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Noureldin YA et al, 2015: Changes in Urolithiasis Referral Patterns for Shock Wave Lithotripsy over a Decade: Was There Adherence to AUA/EAU Guidelines?

Noureldin YA, Elkoushy MA, Andonian S.
Division of Urology, McGill University Health Centre, Montreal, Québec, Canada; Department of Urology, Benha University Hospital, Benha University, Benha, Egypt.
Division of Urology, McGill University Health Centre, Montreal, Québec, Canada; Department of Urology, Suez Canal University, Ismailia, Egypt.
Division of Urology, McGill University Health Centre, Montreal, Québec, Canada.

Abstract

OBJECTIVE: The primary objective was to assess changes in referral patterns of urolithiasis for shock wave lithotripsy (SWL) over a decade. The secondary objective was to evaluate the effect of the number of years of practice of referring physicians on these referral patterns.
METHODS: A retrospective review of SWL database was performed for consecutive referrals for SWL at a tertiary stone center between December 1999 and December 2013. Patient demographics and stone characteristics were assessed. The stone location at the time of referral was used as the reference. Retreatments were excluded. In addition, years of practice of the referring physicians were calculated. The 2007 AUA/EAU guidelines on urolithiasis were considered as a reference.
RESULTS: A total of 8,992 SWL treatments were included. After December 2007, there was a significant increase in the percentage of renal pelvic stones referred for SWL (23.0 vs. 27.1%, p < 0.001). Conversely, proximal ureteral stones significantly decreased after 2007 (24 vs. 18.2%, p < 0.001) including stones > 10 mm (5.1 vs. 2.9%, p < 0.001). Otherwise, there were no changes in the referral patterns for SWL of other stone locations before and after December 2007 (p > 0.05). Furthermore, percentage of stones referred for SWL by urologists practicing for less than 10 years significantly decreased after December 2007 (29.5 vs. 22.8%, p < 0.001).
CONCLUSIONS: The significant reduction in the referral of proximal ureteral stones after December 2007 corresponds to the latest AUA/EAU guidelines on management of ureteral stones.

Curr Urol. 2015 Sep;8(3):144-8. doi: 10.1159/000365706. Epub 2015 Sep 4.

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Comments 1

Hans-Göran Tiselius on Monday, 06 June 2016 08:19

The authors (in a tertiary centre) have studied their database on SWL to analyse any differences in referral pattern during two different periods (1999-2007 and 2008-2013). They concluded that that after 2007 there was a reduced percentage of patients referred for SWL of proximal ureteral stones and a corresponding increased percentage of stones located in the renal pelvis. It is suggested that the major explanation was that the indications for SWL was adapted to the recommendations on stone treatment given in Guidelines from AUA and EAU.

It is possible that this is the case, but there are also other reasonable causes. To me it is not obvious that changes in international recommendations directly will lead to different routines in terms of indications, and the annual number of referrals during the two periods was 591 and 611, respectively. For the whole period the average annual referral rate was 599 and there was obviously no reduction in the total number of patients.

But it can of course be assumed that the number of referrals should increase over time as a result of increased prevalence. If this means that relatively fewer patients were referred to SWL is not known, but if that is the case the reason might be a reluctance of referring patients because the urologists wanted to carry out endoscopic procedures rather than sending the patients away. During the second period that the authors studied there was a dramatic development of endoscopic techniques something that particularly seems to attract interest from young urologists.

The success rate at the SWL-centre might also have been of importance. One factor that needs to be observed is that over time SWL has been taken over from urologists by nurses and technicians and it cannot be excluded that such a shift has resulted in less successful SWL. It is not mentioned who carried out and was responsible for the SWL treatment at this tertiary centre.

The authors (in a tertiary centre) have studied their database on SWL to analyse any differences in referral pattern during two different periods (1999-2007 and 2008-2013). They concluded that that after 2007 there was a reduced percentage of patients referred for SWL of proximal ureteral stones and a corresponding increased percentage of stones located in the renal pelvis. It is suggested that the major explanation was that the indications for SWL was adapted to the recommendations on stone treatment given in Guidelines from AUA and EAU. It is possible that this is the case, but there are also other reasonable causes. To me it is not obvious that changes in international recommendations directly will lead to different routines in terms of indications, and the annual number of referrals during the two periods was 591 and 611, respectively. For the whole period the average annual referral rate was 599 and there was obviously no reduction in the total number of patients. But it can of course be assumed that the number of referrals should increase over time as a result of increased prevalence. If this means that relatively fewer patients were referred to SWL is not known, but if that is the case the reason might be a reluctance of referring patients because the urologists wanted to carry out endoscopic procedures rather than sending the patients away. During the second period that the authors studied there was a dramatic development of endoscopic techniques something that particularly seems to attract interest from young urologists. The success rate at the SWL-centre might also have been of importance. One factor that needs to be observed is that over time SWL has been taken over from urologists by nurses and technicians and it cannot be excluded that such a shift has resulted in less successful SWL. It is not mentioned who carried out and was responsible for the SWL treatment at this tertiary centre.
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