Brain E, Geraghty RM, Lovegrove CE et al: Natural history of post-treatment kidney stone fragments: a systematic review and meta-analysis. J Urol 2021; 206: 526–538.

(Special thanks to Drs. Juan Diego Cedeño and Ervin Kocjancic at the University of Illinois at Chicago)

To render a patient stone-free or to leave little fragments behind that “shouldn’t be a problem” in the treatment of kidney stones: that is the question. It isn’t just about getting rid of stones; what has to be included in the equation are also factors such as recurrence and reintervention that affect patient morbidity and economic concerns such as time off work.

To our knowledge, this is the first systematic review and meta-analysis of the natural history of residual asymptomatic kidney stones after treatment. Interventions sometimes leave small (<4 mm) fragments often considered clinically insignificant, and this study aimed to evaluate the rate of spontaneous passage, intervention, and disease progression of these fragments.

Data were extracted from 18 studies and revealed that fragments <4 mm can carry a risk of the need for a subsequent intervention. Regardless of whether the procedure was percutaneous nephrolithotomy, shock wave lithotripsy or ureteroscopy, these fragments can cause a downstream problem, and the risk of reintervention can be as high as 38% to 88% for up to 4 years and potentially extend beyond. There was no difference between small and large fragments (>4 mm) in disease progression or spontaneous passage. Larger fragments were more likely to need intervention, but a sizable minority of smaller fragments still required intervention, at around 20%.

The authors emphasize that “the term ‘clinically insignificant’ should be abandoned,” and that patients with fragments should be closely followed and advised of the possibility of progression and the potential need for future intervention. We’d say: try to take it all, folks!

Simon DP, Bajic P, Lynch KM et al: Spermatic cord block series as a minimally invasive therapy for chronic scrotal content pain. J Urol 2021; 206: 725-732.

(Special thanks to Drs. Jason Huang and Rodrigo Pagani at the University of Illinois at Chicago)

Chronic scrotal content pain is a debilitating condition, and the typical management of refractory cases involves microsurgical denervation of the spermatic cord. But is there a role for spermatic cord block series for these patients?

In a series of 44 men with chronic scrotal content pain, pain was assessed with an 11-point numerical pain rating scale. The authors found that 31, or 70.5%, of the patients had a response of 1 point or greater, including 9, or 20.5%, of patients who experienced complete response. Between responders and nonresponders, there were no statistically significant differences in the etiology or duration of the pain, nor were there differences in previously failed medical or surgical treatments. Patients with partial response after spermatic cord block series were more likely to respond to subsequent microsurgical denervation of the spermatic cord compared to nonresponders, at 100% vs 20%.

This study highlights that patients with chronic scrotal content pain may benefit from spermatic cord block series regardless of duration or etiology and even after failed microsurgical denervation of the spermatic cord. While microsurgical denervation of the spermatic cord effectively provides durable relief from refractory chronic scrotal content pain, the authors demonstrated that serial injections of a long-acting local anesthetic and steroid is a safe, minimally invasive alternative to surgery for patients who choose to avoid surgery or who are poor surgical candidates. Patients who have unsatisfactory response to spermatic cord block series are still candidates for microsurgical denervation of the spermatic cord, and their response to spermatic cord block series is predictive of the likelihood of microsurgical denervation of the spermatic cord success. This study provides ammunition for a real role for spermatic cord block series in the treatment of chronic scrotal content pain.

Hiller SC, Daignault-Newton S, Pimentel H et al: Ureteral stent placement following ureteroscopy increases emergency department visits in a statewide surgical collaborative. J Urol 2021; 205: 1710–1717.

(Special thanks to Drs. Marcin Zuberek and Simone Crivellaro at the University of Illinois at Chicago)

Not placing a ureteral stent following an uncomplicated ureteroscopy is an option according to the AUA/EAU guidelines. Up to 66% to 84% of urologists will place a stent during ureteroscopy and won’t follow that guideline for multiple reasons. This may stem from a previous Cochrane Database Review, which suggested that stenting might reduce unnecessary visits to the emergency department. These authors aimed to analyze whether stent placement actually matters in the number of emergency department visits.

A total of 9,662 ureteroscopic procedures were performed between June 2016 and May 2019 in the state of Michigan. Overall, a stent was placed in 72.7% of these cases. Stented patients presented to the emergency department 1.4% more often and 0.9% more were hospitalized. After controlling for patient and surgeon differences, stent placement during ureteroscopy was independently associated with 1.25 higher odds of an emergency department visit within 30 days. However, these visits typically did not lead to admissions.

This finding contradicts the previous Cochrane Database finding and could lead to a potential paradigm shift in endoscopic practice. One major limitation of this study is the intrinsic bias of this study noted in the statistically significant difference in stenting based on the kidney stone size. This could have skewed the result toward the numbers favoring that stenting predisposes patients to return to the emergency department due to the fact that the patients with less complicated ureteroscopy are less likely to return. Maybe not stenting every ureter doesn’t sound like a bad idea, but selecting which cases it applies to remains an open need for urology.