Matlaga BR et al, 2014: Management Patterns of Medicare Patients Undergoing Treatment for Upper Urinary Tract Calculi
Matlaga BR, Meckley LM, Kim M, Byrne TW
James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine , Baltimore, Maryland
PURPOSE: We conducted this study to identify differences in the retreatment rates and ancillary procedures for the two most commonly utilized stone treatment procedures in the Medicare population: ureteroscopy(URS) and shock wave lithotripsy(SWL).
MATERIAL AND METHODS: A retrospective claims analysis of the Medicare SAF 5% sample was conducted to identify patients with a new diagnosis of urolithiasis undergoing treatment with URS or SWL from 2009-2010. Outcomes evaluated: (1) repeat stone removal procedures within 120 days post index procedure, (2) stent placement procedures on the index date, 30 days prior to and 120 days post index date, and (3) use of general anesthesia.
RESULTStreatments compared to URS. Among those with ureteral stones, SWL patients were 2.27 times more likely to undergo repeat procedures. The difference was not statistically significant in renal stone patients. Overall, SWL patients were 1.41 times more likely than URS patients to have a stent placed prior to index procedure, and 1.33 times more likely to have a stent placed subsequent to the index procedure. The majority of URS patients(77.8%) had a stent placed at the time of index procedure. There was no significant difference in anesthetic approaches between SWL and URS.
CONCLUSIONS: Patients undergoing SWL are significantly more likely to require re-treatments than URS patients. SWL patients are also significantly more likely to require ureteral stent placement as a separate event. SWL and URS patients have similar rates of general anesthesia.
J Endourol. 2014 Jan 23. [Epub ahead of print]
PMID:24344933[PubMed - as supplied by publisher]
This is a surprise paper in several aspects.
1 The author is a urologist. The three co-authors are employees of Boston Scientific, the company that financed the study. In the Acknowledgments section it says: "All authors independently reviewed the source studies and data analysis, and participated in manuscript preparation and revision"
I realize that the number of company sponsored articles in urological journals increases. May be it is only a new code of conduct that leads to disclose what previously was not visible.
2 The manuscripts message is not knew but it's good to see it proven.
"Overall, 866 (41.9%) of SWL patients and 1,360 (82.0%) of URS patients had a stent procedure before, on index date or during follow up ..."
Why? This is the text of the 2013 EAU Urolithiasis guidelines on stenting in SWL:
5.5 Extracorporeal shock wave lithotripsy (SWL)
5.5.2 Stenting before carrying out extracorporeal shock wave lithotripsy
22.214.171.124 Stenting in kidney stones Routine use of internal stents before SWL does not improve stone-free rate (LE: 1b)
126.96.36.199 Stenting in ureteral stones
The 2007 AUA/EAU Guideline on the management of ureteral calculi states that routine stenting is not recommended as part of SWL. When the stent is inserted, patients often suffer from frequency, dysuria, urgency, and suprapubic pain.
Routine stenting is not recommended as part of SWL treatment of ureteral stones. LE: 1b; GR: A
This is the text of the 2013 EAU Urolithiasis guidelines on stenting in URS:
188.8.131.52.8 Stenting before and after URS
Routine stenting is no longer necessary before URS. However, pre-stenting facilitates ureteroscopic management of stones, improves the stone-free rate, and reduces complications.
Most urologists routinely insert a JJ stent following URS, although several randomised prospective trials have found that routine stenting after uncomplicated URS (complete stone removal) is no longer necessary. Ureteric stenting can be associated with lower urinary tract symptoms and pain reducing quality of life.
Stents should be inserted in patients who are at increased risk of complications (e.g. residual fragments, bleeding, perforation, urinary tract infections or pregnancy), and in all doubtful cases, to avoid stressful emergencies."
Stenting is optional after uncomplicated URS. LE 1a GR A
"There was no significant difference in anesthetic techniques utilized for SWL and URS, with 92% of each cohort receiving a general anesthesia." Why? There is a USA-Europe difference in using anaesthesia for SWL: This is the text of the 2013 EAU Urolithiasis guidelines on "anesthesia" in SWL: 184.108.40.206 Pain control Careful control of pain during treatment is necessary to limit pain-induced movements and excessive respiratory excursions.
RECOMMENDATION Use proper analgesia because it improves treatment results by limiting induced movements and excessive respiratory excursions.
LE 4 GR C
In Europe general anesthesia is used for URS and for SWL in young children.