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Clinical Focus

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

Jason Hafron, MD; Aaron D. Berger, MD; Arpeet Shah, MD

Medical Crossfire® in Adjunctive Testing: Charting a New Course in Prostate Cancer Risk Assessment

Articles

Although percutaneous nephrolithotomy (PCNL) comprises only 4% to 6% of all stone surgeries, it behooves the urologist with an interest in stone disease to be facile in this treatment modality in order to offer patients the most appropriate and effective treatment for their stones.

Percutaneous nephrolithotomy: Tricks and tips for access and stone removal

® Assistant Editor Janelle Hart spoke with 

 They discuss the association between kidney stones and climate change, and what the projections of their recent study evaluating this relationship will mean for future generations. Tasian is an associate professor of surgery and epidemiology at the University of Pennsylvania Perelman School of Medicine, a pediatric urologist at the Children’s Hospital of Philadelphia, and Director of Pediatric KIDney Stone (PKIDS) Care Improvement Network and Kaufman is a medical student at the University of Pennsylvania Perelman School of Medicine in Philadelphia, Pennsylvania.

“The prevalence of kidney stones has increased over 80% over the last 30 years, and the epidemiology has changed such that it's beginning at a younger age now,” says Gregory Tasian, MD, MSc, MSCE.

Why kidney stones will become more prevalent over time

s® Managing Editor Ben Saylor spoke with 

 study, "Multi-institutional prospective randomized control trial of novel intracorporeal lithotripters: ShockPulse-SE vs Trilogy trial," for which she served as senior author. Krambeck is a professor of urology at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

“You have tradeoffs with every device that you use,” says Amy E. Krambeck, MD.

Dr. Krambeck investigates efficacy of Trilogy and ShockPulse-SE lithotripters 

This episode’s guest is Amy E. Krambeck, MD. She discusses a recent Urology Practice paper, "Initial Experience With a Novel Single Use Disposable Ureteroscopy: A Prospective Single Arm 90-day Trial of the Axis Ureteroscope," for which she served as a study author. Krambeck is the Michael O. Koch Professor of Urology at Indiana University School of Medicine, Indianapolis.

Dr. Ranjith Ramasamy on nasal testosterone gel and sperm parameters

Dr. Amanda North on the gender pay gap in urology

Malpractice and stones: What a recent study reveals

On the latest episode of the Speaking of Urology podcast, Dr. Amy Krambeck discusses her recent study evaluating the Axis single-use ureteroscope.

Dr. Amy Krambeck discusses 90-day trial of disposable ureteroscope

This episode's guest is Peter L. Steinberg, MD. He discusses a recent 

 paper titled “Medical Malpractice and Nephrolithiasis: U.S. Appellate Cases From 2001- 2018,” for which he served as co-author. Steinberg is assistant professor of surgery at Harvard Medical School.

Dr. Finkelstein discusses telemedicine for pediatric post-op visits

What patients undergoing HIFU should expect postoperatively

Dr. Angela Smith discusses Jelmyto for low-grade UTUC


In this episode, Peter L. Steinberg, MD, discusses a recent Urology Practice paper that examined medical malpractice cases involving kidney stones.

Speaking of Urology - Malpractice and stones: What a recent study reveals

YOLT-203 is currently being assessed in the early phase 1 YOLT-203-101 trial.

FDA grants rare pediatric disease designation to YOLT-203 for primary hyperoxaluria type 1

In total, 8 of 40 patients who underwent ultrasonic propulsion experienced relapse, compared with 21 of 42 patients who underwent observation.

Ultrasonic propulsion for clearance of residual kidney stone fragments reduces relapse

“What this means for patients is that thiazides remain an important option in the toolkit for preventing kidney stone recurrence,” says Ryan S. Hsi, MD, FACS.

Increasing thiazide doses linked to fewer kidney stone events

In total, the trial plans to enroll 7 patients with PH1 through a single center in China. 

Trial launches of gene editing therapy for primary hyperoxaluria type 1

Any stone fragmentation was achieved in 88% of patients.

Data suggest Break Wave lithotripsy is safe, effective for urolithiasis

Dr Edmonds on “Trends in Patient Complexity, Practice Setting, and Surgeon Reimbursement for Urolithiasis: Do Rural Urologists Pay the Price?” 

Victoria S. Edmonds, MD, on reimbursement disparities for urolithiasis treatments

 paper, “Trends in Patient Complexity, Practice Setting, and Surgeon Reimbursement for Urolithiasis: Do Rural Urologists Pay the Price?” Edmonds is a urology resident at Mayo Clinic in Phoenix, Arizona.

How might the findings of this study influence the decision-making process for urologists when considering the treatment options of ureteroscopy vs PCNL, especially in rural areas or for patients with high medical complexity?

I think it's possible that the relatively lower reimbursement for treating these more complex patients might eventually start to disincentivize urologists from taking care of those kinds of patients, particularly in rural areas, where they have less support and less resources in general. We already know that rural urology practices across the country are struggling. Rural urologists are, on average, older than their urban counterparts. They're delaying retirement, and it's felt that this could either be because of financial hardship, so they're not prepared to retire, or perhaps there's not enough junior partners coming on to sustain those practices. There are large areas of the country where patients need to drive more than 60 minutes just to see a urologist, and so I think in general, we need to be doing more to support those rural practices.

Based on the observed disparities in reimbursement, what specific policy recommendations would you propose to address the identified gaps and ensure equitable compensation for urologists performing these procedures, regardless of patient complexity or practice location?

One idea that we had in thinking about this topic in general, writing the paper, is that we know that hospital and facility payments are both risk adjusted to account for patient complexity, so more complex episodes of care are reimbursed more to the hospital or facility. But this has not been done for physician reimbursement or surgeon reimbursement in the past. So I think we could explore risk adjustment for surgeon reimbursement as a way of incentivizing providers and compensating them fairly for taking care of these more complex patients. The other thing we could think about is that there's maybe room to update and potentially reform the geographic multiplier. As of now, there are 89 payment localities across the country with different GPCIs assigned to each of them, but many of those don't really align in true differences in how rural or urban each of those localities are. For example, Arizona, where I am, has 1 GPCI for the entire state. But if you live here, you know that Phoenix is a huge metropolitan area, but there are other areas of the state that are extremely rural and extremely under resourced.

What is the take-home message for the practicing urologist?

I think just being aware of these trends is very important for urologists moving forward. I think that if we can focus collective efforts on advocating for changes in policy that will allow us to provide high-quality care across the country in a sustainable way, we would be able to make a real difference in the lives of our patients.

Videos

"I think we could explore risk adjustment for surgeon reimbursement as a way of incentivizing providers and compensating them fairly for taking care of these more complex patients," says Victoria S. Edmonds, MD.

Higher patient complexity is associated with lower reimbursement for ureteroscopy

 describes the background and notable findings of the recent

Please describe the background for this study.

A little bit of background: The Medicare surgeon fee-for-service payments are determined by the Medicare Physician Fee Schedule, which assigns each procedure an RVU, which is supposed to represent the cost of providing a service or procedure. Each RVU is then multiplied by the GPCI, which is a geographic multiplier that's meant to account for practice cost variations and wage differentials in each CMS-determined payment locality. We were interested in looking at trends and reimbursement for ureteroscopy and PCNL across the country, and we wanted to stratify those results by geographic location, looking specifically at how more urban and how more rural locations are reimbursed, as well as patient complexity, so how more complex, meaning more comorbid, patients are reimbursed differently than healthier patients.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

Some of them were surprising. We expected that more complex patients would be reimbursed higher because we know that those patients require more resources, they're more time intensive. But interestingly for ureteroscopy, we found that higher patient complexity correlated with lower reimbursement. The other thing we found is that for more rural practices, for ureteroscopy, they also received lower reimbursement than urban practices. This isn't necessarily surprising. In some ways, you could take this to mean that the geographic multiplier is working as intended by adjusting physician payments based on variations in costs when we assume that rural areas have a lower cost of living and lower cost of practice. But I think it is worth noting that the GPCI, the geographic multiplier, was developed back in 1992. It was last updated in 2012, and the landscape of the urology workforce has really changed since then. There's been a decrease in the percentage of physicians that are working in practices that are entirely owned by physicians, and more and more private practices are now employed by or directly contracted with hospital systems.

"For more rural practices, for ureteroscopy, they also received lower reimbursement than urban practices," says Victoria S. Edmonds, MD.

Higher patient complexity associated with lower reimbursement for ureteroscopy

In this interview, Kari A.O. Tikkinen, MD, PhD, shares an update on the APPEAL trial studying the efficacy of antibiotic prophylaxis for patients undergoind shockwave lithotripsy 

Kari Tikkinen, MD, provides an update on the APPEAL trial 

, shares an update on the APPEAL trial (NCT03692715), which was highlighted in the recent publication, “Update on APPEAL, an International Randomized Controlled Trial Evaluating Ciprofloxacin Versus Placebo in Patients Undergoing Shockwave Lithotripsy for Urolithiasis.” Tikkinen is a professor of urology at the University of Helsinki in Finland.

 [for giving us] the chance to report this. The great news is that we have now completed recruitment. We actually recruited more than 1700 patients, and now we're starting to analyze this. We have a statistical analysis plan.

It's very common in large trials, but also in smaller trials, that the recruitment is a challenge, especially in surgery. It's actually the most common reason for discontinuation of trials, and we also had problems. This trial was started in Canada as a single center trial, but it soon was clear that this recruitment was too slow. Then we expanded the trial globally, and we made it a multicenter trial with more than 10 centers in different countries. We renamed this the APPEAL trial, which is antibiotic prophylaxis before shockwave lithotripsy. Then, as we know, the COVID pandemic hit all over the world, and it also hit the APPEAL recruitment. It was also impeded because many units at that time were not able to recruit patients or even treat patients.

Then, the third thing that was a little bit of a challenge [was] that we originally planned to recruit about 1500 patients, but then we looked [at the data]. We didn't open the blinding, but we looked at the data at about 1000 patients, and we noticed that there were less events than what we had planned. That's another common problem in trials is that investigators tend to overestimate the event rate, and we underestimated it a little bit. Then we increased the sample size to a minimum of 1700 patients, and we have now recruited these 1700 patients. We are now ready for analysis and publishing papers.

This transcription has been edited for clarity.

“The great news is that we have now completed recruitment. We actually recruited more than 1700 patients,” says Kari A.O. Tikkinen, MD, PhD.

Dr Payne on “The Use of Genetic Testing in Nephrolithiasis Evaluation: A Retrospective Review from a Multidisciplinary Kidney Stone Clinic.” 

What criteria should be used when considering genetic testing in patients with stones?

 discusses incorporating genetic testing into routine clinical care for patients with kidney stones. She is a co-author of the recent 

 paper, “The Use of Genetic Testing in Nephrolithiasis Evaluation: A Retrospective Review from a Multidisciplinary Kidney Stone Clinic.” Payne is a urology resident at Mayo Clinic in Phoenix, Arizona.

How do you envision integrating genetic testing into routine clinical care for patients with kidney stones? What are the potential challenges and opportunities in implementing such a strategy?

That was another thing we were interested in our study is that there are actually no clear guidelines on when to refer patients with nephrolithiasis to genetic testing. We don't have any clear factors on when our guidelines tell us to send someone to genetics. And so really, it's at the opinion of the referring provider or the urologist that the patient is seeing. In our nephrolithiasis clinic, we use some general criteria to refer to genetics, and that [includes] multiple stone events, stone event before the age of 18, bilateral kidney stones, and kidney stones that required multiple surgeries. Those are some of the criteria. And then, if the patient has undergone a 24-hour urine study, and based on that, we have a high suspicion for a genetic abnormality like a distal renal tubular acidosis or cystinuria, then we'll refer. I think our study showed that based on the high percentages of variants that we found, that the criteria that we're using is a relatively good measure to use to refer to genetics, and so I think, ultimately, it is up to the provider.

But how do we integrate this into clinical practice? I think any patient that you have who has multiple stone events, stone events before the age of 18, requiring multiple surgeries, or stones in both kidneys, I think those are all good factors to use to at least bring it up to the patient and say, "You could benefit from genetic testing. We may be able to find something that we can use to change management." In our study, unfortunately, we didn't find that there were any changes in clinical management made based on the genetic findings, but there have been prior research studies that list out all the different genetic abnormalities that you can have that cause kidney stones and make recommendations of different treatment options, whether that be medications or dietary changes, things like that specific to the disease process. We didn't find changes in our study, but there has been prior research to show that when you identify a variant for a disease process that you can make meaningful clinical changes that are specific to that disease process.

This transcription was edited for clarity.

"There are actually no clear guidelines on when to refer patients with nephrolithiasis to genetic testing," says Nicolette G. Payne, MD. 

Dr Payne on The Use of Genetic Testing in Nephrolithiasis Evaluation: A Retrospective Review from a Multidisciplinary Kidney Stone Clinic.” 

Counseling patients with nephrolithiasis regarding genetic testing

Given the high percentage of variants of unknown significance identified in your study, what are the potential implications for patient care and counseling? How do you address patient concerns and uncertainties regarding these findings?

That's kind of the million-dollar question here. With our findings, what do we do with these? How do we counsel patients? And this is a tough question, because when a patient undergoes genetic testing, they're hoping for answers. They want to know if they have some disease and what we can do about it. And they come back and they have this variant of unknown significance, and it's kind of in the name, right? It's a variant. It's some difference from the population, but we do not know the clinical significance of it yet, and so the short answer is that we can't really make any changes to management, and we can't really change our counseling for those. That's tough to explain to patients after they underwent genetic testing, and they want an answer, and the answer is, "Interesting. We'll keep this in mind. We'll let you know if the research changes, but we can't make any clinical changes." And so I think what's really important for this is that you counsel patients before they undergo testing. Testing can be really expensive. Our test that we use is GeneDx. It looks at 41 different genes, and the test is actually relatively reasonable in comparison to other genetic tests on the market. It's around $200 out of pocket, and insurance may or may not cover it. But other genetic testing, through my research, I found can go as high as $3000 and again, insurance may or may not cover that. So I think it's important to be very transparent with patients and say, "We're going to do this genetic testing. We may find a genetic abnormality that we can counsel you on, but more likely we're going to find a variant of unknown significance or nothing at all. And if we find this variant of unknown significance, we can't make any changes to management based on that, because we don't have enough information yet." And I think if you counsel patients before they take the test, before they spend the money, that will really help in the counseling afterwards; you can say, "Remember how we talked about this? We knew this was a possibility, and this is what we found." I think it will help the conversation afterwards, and it will make things a lot easier to talk about if you've already told them that before they go in.

"I think what's really important for this is that you counsel patients before they undergo testing," says Nicolette G. Payne, MD.

Dr Payne on “The Use of Genetic Testing in Nephrolithiasis Evaluation: A Retrospective Review from a Multidisciplinary Kidney Stone Clinic.”

Nicolette G. Payne, MD, on genetic testing in patients with nephrolithiasis

 describes the background and notable findings from the recent 

Recent studies have suggested that there may be a monogenic genetic cause for nephrolithiasis, and the rates of nephrolithiasis in the United States are rising. Up to 10% of adults in the US have nephrolithiasis, and so there's a lot of literature to look into. What are the causes of kidney stones? How can we better treat these? And a lot of causes of kidney stones have come up; of course, dietary factors, geographical factors, and then, of course, there's this whole component of what could be some genetic or hereditary causes. In the literature, about 7% to 11% of adult stone formers have an underlying genetic cause, and it's even higher in the pediatric population - up to about 17% - and there's been over 40 genes that have been identified that can predispose people to nephrolithiasis. With that information, we sought to describe the genetic and clinical characteristics for patients undergoing genetic testing at our institution that were referred to genetics from our multidisciplinary stone clinic.

I think when we were doing this study, we were hoping to compare patients who had a variant identified with a known pathogenic association, compare those to patients who were identified with a variant of unknown significance, and then to compare those to people who did not have a variant identified. And of course, our hope was that we would find some statistical differences between these groups, both in their clinical factors and in their stone parameters, such as the type of stone they produced, or how frequently they were getting stones, or if they had a stone before the age of 18, or if they had surgery for stones. And so our hope or thought was that we would see some differences between the groups. For example, we might see that those who had a variant with a known pathogenic cause, maybe they had more frequent stone events, or they had a stone event before the age of 18. And I think maybe a surprising finding was that we didn't find any differences between the groups. But the reason for that, most likely, is that our sample size was pretty small. We had 825 patients evaluated in our stone clinic from 2018 to 2022, which was the time parameter for our study. 50 of those patients, which is only about 6%, were ultimately referred to the genetics clinic. And then of those patients, 33 ultimately decided to undergo testing. Of the 33, 19 were found to have a variant, and of those, 9 of those patients had a variant with a known pathogenic association, and 10 had a variant of unknown significance. And so we were working with a pretty small sample size. Only 33 of those patients had genetic testing, and then only 19 of those had a variant identified, whether that was a variant of known pathogenic association or unknown. And unfortunately, with statistics, that gives us a very underpowered study, and so we couldn't really find any significant associations. So in that sense, it wasn't surprising that we didn't find differences among the groups. I think one other interesting finding was that cystinuria is the most common monogenic cause of nephrolithiasis, and in our cohort, we only had 1 patient who had cystinuria. And so when I was presenting this study at a lot of different meetings, that was a common question I got was, why don't you think you guys had more patients with cystinuria? I think the answer to that question lies in the fact that we do a lot of 24-hour urine studies in our clinic. That's when a patient provides a sample of urine for either 24 or 48 hours, it's sent to the lab for analysis, and it gives us a lot of amazing information that can help us counsel patients on dietary factors and metabolic factors. And based on those results, a lot of times, if you have an educated person interpreting those results, you can already diagnose with a pretty high confidence cystinuria, or have suspicion for something like a distal renal tubular acidosis and things like that. And so our stone clinic is full of such educated people who really understand the pathophysiology of stone disease that we think that probably we had already identified patients with cystinuria, or patients came from another center and were referred to our clinic and had already had the diagnosis of cystinuria. So those patients then weren't asked to go get genetic testing, because we either already had high suspicion for it, or they were already given the diagnosis at another institution.

"We sought to describe the genetic and clinical characteristics for patients undergoing genetic testing at our institution that were referred to genetics from our multidisciplinary stone clinic," says Nicolette G. Payne, MD.

Marcelino E. Rivera, MD, highlights the MONARCH platform for minimally invasive, robotic-assisted stone removal. 

Dr. Marcelino Rivera on the MONARCH platform for kidney stone removal

, highlights the MONARCH platform for minimally invasive, robotic-assisted kidney stone removal. The device is currently being studied in the STAR trial (NCT06330701), which is assessing the safety and efficacy of the device in patients undergoing robotic mini-percutaneous nephrolithotomy.

Rivera is an associate professor of urology at Indiana University School of Medicine and the director of the endourology fellowship at Indiana University Health in Indianapolis.

We're very fortunate [to be] working with Johnson & Johnson. We're 1 of the 2 clinical sites for this trial. The MONARCH is a robotic platform that has a couple of different modalities. There is a robotic ureteroscope that can be used for ureteroscopy that essentially uses a joystick. I actually have a model in my office. I could bring it in, but it's an Xbox––that's what it is. We use that to navigate with the ureteroscope into the kidney.

Then there's a second component, which is an access component. These are done with a supine positioning of the patient. They're rolled a little bit on their flank. Then the robot has something called a compact field generator, so basically, the ureteroscope has a little chip in it that can be detected by this field generator that sits above the patient. Then we can actually target the calyx for puncture, utilizing a needle that has a little chip in it that can localize to that area. So essentially, it can triangulate very, very accurately into the calyx. It's pretty slick. It's almost perfect each time in terms of a perfect papillary puncture. Every time we do a perc[utaneous nephrolithotomy], we want to be right in the middle of the papilla. That's where there's less bleeding. That's where there's less of a chance for having a complication. This technology is very slick in getting essentially right through the papilla each time. We did it today; it took about 2 minutes to get into the kidney. From there, the surgery becomes much more simplistic. You don't have to worry about bleeding. The visualization is very good.

Once we get our access, we can then use the third component of this system, [which is] a steerable suction catheter through the back. It has this snake-like catheter that has an opening in it, and it's on continuous suction. So, it can continuously suck the stone debris [and] the stone material out the flank while I laser it with the ureteroscope. Because it has flexible suction, I can steer it into each calyx independently of the ureteroscope. The way you do that is you toggle––just like you're playing a video game, you can toggle between, I don't even know, I don't play video games––but you can toggle between different things with the controller. So, you click a button and it goes to the ureteroscope. You click a button and it goes to the suction cap. You click a button and you can stick out a basket and grab stones. You click a button and you can put a laser fiber in. It's a pretty slick, very novel technology. Obviously, it's very unique, and so we're very fortunate to be able to be studying it and looking at patient outcomes, safety parameters, and stone free rates and other data that we're measuring in these patients. I think the future is very bright for endourology and pushing the envelope with different minimally invasive techniques to remove stones.

“I think the future is very bright for endourology and pushing the envelope with different minimally invasive techniques to remove stones,” says Marcelino E. Rivera, MD. 

John Michael DiBianco, MD, discusses the impact of performing miniPCNL in pediatric patients

John Michael DiBianco, MD, on impact of miniPCNL in pediatric patients

 discusses the impact of performing miniPCNL in pediatric patients. DiBianco is an assistant professor of urology at the University of Florida, Gainesville.

The cases that I've done have been here, at least, have been some of the most, I guess, impactful and really make me proud and happy to be a urologist and to do something [for which] the patients are incredibly grateful. Most of these patients have lived with stents for a long time, and have had to undergo several procedures. It's very remarkable how tough a lot of these kids are, and how well they handle these operations, and what good spirits they're usually in. And so, I think it's something that's very satisfying, and I think with the smaller and smaller and the better equipment that continues to be developed, and different techniques that continue to be developed, I think we're just going to get better and better and hopefully we can prevent a lot of future suffering for a lot of these kids that unfortunately develop stones.

"The cases that I've done have been here, at least, have been some of the most, I guess, impactful and really make me proud and happy to be a urologist and to do something [for which] the patients are incredibly grateful," says John Michael DiBianco, MD. 

John Michael DiBianco, MD, shares pearls on performing miniPCNL in pediatric patients. 

Expert shares pearls on performing miniPCNL in pediatric patients

 shares pearls on performing miniPCNL in pediatric patients. DiBianco is an assistant professor of urology at the University of Florida, Gainesville.

What are some pearls regarding miniPCNL in pediatric patients that you'd like to share?

The biggest thing that I tend to want to dispel is that this is a very invasive and a very dangerous procedure, which is one of the reasons why in the pediatric population, I tend to see that patients don't typically get the most effective procedure. They tend to get minimally invasive, potentially less effective procedures and several of them. It's not because people don't want to do the right thing for the patient. It's because they're worried and when people are small, we don't want anything to go wrong, and it's a very good reason. But what I would tell you is that multiple procedures is not without its risks as well. And the more procedures in the ureter, the potential there is for scar tissue down the line or more suffering with a stent for a longer periods of time. And so I think what's really nice about these minimally invasive PCNL procedures is that they've been shown, especially in adults, to decrease complications compared with maximally invasive PCNL procedures, for sure, but even sometimes compared with ureteroscopy. The fact that we're getting smaller and smaller and keeping some that efficacy is very helpful for patients, and I think, at least at this point, is helping us to provide evidence that it can be done safely. And that's the biggest thing that I typically want to dispel - this idea that anything we do through the back is associated with those older methods of percutaneous nephrolithotomy and that has everybody's attention and maybe some fear. But I would say that you definitely need to be very adaptable. You have to have a great team, a great pediatrics team and great pediatric colleagues if you're not a pediatric urologist yourself. You need to have great anaesthetic team, very supportive, and you need to have a wide variety of tools available in case something unexpected comes up like a UPJ obstruction or ectopic ureter or something, because unfortunately these kids make stones for a reason, and you just have to be ready to handle the unexpected.

"You definitely need to be very adaptable. You have to have a great team," says John Michael DiBianco, MD.

Joseph Song, MD, describes some challenging kidney stone cases

Dr. Song discusses challenging kidney stone cases

 describes some challenging kidney stone cases. Song is a urologist with Georgia Urology.

Kidney stone treatment is all about access. Whether you're doing it ureteroscopically or doing it percutaneously, if you have good access, if you have good flow, then it makes your surgery that much easier. But if you're limited in access, whether that's because you couldn't get a sheath up the ureter, or whether they have an obstructed calyx, or whether you have an anatomy where you're around the corner of a corner, that makes things much, much more difficult. So recently, I had a young lady who was 26, and she had just a kidney completely full of stone, but I had good access; I was able to get in and I was able to do the PCNL in about 30 minutes [and send her] home the same day without a tube. I had a patient the same exact age but had Lesch–Nyhan syndrome and horseshoe kidneys...and his stones were softer. The access was just as good, but his anatomy made it so that the tube could barely reach the far side of the renal pelvis. The tube kept on sliding underneath the surface of the skin, and then you would have to spend 10, 20 minutes sweating bullets, like I lost the tube inside of this patient and I can't get it back out, so then I put some silk stays on either side of it so that I could, when it did that, I was able to angle it back out. That's something I've never seen before during training and never had to do prior to that. That's my tip of the day. If you're doing a PCNL and the patient's got a horseshoe kidney or some other kidney that your nephrostomy tube that you put in is barely at the skin level, go ahead and put a stitch in that because if it slips under and you're having to enlarge an incision and you're trying to get it out, it's so much more difficult once that's happened, but if you have that access, it's so much easier.

"Kidney stone treatment is all about access," says Joseph Song, MD.

Future Perspectives in the Treatment of Patients With Urinary Stones

Drs Bechis and Semins discuss future developments in urinary stone management, emphasizing the potential for improved vacuum aspiration devices, combined intravenous and PCNL surgeries, and the hope for medications to dissolve stones.

UroView

Methods for Continuous IRP Monitoring in Patients With Urinary Stones

Experts converse on the evolving methods for real-time intra-renal pressure monitoring, its benefits in improving surgical procedures, and the potential for future automated adjustments based on the monitored data.

Factors for Consideration When Employing UASs In Patients With Urinary Stones

Drs Bechis and Semins discuss their approaches to employing ureteral access sheaths, reviewing assessing the ureter's caliber, dilation techniques, and the potential need for stenting post-sheath use, considering patient history and logistical factors like on-call availability.

Key Treatment and Outcome Data for Patients Undergoing Therapy with Assistance of Ureteral Access Sheaths (UASs)

Drs Semins and Bechis discuss the utility and benefits of ureteral access sheaths, emphasizing their role in optimizing visualization, reducing intra-renal pressure, and potentially mitigating postoperative complications, while also noting the importance of size selection and highlighting emerging technologies that measure pressures and manage thermal injury.

Strategies for Reducing Risk of Elevated IRP

Dr Michelle Semins discusses strategies to minimize elevated intra-renal pressure, emphasizing the principle of ALARA (as low as reasonably achievable) by reducing inflow and increasing outflow, and suggesting tools and techniques such as stopcocks, gravity bags, ureter access sheaths, and new suction devices, while also highlighting the importance of controlling other risk factors like bacteria.

Seth Bechis, MD, emphasizes the potential complications from elevated intra-renal pressure, such as sepsis from bacterial spread, ruptures leading to pain and difficult recovery, impaired renal function, and hemorrhage, highlighting the need for understanding these risks for better postoperative outcomes and hospital efficiency.

Potential Complications Seen in Patients With Elevated IRP

Michelle Semins, MD, details the variability in intrarenal pressures, explaining that while a clear safe threshold is unknown, pressures over 30-40 might be dangerous; she lists factors influencing these pressures, like inflow/outflow and scope size, and mentions potential complications from prolonged high pressures, such as urosepsis.

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