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Oberlin DT et al, 2015: Contemporary Surgical Trends in the Management of Upper Tract Calculi.

Oberlin DT, Flum AS, Bachrach L, Matulewicz RS, Flury SC.
Department of Urology, Northwestern Memorial Hospital, Chicago, Illinois.

Abstract

PURPOSE: Upper tract nephrolithiasis is a common surgical condition and is treated with multiple surgical techniques including shock wave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL). We analyzed case logs submitted to the American Board of Urology by candidates for initial certification and recertification to help elucidate the trends in management of upper tract urinary calculi.
MATERIALS AND METHODS: Annualized case logs from 2003 to 2012 were analyzed and logistic regression models assessed how surgeon-specific attributes affected how upper tract stones are treated. Cases were identified by CPT code system for corresponding procedure.
RESULTS: A total of 6,620 urologists in three certification groups recorded case logs: initial certification (n=2,275), first recertification (n=2,381) and second recertification (n=1,964). A total of 441,162 total procedures were logged: 54.2% URS, 41.3% SWL, and 4.5% PCNL. From 2003-2013, there was an increase in the use of URS from 40.9% to 59.6% and corresponding drop in use of SWL from 54% to 36.3%. New urologists increased use of URS from 47.6% to 70.9% of all stones cases logged. Senior clinicians displayed an increased use of URS from 40% to 55%. Endourologists performed a significantly higher proportion of PCNL than non-endourologists (10.6% vs. 3.69%, p<0.0001) and a significantly smaller proportion of SWL (34.2% vs. 42.2%, p=0.001).
CONCLUSIONS: Both junior and senior clinicians exhibited a dramatic adoption of endoscopic techniques. The treatment of upper tract calculi is an evolving field and provider-specific attributes affect how these stones are treated. 

J Urol. 2015 Mar;193(3):880-4. doi: 10.1016/j.juro.2014.09.006. Epub 2014 Sep 16.

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Comments 1

Hans-Göran Tiselius on Wednesday, 26 August 2015 13:12

In this report, based on data collected from the American Board of Urology, the technique used for stone removal during the period 2003-2012 disclosed increased use of URS compared with SWL. The frequency of PNL remained stable at a level around 5%. It is not known, however, which fraction of URS that was represented by RIRS.

Translating these American data to an international conclusion is difficult for several reasons, but it can be assumed that the published findings represent a worldwide trend. The reason for this shift is not easily disclosed and the cost for invasive versus non-invasive methods vary considerably from one country to another. Undoubtedly the technical development of endoscopic instruments has played an important role and made the invasive techniques more attractive than before. It is my own interpretation that a majority of urologists find URS more “urological” and more “surgical” than SWL. The advantage of SWL as non-invasive, non-anaesthesia requiring, out-patient procedures with low risks of complications is obviously not fully appreciated. Neither is the fact that rationally applied SWL, in most situations, is economically more favourable than invasive procedures, also when repeat sessions are necessary.

Extended interpretation and appropriate comparison of various technologies for stone removal need to include not only the stone-free rates, but also the complications. The necessity of removing all minor fragments in patients who – even when they are fragment-free - suffer a high risk of recurrent stone formation needs to be carefully elucidated. Moreover, it is essential that all SWL operators have full understanding of what is required from optimal SWL.

In this report, based on data collected from the American Board of Urology, the technique used for stone removal during the period 2003-2012 disclosed increased use of URS compared with SWL. The frequency of PNL remained stable at a level around 5%. It is not known, however, which fraction of URS that was represented by RIRS. Translating these American data to an international conclusion is difficult for several reasons, but it can be assumed that the published findings represent a worldwide trend. The reason for this shift is not easily disclosed and the cost for invasive versus non-invasive methods vary considerably from one country to another. Undoubtedly the technical development of endoscopic instruments has played an important role and made the invasive techniques more attractive than before. It is my own interpretation that a majority of urologists find URS more “urological” and more “surgical” than SWL. The advantage of SWL as non-invasive, non-anaesthesia requiring, out-patient procedures with low risks of complications is obviously not fully appreciated. Neither is the fact that rationally applied SWL, in most situations, is economically more favourable than invasive procedures, also when repeat sessions are necessary. Extended interpretation and appropriate comparison of various technologies for stone removal need to include not only the stone-free rates, but also the complications. The necessity of removing all minor fragments in patients who – even when they are fragment-free - suffer a high risk of recurrent stone formation needs to be carefully elucidated. Moreover, it is essential that all SWL operators have full understanding of what is required from optimal SWL.
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