Kamal WK. et al., 2025: The impact of urolithiasis on urology services in a high-prevalence region: A multicenter study.

Wissam Khalid Kamal, Musab M Alghamdi, Raed A Azhar, Ahmad Bugis, Mohammed Abuzenada, Majed Alharthi, Saeed Bin Hamri, Yahya Ghazwani, Yasser A Noureldin, Hassan Aljifri, Abdulaziz Alamri, Hatem Hamed Althubiany, Mansour Alnazari, Badr Alharbi, Abdulrahman Al Own, Mohanad Jebril Bosily, Mohammed Almansour, Abdullah Alfakhri, Ibrahim Alowidah, Ali Abdel Raheem
Asian J Urol. 2025 Jan;12(1):59-65. doi: 10.1016/j.ajur.2024.04.001 FREE PMC ARTICLE

Abstract

Objective: To assess the effect of upper urinary tract (UUT) urolithiasis on urology services in a region with a high prevalence of the condition, and analyze the trends in endourological procedures for treating UUT urolithiasis and the cost of treatments in 11 hospitals over the last 6 years.

Methods: Using the hospital surgery statistics database, data were gathered from the urology departments of 11 hospitals in Saudi Arabia. The analysis focused on the trends, distribution, and annual cost of endourological procedures for UUT urolithiasis from January 2017 to December 2022.

Results: Out of the total surgery performed (54 711), over half (31 039, 57%) were related to UUT urolithiasis. Extracorporeal shock wave lithotripsy (ESWL) was the most performed procedure among stone-related procedures, accounting for 38% of all procedures. Double-J stent insertion, flexible ureteroscopy (URS), semi-rigid URS, percutaneous nephrolithotomy, and pyelo- and uretero-lithotomy accounted for 25%, 19%, 14%, 3.8%, and 0.35%, respectively. Notably, the number of stone-related UUT procedures in 2022 increased by 35% (from 4671 to 6283) compared to 2017. In the year 2022 compared to 2017, there was a statistically significant increase in the rate of all stone-related UUT procedures (p<0.001), except for ESWL and pyelo- and uretero-lithotomy. The rates of ESWL procedures reduced from 21% in 2017 to 13% in 2022 (p<0.001). Overall, the total cost of treatments has been estimated to be about 192.1 million SAR from 2017 to 2022 with an increase by 107% (47.7 million SAR in 2022 vs. 23.0 million SAR in 2017).

Conclusion: Our research findings suggest that urolithiasis poses a significant burden, accounting for over half of all urological surgery performed at the participating centers. Furthermore, there has been a 35% rise in stone-related UUT procedures over the past 6 years. Percutaneous nephrolithotomy, flexible URS, and semi-rigid URS have experienced significant increase in usage. Furthermore, in 2022 the cost of urolithiasis treatments has been more than doubled compared to 2017.

Comment Hans-Göran Tiselius

Many reports on stone epidemiology have been published and described the patterns of stone removal. In this regard it is of great interest to look at the situation in Saudi-Arabia because this is the country with the highest sone incidence in the world. (19.1%). Active stone removal accounts for 57% of all urological surgery. The most important notations was increased flexible URS (up 124%) and decreased SWL (down 38%). These findings are similar to those in other countries. But although the cost of stone surgery had increased significantly during the six years (2017-2022), the favorable economy of SWL obviously was ignored. Not eve n during the covid-pandemic was the use of SWL increased as a method with lowest risk of aerosol spreading of the virus.
There is no explanation for the decreased use of SWL, but its use has remained in the shadow of attractive ureteroscopy. It is obvious that ureteroscopy is more appealing to young urologists. It also is likely that with high interest in endourogy, the success with SWL is low.
One point that is raised in he article (but without link to SWL) is the shortcomings in stone prevention.
The change in utilization of SWL and URS over time reflects the situation world-wide. Why SWL has become less popular despite its favorable economy and least invasiveness is certainly explained by several factors of which less efficient handling is one. But the assumption that surgical attraction plays an important role definitely, is of importance. Nevertheless, the decreased use of SWL and the increased use of URS are insufficient to explain the overall increased active stone removal. Although it is not directly mentioned in this or other articles, but briefly touched, modern endoscopic stone removal most certainly has resulted in overtreatment.

Hans-Göran Tiselius