Emergency Management of Obstructing Ureteric Stones: A Closed-Loop Audit of Hot Ureteroscopy Uptake Against Getting It Right First Time (GIRFT) Standards.

INTRODUCTION AND AIM: National guidance recommends hot (same-admission) ureteroscopy and laser lithotripsy as the default definitive treatment for suitable obstructing ureteric stones, rather than defaulting to temporizing measures such as ureteric stent insertion. The primary aim was (1) to determine the proportion of emergency ureteric stone cases managed by hot ureteroscopy against the GIRFT standard. Secondary aims were (2) to describe the pattern of emergency management and identify deviations from evidence-based practice, and (3) to assess the impact of a targeted action plan on the hot ureteroscopy rate. In addition, this article reports emergent findings identified during data review, including inter-surgeon variation in hot ureteroscopy uptake and individual case-level governance considerations, which were not prespecified analyses but are presented descriptively for their quality-improvement value.

METHODS: Cycle 1 (baseline) captured all emergency ureteric stone admissions over a three-month period (March to May 2024). Following presentation of results and an agreed action plan, cycle 2 (re-audit) captured all surgically-managed cases over the subsequent three-month period (August to October 2024). The primary outcome was the proportion of surgically-managed cases treated by hot ureteroscopy.

RESULTS: Cycle 1 identified 48 admissions, of which 22 were managed surgically; hot ureteroscopy was performed in only five (22.7%), with 17 (77%) judged retrospectively suitable. Tamsulosin was prescribed for all conservatively-managed stones regardless of size or location, contrary to trial and guideline evidence discussed below. Following the action plan, cycle 2 identified 20 surgically-managed cases; hot ureteroscopy rose to 10 (50%), more than doubling cycle 1's rate. Seven of the 10 stented-only cases were retrospectively judged suitable for hot ureteroscopy; individual surgeon rates ranged up to 100%, against a department average of 50%.

CONCLUSIONS: A structured closed-loop audit with an explicit action plan more than doubled the hot ureteroscopy rate for obstructing ureteric stones, moving practice closer to national standards. Residual missed opportunities and surgeon-level variation support a dedicated hot ureteroscopy list and further audit cycles.