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Schnabel MJ et al, 2015: [Shock wave lithotripsy in Germany : Results of a nationwide survey].

Schnabel MJ, Brummeisl W, Burger M, Rassweiler JJ, Knoll T, Neisius A, Chaussy CG, Fritsche HM.
Klinik für Urologie, Caritas-Krankenhaus St. Josef, Universität Regensburg, Landshuter Straße 65, 93053, Regensburg, Deutschland.

Abstract

BACKGROUND: Following its introduction in the 1980s extracorporeal shock wave lithotripsy (SWL) became the gold standard for therapy of ureteral and renal calculi. The research data published during the last decade suggest a paradigm shift to endourological techniques.
OBJECTIVES: The purpose of this study was to compare whether the suggested loss of status for SWL corresponds with actual real-life treatment in Germany. A further aim was to assess the quality of SWL therapy in German hospitals.
MATERIALS AND METHODS: The board of the German Society for Shock Wave Lithotripsy (DGSWL) sent a questionnaire to 306 urological departments in Germany, which encompassed medical, technical and organizational topics in the therapy of ureteral and renal calculi. A total of 99 (33 %) questionnaires were returned.
CONCLUSION: With the exception of a few departments, non-invasive SWL still plays a major role in the treatment of urolithiasis and a loss of the gold standard status is not in sight. The performance of SWL in German hospitals is carried out at a high level of quality. To maintain and optimize this status a structured SWL training and adherence to clinical practice guidelines are needed.

Urologe A. 2015 Sep;54(9):1277-82. doi: 10.1007/s00120-015-3920-2. German. 

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Comments 1

Hans-Göran Tiselius on Friday, 08 January 2016 11:22

This article is an excellent summary of the present practice of stone removal in Germany (the country in which SWL was invented and has been in use for the longest period of time). The information is based on results from a questionnaire sent to the urological clinics (university departments as well as other departments specialized in urology). Inasmuch as this article contains a lot of interesting data regarding the present role of SWL, I have chosen to extract some points of particular interest, in order to make the information accessible also to readers not familiar with the German language.
Almost all responding clinics had access to SWL, URS, PNL and Ho-YAG laser devices and as many as 89% had stationary SWL equipments. It is also noteworthy that whereas the SWL working table was used for other urological procedures in 56% of the university departments, the corresponding figure for other departments was only 34%.
For an annual average of 600 patients a conservative therapeutic approach was applied in 37%. It is of note, however, that for active stone removal SWL was the preferred method in only 22%!!
For the pre-treatment imaging the following techniques were used:

http://storzmedical.com/images/blog/Schnabel_MJ_20151.png

In this regard it is my impression that urography is used more commonly and CT less commonly than in many other countries.
There was apparently also a variable routine to deal with anticoagulation treatment.

http://storzmedical.com/images/blog/Schnabel_MJ_20152.png

Although all clinics reported that they applied SWL with power ramping; only 17% used a belt during treatment.
Interestingly 7% of the clinics carried out SWL with general anaesthesia. Administration of analgesics and sedatives were used in 87% and 96% for stones in ureters and kidneys, respectively.
Variable intervals were allowed between successive SWL-sessions. There was a wide range from one day to several weeks. Two days between treatments were reported by 39% of the clinics and 3-7 days by 16%. The maximally allowed number of sessions also varied considerably and whereas 7% of the clinics only allowed ONE session; in 31% TWO sessions and in 44% THREE sessions were accepted.
The most interesting aspect, discussed in this article, is how the decision is made for which treatment modality that is chosen and applied for stone removal in the individual patient. It is stated that this decision should be based on two arguments.
1. To use the least invasive therapeutic modality provided the results are comparable between the different alternatives.
2. To use a treatment modality according the patient’s preferences.
Most interestingly is, however, that the further reading indicates that the re-imbursement obviously also plays an important role. The reader can certainly draw a number of conclusions from the extracted data in the following Table:

http://storzmedical.com/images/blog/Schnabel_MJ_20153.png

It is obvious that the re-imbursement system favours not only in-patient treatments but also invasive treatments. The mathematically oriented reader will now realize that the re-imbursement for one ureteroscopic treatment of a stone in the kidney theoretically would correspond to more than five SWL sessions in an out-patient setting. But the system now has another restriction: during a three month period re-imbursement can only be obtained for ONE procedure carried out in the same patient. This leads to the following conclusion:
3. The choice of a specific treatment modality is strongly dictated by the re-imbursement system.
It is unfortunate when the re-imbursement system is given such a powerful influence on which method that should be used and it is at least one important explanation for the relatively low frequency of non-invasive stone removal presently carried out in Germany.

This article is an excellent summary of the present practice of stone removal in Germany (the country in which SWL was invented and has been in use for the longest period of time). The information is based on results from a questionnaire sent to the urological clinics (university departments as well as other departments specialized in urology). Inasmuch as this article contains a lot of interesting data regarding the present role of SWL, I have chosen to extract some points of particular interest, in order to make the information accessible also to readers not familiar with the German language. Almost all responding clinics had access to SWL, URS, PNL and Ho-YAG laser devices and as many as 89% had stationary SWL equipments. It is also noteworthy that whereas the SWL working table was used for other urological procedures in 56% of the university departments, the corresponding figure for other departments was only 34%. For an annual average of 600 patients a conservative therapeutic approach was applied in 37%. It is of note, however, that for active stone removal SWL was the preferred method in only 22%!! For the pre-treatment imaging the following techniques were used: [img]http://storzmedical.com/images/blog/Schnabel_MJ_20151.png[/img] In this regard it is my impression that urography is used more commonly and CT less commonly than in many other countries. There was apparently also a variable routine to deal with anticoagulation treatment. [img]http://storzmedical.com/images/blog/Schnabel_MJ_20152.png[/img] Although all clinics reported that they applied SWL with power ramping; only 17% used a belt during treatment. Interestingly 7% of the clinics carried out SWL with general anaesthesia. Administration of analgesics and sedatives were used in 87% and 96% for stones in ureters and kidneys, respectively. Variable intervals were allowed between successive SWL-sessions. There was a wide range from one day to several weeks. Two days between treatments were reported by 39% of the clinics and 3-7 days by 16%. The maximally allowed number of sessions also varied considerably and whereas 7% of the clinics only allowed ONE session; in 31% TWO sessions and in 44% THREE sessions were accepted. The most interesting aspect, discussed in this article, is how the decision is made for which treatment modality that is chosen and applied for stone removal in the individual patient. It is stated that this decision should be based on two arguments. 1. To use the least invasive therapeutic modality provided the results are comparable between the different alternatives. 2. To use a treatment modality according the patient’s preferences. Most interestingly is, however, that the further reading indicates that the re-imbursement obviously also plays an important role. The reader can certainly draw a number of conclusions from the extracted data in the following Table: [img]http://storzmedical.com/images/blog/Schnabel_MJ_20153.png[/img] It is obvious that the re-imbursement system favours not only in-patient treatments but also invasive treatments. The mathematically oriented reader will now realize that the re-imbursement for one ureteroscopic treatment of a stone in the kidney theoretically would correspond to more than five SWL sessions in an out-patient setting. But the system now has another restriction: during a three month period re-imbursement can only be obtained for ONE procedure carried out in the same patient. This leads to the following conclusion: 3. The choice of a specific treatment modality is strongly dictated by the re-imbursement system. It is unfortunate when the re-imbursement system is given such a powerful influence on which method that should be used and it is at least one important explanation for the relatively low frequency of non-invasive stone removal presently carried out in Germany.
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