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Item Addition of Sodium Bicarbonate to Irrigation Solution May Assist in Dissolution of Uric Acid Fragments During Ureteroscopy(Liebert, 2018) Paonessa, Jessica E.; Williams, James C., Jr.; Lingeman, James E.; Urology, School of MedicineIntroduction: We hypothesized that adding sodium bicarbonate (bicarb) to normal saline (NS) irrigation during ureteroscopy in patients with uric acid (UA) nephrolithiasis may assist in dissolving small stone fragments produced during laser lithotripsy. In vitro testing was performed to determine whether dissolution of UA fragments could be accomplished within 1 hour. Materials and Methods: In total 100% UA renal calculi were fragmented, filtered, and separated by size. Fragment sizes were <0.5 mm and 0.5 to 1 mm. Similar amounts of stone material were agitated in solution at room temperature. Four solutions were tested (NS, NS +1 ampule bicarb/L, NS +2, NS +3). Both groups were filtered to remove solutions after fixed periods. Filtered specimens were dried and weighed. Fragment dissolution rates were calculated as percent removed per hour. Additional testing was performed to determine whether increasing the temperature of solution affected dissolution rates. Results: For fragments <0.5 mm, adding 2 or 3 bicarb ampules/L NS produced a dissolution rate averaging 91% ± 29% per hour. This rate averaged 226% faster than NS alone. With fragments 0.5 to 1 mm, addition of 2 or 3 bicarb ampules/L NS yielded a dissolution rate averaging 22% ± 7% per hour, which was nearly five times higher than NS alone. There was a trend for an increase in mean dissolution rate with higher temperature but this increase was not significant (p = 0.30). Conclusions: The addition of bicarbonate to NS more than doubles the dissolution rate of UA stone fragments and fragments less than 0.5 mm can be completely dissolved within 1 hour. Addition of bicarb to NS irrigation is a simple and inexpensive approach that may assist in the dissolution of UA fragments produced during ureteroscopic laser lithotripsy. Further studies are needed to determine whether a clinical benefit exists.Item Initial Experience with Narcotic-Free Ureteroscopy: A Feasibility Analysis(Liebert, 2018-10) Large, Tim; Heiman, Joshua; Ross, Ashley; Anderson, Blake; Krambeck, Amy; Medicine, School of MedicineBackground and Purpose: In the United States, there is an opioid abuse epidemic fueled by prescription medications. Concerns that uncontrolled pain after surgical procedures will result in poor patient satisfaction and increased workload for ancillary staff are potential factors that influence provider prescription habits. Currently, there is a paucity of literature on analgesic requirements after ureteroscopy (URS) for nephrolithiasis. Our study objective was to evaluate the safety of narcotic-free ureteroscopy (nf-URS) and assess its impact on provider workload. Methods: We performed a retrospective chart review of 104 patients, between October 2017 and May 2018, who underwent URS and who required a stent postprocedure. Starting February 2018, patients without absolute contraindication or allergies to nonsteroidal anti-inflammatory drugs received a prescription for diclofenac instead of hydrocodone or oxycodone. Postoperative phone calls to nurses and residents, emergency room visits, and prescription monitoring reports were evaluated for all patients, and compared between the nf-URS and the standard ureteroscopy (s-URS). Results: There were 52 nf-URS and 52 s-URS procedures. In the postoperative period, 9 (17%) nf-URS and 10 (19%) s-URS patients called with postoperative pain issues. Five (10%) nf-URS vs 9 (17%) s-URS patients obtained narcotics after seeking additional medical care after URS because of inadequate pain control. There were no postoperative complications in our cohort. Compared with s-URS, 6871.5 mg less of morphine equivalent dosage (1375 hydrocodone tablets) was administered to nf-URS patients immediately after surgery. Conclusions: Attempts to reduce the number of narcotic prescriptions are paramount in the fight against narcotic addiction in the United States. Although our initial cohort is small, this feasibility study provides compelling evidence that nf-URS is a safe and effective practice. Furthermore, nf-URS resulted in a dramatic decrease in the number of narcotics circulating in the community.Item Same-Session Bilateral Ureteroscopy: Safety and Outcomes(Elsevier, 2017) Ingimarsson, Johann P.; Rivera, Marcelino; Knoedler, John J.; Krambeck, Amy E.; Department of Urology, School of MedicineObjective To assess the complications and outcomes associated with same-session bilateral ureteroscopy in a tertiary referral center, as same-session bilateral ureteroscopy for stone disease has been critiqued for the theoretical risk of injury to both ureters with subsequent risk to renal function. Methods We retrospectively reviewed all cases of bilateral ureteroscopy performed for urolithiasis by a single surgeon at out institution between 2009 and 2014. These were compared to a prospective unilateral ureteroscopy database. Results There were 117 same-session bilateral ureteroscopic procedures performed in 113 patients totaling 234 ureteroscopies. A flexible ureteroscope was used in 228 ureters (97.4%), and 6 (2.6%) were semirigid only. Ureteral dilators were required in 8 (6.8%) cases. Pre-stenting was performed in 23 (19.6%) patients. Short-term complications were observed following 19 (16.2%) procedures, including 11 (9.4%) Clavien I, 4 (3.4%) Clavien II, and 4 (3.4%) Clavien III. Of the 84 (71.8%) patients who completed a 6-week follow-up, there were no long-term complications. Stone-free rates were 91.4% for patients imaged with abdominal x-ray and ultrasound, and 84.2% for those imaged with computed tomography scans. Neither complications nor re-admissions were significantly different in the unilateral group. Median length of follow-up for the entire cohort was 2.8 years (range 0-7 years). Conclusion Bilateral ureteroscopy can be performed safely with short-term complications, consistent with published literature. We found no long-term complications and high stone-free rates. Bilateral ureteroscopy in a single procedure represents a viable standard of care for patients with bilateral stone disease.