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Childs MA et al, 2012: Factors Influencing Urologist Treatment Preference in Surgical Management of Stone Disease

Childs MA, Rangel LJ, Lingeman JE, Krambeck AE
Department of Urology, Mayo Clinic, Rochester, Minnesota


Abstract

OBJECTIVE: To assess the surgeon factors influencing the surgical treatment decisions for symptomatic stone disease. The factors influencing the selection of shock wave lithotripsy (SWL), ureteroscopy, or percutaneous nephrolithotomy to treat symptomatic stone disease are not well studied.

METHODS: Electronic surveys were sent to urologists with American Medical Association membership. Information on training, practice, and ideal treatment of common stone scenarios was obtained and statistically analyzed.

RESULTS: In November 2009, 600 surveys were sent and 180 were completed. High-volume SWL practices (>100 cases annually) were more common in community practice (P < .01), and high-volume ureteroscopy and percutaneous nephrolithotomy practices were more common in academic practice (P = .03). Community practice was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .005). An increasing time since urologic training was associated with SWL selection for proximal urolithiasis and upper pole nephrolithiasis (P < .01). Urologists reporting shock wave lithotriptor ownership were 3-4 times more likely to select SWL for urolithiasis or nephrolithiasis compared with urologists who did not own a lithotripter (P < .01). Routine concern for stent pain and rigid ureteroscope preference (vs flexible) were associated with SWL selection (P < .03).

CONCLUSION: Surgeon factors significantly affected urolithiasis treatment selection. SWL was associated with community urology practice, increasing time since training, shock wave lithotriptor ownership, concern for stent pain, and ureteroscope preference.

Copyright © 2012 Elsevier Inc. All rights reserved.
Urology. 2012 May;79(5):996-1003. doi: 10.1016/j.urology.2011.11.024. Epub 2012 Jan 13
PMID: 22245295 [PubMed - as supplied by publisher]

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Comments 1

Hans-Göran Tiselius on Monday, 16 January 2012 07:10

What determines the urologist’s choice of treatment modality for active removal of renal and ureteral stones is indeed highly interesting. The present survey, although responded by only 30% of the approached urologists, gives some hints. It is not surprising that ownership of a lithotripter was associated with a more frequent use of SWL. Partly because the equipment was there and probably also because the urologists at that place knew what could be accomplished with SWL. A preference for URS and PNL reflects the current trend in direction of using more invasive procedures. This choice is probably an effect of technological improvements and the fact that focus presently is placed on this kind of treatment, with the ultimate aim of getting a faster and higher rate of stone clearance. For those urologist’s who have been trained recently, the skill and education in SWL appear to have gained less attention than that of the invasive and surgically more”attractive” and demanding procedures. It would have been of interest if the questionnaire also had included a question on which type of anesthesia that was used for the various procedures. I have been told that in USA in several places general anesthesia is still used for SWL. Thereby one of the major advantages of this non-invasive treatment modality is lost.

Moreover, it would have been of interest to know how well the urologist’s choice was in agreement with the patient’s preference and to which extent the actual treatment profile at a certain center corresponded to the theoretical decision made by the urologist in view of the case scenarios.

Hans-Göran Tiselius

What determines the urologist’s choice of treatment modality for active removal of renal and ureteral stones is indeed highly interesting. The present survey, although responded by only 30% of the approached urologists, gives some hints. It is not surprising that ownership of a lithotripter was associated with a more frequent use of SWL. Partly because the equipment was there and probably also because the urologists at that place knew what could be accomplished with SWL. A preference for URS and PNL reflects the current trend in direction of using more invasive procedures. This choice is probably an effect of technological improvements and the fact that focus presently is placed on this kind of treatment, with the ultimate aim of getting a faster and higher rate of stone clearance. For those urologist’s who have been trained recently, the skill and education in SWL appear to have gained less attention than that of the invasive and surgically more”attractive” and demanding procedures. It would have been of interest if the questionnaire also had included a question on which type of anesthesia that was used for the various procedures. I have been told that in USA in several places general anesthesia is still used for SWL. Thereby one of the major advantages of this non-invasive treatment modality is lost. Moreover, it would have been of interest to know how well the urologist’s choice was in agreement with the patient’s preference and to which extent the actual treatment profile at a certain center corresponded to the theoretical decision made by the urologist in view of the case scenarios. Hans-Göran Tiselius
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