Changing surgical aspects of urinary stone disease

Surgical management of urinary calculous disease has changed dramatically in the past decade. The development of percutaneous nephrostomy techniques has allowed new access to upper tract stones. Percutaneous removal of large calculi was made possible by the development of ultrasonic and electrohydraulic lithotripsy. All upper tract calculi can now be removed in 70 to 100 per cent of cases with minimal complications. Nephrostolithotomy has reduced transfusion rates and hospitalization costs and has markedly shortened convalescence periods compared with open surgery. Ureteroscopy followed nephrostolithotomy as advanced fiberoptic technology allowed the development of the small-caliber instruments required for this procedure. With experience, successful stone retrieval has occurred in 90 per cent or more of cases, again with minimal complications. As nephrostolithotomy and ureteroscopy have become available, the subspecialty of endourology has emerged and significantly changed the management of urinary tract calculi. Perhaps the most significant advance in stone therapy has been the design and implementation of extracorporeal shock wave lithotripsy. With this noninvasive technique, most renal and proximal ureteral calculi can be effectively treated with minimal morbidity and convalescence. Research in lithotripter design is continuing, with more advanced and effective machines on the horizon. The applicability of extracorporeal therapy for the treatment of biliary tract calculi is currently under investigation. Finally, one should not disparage medical therapy for recurrent nephrolithiasis. A comprehensive metabolic evaluation combined with selective medical therapy provides almost complete relief from recurrent stone formation and makes medical therapy an integral component of treating the patient with renal or ureteral calculi.     

In-hospital mortality of heparin-induced thrombocytopenia in end-stage kidney disease. A retrospective national population-based cohort study

Aim

Heparin induced thrombocytopenia (HIT) and end stage kidney disease (ESKD) are independent conditions associated with increased mortality and morbidity, however, whether ESKD is an independent risk factor for increased mortality in HIT admissions is not well studied. Therefore, we aimed to compare in-hospital mortality in HIT admissions based on their ESKD status.

Methods

This is a retrospective cohort study of HIT hospitalizations aged 18 and older using the 2016–2019 national inpatient sample (NIS) database.

Results

From 2016 to 2019 we had 12 161 admissions for HIT among 28 484 087 total hospitalizations. The annual incidence rate for HIT admissions per 100 000 admissions were: 47, 46, 41.1, and 36.6, respectively (p < .001) in 2016, 2017, 2018, and 2019 respectively. Among HIT admissions, the mean age was 64.3 years, 46.8% were females, 68% were Whites and 16% were Blacks. Black patients have a significantly higher likelihood of in-hospital mortality than White patients (aOR 1.25; 95% CI: 1.06, 1.48; p = .007). Patients who did not have any insurance or self-pay had higher mortality compared to Medicare (aOR 1.64; 95% CI: 1.13, 2.38; p = .009). ESKD status was not associated with higher or lower in-hospital mortality among HIT admissions (aOR 1.002; 95% CI: 0.84, 1.19; p = .981) after adjusting for age, sex, race, and insurance status.

Conclusion

There are no higher or lower odds of in-hospital mortality in the ESKD subgroup in HIT admissions in adults. Decreasing incidence of HIT hospitalizations was seen over the years from 2016 to 2019.     

Association of spondyloarthritis and sarcoidosis: A retrospective observational population-based matched cohort study

ObjectivesTo investigate the association between spondyloarthritis (SpA) and sarcoidosis.MethodsAn observational retrospective population-based matched cohort study was conducted. Using data from the Spanish Minimum Basic Data Set. All the admissions of patients with SpA reported between 1999 and 2015 were analysed and a control group matched by age, sex and year of admission was selected. Crude and age- and sex-adjusted incidence rates for sarcoidosis were calculated. Generalized linear models were used for trend analysis and unconditional logistic regression models for calculating crude and adjusted odds ratios (ORs) to assess the association between sarcoidosis and SpA.ResultsThe study database contained data on 214,280 hospitalisations: 107,140 admissions of patients with SpA and 107,140 of patients without SpA. Overall, 220 of the admissions were of patients with sarcoidosis: 133 (0.12%) in the SpA group and 87 (0.08%) in the non-SpA group (P < 0.05). The incidence rates of sarcoidosis were 2.68 and 1.64 per 100,000 per year in the SpA and non-SpA groups, respectively. The trend was similar in the two cohorts. Regarding potential associations between SpA and sarcoidosis, the crude and adjusted ORs were 1.52 (95% CI: 1.16–2.01) and 1.50 (95% CI: 1.14–1.97) overall in patients with SpA, with adjusted ORs of 1.42 (95% CI: 1.03–1.94) and 1.81 (95% CI: 1.29–2.55) in patients with ankylosing spondylitis and psoriatic arthritis, respectively.ConclusionsThere is a relationship that is not due to chance between sarcoidosis and SpA and specifically that sarcoidosis is significantly associated with ankylosing spondylitis and psoriatic arthritis.     

Therapeutic management of upper urinary tract stone disease in 172 subjects

Three hundred one patients with recurrent renal calculi were studied: 129 patients received no treatment, and 172 received either bendrofluazide (90) or allopurinol (82). The renal stone recurrence rate was assessed over a five-year period, and it was noted that the incidence of recurrence was significantly lower in patients receiving either bendrofluazide or allopurinol. In male patients there was no difference in recurrence rates in those receiving the different drugs, but female patients receiving allopurinol had a significantly lower five-year recurrence rate when compared with those receiving bendrofluazide.     

A retrospective cohort study of perioperative management on the morbidity of urogynecologic surgery

Introduction and hypothesis

To determine whether premenopausal and early (<70) and late postmenopausal women whose comorbidities were screened and managed using a standardized protocol experienced comparable perioperative complications after urogynecologic surgery.

Methods

We retrospectively reviewed the charts of all women who presented for surgical management of their pelvic floor disorders over 4.5?years for any complications, which occurred intraoperatively to 6?weeks postoperatively.

Results

Late postmenopausal women underwent more vaginal (100/124, 159/246, and 226/288, p?p?p?P?p?P?=?0.789).

Conclusions

With standardized screening and management, our premenopausal and early and late postmenopausal women experienced similar perioperative complications.     

Patterns of health care use of injured adults: A population-based matched cohort study

BackgroundHealthcare use by traumatically injured individuals prior to and subsequent to their injury are not often explored for different types of injuries. This study aims to describe health care use 12 months preceding and 12 months following a traumatic injury by injury type and injury severity.MethodHospital and mortality data from three Australian states were linked in a population-based matched cohort study. Individuals ≥18 years who had an injury-related hospital admission in 2009 were identified as the injured cohort. A comparison cohort of non-injured people, matched 1:1 on age, gender and postcode of residence, was randomly selected from the electoral roll. Twelve-month pre- and post-index injury health service use was examined. Rates, adjusted rate ratios and attributable risk proportions were calculated by injury type and severity.ResultsThe injury cohort experienced higher 12-month pre- and post-injury hospital admissions than the non-injured group. By 6 to 7 months post-injury, the injury cohort had largely returned to their pre-injury health service use levels, except for injuries involving dislocations, sprains and strains and injury to nerves and spinal cord. Hip fracture (17.69 per 100 person-months) and poisoning (16.09 per 100 person-months) had the highest rates of post-injury hospitalisation in the injured cohort. The adjusted rate ratios (ARR) for post-injury hospitalisation were highest for poisoning (ARR: 3.77; 95% CI: 3.38–4.21) and injury to nerves and spinal cord (ARR: 2.73; 95% CI: 2.27–3.28). Poisoning also had the highest ARR for post-injury LOS (ARR: 5.31; 95% CI: 4.51–6.27).ConclusionsAfter sustaining a traumatic injury, many individuals are readmitted to hospital and require ongoing care up to 12 months post-injury. That injured individuals post-injury largely return to their pre-index injury hospital use by 6 to 7 months could imply a return to pre-injury function and/or that other measures of health service use should be explored. Trauma services should consider long-term follow-up and support services for seriously injured patients post-hospital discharge.     

Impact of socioeconomic status in etiology and management of urinary stone disease

INTRODUCTION: The diverse manifestations of urolithiasis provide a very interesting epidemiological study from the standpoints of geography, socioeconomic status, nutrition and culture. Stone disease not only affects the patient, but also the national economy, as the disease is prevalent in the productive age group. There has been a continuous search for the cost-effectiveness of different treatment modalities not only to treat the patient but also to prevent its recurrence. MATERIALS AND METHODS: The various socioeconomic and dietary factors playing roles in the etiology of urinary calculi in the stone-prevalent areas of the world were analyzed. The impact of urinary tract stone disease on the socioeconomic infrastructure of the patient and national economy was studied. A cost-effectiveness analysis vis-à-vis the safety and efficacy of various treatment modalities in both developed and developing countries was done. RESULTS: The standard of living and level of nutrition have directly influenced the process of urolithiasis amongst the communities of the world. A low socioeconomic status has been linked to endemic bladder calculi seen in many poor countries with people subsisting on a deficient diet. The incidence of upper urinary tract calculi increases with prosperity and more nutritious diets. Replacement of open surgery with minimally invasive techniques (ESWL, PCNL, URS) for treating stones in the urinary tract has greatly reduced the patients' morbidity and mortality and the period of hospitalization and convalescence. This change in treatment has also led to less days of absence from work and could minimize the loss to national economy. Minimally invasive surgery is more cost effective in developed countries because of the short hospital stay. However, in developing countries open surgery still appears to be cost-effective in certain subset of the patients. CONCLUSIONS: There is a need for proper health care and a medical insurance system to take care of the financial burden, especially in developing countries, of a disease with a high magnitude of recurrence and morbidity. The need and type of medical treatment should be appraised continually to accommodate advances in techniques of stone removal. Lastly, the quest for etiology, cost-effective treatment and prevention still continues and even today we cannot stay better than Frère Jacques, 'I have removed the stone, it is up to God to cure the patient'.     

Congenital heart disease in adults: surgical management.

Fifty patients between 17 and 62 years of age who had been operated on in the past five years were reviewed. Of 24 patients with atrial septal defects, pulmonary hypertension and dysarrhythmia, which occurred more frequently in the older patients, contributed to marked disability in 54 percent and congestive heart failure in 25 percent. Correction carried minimal risk. All seven patients with coarctation of the aorta were previously hypertensive, and two remain moderately hypertensive after repair. Three patients with Ebstein anomaly were severely disabled but have improved after plastic repairs, although mild tricuspid insufficiency persists. The eight patients with ventricular septal defect were asymptomatic, but the rest, treated for tetralogy, pulmonic stenosis, patent ductus arteriosus, and coronary artery fistula, were moderately symptomatic. Clinical improvement has been achieved and sustained in all patients following repair. The results confirm that congenital heart malformations can be corrected with a good outcome in adults.     

Subsequent cancer risk of children receiving post voiding cystourethrography: A nationwide population-based retrospective cohort study

Background

To estimate the subsequent cancer risk of children receiving post voiding cystourethrography (VCUG), a nationwide population-based retrospective cohort study with the data from the Taiwan National Health Insurance Research Database (NHIRD) were used for the analysis.

Methods

In the VCUG cohort, 31,908 participants younger than 18 years of age who underwent VCUG between 1997 and 2008 were identified from the NHIRD. A comparison cohort, the non-VCUG cohort, was randomly selected among children without VCUG examination histories during 1997–2008, frequency matched for age (every 5 years), sex, geographic region area, parents’ occupation, and index year based on a 1:4 ratio. Cox’s proportional hazard regression analysis was conducted to estimate the subsequent cancer risk of children receiving VCUG.

Results

The overall cancer risk of the VCUG cohort is 1.92-fold (95 % CI?=?1.34–2.74) higher than that of the non-VCUG cohort with statistical significance. The genital cancer and urinary system cancer risks of the VCUG cohort are respectively 6.19-fold (95 % CI?=?1.37–28.0) and 5.8-fold (95 % CI?=?1.54–21.9) higher than those of the non-VCUG cohort with statistical significance. The hazard ratios are higher in genital cancer, urinary system cancer (the major radiation exposure area), and cancer of the abdomen, except for the genitourinary system (the minor radiation exposure area), in sequence.

Conclusions

Pediatric VCUG is associated with increased subsequent cancer risk, especially in the genitourinary system.     

The epidemiology of reno-ureteral stone disease in Koreans: a nationwide population-based study

The objective of this study was to evaluate the annual incidence of upper tract urolithiasis based on a large population-based study in Korea. This study used a subset of the 2009 Health Insurance and Review and Assessment service-National Patient Sample (HIRA-NPS). The 2009 HIRA-NPS contains data for 1,115,721 patients (711,285 inpatients and 404,436 outpatients) from January 2009 to December 2009. Based on these data, we selected patients who had been diagnosed with urolithiasis using the ICD code and calculated the incidence of urolithiasis. The total number of estimated urolithiasis patients was 219,328. The annual incidence of upper tract urolithiasis was estimated to be 457.02 per 100,000 in the overall population, with 589.09 per 100,000 men and 326.64 per 100,000 women. The male-to-female ratio was about 1.8:1. The annual incidence of urolithiasis in Korea was 457 per 100,000. It is higher than that previously reported in Japan, but lower than that in Western countries.