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Does early intervention improve outcomes for patients with acute ureteral colic?

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Abstract

Objectives

Early surgical intervention is increasingly employed for patients with ureteral colic, but guidelines and current practice are variable. We compared 60-day outcomes for matched patients undergoing early intervention vs. spontaneous passage.

Methods

This multicentre propensity-matched cohort analysis used administrative data and chart review to study all eligible emergency department (ED) patients with confirmed 2.0–9.9 mm ureteral stones. Those having planned stone intervention within 5 days comprised the intervention cohort. Controls attempting spontaneous passage were matched to intervention patients based on age, sex, stone width, stone location, hydronephrosis, ED site, ambulance arrival and acuity level. The primary outcome was treatment failure, defined as rescue intervention or hospitalization within 60 days, using a time to event analysis. Secondary outcome was ED revisit rate.

Results

Among 1154 matched patients, early intervention did not reduce the risk of treatment failure (adjusted hazard ratio 0.94; P = 0.61). By 60 days, 21.8% of patients in both groups experienced the composite primary outcome (difference 0.0%; 95% confidence interval − 4.8 to 4.8%). Intervention patients required more hospitalizations (20.1% vs. 12.8%; difference 7.3%; 95% CI 3.0–11.5%) and ED revisits (36.1% vs. 25.5%; difference 10.6%; 95% CI 5.3–15.9%), but (insignificantly) fewer rescue interventions (18.9% vs. 21.3%; difference − 2.4%; 95% CI − 7.0 to 2.2%).

Conclusions

In matched patients with 2.0–9.9 mm ureteral stones, early intervention was associated with similar rates of treatment failure but greater patient morbidity, evidenced by hospitalizations and emergency revisits. Physicians should adopt a selective approach to interventional referral and consider that spontaneous passage probably provides better outcomes for many low-risk patients.

Résumé

Objectifs

L’intervention chirurgicale précoce est de plus en plus utilisée pour les patients atteints de coliques urétérales, mais les lignes directrices et la pratique actuelle sont variables. Nous avons comparé les résultats à 60 jours pour les patients appariés subissant une intervention précoce par rapport au passage spontané.

Les méthodes

Cette analyse de cohorte multicentrique par appariement de propension a utilisé des données administratives et l'examen des dossiers pour étudier tous les patients admissibles des services d'urgence (ED) ayant des calculs urétéraux confirmés de 2,0-9,9 mm Ceux qui avaient planifié une intervention de calcul dans les cinq jours constituaient la cohorte d'intervention. Les témoins tentant de passer spontanément ont été appariés aux patients d'intervention en fonction de l'âge, du sexe, de la largeur du calcul, de l'emplacement du calcul, de l'hydronéphrose, du site de l'urgence, de l'arrivée de l'ambulance et du niveau d'acuité. Le résultat principal était l’échec de traitement, défini comme l’intervention de sauvetage ou l’hospitalisation dans les 60 jours, utilisant un temps à l’analyse d’événement. Le résultat secondaire était le taux de revisite à l'urgence

Résultats

Sur 1154 patients appariés, une intervention précoce n'a pas réduit le risque d'échec du traitement (ratio de risque ajusté = 0,94 ; P = 0,61). Au bout de 60 jours, 21,8 % des patients des deux groupes avaient atteint le résultat primaire composite (différence = 0,0 % ; intervalle de confiance à 95 % -4,8 % à 4,8 %). Les patients d'intervention ont nécessité plus d'hospitalisations (20,1 % contre 12,8 % ; différence = 7,3 % ; IC 95 %, 3,0 à 11,5 %) et de nouvelles visites à l'urgence (36,1 % contre 25,5 % ; différence = 10,6 % ; IC 95 %, 5,3 à 15,9 %), mais (de manière non significative) moins d'interventions de sauvetage (18,9 % contre 21,3 % ; différence = 2,4 % ; IC 95 %, -7,0 à 2,2 %).

Conclusions

Chez des patients appariés présentant des calculs urétéraux de 2,0 à 9,9 mm, l'intervention précoce a été associée à des taux similaires d'échec du traitement mais à une morbidité plus importante des patients, comme en témoignent les hospitalisations et les revisites aux urgences. Les médecins devraient adopter une approche sélective de l'orientation interventionnelle et considérer que le passage spontané offre probablement de meilleurs résultats pour de nombreux patients à faible risque

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References

  1. Scales CD, Smith AC, Hanley JM, et al. Prevalence of kidney stones in the United States. Eur Urol. 2012;62:160–5.

    Article  Google Scholar 

  2. Bensalah K, Tuncel A, Gupta A, et al. Determinants of quality of life for patients with kidney stones. J Urol. 2008;179:2238–43.

    Article  Google Scholar 

  3. Saigal CS, Joyce G, Timilsina AR. Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management? Kidney Int. 2005;68:1808–14.

    Article  Google Scholar 

  4. Bryant M, Angell J, Tu H, et al. Health related quality of life for stone formers. J Urol. 2012;188:436–40.

    Article  Google Scholar 

  5. Hofman B. Is there a technological imperative in health care? Int J Technol Asses Health Care. 2002;18(3):675–89.

    Article  Google Scholar 

  6. Picozzi SCM, Ricci C, Gaeta M, et al. Urgent ureteroscopy as first-line treatment for ureteral stones: a meta-analysis of 681 patients. Urol Res. 2012;40(5):581–6.

    Article  Google Scholar 

  7. Youn JH, Kim SS, Yu JH, et al. Efficacy and safety of emergency ureteroscopic management of ureteral calculi. Korean J Urol. 2012;53(9):632–5.

    Article  Google Scholar 

  8. Sarica K, Tanriverdi O, Aydin M, et al. Emergency ureteroscopic removal of ureteral calculi after first colic attack: is there any advantage? Urology. 2011;78(3):516–20.

    Article  Google Scholar 

  9. Ordon M, Andonian S, Blew B, et al. Canadian urological association guideline: management of ureteral calculi. Can Urol Assoc J. 2015;9(11–12):E837-851.

    Article  Google Scholar 

  10. Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society guideline PART II. J Urol. 2016;196(4):1161–9.

    Article  Google Scholar 

  11. Turk C, Neisius A, Petrik A, et al. EAU guidelines on urolithiasis (Limited Update March 2017). European Association of Urology 2017. p. 25–8. https://www.uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urolithiasis_2017_10-05V2.pdf. Accessed 2 Apr 2020.

  12. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. Am J Roentgenol. 2002;178:101–3.

    Article  Google Scholar 

  13. Coursey C, Casalino D, Remer E, et al. ACR appropriateness criteria: acute onset flank pain suspicion of stone disease. Ultrasound Q. 2012;28(3):227–33.

    Article  Google Scholar 

  14. Teichman JM. Acute renal colic from ureteral calculus. N Engl J Med. 2004;350:684–93.

    Article  CAS  Google Scholar 

  15. Ordon M, Urbach D, Mamdani M, et al. The surgical management of kidney stone disease: a population based time series analysis. J Urol. 2014;192(5):1450–6.

    Article  Google Scholar 

  16. Innes G, Mcrae A, Grafstein E, et al. Variability of renal colic management and outcomes in two Canadian cities. Can J Emerg Med. 2018;20(5):1–11.

    Article  Google Scholar 

  17. Heers H, Turney BW. Trends in urological stone disease: a 5-year update of hospital episode statistics. BJU Int. 2016;118(5):785–9.

    Article  Google Scholar 

  18. Al-Ghazo MA, Ghalayini IF, Al-Azab RS, et al. Emergency ureteroscopic lithotripsy in acute renal colic caused by ureteral calculi: a retrospective study. Urol Res. 2011;39:497–501.

    Article  Google Scholar 

  19. Zargar-Shoshtari K, Anderson W, Rice M. Role of emergency ureteroscopy in the management of ureteric stones: analysis of 394 cases. BJU Int. 2015;115(6):946–50.

    Article  Google Scholar 

  20. Osorio L, Lima E, Soares J, et al. Emergency ureteroscopic management of ureteral stones: why not? Urology. 2007;69(1):27–31.

    Article  Google Scholar 

  21. Scales CD, Saigal CS, Hanley JM, et al. The impact of unplanned postprocedure visits in the management of patients with urinary stones. Surgery. 2014;155(5):769–75.

    Article  Google Scholar 

  22. Dauw C, Kaufman SR, Hollenbeck BK, et al. Expulsive therapy versus early endoscopic stone removal in patients with acute renal colic: a comparison of indirect costs. J Urol. 2014;191(3):673–7.

    Article  Google Scholar 

  23. Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28:3083–107.

    Article  Google Scholar 

  24. Sekhon JS. Multivariate and propensity score matching. J Stat Softw. 2011;42(7):52.

    Article  Google Scholar 

  25. Innes GD, Lang E, Wang D, et al. Thirty day outcomes after medical vs. surgical management of acute renal colic. Can J Emerg Med. 2015;17(Suppl):S49–50.

    Google Scholar 

  26. Hollingsworth JM, Norton EC, Kaufman SR, et al. Medical expulsive therapy versus early endoscopic stone removal for acute renal colic: an instrumental variable analysis. J Urol. 2013;190:882–7.

    Article  Google Scholar 

  27. Shah TT, Gao C, Peters M, et al. Factors associated with spontaneous stone passage in a contemporary cohort of patients presenting with acute ureteric colic. BJU Int. 2019;124:504–13.

    Article  Google Scholar 

  28. Innes GD, Scheuermeyer FX, Law MR, et al. Sex-related differences in emergency department renal colic management: females have fewer computed tomography scans but similar outcomes. Acad Emerg Med. 2016;23(10):1153–60.

    Article  Google Scholar 

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Acknowledgements

We wish to thank Heidi Boyda, Kevin Lonergan, Dongmei Wang, Lena Cuthbertson, Jennifer Dotchin, Kelsey Innes, Bryce Weber, Kevin Carlson, Eddy Lang, Peter Dickhoff, Kat Koger, David Ward and Brit Sunderani for their valuable contributions. Within the last 3 years, Dr. Teichman has received grants and personal fees from Boston Scientific, grants from Cook Urologic, personal fees from Urigen and non-financial support from Innova Quartz, although none were related to this research. None of the other investigators have any potential conflicts to report.

Funding

This study was funded by the MSI Foundation (a non-profit health research funding agency). MRL received salary support through a Canada Research Chair and the Michael Smith Foundation for Health Research.

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Authors and Affiliations

  1. Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Room C231, Foothills Medical Centre, 1403, 29 Street NW, Calgary, AB, T2N 2T9, Canada

    Grant D. Innes, Andrew D. McRae & James Andruchow

  2. Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada

    Joel M. H. Teichman

  3. Department of Emergency Medicine and Center for Healthcare Evaluation and Outcome Sciences, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada

    Frank X. Scheuermeyer & Eric Grafstein

  4. Centre for Health Services and Policy Research, School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada

    Lucy Cheng & Michael R. Law

Authors
  1. Grant D. Innes
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  2. Joel M. H. Teichman
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  7. Lucy Cheng
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  8. Michael R. Law
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Correspondence to Grant D. Innes.

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Conflict of interest

JA reports grants from MSI Foundation, during the conduct of the study; MHT reports grant from Cook Urologic, from Boston Scientific, from Lumenis, other from Urigen, outside the present work; the remaining authors have nothing to disclose.

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Innes, G.D., Teichman, J.M.H., Scheuermeyer, F.X. et al. Does early intervention improve outcomes for patients with acute ureteral colic?. Can J Emerg Med 23, 679–686 (2021). https://doi.org/10.1007/s43678-020-00016-4

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  • DOI: https://doi.org/10.1007/s43678-020-00016-4

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