrado More articles by this author Golena Fernandez Moncaleano More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author FOR the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 Apr 2023MP06-03 EXTERNAL VALIDATION OF DECREASED ED VISITS AFTER URETEROSCOPY DUE TO QUALITY IMPROVEMENT INITIATIVES OF A STATEWIDE COLLABORATIVE Andrew Higgins, Stephanie Daignault-Newton, Russell Becker, Golena Fernandez Moncaleano, Bronson Conrado, John Hollingsworth, Khurshid Ghani, and Casey Dauw Andrew HigginsAndrew Higgins More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Russell BeckerRussell Becker More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Bronson ConradoBronson Conrado More articles by this author , John HollingsworthJohn Hollingsworth More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , and Casey DauwCasey Dauw More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Michigan Urological Surgery Improvement Collaborative Reducing Operative Complications from Kidney Stones (ROCKS) was created to optimize outcomes after ureteroscopy (URS). Through outcomes data collection, distribution of performance reports, patient educational efforts, and standardization of an opioid-free postoperative pain regimen, emergency department (ED) visits in Michigan have declined. It is unclear, whether this trend is unique to Michigan and thus a reflection of these quality efforts or is similar to national data. We thus sought to understand ED visit rates in Michigan compared to a large national dataset. METHODS: We used data from two sources for this study to understand 30-day ED visits after URS. In Michigan, the ROCKS database, a prospectively maintained registry including more than 90% of participating urologic practices in the state was utilized, capturing patients from 2016-2021. To serve as comparison, we used Optum claims data from 2011 to 2021 (excluding Michigan), which includes commercially insured adults and dependents. We identified patients who underwent URS defined by CPT codes and calculated the proportion who had an ED visit within 30 days of URS. Cohort age and gender were compared with rank and chi-square tests, respectively. ED rates were modeled (logistic) adjusting for age and gender to compare cohorts over time. RESULTS: Overall, we identified 24,163 patients in ROCKS who underwent URS and 162,642 patients in Optum. Significant differences were seen with regards to gender (51% vs 44% female, p<0.01) and median age (58 vs 62 years, p<0.01) between ROCKS and Optum cohorts. The mean ED rate in ROCKS was 7.9% (range 6.3 to 10.5%) with a significant decline over time (p<0.01, Figure 1). The ED rate in Optum was 9.9% (range 9.1 to 10.5%) with an increase over time (p<0.01). Comparing ED visits between the two cohorts after adjusting for observed demographic differences, the ROCKS ED visit rate declined significantly relative to national Optum rates (p<0.01). CONCLUSIONS: ED visit rates in Michigan have declined significantly after URS since establishment of the ROCKS initiative. This decline outpaces national ED rates, which have gradually increased over the past 10 years. This lends credence to systematic quality initiatives seeking to improve urologic care. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e53 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Higgins More articles by this author Stephanie Daignault-Newton More articles by this author Russell Becker More articles by this author Golena Fernandez Moncaleano More articles by this author Bronson Conrado More articles by this author John Hollingsworth More articles by this author Khurshid Ghani More articles by this author Casey Dauw More articles by this author Expand All Advertisement PDF downloadLoading ...

EDITORIAL article Front. Surg., 24 October 2022Sec. Genitourinary Surgery Volume 9 - 2022 | https://doi.org/10.3389/fsurg.2022.1050285

You have accessJournal of UrologyCME1 May 2022PD12-07 ADDITION OF ANTI-PD-L1 ENHANCES ANTITUMOR EFFICACIES OF BCG AND BCG-STING BY CD8+ T CELL EXPANSION IN A MURINE SYNGENEIC MB49 MODEL OF UROTHELIAL CARCINOMA Kara Lombardo, Monali Praharaj, Russell Becker, Kelly Harris, William Bishai, Andres Matoso, Trinity Bivalacqua, and Alok Singh Kara LombardoKara Lombardo More articles by this author , Monali PraharajMonali Praharaj More articles by this author , Russell BeckerRussell Becker More articles by this author , Kelly HarrisKelly Harris More articles by this author , William BishaiWilliam Bishai More articles by this author , Andres MatosoAndres Matoso More articles by this author , Trinity BivalacquaTrinity Bivalacqua More articles by this author , and Alok SinghAlok Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002538.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: BCG induces PD-L1 in bladder carcinoma cells which decreases antitumor T cell responses in the tumor microenvironment (TME). In the present study aimed to compare efficacy of a PD-L1 checkpoint inhibitor combined with both wild-type BCG (BCG-WT) and our previously reported recombinant BCG overexpressing STING agonist, c-di-AMP (BCG-STING) in a murine MB49 flank model of urothelial carcinoma. METHODS: Syngeneic mouse MB49 flank tumors in C57BL/6J female mice were randomized into treatment groups: 1. Isotype (250 mg/animal 4x every 3rd day), 2. intratumorally (IT) treated BCG-WT (Tice, 5x106 CFU, 4x every 3rd day), 3. IT treated BCG-STING (Tice, 5x106 CFU, 4x every 3rd day), 4. Intraperitoneally (IP) treated with anti-PD-L1 Ab (250 mg/animal, 4x every 3rd day), 5. combination therapy of IT WT-BCG plus IP andi-PD-L1 or 6. combination of IT BCG-STING and IP anti-PD-L1. Endpoint measurement included tumor volume, histopathological analyses for percent necrosis and flow cytometry analyses of tumor infiltrating lymphocytes. Bulk RNA sequencing on MB49 tumor cells following IT administration of WT-BCG and BCG-STING was performed. Data analysis was performed in R studio, FlowJo and Graphpad with ANOVA tests for significance. RESULTS: Addition of anti-PDL1 improved antitumor efficacies of both BCG-WT and BCG-STING, but anti-PD-L1 alone was less effective than either BCG strains alone. BCG-STING plus anti-PD-L1 combination showed greatest antitumor response with lowest tumor volume and highest percentage of necrosis (P <0.0001). BCG-STING caused increased recruitment of infiltrating CD4+ and CD8+ T cells in MB49 tumors . However, anti-PD-L1 alone or in combination with BCG-WT or BCG-STING caused significantly higher recruitment of effector (IFN-g+ or IFN-g+PD-1+) CD8+ T cells over BCG-WT or BCG-STING. Bulk RNAseq unveiled significant reprogramming of TME as BCG-STING induced a stronger upregulation of hallmark gene sets from antitumor type I IFN (IFN-a), type II INF (IFN-g) and TNF-a pathways over BCG-WT. CONCLUSIONS: Therapeutic combination of anti-PD-L1 improves antitumor efficacies of BCG-WT or BCG-STING by inducing stronger recruitment of effector CD8+ T cells at tumor sites, while BCG-STING alone more strongly activates antitumor inflammatory pathways than BCG-WT. These findings highlight the importance of detailed investigations of BCG-resistant mechanisms in preclinical models to address suboptimal efficacies of BCG and develop improved or novel therapies for urothelial carcinoma. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e197 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kara Lombardo More articles by this author Monali Praharaj More articles by this author Russell Becker More articles by this author Kelly Harris More articles by this author William Bishai More articles by this author Andres Matoso More articles by this author Trinity Bivalacqua More articles by this author Alok Singh More articles by this author Expand All Advertisement PDF DownloadLoading ...

Background: Standard of care for patients with muscle-invasive bladder cancer (MIBC) includes neoadjuvant cisplatin-based chemotherapy (NAC) followed by consolidative therapy with either chemoradiation or radical cystectomy (RC). Some patients experience robust pathologic responses to NAC, and these have been reported to associate with somatic mutations in specific gene pathways including DNA damage response genes. Objective: To evaluate the ability of post-NAC clinical restaging, with or without tumor sequencing, to predict final RC pathologic staging. Design, setting, and participants: We reviewed our institutional review board-approved institutional database to identify patients with MIBC who underwent NAC followed by RC from 2003 to 2016. Following NAC prior to RC, cystoscopy was performed routinely, with resection of residual visible tumor and/or tumor base (transurethral resection [TUR]). For patients with pre-NAC tumor tissue available, tumor sequencing was performed. Outcome measurements and statistical analysis: Clinical restaging and tumor sequencing were evaluated for their ability to predict the final pathologic stage accurately at RC using chi-square or Fisher's exact test. Results and limitations: A total of 114 patients underwent restaging TUR following NAC and prior to RC. The diagnostic accuracy of post-NAC clinical restaging including TUR was poor, with 32% of patients being downstaged falsely when compared with their final RC pathology. Forty-nine patients had sequencing of pre-NAC tumor tissue, of whom 32 showed at least one mutation of interest. However, NAC responses and rates of false downstaging did not differ significantly according to tumor mutation status. Conclusions: This study highlights the inaccuracy of post-NAC clinical restaging TUR with or without adjunctive tumor mutation analysis, to assess pathologic residual disease accurately. Caution must be taken when performing post-NAC restaging, especially when considering conservative management strategies such as active surveillance on this basis. Patient summary: Several groups are evaluating whether certain patients, whose bladder cancer responds well to upfront chemotherapy, may be able to forego cystectomy safely. We demonstrate that currently available staging tools and tumor DNA sequencing cannot identify such patients reliably and accurately. (C) 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.