Purpose: Nephrolithiasis affects approximately 10% of North Americans, placing a significant burden on health care systems. This study evaluates the effectiveness of a novel, virtual Small Acute Ureteral Stone (SAUS) protocol for managing ureteral stones ≤5 mm, aiming to optimize resource utilization and patient care. Materials and Methods: A retrospective review was conducted on 209 consecutive patients enrolled in the SAUS protocol from June 2018 to May 2019. The protocol included follow-up renal bladder ultrasound and nurse case manager telephone assessment. Patients were followed for a median of 5.4 years, with data collected on stone passage rates, interventions, and long-term outcomes. Results: The SAUS protocol successfully redirected 53% of patients from urgent clinic visits. Of these, 98% did not necessitate urologic intervention for their small ureteral stone. Overall, 77% of patients showed radiographical confirmation of stone passage, and 74% reported being symptom-free. Only 13% of all patients underwent intervention for their initial ureteral stone. Long-term follow-up revealed that after discharge from our protocol, 67% of patients did not re-present over 5 years, and 90% remained free from urologic intervention. The study's retrospective nature and reliance on electronic medical records may have introduced bias. Patient adherence to follow-up recommendations varied, potentially affecting outcome accuracy. Conclusion: The SAUS protocol demonstrates effectiveness in virtually managing small ureteral stones, reducing unnecessary clinic visits and interventions. The protocol's success suggests its potential for implementation in similar clinical scenarios, potentially reducing health care costs and improving patient care in urolithiasis management.

INTRODUCTION:We sought to identify predictors of failed retrograde ureteric stent (FRS) placement in the setting of obstructing ureteric calculi. In addition to patient- and stone-specific characteristics, we also considered computed tomography (CT) measures of ureteric wall thickness (UWT), as it has shown clinical potential in predicting outcomes of shockwave lithotripsy, ureteroscopy, and spontaneous stone passage. METHODS:We performed a retrospective, case-control study comparing patients who had successful retrograde stent (SRS) insertions with those who failed stent placement and ultimately required nephrostomy tube (NT) insertion (2013-2019). Patients were identified using administrative data from a shared electronic medical record (capturing all urology patients in our geographic area) and a prospective database capturing all institutional interventional radiology procedures. Patient demographics, as well as clinical and stone characteristics, were then collected, and imaging manually reviewed. Statistical analysis was performed using univariate and multivariate logistic regression analysis in collaboration with a statistician. RESULTS:A total of 109 patients met inclusion for analysis (34 FRS, 75 SRS). The most common indication for stent insertion included sepsis (79%). On multivariate analysis, both acute kidney injury as primary indication for stent insertion (odds ratio [OR ] 9.16, 95% confidence interval [CI] 1.91-44.00, p=0.006) and UWT (OR 0.34, 95% CI 0.15-0.74, p=0.007) were found to be significantly associated with FRS placement. A receiver operator characteristic curve analysis demonstrates an optimal UWT cutoff of 3.2 mm (sensitivity 60.6%, specificity 83.3%). CONCLUSIONS:Elevated UWT and acute kidney injury as an indication for urgent urinary decompression in the setting of obstructing ureteric stones are predictive of FRS placement. These patients may benefit from upfront nephrostomy tube insertion.

PURPOSE:This study reports on a prospective, multicenter, single-arm, clinical trial utilizing the SonoMotion (San Mateo, California) Break Wave lithotripsy (BWL) device to fragment urinary stones. MATERIALS AND METHODS:Patients with a urinary stone underwent a single treatment of 30 minutes and peak negative pressure of 4.5 to 8 MPa. Subjects were contacted and outcomes assessed at 7, 14, and 35 days after treatment, with clinical follow-up and CT imaging 70 ± 14 days postprocedure. The primary objectives were to assess the safety (hematomas, complications, etc) and effectiveness of BWL (any fragmentation, residual fragments ≤4 mm or ≤2 mm, and completely stone-free rate) as assessed via noncontrast CT-kidneys, ureters, and bladder. RESULTS:Forty-four patients with a ureteral (43%) or renal (57%) stone were treated across 5 centers. Stone fragmentation occurred in 88% of cases; 70% had fragments ≤ 4 and 51% ≤ 2 mm, while 49% were completely stone free on CT; no serious adverse events were reported. Eighty-six percent of patients received either no analgesic medication at all (50%) or minor analgesia (36%). After determining optimal therapy settings, 36 patients were treated and the effectiveness improved exhibiting fragmentation in 92% (33/36), residual fragments ≤ 4 mm in 75% and 58% with fragments ≤ 2 mm with 58% completely stone free. Effectiveness was less in subjects with lower pole stones with 81% fragmentation, 71% having fragments ≤ 4 mm, 29% with fragments ≤ 2 mm, and 29% completely stone free; of distal ureteral stone patients, 89% were completely stone free. CONCLUSIONS:BWL offered safe and effective noninvasive stone therapy requiring little to no anesthesia and was carried out successfully in nonoperative environments. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT03811171.

Introduction: Non-contrast computed tomography (CT) is the gold-standard diagnostic test for urolithiasis. Little is published regarding which information needs to be included in the report for it to be most useful to the healthcare team for efficient triage and high-quality patient care. This study aimed to assess the quality and variability of CT scan reporting at a single Canadian tertiary academic medical center. Methods: We completed a retrospective review of 100 consecutive renal colic CT scans. Descriptive statistics were used to report the frequency with which specific elements commonly used by urologists to triage and treat patients were included in radiology reports. Results: Our sample had a mean age of 51.4±13.1 years. Stone size was universally reported for obstructing stones but was less frequently reported for non-obstructing stones (100% vs. 86.8%). A similar trend was observed for the exact stone number (100% vs. 93.4%). Non-obstructing stones were more likely than obstructing stones to be reported in one dimension (77.5% vs. 47%). Obstructing stones were reported in three dimensions 27% of the time. CT reports commonly include the presence or absence of hydronephrosis status (98%) but are less likely to include renal size (32%) and periureteral stranding (16%). Hounsfield units (HU) were reported in 3% of the reports, but skin-to-stone distance (SSD) and radiation dose were never reported. Conclusions: Reports routinely included assessments of stone size, location, and number (although not uniformly). HU, SSD, and radiation dose were rarely reported. This provides insight into opportunities for standardized reporting to optimize knowledge transfer that may result in clinical efficiency and improved quality of patient care.

INTRODUCTION: Limited literature surrounds medical extenders’ roles in the management of specific patient populations. Our Stone Clinic utilizes a stone clinic registered nurse (SRN) to review and communicate details of new patients to the treating urologist. The objective of this study was to characterize the accuracy of SRN generated management plans, when compared to those of the treating urologists. METHODS: A retrospective review of our Acute Stone Clinic patients was performed over a 90 day period. A standardized ‘Clinical Summary and Disposition Planning’ document was utilized by the SRN for all new patients. Management plans were compared between SRN and Urologist, categorical data was compared using Chi-Square test, and agreement was tested with Kappa Tests. RESULTS: Of the 226 patients reviewed (67.7% male, mean age 54 years) disposition plans included; Follow-up imaging (34.5%), ureteroscopy (URS, 28.3%), Shock Wave Lithotripsy (SWL, 20.4%), observation (10.2%), and other (6.6%). Comparing SRN to urologist plans, overall agreement was 55.3% with moderate agreement (Kappa=0.43). When selecting between intervention or observation, overall agreement was 70.8% with moderate agreement (Kappa=0.46). When choosing intervention vs. observation, the SRN was correct in 75.0% though the correct intervention was only selected in 55.1%. The SRN was more likely to select intervention than surgeon when patients were symptomatic (84.0% vs. 64.5%, chi=12.54 p<0.01). CONCLUSION: This study demonstrates that within our clinic extenders are able to predict the management plan in 55.3% of cases. Further work is required in understanding which factors may contribute to errors in disposition planning, and where opportunities for education may exist.

You have accessJournal of UrologyCME1 May 2022LBA02-10 ASSESSING THE RISKS OF A POSITIVE URINE CULTURE IN UNCOMPLICATED RENAL COLIC PATIENTS Nikhile Mookerji, Matthew Mancuso, Vardhil Gandhi, Efrem Violato, Stacey Broomfield, Tim Wollin, Trevor Schuler, and Shubha De Nikhile MookerjiNikhile Mookerji More articles by this author , Matthew MancusoMatthew Mancuso More articles by this author , Vardhil GandhiVardhil Gandhi More articles by this author , Efrem ViolatoEfrem Violato More articles by this author , Stacey BroomfieldStacey Broomfield More articles by this author , Tim WollinTim Wollin More articles by this author , Trevor SchulerTrevor Schuler More articles by this author , and Shubha DeShubha De More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002670.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Though septic stones are well recognized as a medical emergency, patients with uncomplicated renal colic (without systemic inflammatory responses or renal impairment) and positive urine cultures pose a dilemma in management considerations. Therefore, the objective of this study is to: 1) Assess the rate of ‘incidental’ positive urine cultures in patients with ureteral stones referred to our Stone Clinic. 2) Determine the risk of infectious adverse events (IAE) in patients with ureteral stones and positive urine cultures. METHODS: A retrospective chart review was performed for all Acute Stone Clinic referrals between November 10, 2019 and October 1, 2020. Urgent referrals necessitating immediate intervention were excluded. Demographics, investigations, procedures, unscheduled visits, and IAE were all documented. Descriptive statistics were used to group patients based on their urine cultures (UC). RESULTS: Over the study period 1029 patients were identified, and 35.4% (n=374) of them had urine cultures (UC) drawn at presentation. Of the 655 patients without UC, 0.6% (n=6) eventually developed sepsis and required urgent renal decompression. 87% (n=333) of UC completed at presentation were negative (no growth or mixed flora), and none of these patients went on to have an IAE. Of the 13% of urine cultures that were positive (n=39) only 2 IAEs (5.13%) were identified, 2-30 days after initial presentation. Both patients had normal acute phase reactants (WBC, CRP) and a history of recurrent UTIs. CONCLUSIONS: Approximately one third of patients referred to our Acute Stone clinic had UC at presentation, with an overall delayed IAE rate of 0.7%. Of those with positive urine cultures, only 5% experienced an IAE, suggesting conservative management may be a reasonable consideration in this patient population. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1045 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nikhile Mookerji More articles by this author Matthew Mancuso More articles by this author Vardhil Gandhi More articles by this author Efrem Violato More articles by this author Stacey Broomfield More articles by this author Tim Wollin More articles by this author Trevor Schuler More articles by this author Shubha De More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyCME1 May 2022MP26-19 THE SMALL ACUTE URETERAL STONE PROTOCOL: LONGITUDINAL OUTCOMES Conrad Bayley, Tim Wollin, Shubha De, Sentil Senthilselvan, and Trevor Schuler Conrad BayleyConrad Bayley More articles by this author , Tim WollinTim Wollin More articles by this author , Shubha DeShubha De More articles by this author , Sentil SenthilselvanSentil Senthilselvan More articles by this author , and Trevor SchulerTrevor Schuler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002569.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The small acute ureteral stone (SAUS) protocol was developed in 2018 for patients with ureteral stones <5mm to improve access to urological services. A nurse case manager phones patients to review their symptoms and imaging, and a disposition is determined to the acute stone clinic (ASC), elective stone clinic (ESC), or GP follow up. The clinical outcomes of the protocol were reviewed via a retrospective study in 2019. This study aims to review the long-term outcomes and provide descriptive analysis of the previously studied SAUS protocol patients. This will elucidate the safety and long-term impact of the protocol on patients’ access to the urology clinics, the impact on repeat emergency department visits, freedom from intervention for the same stone, and ongoing burden on the larger healthcare system. METHODS: A retrospective EMR review of all patients in the previous study was conducted. Data was collected in a REDCap database, with identifiable data stored in a separate encrypted spread sheet to maintain patient confidentiality. A total of 215 records were accessed, 8 excluded due to inaccessible records, and 207 were included. RESULTS: The 207 patients had a mean age of 49, with a male to female ratio of 2:1. 73.4% (152) of patients had no renal colic presentations in the 2-year period after initial completion of the SAUS protocol. 20.3% (42) of patients returned to ED with renal colic. Of these patients, 21 were referred to urology, 12 opted for conservative management, and 9 had negative imaging in the ED. 6.3% (13) of patients presented to their GP with renal colic. Of these patients, 7 opted for conservative management, 5 had negative imaging, and 1 were referred to urology (for SWL). Of the 22 urology referrals, 12 of patients had passed their stone(s) by the time they attended their ASC appointment, 8 required ureteroscopy, 1 required PCNL, and 1 required SWL. 94.2% (195) of patients required no urologic interventions. CONCLUSIONS: Initial introduction of the SAUS Protocol to acute ureteral stone management led to a reduction in the need for ASC appointments and interventions for patients with stones <5mm. This is maintained long-term, as the vast majority of SAUS Protocol patients do not re-present or require intervention within 2 years. This study supports the long-term use of the SAUS Protocol as a tool to determine disposition in this population. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e447 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Conrad Bayley More articles by this author Tim Wollin More articles by this author Shubha De More articles by this author Sentil Senthilselvan More articles by this author Trevor Schuler More articles by this author Expand All Advertisement PDF downloadLoading ...

Objective: Negative ureteroscopy (nURS) describes the absence of ureteric stones during endoscopic visualization, despite imaging confirmation before surgery. This study aimed to identify the prevalence of, and factors predicting nURS in patients presenting with ureteral stones. Materials and Methods: We performed a retrospective review of all uretersocopies for ureteral stones performed by three endourologists over a six-month periods. Only patients without previous intervention for the stone in question were considered for this study. nURS was investigated in relation to demographics, time from imaging to procedure, stone and procedure-specific characteristics, etc. Statistical analysis consisted of descriptive statistics and univariate and multivariate logistic regression analyses using SPSS statistical software. Results: Eighty-two patients were reviewed, with 14.6% of those patients experiencing a nURS. The frequency of computed tomography imaging and time from imaging to procedure did not differ significantly between +URS and nURS. Stone size (7.74 +/- 3.09 vs 6.73 +/- 2.28 mm; p=0.298), and stone location (68.6% vs 75.0% distal; p=0.686) were also not significantly different. Significantly more nURS procedures were performed in the emergency (21.7% vs 50.0%; p=0.048). These emergency nURS patients also had a statistically significant shorter duration from imaging to URS (7.1 vs 20.7 days; p=0.001). nURS procedures were 3.60 times more likely to be performed as an emergency (odds ratio=3.60; 95% confidence interval=1.01-12.79; p=0.048). Conclusion: We have identified 14% of patients undergoing ureteroscopy for ureteral stones at our center are being overtreated. Therefore, we believe that it is imperative that reimaging be considered in this patient population before surgery.

Globally, the prevalence of urolithiasis is steadily increasing, and though some regional variability exists, contemporary estimates report up to 10–12% of men and 7–8% of women now suffer from nephrolithiasis.1-3 Renal colic is one of the most frequent and expensive emergency department (ED) presentations.1,2 A study comparing renal colic management patterns in two Canadian cities identified widely varying trends in care, with admission rates as high as 60%, and surgical intervention rates over 50%. Though early intervention has been purported to allow patients to return back to normal life sooner, it appears early intervention led to increased subsequent ED visits, re-admissions, and secondary procedures.4 Another study looking at costs associated with management of acute renal colic found that an initial trial of non-surgical management was associated with lower indirect costs.5 The aim of this Canadian Urological Association (CUA) guideline document is to provide evidence-based consensus recommendations on various aspects relevant to the management of ureteral stones; the major topic areas included were conservative management, medical expulsive therapy, shockwave lithotripsy (SWL), ureteroscopy (URS), and special clinical scenarios (e.g., pregnancy, pediatrics).

Jason Y. Lee, MD1; Sero Andonian, MD2; Naeem Bhojani, MD3; Jennifer Bjazevic, MD4; Ben H. Chew, MD5; Shubha De, MD6; Hazem Elmansy, MD7; Andrea G. Lantz-Powers, MD8; Kenneth T. Pace, MD1; Trevor D. Schuler, MD6; Rajiv K. Singal, MD1; Peter Wang, MD9; Michael Ordon, MD10 1Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada; 2Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; 3Department of Urology, Université de Montréal, Montreal, QC, Canada; 4Division of Urology, Department of Surgery, Western University, London, ON, Canada; 5Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada; 6Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada; 7Urology, Northern Ontario School of Medicine, Thunder Bay, ON, Canada; 8Department of Urology, Dalhousie University, Halifax, NS, Canada; 9London Health Sciences Centre, Western University, London, ON, Canada; 10Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II (PD14)1 Apr 2020PD14-09 CLINICAL OUTCOMES OF THE SMALL ACUTE URETERAL STONE (SAUS) PROTOCOL AT AN AMBULATORY UROLOGY CLINIC Conrad Bayley*, Tim Wollin, Shubha De, and Trevor Schuler Conrad Bayley*Conrad Bayley* More articles by this author , Tim WollinTim Wollin More articles by this author , Shubha DeShubha De More articles by this author , and Trevor SchulerTrevor Schuler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000848.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: At our ambulatory urology clinic, with a catchment area of 2.5 million people, all incoming stone referrals from the ED are triaged by one of four endourologists, and eligible patients are triaged to Acute Stone Clinic (ASC) appointments. It was noted that many patients with stones ≤5mm missed ASC appointments due to resolution of symptoms or stone passage. This led to underutilization of ASC appointments and decreased access for patients who may require surgical intervention. To improve access to the ASC and, if necessary, urgent intervention, the small acute ureteral stone (SAUS) protocol was developed. A nurse case manager contacts patients to review their symptoms and the results of a follow-up ultrasound. Disposition to an ASC, elective stone clinic or follow-up with a family physician is determined based on symptoms, imaging findings, and patient preferences. The objective of this study is to determine the disposition of patients enrolled in the SAUS protocol. In addition, this study provides further data on the natural history of small ureteral stones and the impact of the SAUS protocol on ASC resources. METHODS: We completed a retrospective EMR review of all 216 patients enrolled in the SAUS protocol over the 12 months since its inception. Data was stored in a REDCap database. RESULTS: Patients with ureteral stones ≤5mm were eligible for enrolment in the SAUS protocol at the discretion of the triaging urologist. The 216 patients had a mean age of 49, with a male to female ratio of 2:1 and a mean stone size of 3.89mm. 17% (37) were recurrent stone formers. At initial phone contact by the RN, 66.2% (143) reported symptom resolution and 78.7% (170) of patients had no evidence of hydronephrosis or ureteral stone(s) on follow up imaging. The disposition distribution was 46.8% (101) ASC, 34.3% (74) general practitioner (GP), 13.0% (28) ESC, and 5.9% (13) other. Failure to attend a scheduled ASC or ESC was 12.4% (12/97). At last contact with urology, 73.5% (159) had passed their stone spontaneously, and thus didn’t require intervention. Stone passage rate was found to be independent of ureteral position. CONCLUSIONS: Introduction of the SAUS protocol to acute ureteral stone management led to a reduction in the need for ASC appointments by 52.8% for patients with stones ≤5mm. This results in more rapid access for patients with stones more likely to require intervention. Moreover this confirms that few stone 5mm or less require intervention. Our results support the utility of the SAUS protocol as a tool to determine patient disposition in this population. Source of Funding: 2019 Dr. William H. Lakey Summer Studentship © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e275-e275 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Conrad Bayley* More articles by this author Tim Wollin More articles by this author Shubha De More articles by this author Trevor Schuler More articles by this author Expand All Advertisement PDF downloadLoading ...

ObjectivesSince the introduction of the Holmium:yttrium-aluminum-garnet (Ho:YAG) laser over 2 decades ago, it has become an indispensable tool in the urologist's armamentarium.More specifically, in the subspecialty of endourology, the Ho:YAG laser has revolutionized the approach to kidney, ureteral and bladder stones, endoluminal tumours, strictures and benign prostatic hyperplasia (BPH) [1].Since its widespread adoption, and as with other laser wavelengths there have been concerns regarding its safety.In particular, the potential risks of eye injury to patients and operating room personnel have led laser manufacturers and governing bodies (including the Canadian Standards Association (CSA)) to require/mandate that all intraoperative personnel wear laser safety goggles.Despite this recommendation, the actual risk of eye damage associated with the Ho:YAG laser during endourological procedures has not been clearly defined.The objectives of this best practice report are to review the current literature regarding the risks of eye injuries and to provide practical and evidence-based recommendations on eye safety with the use of the Ho:YAG laser.This best practice report was developed in conjunction with members of the Canadian Endourology Group.

Introduction Failed Access ureteroscopy (FA) describes the inability to gain adequate access to a stone to allow for treatment. The purpose of this study was to identify the prevalence of, and factors predicting FA in patients presenting with renal and ureteral stones. Methods: We performed a retrospective review of all uretersocopies for ureteral stones performed by three endourologists over a six month period. All patients who underwent URS for the purpose of stone treatment were included. Patients were excluded if they underwent ureteroscopy for non-stone diagnosis or treatment. FA was investigated in relation to demographics, medical history, stone specific characteristics, procedure specific characteristics etc. Statistical analysis consisted of descriptive statistics as well as chi-square and t-test analysis using SPSS statistical software version 23.0. Results: 188 cases were reviewed, with 8% of patients experiencing FA. Patient age, gender, BMI, ASA score, emergency cases, previous stone treatment, use of CT imaging, presence of hydronephrosis, and surgeon did not differ significantly between FA and successful access (SA) groups. Stone size (9.88±5.8 vs 8.76±4.3mm; p=0.361) was also not significantly different. However, a significant difference was noted in time from first diagnosis to ureteroscopy (128 vs 65 days; p=0.044) and in stone location 62.5% vs 22.0% proximal ureter; p=0.043; OR=4.77 (1.05-21.64) Conclusions: Proximal ureteric stones were more likely to result in failed access ureteroscopy, and FA procedures were more likely to be preceded by extended time from first diagnosis to ureteroscopy. Further investigation is necessary, and all endourology centres should track their own personal outcome data in order to allow for more meaningful analysis to be performed to improve patient outcomes.

INTRODUCTION AND OBJECTIVE: Limited literature surrounds medical extenders’ roles in the management of specific patient populations. Our Stone Clinic utilizes a registered nurse extender (NE) to review and communicate details of new patients to the treating urologist. As questions around the limits of extender independence within a stone clinic, the objective of this study was to characterize the accuracy of NE generated management plans, when compared to those of the treating urologists. METHODS: A retrospective review of Acute Stone Clinic patients between June – September 2019 was performed. A standardized ‘Clinical Summary and Disposition Planning’ document was utilized by the NE for all new Acute Stone Clinic patients. Management plans were then compared between NE and Urologist, and categorical data was compared using Chi-Square test, Fisher Exact Test and Kappa, when appropriate. RESULTS: Of the 226 patients reviewed over this 12week period (67.7% male, mean age 54 years) disposition plans included; Follow up imaging (34.5%), ureteroscopy (URS, 28.3%), Shock Wave Lithotripsy (SWL, 20.4%), observation (10.2%), and other (6.6%). Comparing NE to urologist plans, overall agreement was 55.3% with moderate agreement (Kappa=0.506). When patients were to be followed with imaging, the NE was correct in 85.4%. When choosing intervention vs. observation, the NE was correct in 75.0% though the correct intervention was only selected in 55.1%. When NE incorrectly chose an intervention (n=61), 55.7% of cases were actually managed with observation and 44.3% with an alternate intervention modality. When observation was incorrectly chosen (n=14), 21.4% of patients were selected to undergo URS and 21.4% SWL. The NE selected multiple possible management options in 18.6% and did not select any treatment options in 11.5% of cases. NE was more likely to select intervention than surgeon when patients were symptomatic (84.0% vs. 64.5%, chi=12.54 p<0.001). There was no difference in intervention rates when the patients were asymptomatic (49.% vs 40.9%, chi=1.22, p=0.269). CONCLUSIONS: This study demonstrates that within our clinic extenders are able to predict the management plan in 55.3% of cases. Further work is required in understanding which factors may contribute to errors in disposition planning, and where opportunities for education may exist. Source of Funding: unfunded

Introduction: Asymptomatic microscopic hematuria (AMH) is defined in the Canadian Urological Association (CUA) guideline as >2 red blood cells (RBCs) per high-powered field (HPF). Our objective was to evaluate guideline adherence for AMH at our center. Secondarily, we aimed to identify areas of the guideline that can be optimized. Methods: We retrospectively reviewed 875 consecutive adults referred to two urologists for hematuria between June 2010 and June 2016. Patient characteristics, risk factors, and outcomes were added to an encrypted Research Electronic Data Capture (REDCap) database. Evaluation of microscopic hematuria reporting was performed by analyzing 681 urine samples reported as 1-5 RBC/HPF. Healthcare costs were obtained from Alberta Health Services (AHS), Data Integration and Management Repository (DIMR), and Alberta Society of Radiologists (ASR). Results: Of the 875 patients referred with hematuria, 400 had AMH. Overall, 96.5% completed evaluation consistent with the CUA guideline. The incidence of pathology requiring surgical intervention was 21/400 (5%) with a 0.8% rate (3/400) of urothelial cell carcinoma (UCC) (non-invasive, low-grade). No malignancy was found in non-smokers with normal cytology, normal imaging and <50 RBC/HPF; 44% had AMH in the 1-5 RBCs/HPF range. Only 41% (279/681) of urine samples categorized as 1-5 RBCs/HPF had guideline-defined microscopic hematuria. By changing local microscopic hematuria reporting to differentiate 1-2 and 3-5 RBCs/HPF, we estimate $745 000 in annual savings. Conclusions: At our center, CUA AMH guideline adherence is high. We did not find malignancy in non-smokers with normal cytology, imaging and <50 RBC/HPF. We identified and changed regional microscopic hematuria reporting to fit the CUA definition, eliminating unnecessary investigations and healthcare costs.

Catheters are widely used for urinary retention or incontinence and neurogenic lower urinary tract dysfunction (NLUTD). This includes intermittent catheterization (IC), indwelling urethral catheters, and suprapubic catheters. Both intermittent and indwelling catheterization provide means for long-term, effective urinary drainage with the aim to protect the upper urinary tract, improve urinary continence, and minimize urinary tract complications.1 However, urinary catheters can be associated with an increased risk of urinary tract infections, incontinence, calculi, and compromised kidney function. IC is generally the gold standard method of bladder drainage. Although technology has progressed in the field of catheter design, material, and technique, there is limited high-quality evidence and few good practice recommendations around catheter usage in chronic conditions such as NLUTD. Our objective was to review the evidence around the use of long-term urinary catheters in patients with chronic conditions and make practice recommendations for physicians in Canada who manage catheters in this population. We pay specific attention to the current best evidence of the available techniques, design, material, and practices of intermittent self-catheterization and its position in the treatment pathway.

INTRODUCTION AND OBJECTIVES: Treatment options for renal calculi are well established for smaller stones (<10mm), and larger stones (>20mm).Smaller stones are often treated with surveillance, shockwave lithotripsy, or flexible ureteroscopy (URS) while calculi larger than 20 mm are typically treated with percutaneous nephrolithotripsy (PCNL).Treatment guidelines for renal calculi in the transition zone with stone sizes that approach 20 mm are not as well defined.The objective of this study was to compare ureteroscopic laser lithotripsy to PCNL for the treatment of renal calculi measuring 15-20 mm and to determine which of these two would be the preferred treatment considering cost and patient preferences (utilities).METHODS: The cost and utilities of URS and PCNL were compared for the treatment of 15-20 mm renal calculi using a cost-utility decision analysis model.Probability estimates were derived from the literature.Direct third-party payer costs were determined in Canadian dollars and obtained from Data Integration and Management Repository (DIMR) of Alberta Health Services and the Schedule of Medical Benefits, Alberta Health and Wellness.There is a paucity of previously reported measured health utilities for the treatment of nephrolithiasis, therefore, preferences were measured by proxy via an expert panel using the validated EQ-5D health status instrument.The decision analysis model was created and then run using TreeAge Pro software.RESULTS: The model predicted URS and laser lithotripsy ($6356 per patient with utility [ 0.75) to dominate PCNL ($10,244 per patient with utility [ 0.77) with a cost/utility ratio of $8475 for URS compared $13,304 for PCNL.This yields an incremental cost-savings of $4829 per patient favoring the URS strategy.The validity of the model was tested with sensitivity analysis.CONCLUSIONS: From an economic perspective, this model predicts that ureteroscopic laser lithotripsy should be used over PCNL for the treatment of most renal calculi measuring 15-20 mm.However, the model also predicts that overall patient preference/utility is similar for both treatments with PCNL having a slightly better estimated patient preference.