Metzler I. et al., 2021: Surgical Trends in Nephrolithiasis - Increasing de novo renal access by urologists for PCNL
Metzler I, Holt SK, Harper JD.
Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA.
Purpose: Percutaneous nephrolithotomy (PCNL) has wide variability in the methods of renal access. In many centers, this is done as a separate nephrostomy procedure by interventional radiology (IR), while other urologists gain initial access themselves during the PCNL. We aimed to characterize these trends to confirm the need for continued training in this aspect of PCNL.
Methods: Using MarketScan insurance claims we examined surgical volume for ureteroscopy (URS), shockwave lithotripsy (SWL) and PCNL during 2007-2017. For PCNL, CPT codes were used to identify the provider performing the de novo renal access over time. We stratified post-operative outcomes for PCNL by provider type.
Results: From 2007-2017, the annual proportion of PCNL procedures peaked at 4.5% with a recent decline in 2016 and 2017 to 3.2%. URS steadily increased from 46.3% to 60.0% of procedures and SWL mirrored that change with a decrease from 50.0% to 36.7%. Within 19743 PCNLs, there was a notable increase from 12.8% to 32.3% in the number of procedures with urologists performing de novo renal access. Most cases (40.0%) still had a de novo access code assigned to a radiologist. Length-of-stay, readmission, transfusion and secondary stone procedure rates were higher in the radiologist-gained access PCNLs.
Conclusions: URS has surpassed SWL as the most common stone procedure. While the proportion of PCNLs has remained fairly stable over the last decade, urologists obtaining their own de novo access has increased substantially. Continued outreach efforts focused on urologist-obtained access may further increase this proportion and improve outcomes for PCNL.
J Endourol. 2021 Jan 11. doi: 10.1089/end.2020.0888. Online ahead of print. PMID: 33430693
This is a report with focus on PCNL and it is therefore of limited interest in terms of SWL. There are, however, some epidemiological data that deserves attention. Whereas PCNL during the 10-year study period between 2007 and 2017 remained at a constant level of 3.2-4.5% in USA, it was evident that URS had increased from 46 to 60% and SWL decreased from 50 to 37%.
That URS has surpassed SWL is similar worldwide. The authors discuss in the article the possible overuse of SWL. My own opinion, however, is that there currently is an overuse of endoscopic surgery.
There is one specific point that need to be observed and that is that most stones do not require surgical (active) treatment.