Emergency ureteroscopy for all acute stone patients is not widespread in the UK but this is not the case elsewhere. In Auckland, New Zealand, it is commonly carried out in the emergency setting to reduce pressure on elective lists and expedite patient management. The authors report their two-year experience of emergency ureteroscopy in a hospital with a 1.6 million catchment population. Emergency ureteroscopy was undertaken for patients who had failed medical management of colic; defined as persistent pain, large stone size or re-admission with pain following failed conservative treatment. Patients with urosepsis or those unfit for anaesthesia were excluded. The intention was always to complete ureteroscopic management in one sitting. Standard 6.4/7.8F semi-rigid ureteroscope was used with access to holmium: YAG laser or lithoclast. A flexible ureteroscope was available in all cases. A total of 499 ureteroscopies were carried out, of which 394 were emergency ureteroscopy. A total of 285 patients (72%) were successfully treated in one sitting. Ureteroscopic failure was defined as residual fragment >3mm or the need for additional subsequent procedures. Patient demographics, BMI and length of procedure were similar in the two groups. Stone size was a predictor of failure (mean stone size for the successful group was 7mm and unsuccessful group was 9mm). Similarly, successfully treated patients were more likely to have an ASA score of 1 (103 vs. 26 patients) Failures were due to a combination of factors: narrow ureter, proximal migration, residual fragments and impaction. The rate of success was higher in distal ureteric (91%) rather than proximal (60%), where the iliac vessels were defined as the boundary. The majority of these patients underwent ureteric stenting and a subsequent procedure. Only 11% of the failed group had flexible ureteroscopy. Complications were identified in 20 (5%) of patients. These included anaesthetic complications, urinary retention and haematuria. In six patients, mucosal injury occurred but the majority of these were minor. The incidence of infective complications was low, which the authors attribute to the fact that patients with evidence of infection were excluded. This paper demonstrates that emergency ureteroscopy can be carried out safely, albeit with a lower success rate than in elective cases. This is likely to be due, in part, to the absence of pre-stented patients and the relatively low use of the flexible uretero-renoscope. Against this is the removal of any patient from the cohort with a suggestion of infection. There is no analysis of economic or patient experience data in this study, which the authors agree would be ideal. Many urologists in the UK would prefer to stent in haste and laser at leisure but this may be due to availability of operative time and other factors rather than a reluctance to treat stones acutely. The authors describe reasonable success in the emergency management of acute stone disease and make a good case for its widespread use. 

Role of emergency ureteroscopy in the management of ureteric stones: analysis of 394 cases.
Zargar-Shoshtari K, Anderson W, Rice M.
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Ciaran Lynch

Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, UK.

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