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Clinical Focus

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

® 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

"The Stone Clear device provides patients with a non-invasive option to reduce their residual fragment stone burden in the clinic environment while being fully awake," says James E. Lingeman, MD. 

FDA grants de novo clearance to Stone Clear device 

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

Marcelino E. Rivera, MD, highlights potential future advancements in the areas of stone disease and benign prostatic hyperplasia 

Marcelino Rivera, MD, on potential future advancements in stone disease, BPH

, shares what he envisions for the future of stone disease and benign prostatic hyperplasia (BPH). 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.

For stone disease and stone removal, we're really seeing the use of steerable suction catheter, steerable suction scopes, making surgery much safer and much more efficient. I just mentioned the MONARCH trial; we got a miniPCNL that has the ability to remove large amounts of stone through suction steerable catheters. There's a new scope, the CVAC, or the Calyxo scope, that has the ability to do suction ureteroscopy. There's also a handful of suction steerable ureteral access sheaths out there as well. So, we have all of this new technology that’s about a year old, making surgery a lot safer for patients, making things more efficient, and [giving us] the ability to see stone removal happening from a perspective where we can visualize stone clearance in a way that we haven't been able to before.

When we look at the BPH arm, or the HoLEP arm of the change in technology, when it comes to BPH, there's always going to be a lot of different technology out there. One of my partners does Aquablation, we're looking into other technologies, like Optilume, trying to get those on board as well. It's very important to have an armamentarium that you're offering your patients. We'll always have that in BPH. But I think the important thing is "let's make sure we're doing the right procedure for the right patient." And also, if we have people who want to learn how to do enucleation, what do we have to educate and to teach them how to do these procedures? I think the future is really bright from an educational perspective on the HoLEP or enucleation arm, training people with different modalities. Instead of using patients right away, do we have certain models that are very facile and that work really well? And then do we have a curriculum in place that can do that? I think with the study of our residents, getting an idea of what they find as difficult for an enucleation procedure, we can really focus on the more challenging parts of the procedure, perhaps teach them outside the patient, and then start to utilize that curriculum and advance and make their learning career much less. That's the bright side of the BPH or enucleation technology.

This transcription has been edited for clarity.

Videos

Advancements in stone disease and BPH treatment are being driven by new technologies, such as steerable suction catheters and scopes, which enhance surgical safety and efficiency. The MONARCH trial and innovations like the CVAC scope are pivotal in improving stone removal. In BPH management, diverse technologies, including Aquablation and Optilume, are expanding treatment options. Emphasis is placed on matching procedures to patient needs and enhancing education for enucleation techniques. Developing effective training models and curricula is crucial for improving procedural proficiency and reducing learning curves.

“So, we have all of this new technology that's about a year old, making surgery a lot safer for patients, making things more efficient, and [giving us] the ability to see stone removal happening from a perspective where we can visualize stone clearance in a way that we haven't been able to before,” says Marcelino E. Rivera, MD. 

Thomas Chi, MD, MBA, discusses future directions for research and development of the CVAC System

Future directions and research on the CVAC System for kidney stones

 discusses future directions for research and development of the CVAC System. Chi is a professor of urology, associate chair for Clinical Affairs, and the Kutzmann Endowed Professor in Clinical Urology at the University of California, San Francisco.

What are the potential future directions for research and development of the CVAC System? Are there any specific areas where you envision further improvements or additional applications?

Well, 1 of the things that I think is a difference between the CVAC first- and second-generation devices compared to the direction that traditional ureteroscopes are going is that, whether you're talking about reusable, single-use ureteroscopes, either one of those form factors, people are making smaller and smaller scopes. So it's pretty typical for folks to be advertising that they have a 7.9 Fr tip scope nowadays for ureteroscopy. Now, by comparison, the CVAC first- and second-generation devices have wider bore lumens, so they have a larger device in order to achieve good suction. So that's 1 space I think that brings 2 different questions up. One is, could you do CVAC, whether it's first- or second-generation procedures, without using an access sheath, so maybe save the patient a stent, if you can. And the second area of technology development to your original question is whether or not that same technology that's gone into making the CVAC System very efficient and effective for stone removal, can that be preserved using a smaller form factor? How small could you push the limits of a CVAC-type device, so that maybe you could do these without a stent, without an access sheath, and also more comfortably for the patients with a potentially lower risk for things like damage to the ureter. [One] of the things that makes the technology really interesting, in my mind, for CVAC, is that it's not just a suction device. In order to make the suction effective, they've changed the way that the irrigation comes out of the tip of the scope, and they've changed the way that the instruments come out of the tip of the scope. So those things have helped make the device more effective, so then can you preserve the things that are working great, but also shrink down the form factor? Those I imagine—this is just speculation on my part—but those are areas where I imagine there can be space for technology development.

"[One] of the things that makes the technology really interesting, in my mind, for CVAC, is that it's not just a suction device," says Thomas Chi, MD, MBA.

Thomas Chi, MD, MBA, discusses the economics of the CVAC System

Dr. Thomas Chi on the economics of the CVAC system for kidney stones

 discusses the economics of the CVAC System. Chi is a professor of urology, associate chair for Clinical Affairs, and the Kutzmann Endowed Professor in Clinical Urology at the University of California, San Francisco.

Could you discuss the cost-effectiveness of the CVAC System compared with traditional URS methods?

Now, the CVAC device does cost more. You have to utilize a ureterscope, whether you use a single-use or a reusable ureterscope, there's the cost induced with using a ureterscope. And then on the CVAC first generation, you would be opening an additional suction device that's on top of your ureteroscope. In the second generation, a steerable suction device exists for stone removal, and it's in the form factor of a ureteroscope. So now you can do your entire procedure using 1 device that looks and feels like a ureteroscope, but it's really a suction device that's quite innovative as a design, but you can now do laser lithotripsy through that same device under direct vision, and then when you're done, utilize suction through that direct vision device to remove the stone fragments. So in that second-generation device, now you're taking out the cost of a separate ureteroscope, because you can do it all through the same second generation CVAC device. You still have to pay for the laser, and you don't have to pay for a basket anymore. Now, when you look at the cost comparison for straight cost, the second-generation CVAC device costs overall more than a traditional ureteroscope plus a basket. But one of the things that I've appreciated about the team for Calyxo is that they've really paid a lot of attention to the economics of reimbursement and the economics of cost. When you look at the way that this particular device has been coded and will be reimbursed, they're cross referencing several CPT codes that should allow the physician to actually bill for different CPTs. So from a revenue, profit and loss perspective, actually, in many instances, they anticipate that physicians may actually make more money using the second-generation CVAC device compared to traditional ureteroscopy, depending on your payer mix and your practice. So those types of strategies, I think, from a pragmatic standpoint, will be very impactful for physicians who are looking to adopt the CVAC device into their practices.

"From a revenue, profit and loss perspective, actually, in many instances, they anticipate that physicians may actually make more money using the second-generation CVAC device compared to traditional ureteroscopy, depending on your payer mix and your practice," says Thomas Chi, MD, MBA.

Thomas Chi, MD, MBA, discusses advantages to the CVAC System

How the CVAC System compares with URS for treating kidneyfd stones

 discusses advantages to the CVAC System. Chi is a professor of urology, associate chair for Clinical Affairs, and the Kutzmann Endowed Professor in Clinical Urology at the University of California, San Francisco.

Could you provide more information on the long-term clinical outcomes, such as recurrence rates, complications, and patient satisfaction associated with the CVAC System?

For this particular first study, we didn't look at long-term outcomes, but in a second project that's being completed now, and in a couple of studies that have been performed using the CVAC device, people have looked at longer term outcomes. More recently, some unpublished data have demonstrated that at 1 year, one of the things that we saw that was a significant difference between patients who had the first-generation CVAC device and traditional ureteroscopy with basketing was that patients who underwent procedures that cleared stones using the CVAC suction device actually had fewer ER and unanticipated clinic and hospital visits compared with traditional ureteroscopy, and that held up at a year. So it does seem like while we may clear more stones with the CVAC, one of the big benefits with the CVAC device is that it keeps people out of the hospital more often than compared with traditional ureteroscopy.

Thomas Chi, MD, MBA, discusses advantages to the CVAC System.

How the CVAC System compares with URS for treating kidney stones

Thomas Chi, MD, MBA, discusses data from the ASPIRE study evaluating the CVAC System. 

Dr. Thomas Chi on the CVAC System for treating kidney stones

 discusses data from the ASPIRE study evaluating the CVAC System. Chi is a professor of urology, associate chair for Clinical Affairs, and the Kutzmann Endowed Professor in Clinical Urology at the University of California, San Francisco.

Please provide an overview of this study and its results.

The results of the ASPIRE study really demonstrated the short-term clinical outcomes related to the CVAC system, and we were largely centered around the first-generation device, of course, and that is a steerable suction device that's designed to go into the kidney after a traditional ureteroscopy is done in order to suction out the fragments of stones that are remaining, as opposed to having to basket the fragments out. And what we demonstrated was that at 30-day and 90-day interval outcomes, the patients actually had equivalent safety profiles compared to traditional ureteroscopy with basketing. And what it looked like was that there is an increased stone clearance rate. Usually, we talk about stone-free rates being, did we get all the stones out at once or not? But one of the things that we did here was we looked at very closely read CT scans. Everybody got a CT scan, and they were 1 to 1 and a quarter-mm slices. So these are very precise CT scans. We found that with using the CVAC device, we could clear a larger volume of stones. And what that really translates to is, usually, when patients come to see you in the clinic after the surgery for stones, at least in my practice, they generally ask 2 questions. One is, did we get it all? And then 2 is, how much did we get if we didn't get it all? Those are the 2 most common questions I [get asked by] our stone patients, and this really speaks toward that second question as well: If we didn't get it all, what percentage did we get? And there are lots of benefits to probably getting more, rather than less, of stone burdens out, even if you don't clear all the stones, including preventing future stone issues and events and potential complications related to residual stones.

"What we demonstrated was that at 30-day and 90-day interval outcomes, the patients actually had equivalent safety profiles compared to traditional ureteroscopy with basketing," says Thomas Chi, MD, MBA.

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.

"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.

“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.

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.

Kidney Stones

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