Impact of Personnel Scarcity on Urolithiasis Treatment: A Comparative Study of the Pre- and Post-Pandemic Eras

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Hassler, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3839554/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: This study examines the impact of medical personnel scarcity on urolithiasis treatment by comparing complication rates in urinary stone patients undergoing ureterorenoscopic (URS) treatment before and after the onset of this novel circumstance. Patients and Methods: A total of 160 patients who received URS (including flexible URS) treatment for urolithiasis at the Vienna General Hospital were included. Specifically, 80 consecutive patients from the year 2018, before the scarcity of personnel, and 80 patients from 2023, following the emergence of this situation, were analyzed in two patient cohorts. Complications that occurred during the waiting period, intraoperatively, and postoperatively, were recorded. Moreover, demographic and clinical data were collected to compare the two patient cohorts. The primary endpoint was the differences in the complication rates of the two cohorts. The secondary endpoints were readmission, ureteral stent (re-)placement, stent encrustation, or length of hospital stay. Results: The study revealed a significant increase in complications during the waiting period in the 2023 cohort (p < .001), concomitant with a substantial rise in the median waitingtime from 20 days to 94 days (p < .001). No significant disparities were observed in intra- and postoperative complications. Furthermore, patients in 2023 demonstrated a higher rate of readmissions during the waiting time for surgery (16.25% vs 2.5%, p = .002) and longer length of stays (2.94 vs. 2.10 days, p < .001). Conclusion: In the new era of personnel scarcity with longer waiting time for surgery, increased complication rates during the waiting period pose a significant challenge in the treatment of urolithiasis requiring URS. There is a need for an adaptation of the treatment strategies to address this issue. Ureterorenoscopy Urolithiasis Waiting time Complication Personnel Scarcity 1. Introduction The healthcare system has undergone significant changes in past years, especially in the aftermath of the global COVID-19 pandemic, which led to considerable implications for the management of various diseases, including urolithiasis. The scarcity of healthcare personnel in many regions has resulted in extended waiting times for elective operations ( 1 ), thereby affecting the timely access to treatment. During the course of the pandemic, the decision to postpone elective surgeries demonstrated a detrimental effect on their outcomes, leading to the development of triage strategies ( 2 , 3 ). However, as the pandemic subsides and triage systems are phased out, the persisting shortage of healthcare personnel presents a novel and unparalleled limitation to healthcare delivery in the western world ( 4 ). As a result, this study set out to investigate and contrast the perioperative complications in patients who underwent ureterorenoscopy (URS) for urolithiasis before and after the introduction of this new situation. 2. Methods 2.1. Complication Reporting Non-urological risk factors were assessed with the American Society of Anaesthesiologists’ physical status classification system (ASA) ( 5 ), and presence of cardiovascular disease, in accordance with Mitropoulos et al., which was specifically designed for the reporting of urological procedures ( 6 ). The extent of stone disease was assessed by the number of urinary stones, the maximal diameter of the primary stone, bilaterality of the surgery, and the creatinine value at the initial presentation. The complication reporting was divided into three time periods; intraoperative, perioperative, and complications occurring during waiting time for surgery. The complication reporting was performed in line with the urological surgery reporting of Mitropoulos et al. and with the URS Global study of Somani et al. ( 6 , 7 ). Intraoperatively observed complications were bleeding, failed access, and extravasation. Postoperatively observed complications and complications during the waiting time were bleeding, stent migration, urinary tract infection (UTI) with or without fever, and colic/pain. Noteworthy is the inclusion of complications arising during the waiting time ensuring an all-encompassing assessment of procedural outcomes. Further evaluated variables without immediate clinical significance, such as significant urinary culture findings or stent encrustation, were excluded from the classification of complications and assessed separately. Readmissions, reoperations, and incomplete operations were documented with the underlying causes. Operational distinctions, such as surgery duration, stone-free rates, and length of hospital stay, were also scrutinized to discern disparities in procedural facets. Patients were routinely followed for up to 8 weeks after surgery. 2.2. Sample Size To determine the sample size, a non-systematic search was conducted using the MEDLINE/PubMed and EMBASE databases to investigate literature about the impact of waiting time on ureterorenoscopic treatment outcomes for urolithiasis. The search terms were "waiting time," "wait time," "ureterorenoscopy," "urolithiasis," "urinary stone disease," “personnel scarcity”, “staff scarcity”, and "complications". The only identified study with a similar topic was by Medina et al., which observed a substantial 186% increase in postoperative complications subsequent to stone treatment, as the waiting period extended from 46.4 days to 70 days ( 8 ). Given the scarcity of literature addressing the current personnel shortage situation, the aforementioned study was leveraged to calculate the requisite sample size. Expert estimation of the variance was incorporated into the calculation, guided by the methodology outlined by Jones et al. ( 9 ). For the 2018 group, it was estimated that the mean total complication frequency stood at 0.2 complications per patient, with an anticipated 100% increase in complication frequency, resulting in an expected rate of 0.4 complications per patient in the 2023 group. A significance level of 0.05 and a power of 0.8 were employed in the sample size calculation, yielding an initial estimate of 64 patients as statistically sufficient. However, acknowledging the reliance on estimations inherent in this process, we opted to include 80 patients in each patient group to bolster the study's statistical robustness. 2.3. Patient Population A consecutive sample of the initial 80 patients who underwent URS treatment (including flexible URS) for urolithiasis at the Vienna General Hospital in the year 2018 and the year 2023 were included in the study for analysis. The last patient included in 2023 was operated in September, the last patient included in 2018 was operated in May. Patients with documented anatomical anomalies of the urinary tract, undergoing URS for a malignancy, receiving concomitant operations, or with other planned operations within 30 days before or after the surgery were excluded from this study. 2.4. Outcomes The primary outcomes of this study were the differences in waiting times and complication rates in the intraoperative, postoperative, and waiting periods, together with the total complication rate. The secondary outcomes were the differences in operation duration, encrustation, urinary tract infection (UTI), febrile urinary tract infection (fUTI), significant preoperative urinary culture (defined as detection of uropathogenic microorganisms in the preoperative urine culture, quantity ≥ 103 CFU), frequency of stent (re-)placement, return to the operation theatre, incomplete operation, length of stay, readmission rates, and stone-free rates. 2.5. Statistical Methods A confidence interval of 95% was applied for all statistical tests. The descriptives of the two cohorts were explored to identify differences that could potentially influence the outcomes. An independent t-test was used to compare the descriptives age, ASA, creatinine at initial visit, number of kidney stones, and diameter of the primary kidney stone between the two samples. Furthermore, a Fisher’s exact test was employed to compare the distribution of gender, presence of cardiovascular disease, bilaterality, significant urinary culture, localisation of the stones, and preoperative double-J placement. As the primary outcome, the differences in the frequency of complications in each phase (during waiting time, intraoperative, postoperative) were assessed with an independent t-test. The independent t-test was utilized to compare the waiting times for surgery, operation duration, and length of hospital stay between 2018 and 2023. To evaluate the relationship between the operation year and stone-free rates, postoperative double-J placements, proportion of complication-free URS stone treatments, incomplete operations, readmission rates, occurrences of Clavien-Dindo complications ( 10 ), and specific complications, Chi2-test was utilized. Subsequently, a linear regression analysis was conducted to examine the relationship between various fixed factors and the frequency of complications. The fixed factors were age, operation year, gender, creatinine level at the initial visit, American Society of Anaesthesiologists (ASA) classification, bilaterality, operation duration, preoperative double-J stent placement, presence of cardiovascular disease, size of the primary stone, and quantity of urinary stones. The linear regression analysis was conducted for all three dimensions separately, with the independent variable of interest being the frequency of complications. Considering that preoperative ureteral stenting has been proposed as a significant element linked to particular complications ( 11 ), its impact on significant differences was seperately assessed with an univariate ANOVA, taking year and preoperative stenting as fixed variables. 3. Results 3.1. Descriptives and Exclusions No significant differences were detected in baseline characteristics of the two cohorts (see Table 1). 18 patients were excluded from the study based on the exclusion criteria: documented anatomical anomalies of the urinary tract in 4 patients, 11 patients undergoing URS for malignancy, 2 patients with other planned operations within 30 days before or after the surgery, and 1 patient receiving a concomitant operation (transurethral resection of the bladder). 3.2. Primary Outcomes (Complications) Patients who underwent URS treatment in 2023 had significantly longer waiting times with an average of 94 days (58-114.75 days) compared to those in 2018 with an average waiting time of 20 days (13.25-30.75 days) (p < .001). In 2023, patients experienced significantly more complications during the waiting time compared to 2018 (F(9,141) = 3.892, p < .001). The multivariate analysis, conducted using linear regression, identified the operation year as the sole factor significantly influencing the total complication rate during the waiting time (β = .459, p < .001). Furthermore, the univariate ANOVA revealed a significant effect of the operation year on the complication rate during the waiting time (F(1, 156) = 24.067, p = .001), with no observed significant effect of preoperative stenting on the complication rate during the waiting time (F(1, 156) = 0.411, p = .522). No significant differences in intra- and postoperative complication rates between the two cohorts were observed, as shown in Table 2. No mortality was observed. 3.3. Secondary Outcomes (Procedural Facets) The rates of UTI and fUTI showed a significant increase in the 2023 cohort, while significantly more stents showed encrustation, and significantly more urinary cultures were positive with uropathogenic microorganisms (see Table 3). Accordingly, the incidence of readmissions showed a statistically significant increase in 2023. Specifically, within the 2023 cohort, 14 readmissions occurred during the waiting period necessitating stent (re-)placement, composing of 10 replacements and four new placements. 12 of these 14 operations in 2023 were due to UTI, and two of them were due to renal colic only. The only stent replacement in 2018 during the waiting time was also due to fUTI, which took place 20 days following the initial placement. The median time point for stent replacement in 2023 was 61 days (50.25-112.5 days) after the initial stent placement. Moreover, it is noteworthy that the duration of surgical procedures demonstrated a statistically significant prolongation for the 2023 cohort. Additionally, there was a statistically significant increase observed in the length of hospital stay for patients in the same cohort (see Table 3). 4. Discussion This research aimed to assess the consequences of prolonged waiting times for URS for urolithiasis during the current medical personnel scarcity, acknowledging that this novel circumstance could potentially become the norm. In contrast to the findings of Medina et al. ( 8 ), no increase in the postoperative or intraoperative complications was observed in the 2023 cohort, which was subjected to substantially longer waiting times. However, the study revealed a notable rise in complications during the waiting period within the 2023 cohort, highlighting a significant obstacle in the era of personnel scarcity. Current literature addressing this new circumstance is scarce. In this study, with 10 patients requiring stent replacement, indwelling ureteral stent has been shown to be a limiting factor in the treatment quality of urolithiasis in 2023, which is already a known risk factor for several complications such as pre- and postoperative UTI ( 12 , 13 ). Acknowledging this novel situation, an approach adopting more frequent primary URS has been recommended ( 14 ), which has also been suggested as feasible in most patients ( 15 ). However, it should be underlined that the choice of treatment modality is also based on the availability of resources ( 16 ), which might vary among different settings, especially in the era of personnel scarcity. The EAU guidelines suggest performing the stone operation in one or two weeks after the preoperative stenting (if required), while additionally stating the unclarity of the ideal stent indwelling time ( 17 ). Yet, it should be underlined that the statistical analyses did not show an influence of the preoperative stenting on the waiting time complication rates. Therefore, the observed complications cannot be solely attributed to the extended stent indwelling time. Operation times and length of hospital stays were longer in the 2023 cohort, which implies an increased complexity of the urolithiasis patients in the personnel scarcity era. Factors such as higher rates of UTI during the waiting period, higher rates of preoperative positive urinary cultures, and higher encrustation rates of ureteral stents might contribute to this heightened complexity of the treatment of urinary stone patients. It is important to note that longer operation durations, longer hospital stays, and higher rates of readmissions, impose an increased burden on the healthcare system, which already operates with reduced capacity. Additionally, given that urolithiasis imposes a significant symptomatic burden, it is important to incorporate considerations related to the quality of life into regular assessments. It is noteworthy that this aspect was not evaluated in the present study, potentially indicating a limitation in its scope. Furthermore, it is important to note that, despite depicting outcomes of common situation in the western world, this study was conducted within a single institution. Experiences from different settings will help enhancing comprehension and development of solutions to the issue. In light of these findings, it is reasonable to suggest that patients with urolithiasis requiring ureterorenoscopic intervention and facing extended waiting times may benefit from a more comprehensive management during the waiting period. To determine the most effective form or timing of these preventive measures, specific complications within distinct subgroups must be analysed, and prospective trials with different approaches should be undertaken. 5. Conclusion In the current era of personnel scarcity and prolonged waiting times for surgery, increased complication rates during the waiting time have been demonstrated to be a major hindrance in the treatment of urolithiasis requiring URS. To improve the treatment quality of urolithiasis requiring surgery, a more close-meshed management of the waiting period is required. Subgroup analyses and prospective trials are needed to identify the timing and modality of the best preventive measures. Declarations Author Contribution OY and MR performed the design and conception of the investigation. OY, CS, JV, MRH, SFS, and MR conducted data collection and analysis. The initial version of the manuscript was authored by OY and MR. Subsequent versions were reviewed and commented on by all authors. No funding was received to assist with the preparation of this manuscript. Acknowledgments OY and MR performed the design and conception of the investigation. OY, CS, JV, MRH, SFS, and MR conducted data collection and analysis. The initial version of the manuscript was authored by OY and MR. Subsequent versions were reviewed and commented on by all authors. No funding was received to assist with the preparation of this manuscript. Conflict of Interest Authors declare no conflict of interest. Ethics Statement This study was approved by the Institutional Review Board at our institution (IRB No. 1836/2023) prior to data collection. References van Ginneken E, Siciliani L, Reed S, Eriksen A, Tille F, Zapata T (2022) Addressing backlogs and managing waiting lists during and beyond the COVID-19 pandemic. TEN 28(1):35. https://doi.org/10.1007/s12345-022-0000-0 Abdel Raheem A, Alowidah I, Soliman M, Haresy M, Almozeni A, Althagafi S et al (2020) Urolithiasis treatment options during COVID-19 pandemic: review of current recommendations and triage systems. Afr J Urol 26(1):1–7. https://doi.org/10.1007/s12345-020-0000-0 Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P et al (2020) COVID-19 and urology: a comprehensive review of the literature. BJU Int 125(6):E7–E14. https://doi.org/10.1007/s12345-020-0000-1 Poindexter K (2022) The Great Resignation in health care and academia: rebuilding the postpandemic nursing workforce. Nurs Educ Perspect 43(4):207–208. https://doi.org/10.1007/s12345-022-0000-1 ASo A (2022) ASA physical status classification system 2014 [06.05.2022]. Available from: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system . Accessed May 6, Mitropoulos D, Artibani W, Graefen M, Remzi M, Rouprêt M, Truss M (2012) Reporting and Grading of Complications After Urologic Surgical Procedures: An ad hoc EAU Guidelines Panel Assessment and Recommendations. Eur Urol 61(2):341–349. https://doi.org/10.1007/s12345-020-0000-2 Somani B, Giusti G, Sun Y, Osther P, Frank M, De Sio M et al (2017) Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study. 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EAU Guidelines Edn presented at the EAU Annual Congress Amsterdam; https://doi.org/10.1007/s12345-022-0000-3 Tables Table 1 Descriptives Variable 2018 (n=80) 2023 (n=80) Finding Age (in years) median (IQR) 54.57 (44-63.85) 55 (50.27-66.03) p = .136 Gender n (%) Female = 30 (37.5%) Female = 32 (40%) p = .746 ASA* mean ± SD 2.03 ± 0.45 2.1 ± 0.44 p = .282 Presence of cardiovascular disease n (%) 44 (55%) 43 (53.8%) p = .874 Creatinine at first visit (mg/dL) median (IQR) 0.9 (0.8-1.1) 0.9 (0.75-1.0) p = .373 Preoperative double-J placement 48/80 (60%) 49/80 (61.25%) p = .871 Bilaterality 4/80 (5%) 7/80 (8.75%) p = .349 Quantity of urinary stones 1 (1-2) 2 (1-2) p = .073 Diameter of the primary stone (in mm) 8 (6-11) 10 (7.25-13) p = .161 * American Society of Anaesthesiologists (ASA) classification Table 2 Complications Variable 2018 2023 Finding Complications during the waiting time Mean ± SD 0.08 ± .31 0.54 ± 0.70 p < .001 Nausea 3/80 (3.75%) 3/80 (3.75%) p = 1 Stent migration 0/80 (0%) 3/80 (3.75%) p = .08 Pain 1/80 (1.25%) 14/80 (17.5%) p < .001 UTI 1/80 (1.25%) 11/80 (13.75%) p = .003 f-UTI 1/80 (1.25%) 13/80 (16.25%) p < .001 Intraoperative complications Mean ± SD 0.14 ± 0.41 0.21 ± 0.54 p = .164 Bleeding 3/80 (3.75%) 3/80 (3.75%) p = 1 Failed access 5/80 (6.25%) 8/80 (10%) p = .385 Extravasation 3/80 (3.75%) 6/80 (7.5%) p = .303 Postoperative complications Mean ± SD 0.08 ± 0.31 0.15 ± 0.42 p = .102 Bleeding 2/80 (2.5%) 4/80 (5%) p = .405 Nausea 1/80 (1.25%) 1/80 (1.25%) p = 1 Stent migration 0/80 (0%) 1/80 (1.25%) p = .316 Pain 1/80 (1.25%) 2/80 (2.5%) p = .56 UTI 2/80 (2.5%) 1/80 (1.25%) p = .56 f-UTI 0/80 (0%) 1/80 (1.25%) p = .316 Other* 0/80 (0%) 2/80 (2.5%) p = .155 Grade 1*** 3/80 (3.75%) 6/80 (7.5%) p = .303 Grade 2*** 2/80 (2.5%) 3/80 (3.75%) p = .65 Grade 3*** 1/80 (1.25%) 2/80 (2.5%) p = .56 Grade 4*** 0/80 (0%) 1/80 (1.25%) p = .316 Total complications Mean ± SD 0.26 ± 0.68 0.9 ± 1.06 p < .001 * Other complications were aspiration pneumonia and brief psychotic disorder. ** The operations were performed by the same physicians in the two cohorts. *** According to Clavien-Dindo classification Table 3 Procedural Outcomes Variable 2018 2023 Finding OP duration (in minutes) median (IQR) 55 (25-80) 59 (40,73-91,75) p = .025 Waiting time (in days) median (IQR) 20 (13.25-30.75) 94 (58-114.75) p < .001 Postoperative double-J placement 50/80 (62.5%) 71/80 (88.75%) p < .001 Length of stay (in days) mean ± SD 2.10 ± 0.94 2.95 ± 1.80 p < .001 Patient without any complication 65/80 (81.25%) 35/80 (43.75%) p < .001 Readmission 2/80 (2.5%) 14/80 (16.25%) p = .002 Encrustation 1/48 (2.1%) 11/49 (22.45%) p < .002 Preoperative significant urinary culture* 10/80 (12.5%) 31/80 (38.75%) p < .001 Stent (re-)placement 1/80 (1.25%) 14/80 (17.5%) p < .001 Return to the operation theatre 1/80 (1.25%) 2/80 (2.5%) p = .56 Stone-free rates 66/80 (82.5%) 58/80 (72.5%) p = .13 * Detection of uropathogenic microorganisms in the preoperative urine culture, quantity ≥ 10 3 CFU Additional Declarations No competing interests reported. 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Shariat","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Shahrokh","middleName":"F.","lastName":"Shariat","suffix":""},{"id":266143771,"identity":"ca6a8a9a-888e-47a9-b80a-e0b10dab7281","order_by":5,"name":"Mesut Remzi","email":"data:image/png;base64,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","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":true,"prefix":"","firstName":"Mesut","middleName":"","lastName":"Remzi","suffix":""}],"badges":[],"createdAt":"2024-01-06 11:14:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3839554/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3839554/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50439345,"identity":"2d8b6923-0fd8-4193-aecc-a255f1b86b9f","added_by":"auto","created_at":"2024-01-31 14:42:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":348178,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3839554/v1/8488bdeb-c7f4-465d-9614-57d51200934f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Personnel Scarcity on Urolithiasis Treatment: A Comparative Study of the Pre- and Post-Pandemic Eras","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe healthcare system has undergone significant changes in past years, especially in the aftermath of the global COVID-19 pandemic, which led to considerable implications for the management of various diseases, including urolithiasis. The scarcity of healthcare personnel in many regions has resulted in extended waiting times for elective operations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), thereby affecting the timely access to treatment. During the course of the pandemic, the decision to postpone elective surgeries demonstrated a detrimental effect on their outcomes, leading to the development of triage strategies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, as the pandemic subsides and triage systems are phased out, the persisting shortage of healthcare personnel presents a novel and unparalleled limitation to healthcare delivery in the western world (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As a result, this study set out to investigate and contrast the perioperative complications in patients who underwent ureterorenoscopy (URS) for urolithiasis before and after the introduction of this new situation.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Complication Reporting\u003c/h2\u003e \u003cp\u003eNon-urological risk factors were assessed with the American Society of Anaesthesiologists\u0026rsquo; physical status classification system (ASA) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and presence of cardiovascular disease, in accordance with Mitropoulos et al., which was specifically designed for the reporting of urological procedures (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The extent of stone disease was assessed by the number of urinary stones, the maximal diameter of the primary stone, bilaterality of the surgery, and the creatinine value at the initial presentation.\u003c/p\u003e \u003cp\u003eThe complication reporting was divided into three time periods; intraoperative, perioperative, and complications occurring during waiting time for surgery. The complication reporting was performed in line with the urological surgery reporting of Mitropoulos et al. and with the URS Global study of Somani et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Intraoperatively observed complications were bleeding, failed access, and extravasation. Postoperatively observed complications and complications during the waiting time were bleeding, stent migration, urinary tract infection (UTI) with or without fever, and colic/pain. Noteworthy is the inclusion of complications arising during the waiting time ensuring an all-encompassing assessment of procedural outcomes. Further evaluated variables without immediate clinical significance, such as significant urinary culture findings or stent encrustation, were excluded from the classification of complications and assessed separately.\u003c/p\u003e \u003cp\u003eReadmissions, reoperations, and incomplete operations were documented with the underlying causes. Operational distinctions, such as surgery duration, stone-free rates, and length of hospital stay, were also scrutinized to discern disparities in procedural facets. Patients were routinely followed for up to 8 weeks after surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Sample Size\u003c/h2\u003e \u003cp\u003eTo determine the sample size, a non-systematic search was conducted using the MEDLINE/PubMed and EMBASE databases to investigate literature about the impact of waiting time on ureterorenoscopic treatment outcomes for urolithiasis. The search terms were \"waiting time,\" \"wait time,\" \"ureterorenoscopy,\" \"urolithiasis,\" \"urinary stone disease,\" \u0026ldquo;personnel scarcity\u0026rdquo;, \u0026ldquo;staff scarcity\u0026rdquo;, and \"complications\". The only identified study with a similar topic was by Medina et al., which observed a substantial 186% increase in postoperative complications subsequent to stone treatment, as the waiting period extended from 46.4 days to 70 days (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Given the scarcity of literature addressing the current personnel shortage situation, the aforementioned study was leveraged to calculate the requisite sample size. Expert estimation of the variance was incorporated into the calculation, guided by the methodology outlined by Jones et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor the 2018 group, it was estimated that the mean total complication frequency stood at 0.2 complications per patient, with an anticipated 100% increase in complication frequency, resulting in an expected rate of 0.4 complications per patient in the 2023 group. A significance level of 0.05 and a power of 0.8 were employed in the sample size calculation, yielding an initial estimate of 64 patients as statistically sufficient. However, acknowledging the reliance on estimations inherent in this process, we opted to include 80 patients in each patient group to bolster the study's statistical robustness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Patient Population\u003c/h2\u003e \u003cp\u003eA consecutive sample of the initial 80 patients who underwent URS treatment (including flexible URS) for urolithiasis at the Vienna General Hospital in the year 2018 and the year 2023 were included in the study for analysis. The last patient included in 2023 was operated in September, the last patient included in 2018 was operated in May.\u003c/p\u003e \u003cp\u003ePatients with documented anatomical anomalies of the urinary tract, undergoing URS for a malignancy, receiving concomitant operations, or with other planned operations within 30 days before or after the surgery were excluded from this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Outcomes\u003c/h2\u003e \u003cp\u003eThe primary outcomes of this study were the differences in waiting times and complication rates in the intraoperative, postoperative, and waiting periods, together with the total complication rate. The secondary outcomes were the differences in operation duration, encrustation, urinary tract infection (UTI), febrile urinary tract infection (fUTI), significant preoperative urinary culture (defined as detection of uropathogenic microorganisms in the preoperative urine culture, quantity\u0026thinsp;\u0026ge;\u0026thinsp;103 CFU), frequency of stent (re-)placement, return to the operation theatre, incomplete operation, length of stay, readmission rates, and stone-free rates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Statistical Methods\u003c/h2\u003e \u003cp\u003eA confidence interval of 95% was applied for all statistical tests. The descriptives of the two cohorts were explored to identify differences that could potentially influence the outcomes. An independent t-test was used to compare the descriptives age, ASA, creatinine at initial visit, number of kidney stones, and diameter of the primary kidney stone between the two samples. Furthermore, a Fisher\u0026rsquo;s exact test was employed to compare the distribution of gender, presence of cardiovascular disease, bilaterality, significant urinary culture, localisation of the stones, and preoperative double-J placement.\u003c/p\u003e \u003cp\u003eAs the primary outcome, the differences in the frequency of complications in each phase (during waiting time, intraoperative, postoperative) were assessed with an independent t-test. The independent t-test was utilized to compare the waiting times for surgery, operation duration, and length of hospital stay between 2018 and 2023. To evaluate the relationship between the operation year and stone-free rates, postoperative double-J placements, proportion of complication-free URS stone treatments, incomplete operations, readmission rates, occurrences of Clavien-Dindo complications (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and specific complications, Chi2-test was utilized.\u003c/p\u003e \u003cp\u003eSubsequently, a linear regression analysis was conducted to examine the relationship between various fixed factors and the frequency of complications. The fixed factors were age, operation year, gender, creatinine level at the initial visit, American Society of Anaesthesiologists (ASA) classification, bilaterality, operation duration, preoperative double-J stent placement, presence of cardiovascular disease, size of the primary stone, and quantity of urinary stones. The linear regression analysis was conducted for all three dimensions separately, with the independent variable of interest being the frequency of complications.\u003c/p\u003e \u003cp\u003eConsidering that preoperative ureteral stenting has been proposed as a significant element linked to particular complications (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), its impact on significant differences was seperately assessed with an univariate ANOVA, taking year and preoperative stenting as fixed variables.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Descriptives and Exclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo significant differences were detected in baseline characteristics of the two cohorts (see Table 1). 18 patients were excluded from the study based on the exclusion criteria: documented anatomical anomalies of the urinary tract in 4 patients, 11 patients undergoing URS for malignancy, 2 patients with other planned operations within 30 days before or after the surgery, and 1 patient receiving a concomitant operation (transurethral resection of the bladder).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Primary Outcomes (Complications)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who underwent URS treatment in 2023 had significantly longer waiting times with an average of 94 days (58-114.75 days) compared to those in 2018 with an average waiting time of 20 days (13.25-30.75 days) (p \u0026lt; .001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2023, patients experienced significantly more complications during the waiting time compared to 2018 (F(9,141) = 3.892, p \u0026lt; .001). The multivariate analysis, conducted using linear regression, identified the operation year as the sole factor significantly influencing the total complication rate during the waiting time (\u0026beta; = .459, p \u0026lt; .001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, the univariate ANOVA revealed a significant effect of the operation year on the complication rate during the waiting time (F(1, 156) = 24.067, p = .001), with no observed significant effect of preoperative stenting on the complication rate during the waiting time (F(1, 156) = 0.411, p = .522).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo significant differences in intra- and postoperative complication rates between the two cohorts were observed, as shown in Table 2. No mortality was observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Secondary Outcomes (Procedural Facets)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe rates of UTI and fUTI showed a significant increase in the 2023 cohort, while significantly more stents showed encrustation, and significantly more urinary cultures were positive with uropathogenic microorganisms (see Table 3). Accordingly, the incidence of readmissions showed a statistically significant increase in 2023. Specifically, within the 2023 cohort, 14 readmissions occurred during the waiting period necessitating stent (re-)placement, composing of 10 replacements and four new placements. 12 of these 14 operations in 2023 were due to UTI, and two of them were due to renal colic only. The only stent replacement in 2018 during the waiting time was also due to fUTI, which took place 20 days following the initial placement. The median time point for stent replacement in 2023 was 61 days (50.25-112.5 days) after the initial stent placement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, it is noteworthy that the duration of surgical procedures demonstrated a statistically significant prolongation for the 2023 cohort. Additionally, there was a statistically significant increase observed in the length of hospital stay for patients in the same cohort (see Table 3).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis research aimed to assess the consequences of prolonged waiting times for URS for urolithiasis during the current medical personnel scarcity, acknowledging that this novel circumstance could potentially become the norm. In contrast to the findings of Medina et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), no increase in the postoperative or intraoperative complications was observed in the 2023 cohort, which was subjected to substantially longer waiting times. However, the study revealed a notable rise in complications during the waiting period within the 2023 cohort, highlighting a significant obstacle in the era of personnel scarcity.\u003c/p\u003e \u003cp\u003eCurrent literature addressing this new circumstance is scarce. In this study, with 10 patients requiring stent replacement, indwelling ureteral stent has been shown to be a limiting factor in the treatment quality of urolithiasis in 2023, which is already a known risk factor for several complications such as pre- and postoperative UTI (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Acknowledging this novel situation, an approach adopting more frequent primary URS has been recommended (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), which has also been suggested as feasible in most patients (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, it should be underlined that the choice of treatment modality is also based on the availability of resources (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), which might vary among different settings, especially in the era of personnel scarcity. The EAU guidelines suggest performing the stone operation in one or two weeks after the preoperative stenting (if required), while additionally stating the unclarity of the ideal stent indwelling time (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Yet, it should be underlined that the statistical analyses did not show an influence of the preoperative stenting on the waiting time complication rates. Therefore, the observed complications cannot be solely attributed to the extended stent indwelling time.\u003c/p\u003e \u003cp\u003eOperation times and length of hospital stays were longer in the 2023 cohort, which implies an increased complexity of the urolithiasis patients in the personnel scarcity era. Factors such as higher rates of UTI during the waiting period, higher rates of preoperative positive urinary cultures, and higher encrustation rates of ureteral stents might contribute to this heightened complexity of the treatment of urinary stone patients. It is important to note that longer operation durations, longer hospital stays, and higher rates of readmissions, impose an increased burden on the healthcare system, which already operates with reduced capacity.\u003c/p\u003e \u003cp\u003eAdditionally, given that urolithiasis imposes a significant symptomatic burden, it is important to incorporate considerations related to the quality of life into regular assessments. It is noteworthy that this aspect was not evaluated in the present study, potentially indicating a limitation in its scope. Furthermore, it is important to note that, despite depicting outcomes of common situation in the western world, this study was conducted within a single institution. Experiences from different settings will help enhancing comprehension and development of solutions to the issue.\u003c/p\u003e \u003cp\u003eIn light of these findings, it is reasonable to suggest that patients with urolithiasis requiring ureterorenoscopic intervention and facing extended waiting times may benefit from a more comprehensive management during the waiting period. To determine the most effective form or timing of these preventive measures, specific complications within distinct subgroups must be analysed, and prospective trials with different approaches should be undertaken.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn the current era of personnel scarcity and prolonged waiting times for surgery, increased complication rates during the waiting time have been demonstrated to be a major hindrance in the treatment of urolithiasis requiring URS. To improve the treatment quality of urolithiasis requiring surgery, a more close-meshed management of the waiting period is required. Subgroup analyses and prospective trials are needed to identify the timing and modality of the best preventive measures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eOY and MR performed the design and conception of the investigation. OY, CS, JV, MRH, SFS, and MR conducted data collection and analysis. The initial version of the manuscript was authored by OY and MR. Subsequent versions were reviewed and commented on by all authors. No funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOY and MR performed the design and conception of the investigation. OY, CS, JV, MRH, SFS, and MR conducted data collection and analysis. The initial version of the manuscript was authored by OY and MR. Subsequent versions were reviewed and commented on by all authors. No funding was received to assist with the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board at our institution (IRB No. 1836/2023) prior to data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003evan Ginneken E, Siciliani L, Reed S, Eriksen A, Tille F, Zapata T (2022) Addressing backlogs and managing waiting lists during and beyond the COVID-19 pandemic. 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Ann Surg 250(2):187\u0026ndash;196. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-009-0000-0\u003c/span\u003e\u003cspan address=\"10.1007/s12345-009-0000-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssimos D, Crisci A, Culkin D, Xue W, Roelofs A, Duvdevani M et al (2016) Preoperative JJ stent placement in ureteric and renal stone treatment: results from the Clinical Research Office of Endourological Society (CROES) ureteroscopy (URS) Global Study. BJU Int 117(4):648\u0026ndash;654. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-016-0000-0\u003c/span\u003e\u003cspan address=\"10.1007/s12345-016-0000-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNevo A, Mano R, Baniel J, Lifshitz DA (2017) Ureteric stent dwelling time: a risk factor for post-ureteroscopy sepsis. BJU Int 120(1):117\u0026ndash;122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-017-0000-1\u003c/span\u003e\u003cspan address=\"10.1007/s12345-017-0000-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanna B, Zhuo K, Chalasani V, Vass J, Rasiah K, Wines M et al (2021) Association between ureteric stent dwell time and urinary tract infection. ANZ J Surg 91(1\u0026ndash;2):187\u0026ndash;191. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-021-0000-0\u003c/span\u003e\u003cspan address=\"10.1007/s12345-021-0000-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasmani Z, Donati-Bourne J, Dhanasekaran A, Malik S, Jamal A, Doody J et al (2023) 1063 Prioritising Primary Ureteroscopy: Getting It Right First Time in Patients with Obstructing Urolithiasis by Using a New Treatment Pathway. Br J Surg 110(Supplement7):znad258. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-023-0000-1\u003c/span\u003e\u003cspan address=\"10.1007/s12345-023-0000-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMckay A, Somani BK, Pietropaolo A, Geraghty R, Whitehurst L, Kyriakides R et al (2021) Comparison of primary and delayed ureteroscopy for ureteric stones: a prospective non-randomized comparative study. Urol Int 105(1\u0026ndash;2):90\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-021-0000-1\u003c/span\u003e\u003cspan address=\"10.1007/s12345-021-0000-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsawi M, Nalagatla S, Ahmad N, Chandiramani AS, Mokool L, Nalagatla SK et al (2022) Primary versus delayed ureteroscopy for ureteric stones: A systematic review and meta-analysis. J Clin Urol 20514158221088687. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-022-0000-2\u003c/span\u003e\u003cspan address=\"10.1007/s12345-022-0000-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkolarikos A, Neisius A, Petř\u0026iacute;k A, Somani B, Thomas K, Gambaro G et al (eds) (2022) Urolithiasis. EAU Guidelines Edn presented at the EAU Annual Congress Amsterdam; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12345-022-0000-3\u003c/span\u003e\u003cspan address=\"10.1007/s12345-022-0000-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDescriptives\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"575\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2018 (n=80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2023 (n=80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eAge (in years) median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e54.57 (44-63.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e55 (50.27-66.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eGender n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003eFemale = 30 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003eFemale = 32 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eASA* mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e2.03 \u0026plusmn; 0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .282\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003ePresence of cardiovascular disease n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e44 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e43 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .874\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eCreatinine at first visit (mg/dL) median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e0.9 (0.8-1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e0.9 (0.75-1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .373\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003ePreoperative double-J placement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e48/80 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e49/80 (61.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .871\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eBilaterality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e4/80\u0026nbsp;(5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e7/80 (8.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .349\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eQuantity of urinary stones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e2 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.24390243902439%\"\u003e\n \u003cp\u003eDiameter of the primary stone (in mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.693379790940767%\"\u003e\n \u003cp\u003e8 (6-11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.609756097560975%\"\u003e\n \u003cp\u003e10 (7.25-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.452961672473867%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u0026nbsp;American Society of Anaesthesiologists (ASA) classification\u003c/p\u003e\n\u003cp\u003eTable 2 Complications\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eComplications during the waiting time\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMean \u0026plusmn; SD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.08 \u0026plusmn; .31\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.54 \u0026plusmn; 0.70\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep \u0026lt; .001\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eNausea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eStent migration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e0/80 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e14/80 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eUTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e11/80 (13.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003ef-UTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e13/80 (16.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIntraoperative complications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMean \u0026plusmn; SD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.14 \u0026plusmn; 0.41\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.21 \u0026plusmn; 0.54\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep = .164\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eFailed access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e5/80 (6.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e8/80 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eExtravasation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e6/80 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePostoperative complications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMean \u0026plusmn; SD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.08 \u0026plusmn; 0.31\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.15 \u0026plusmn; 0.42\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep = .102\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e4/80 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .405\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eNausea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eStent migration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e0/80 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eUTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003ef-UTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e0/80 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eOther*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e0/80 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eGrade 1***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e6/80 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eGrade 2***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e3/80 (3.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eGrade 3***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003eGrade 4***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e0/80 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.590682196339436%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal complications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMean \u0026plusmn; SD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.80199667221298%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.26 \u0026plusmn; 0.68\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.465890183028286%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.9 \u0026plusmn; 1.06\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.141430948419302%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep \u0026lt; .001\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e* Other complications were aspiration pneumonia and brief psychotic disorder.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e** The operations were performed by the same physicians in the two cohorts.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e*** According to Clavien-Dindo classification\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3 Procedural Outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eOP duration (in minutes) median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e55 (25-80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e59 (40,73-91,75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eWaiting time (in days) \u0026nbsp;median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e20 (13.25-30.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e94 (58-114.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003ePostoperative double-J placement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e50/80 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e71/80 (88.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eLength of stay (in days) mean \u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e2.10 \u0026plusmn; 0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e2.95 \u0026plusmn; 1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003ePatient without any complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e65/80 (81.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e35/80 (43.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eReadmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e14/80 (16.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eEncrustation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e1/48 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e11/49 (22.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003ePreoperative significant urinary culture*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e10/80 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e31/80 (38.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eStent (re-)placement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e14/80 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eReturn to the operation theatre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e1/80 (1.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e2/80 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e = .56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.333333333333336%\"\u003e\n \u003cp\u003eStone-free rates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e66/80 (82.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22%\"\u003e\n \u003cp\u003e58/80 (72.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e* Detection of uropathogenic microorganisms in the preoperative urine culture, quantity \u0026ge; 10\u003csup\u003e3\u003c/sup\u003e CFU\u003c/em\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ureterorenoscopy, Urolithiasis, Waiting time, Complication, Personnel Scarcity","lastPublishedDoi":"10.21203/rs.3.rs-3839554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3839554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003eThis study examines the impact of medical personnel scarcity on urolithiasis treatment by comparing complication rates in urinary stone patients undergoing ureterorenoscopic (URS) treatment before and after the onset of this novel circumstance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods:\u003c/strong\u003eA total of 160 patients who received URS (including flexible URS) treatment for urolithiasis at the Vienna General Hospital were included. Specifically, 80 consecutive patients from the year 2018, before the scarcity of personnel, and 80 patients from 2023, following the emergence of this situation, were analyzed in two patient cohorts. Complications that occurred during the waiting period, intraoperatively, and postoperatively, were recorded. Moreover, demographic and clinical data were collected to compare the two patient cohorts. The primary endpoint was the differences in the complication rates of the two cohorts. The secondary endpoints were readmission, ureteral stent (re-)placement, stent encrustation, or length of hospital stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eThe study revealed a significant increase in complications during the waiting period in the 2023 cohort (p \u0026lt; .001), concomitant with a substantial rise in the median waitingtime from 20 days to 94 days (p \u0026lt; .001). No significant disparities were observed in intra- and postoperative complications. Furthermore, patients in 2023 demonstrated a higher rate of readmissions during the waiting time for surgery (16.25% vs 2.5%, p = .002) and longer length of stays (2.94 vs. 2.10 days, p \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eIn the new era of personnel scarcity with longer waiting time for surgery, increased complication rates during the waiting period pose a significant challenge in the treatment of urolithiasis requiring URS. There is a need for an adaptation of the treatment strategies to address this issue.\u003c/p\u003e","manuscriptTitle":"Impact of Personnel Scarcity on Urolithiasis Treatment: A Comparative Study of the Pre- and Post-Pandemic Eras","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-10 09:17:45","doi":"10.21203/rs.3.rs-3839554/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec56220c-0993-400e-a66b-08dee1d184f9","owner":[],"postedDate":"January 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-31T14:34:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-10 09:17:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3839554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3839554","identity":"rs-3839554","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}