Dor Golomb et al., 2024: A retrospective cohort study, analyzing trends in management of upper urinary tract stones in the adult Israeli population

Thursday, 18 July 2024

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Dor Golomb, Amir Cooper, Orit Raz
Department of Urology, Assuta Ashdod University Hospital, Ashdod, Israel.
Clalit Health Services, Central District, Israel.

Abstract

Objective: To assess trends of surgical intervention in adults with upper urinary tract stones in Israel.

Methods: A retrospective cohort study utilizing administrative databases held at Clalit Health Services, to identify all adults (⩾18 years) who underwent their first surgical treatment for upper tract urolithiasis. Descriptive statistics were employed to summarize baseline patient demographics and surgical trends were analyzed using the Cochrane-Armitage test for trend.

Results: Between 2003 and 2020, 36,624 adult patients were treated surgically for upper tract urinary stones. Mean age was 53.6 years (SD16.1). During the period investigated, the number of insured by Clalit Health Services increased by 25% and the total number of surgically treated stones increased by 98.7%. By type of procedure: Ureteroscopy (URS) increased by 351%, percutaneous nephrolithotripsy (PCNL) increased by 67%, shockwave lithotripsy (SWL) declined by 79%. The number of procedures per 100,000 population grew from to 37.5 in 2003 to 58.05 in 2022. The percentage increase in total number of surgical procedures was 103% and 90% in males and females, respectively.

Conclusions: Our findings reveal significant increases in the total number of surgically treated stones over the investigated period. Notably, this increase far outpaced the growth in the number of individuals insured by Clalit Health Services. Further research and interventions are warranted to explore the underlying factors driving these trends and to develop targeted approaches for prevention, early detection, and minimally invasive treatment of upper urinary tract stones in Israel.

Urologia. 2024 Feb;91(1):131-135. doi: 10.1177/03915603231203430. Epub 2023 Sep 30.
PMID: 37776156 DOI: 10.1177/03915603231203430

Comments 1

Hans-Göran Tiselius on Thursday, 18 July 2024 11:00

In the whole World as well as in Israel, there is a trend to reduce the number of patients treated with SWL. Endoscopy has become extremely popular.
The most remarkable in this report is the sharp rise in URS with a 351% (!) increase during the 17 years studied. The total number of procedures increased from 375 to 581 per million. Why is this so? The reason why the annual increase in active/surgical procedures for stone abdominal plates and respiratory removal was 4% is left unexplained and it is surprising that the number of patients treated surgically increased by almost 99%, while the number of patients from which the cohort was drawn only increased by 28.4%.
The reason why SWL has decreased, probably is that there has been limited success with non-invasive methods. Several explanations can be provided for this outcome:
The development of lithotripters has not corresponded to what previously was the case. There is a Worldwide trend to carry out SWL, not only without anesthesia but also ideally without analgesics. This behavior partly can explain insufficient stone disintegration. There also is a great variation in how SWL has been carried out, and with lack of attention to details, SWL results often will be markedly inferior to those of endoscopy. This is not specific for Israel, however, but a common feature of modern SWL.
There is no doubt that URS has become more attractive to urologists and that this change in attitude has changed parallel with the transfer of SWL-treatment to technicians and nurses. Although this organization in some places is good, it is far from generally optimal for SWL.
Another comment to the astonishing increase in URS is that there probably is a pronounced overtreatment of patients with URS.
The authors claim that the current shift in treatment principles towards endoscopy provides greater efficacy and versatility. But although this in some centers may be correct, endoscopy is more expensive and adds a significant increase to the health care cost, particularly if patients are overtreated with endoscopic methods.
There probably are different explanations for the therapeutic shift in different parts of the World.

Hans-Göran Tiselius

In the whole World as well as in Israel, there is a trend to reduce the number of patients treated with SWL. Endoscopy has become extremely popular.
The most remarkable in this report is the sharp rise in URS with a 351% (!) increase during the 17 years studied. The total number of procedures increased from 375 to 581 per million. Why is this so? The reason why the annual increase in active/surgical procedures for stone  abdominal plates and respiratory removal was 4% is left unexplained and it is surprising that the number of patients treated surgically increased by almost 99%, while the number of patients from which the cohort was drawn only increased by 28.4%. 
The reason why SWL has decreased, probably is that there has been limited success with non-invasive methods. Several explanations can be provided for this outcome:
The development of lithotripters has not corresponded to what previously was the case. There is a Worldwide trend to carry out SWL, not only without anesthesia but also ideally without analgesics. This behavior partly can explain insufficient stone disintegration. There also is a great variation in how SWL has been carried out, and with lack of attention to details, SWL results often will be markedly inferior to those of endoscopy. This is not specific for Israel, however, but a common feature of modern SWL.
There is no doubt that URS has become more attractive to urologists and that this change in attitude has changed parallel with the transfer of SWL-treatment to technicians and nurses. Although this organization in some places is good, it is far from generally optimal for SWL.
Another comment to the astonishing increase in URS is that there probably is a pronounced overtreatment of patients with URS.
The authors claim that the current shift in treatment principles towards endoscopy provides greater efficacy and versatility.  But although this in some centers may be correct, endoscopy is more expensive and adds a significant increase to the health care cost, particularly if patients are overtreated with endoscopic methods.
There probably are different explanations for the therapeutic shift in different parts of the World.

Hans-Göran Tiselius

In the whole World as well as in Israel, there is a trend to reduce the number of patients treated with SWL. Endoscopy has become extremely popular. The most remarkable in this report is the sharp rise in URS with a 351% (!) increase during the 17 years studied. The total number of procedures increased from 375 to 581 per million. Why is this so? The reason why the annual increase in active/surgical procedures for stone abdominal plates and respiratory removal was 4% is left unexplained and it is surprising that the number of patients treated surgically increased by almost 99%, while the number of patients from which the cohort was drawn only increased by 28.4%. The reason why SWL has decreased, probably is that there has been limited success with non-invasive methods. Several explanations can be provided for this outcome: The development of lithotripters has not corresponded to what previously was the case. There is a Worldwide trend to carry out SWL, not only without anesthesia but also ideally without analgesics. This behavior partly can explain insufficient stone disintegration. There also is a great variation in how SWL has been carried out, and with lack of attention to details, SWL results often will be markedly inferior to those of endoscopy. This is not specific for Israel, however, but a common feature of modern SWL. There is no doubt that URS has become more attractive to urologists and that this change in attitude has changed parallel with the transfer of SWL-treatment to technicians and nurses. Although this organization in some places is good, it is far from generally optimal for SWL. Another comment to the astonishing increase in URS is that there probably is a pronounced overtreatment of patients with URS. The authors claim that the current shift in treatment principles towards endoscopy provides greater efficacy and versatility. But although this in some centers may be correct, endoscopy is more expensive and adds a significant increase to the health care cost, particularly if patients are overtreated with endoscopic methods. There probably are different explanations for the therapeutic shift in different parts of the World. Hans-Göran Tiselius

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