# DiBianco JM. et al., 2025: Ureteroscopy vs Shock Wave Lithotripsy for Lower Pole Renal Stones: Treatment Variation and Outcomes in a Surgical Collaborative. Peter Alken Wednesday, 07 January 2026 581 Hits [ 0 Comments ](https://www.storzmedical.com/en/disciplines/literature-database-blog/database-lithotripsy/dibianco-jm-et-al-2025-1/?layout=listings#comments) John Michael DiBianco 1, Stephanie Daignault-Newton 2, Golena Fernandez Moncaleano 2, Eric Stockall 3, Spencer Hiller 4, Hyung Joon Kim 2, Hector Pimentel 5, David Wenzler 6, Brian Seifman 7, Naveen Kachroo 8, Casey A Dauw 2, Khurshid R Ghani 2 J Urol. 2025 Oct;214 Abstract (4):415-425. [doi: 10.1097/JU.0000000000004628. ](https://pubmed.ncbi.nlm.nih.gov/40489579/) ## Abstract Purpose: AUA guidelines recommend ureteroscopy (URS) or shock wave lithotripsy (SWL) for lower pole (LP) stones ≤ 1 cm, while SWL is second line for stones > 1 to 2 cm. In the era of increasing URS, there are limited data on the modality used and outcomes. We assessed treatment distribution, stone-free rates (SFRs), and unplanned health care. Materials and methods: Using the Michigan Urological Surgery Improvement Collaborative registry, we identified URS and SWL cases for LP stones ≤ 2 cm (2016-2021). We assessed the frequency of patients receiving URS or SWL as a proportion of their LP treatment. A logistic model determined predictive probability of treatment modality. Differences in complete SFRs, postoperative emergency department visits, and hospitalizations were assessed by size (≤1 cm, >1-2 cm), adjusted for patient factors and correlation within practice/provider. Results: There were 3645 procedures from 35 practices (209 surgeons); 2287 (62.7%) had SWL. Of the stones 80.2% were ≤ 1 cm. There was variation in modality based on practice (P < .001) and surgeon (P < .001). For stones ≤ 1 cm, the SFR was higher for URS (56% vs 39%; P < .001). There were no significant differences in SFRs for > 1 to 2 cm stones. Emergency department visits were higher after URS for stones ≤ 1 cm (odds ratio \[OR\]: 2.95, 95% CI: 1.7-5.0) but not for > 1 to 2 cm stones (OR: 0.97, 95% CI: 0.4-2.2). URS for stones ≤ 1 cm was associated with increased hospitalizations (OR: 4.67, 95% CI: 1.7-12.9) but not for stones > 1 to 2 cm (OR: 0.96, 95% CI: 0.4-2.2). Conclusions: In Michigan, SWL is the chosen modality for LP stones ≤ 2 cm. For smaller stones, URS was more effective but had greater morbidity. For larger stones, both modalities demonstrated suboptimal efficacy. Our work demonstrates the need for interventions to improve outcomes. ## Comment Peter Alken Me God! Unfortunately, this is a very old story: The door you pass into a practice or hospital for stone treatment decides about the kind of therapy you will get. The frequency of URS and SWL - basically for the same type of stone varies by 100% with the 209 surgeons. That said, except the 100% variation, all data used to draw any conclusions are biased by the door or the physician deciding on the therapy according to his preferences. . Some conclusion will be difficult to realize: “… if only 1 treatment modality is performed, efforts to understand the extent of shared decision-making represents an area for quality improvement. “ “While postoperative imaging rates after URS were lower than those for SWL in this work, they also provide real-world evidence that both SWL and URS have significant room for improvement.” “ … these patients may be better treated with percutaneous techniques, especially in the era of miniaturized techniques having less morbidity. Our work emphasizes the need for high-quality randomized clinical trials to address this clinical scenario.” “It has been shown that patients with stone disease place significant importance on their urologist’s treatment recommendation. Therefore, if only 1 treatment modality is performed, efforts to understand the extent of shared decision-making represents an area for quality improvement.” “Going forward, by collecting data on patient-reported outcomes, unplanned health care utilization, and stone treatment success, we have the opportunity to develop a composite outcome metric that provides a more nuanced assessment of stone intervention success. This, if integrated with machine learning, may allow patients to select the treatment choice that suits their preferences, priorities, and risk profile.” AI will just repeat what has been written in the literature without being able to inform about the reasons what the causes are that “real life” is different from guideline recommendations. An introduction to the paper states “This recommendation is based on evidence from expert centers, which may not reflect current real-world practice.” What are expert centres and what evidence do the data disclose? See also: Scales CD Jr. Editorial Comment. J Urol. 2025 Oct;214(4):424-425. doi: 10.1097/JU.0000000000004647. Epub 2025 Jun 30. PMID: 40587844. Peter Alken 0 #### Comments No comments made yet. Be the first to submit a comment Monday, 27 July 2026 I have read and agreed to the [Privacy Policy](https://www.storzmedical.com/javascript:void(0);)