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Introduction:To bridge the gap between evidence and clinical judgment, we defined scenarios appropriate for ureteral stent omission after uncomplicated ureteroscopy (URS) using the RAND/UCLA Appropriateness Method. We retrospectively assessed rates of appropriate stent omission, with the goal to implement these criteria in clinical practice.Methods:A panel of 15 urologists from the MUSIC (Michigan Urological Surgery Improvement Collaborative) met to define uncomplicated URS and the variables that influence stent omission decision making. Over 2 rounds, they scored clinical scenarios for appropriateness criteria (AC) for stent omission based on a combination of variables. AC were defined by median scores of 1 to 3 (inappropriate), 4 to 6 (uncertain) and 7 to 9 (appropriate). Multivariable analysis determined the association of each variable with AC scores. Uncomplicated URS cases in the MUSIC registry were assigned AC scores and stenting rates assessed.Results:Seven variables affecting stent decision making were identified. Of the 144 scenarios, 26 (18%) were appropriate, 88 (61%) inappropriate and 30 (21%) uncertain for stent omission. Most scenarios appropriate for omission were pre-stented (81%). Scenarios with ureteral access sheath or stones >10 mm were only appropriate if pre-stented. Stenting rates of 5,181 URS cases correlated with AC scores. Stents were placed in 61% of cases appropriate for omission (practice range, 25% to 98%).Conclusions:We defined objective variables and AC for stent omission following uncomplicated URS. AC scores correlated with stenting rates but there was substantial practice variation. Our findings demonstrate that the appropriate use of stent omission is underutilized.

Purpose:The ROCKS (Reducing Operative Complications from Kidney Stones) program in MUSIC (Michigan Urological Surgery Improvement Collaborative) was created to optimize ureteroscopy outcomes. Through data collection, distribution of reports, patient education, and standardization of medication, post-ureteroscopy emergency department visits in Michigan have declined. It is unclear whether this is because of statewide quality efforts or due to national trends. We therefore sought to understand emergency department visit rates in Michigan compared to a national data set.Materials and Methods:We compared the MUSIC ROCKS clinical registry in Michigan against a national cohort, Optum’s de-identified Clinformatics Data Mart, from 2016-2021 (excluding Michigan). We identified patients who underwent ureteroscopy and the proportion who had a postoperative emergency department visit within 30 days. Emergency department rates were modeled over time, adjusting for age, gender, comorbidity, and ureteral stenting.Results:We identified 24,688 patients in MUSIC ROCKS and 99,340 in the Clinformatics Data Mart database who underwent ureteroscopy. The risk-adjusted emergency department visit rate in MUSIC ROCKS significantly declined over the study period (10.5% in 2016 to 6.9% in 2021, P < 0.001) while the mean emergency department visit rate in the Clinformatics Data Mart cohort was 9.9% and did not change over time (9.6% in 2016 to 10% in 2021). Comparing emergency department visits between the cohorts, the MUSIC ROCKS rate significantly declined relative to the Clinformatics Data Mart (P < 0.001) over the study period.Conclusions:Postoperative emergency department visit rates in Michigan have declined significantly after ureteroscopy since the establishment of MUSIC ROCKS. This decline outpaced national rates, providing evidence that systematic quality initiatives can improve urological care.

choice but currently RIRS seems to be equally effective and even preferred when the access particularly in lower pole is difficult. TFL laser complements the surgery and helps improve SFR. A key step is widening of the opening post intervention to minimize residual fragments.

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