Understanding ureteral access sheath use within a statewide collaborative and its effect on surgical and clinical outcomes.

INTRODUCTION Ureteral access sheaths (UAS) are frequently used during ureteroscopy (URS), but their use is not without potential risk. We investigated patterns of UAS use and associated outcomes across practices in Michigan within a quality improvement collaborative. METHODS The Michigan Urological Surgery Improvement Collaborative's (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) initiative maintains a web-based prospective clinical registry of patients undergoing URS for urinary stone disease (USD). We analyzed all patients undergoing primary URS for renal and ureteral stones from June 2016 to July 2018 in the ROCKS registry. We determined rates of UAS usage across practices, associated outcomes, including 30-day ED visit and hospitalization as well as stone-free rates. Using multivariate logistical regression we determined the predictors of UAS use as well as outcomes including stone-free rates, ED visits, and hospitalizations associated with UAS use. RESULTS Of the 5316 URS identified, UAS was used in 1969 (37.7%) of cases. Stones were significantly larger and more likely to be located in the kidney in cases with UAS use. UAS use during URS varied greatly across practices (1.9% to 96%, p<0.05). After adjusting for clinical and surgical risk factors, UAS use significantly increased the odds of postoperative ED visit (OR 1.50, 95% CI 1.17 - 1.93, p<0.05) and hospitalization (OR 1.77, 95% CI 1.22 - 2.56, p<0.05) as well as decreased the odds of being stone free (OR 0.75, 0.57 - 0.99, p<0.05). CONCLUSIONS In the current study, UAS use during URS for USD was not associated with increased likelihood of being stone-free; moreover, it increased the odds of a postoperative ED visit and or hospitalization. Our findings demonstrate that UAS use is not without risk and should be employed judiciously.