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Friedlander DF. et al., 2020: Real-world comparative effectiveness of shockwave lithotripsy versus ureterorenoscopy for the treatment of urinary stones

Friday, 27 November 2020

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Friedlander DF, Brant A, McClure TD, Del Pizzo J, Nowels MA, Trinh QD, Sedrakyan A, Chughtai B.
Brigham and Women's Hospital, Division of Urological Surgery, Harvard Medical School, Boston, MA, USA.
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.

Abstract

Purpose: To identify clinical and non-clinical predictors of treatment failure and perioperative complications following ureterorenoscopy versus shockwave lithotripsy.

Methods: The New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) database was used to identify 226,331 patients who underwent index ureteroscopy or shockwave lithotripsy for renal stones from 2000 to 2016. Propensity-matched generalized linear-mixed modeling was utilized to compare failure and complication rates between the two procedure groups.

Results: 219,383 individuals meeting inclusion criteria who underwent either ureterorenoscopy (n = 124,342) or shockwave lithotripsy (n = 95,041) in New York State between 2000 and 2016 were included in our analysis. After propensity score matching, patients undergoing shockwave lithotripsy were found to have decreased odds of experiencing any type of 30-day complication (P < 0.001 for all) but increased odds of treatment failure at both 90 (OR 1.70, 95% CI 1.64-1.77) and 180 (OR 1.83, 95% CI 1.76-1.89) days (P < 0.001 for both).

Conclusion: Patients undergoing shockwave lithotripsy experienced significantly higher odds of treatment failure, although this undesirable outcome appears to be partially offset by lower 30-day complication rates.
World J Urol. 2020 Sep 9. doi: 10.1007/s00345-020-03430-6. Online ahead of print. PMID: 32909172

Comments 1

Peter Alken on Friday, 27 November 2020 09:30

This publication offers a refreshingly unbiased view on the two most frequent urological procedures. One feels a relief reading it compared to prospective randomized studies.
An idea, also formulated in the present paper, is getting popular: “Increasing emphasis on outcome measures that more accurately characterize the patient experience and the value of that experience draws into question the utility of past literature using traditional outcome measures, such as stone-free rate.”
There is additional interesting information on driving forces: “… a post-operative emergency department visit … may add as much as $6000 in episode based costs“ and “patients undergoing URS versus SWL were more frequently privately insured. To our knowledge, our paper is the first to identify payer status as a potential predictor of treatment modality for urinary stone disease.”
This reminds me of a paper by Wang et al. (1) which you find in this SWL literature database. I reviewed it 8 years ago. The authors looked at URS and ESWL treatments performed on ~ 1000 children in the Pediatric Health Information System (PISH) database. This is an US national database from 42 freestanding children’s hospitals in the US. One conclusion was: “Treatment choice depends significantly on the hospital at which a patient undergoes treatment” In other words, it was not the stone but the hospital door the parents opened that influenced the kind of therapy the child would get.

DJ-stent removal is of course not included in the evaluated data but will add to cost and patients discomfort

1. Wang HH, Huang L, Routh JC, Nelson CP. Shock wave lithotripsy vs ureteroscopy: variation in surgical management of kidney stones at freestanding children's hospitals. J Urol. 2012 Apr;187(4):1402-7. doi: 10.1016/j.juro.2011.12.010.

Peter Alken

This publication offers a refreshingly unbiased view on the two most frequent urological procedures. One feels a relief reading it compared to prospective randomized studies.
An idea, also formulated in the present paper, is getting popular: “Increasing emphasis on outcome measures that more accurately characterize the patient experience and the value of that experience draws into question the utility of past literature using traditional outcome measures, such as stone-free rate.”
There is additional interesting information on driving forces:  “… a post-operative emergency department visit … may add as much as $6000 in episode based costs“ and “patients undergoing URS versus SWL were more frequently privately insured. To our knowledge, our paper is the first to identify payer status as a potential predictor of treatment modality for urinary stone disease.”  
This reminds me of a paper by Wang et al. (1) which you find in this SWL literature database. I reviewed it 8 years ago. The authors looked at URS and ESWL treatments performed on ~ 1000 children in the Pediatric Health Information System (PISH) database. This is an US national database from 42 freestanding children’s hospitals in the US. One conclusion was: “Treatment choice depends significantly on the hospital at which a patient undergoes treatment” In other words, it was not the stone but the hospital door the parents opened that influenced the kind of therapy the child would get.

DJ-stent removal is of course not included in the evaluated data but will add to cost and patients discomfort

1. Wang HH, Huang L, Routh JC, Nelson CP. Shock wave lithotripsy vs ureteroscopy: variation in surgical management of kidney stones at freestanding children's hospitals. J Urol. 2012 Apr;187(4):1402-7. doi: 10.1016/j.juro.2011.12.010.

Peter Alken

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