Schoenthaler M et al, 2017: The stone surgeon in the mirror: how are German-speaking urologists treating large renal stones today?
Schoenthaler M, Hein S, Seitz C, Türk C, Danuser H, Vach W, Miernik A.
Department of Urology, Faculty of Medicine, Medical Centre-University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
Department of Urology, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
Department of Urology/Stone Centre, Hospital Rudolfstiftung, Ziehrerplatz 7/7, 1030, Vienna, Austria.
Department of Urology, Kantonsspital, 6000, Lucerne 16, Switzerland.
Centre for Medical Biometry and Medical Informatics, University of Freiburg, Stefan-Meier Str. 26, 79104, Freiburg, Germany.
OBJECTIVE: To elucidate the current treatment strategies of LRS in German-speaking Europe. Little is known about the treatment of large renal stones (LRS > 3 cm) in daily urological practice. LRS therapy can be, however, challenging and hazardous.
MATERIALS AND METHODS: A 39 item web-based survey was performed among urologists listed by the German, Austrian and Swiss Associations of Urology, addressing professionals treating LRS "on their own" and working in a German-speaking country. Uniparametric descriptions indicated as absolute numbers and percentages without p values, simple linear associations and bubble plots without arithmetic means or bar charts with standard deviation between targeted parameters and percentages were used.
RESULTS: 266 of the 6586 responding urologists claimed to treat urinary stones on a regular basis. The majority of them were male (90.2%) and over 50 years old (42.9%). Most stones are treated in non-university hospitals (69.5%). 81.9% of all the institutions treat more than 150 cases/y. Open surgery is still performed in 45.5% of the centres, laparoscopy in 32%. Percutaneous nephrolithotomy (PNL) is the primary treatment option. Antimicrobial strategies vary considerably. Serious complications seem to be rare. However, quite a few responders reported treatment-related deaths. The main limitation is the absolute number of urologists performing LRS treatment, which is unknown.
CONCLUSIONS: The German-speaking urologist treating LRS is a male and over 50. Although he performs PNL primarily, he is not averse to open surgery and SWL. He applies guidelines and employs modern equipment. Only antimicrobial strategies are out of line with the international standards.
World J Urol. 2017 Dec 7. doi: 10.1007/s00345-017-2148-8. [Epub ahead of print]
I have some doubts on the ways the data were collected, and how they are interpreted and presented. “Open surgery is still performed in 45.5% of the centres, laparoscopy in 32%. Percutaneous nephrolithotomy (PNL) is the primary treatment option.“ Although the German speaking Urologists “performs PNL primarily, he is not averse to open surgery and SWL. He applies guidelines and employs modern equipment.” Treating nearly half of the large stones by open surgery would not fit to a guideline orientated attitude.
In the text it says: “45.5% of our responders perform open stone surgery in selected cases, while urological centres worldwide report open surgery rates between 1 and 5.4%. At tertiary US centres, this was even below 1%. We attribute this 45.5% to the fact that our survey was addressed to the surgeons themselves and they were asked to estimate this number for not just one but 5 years in the past.” This is a misleading comparison. Closer to reality is this sentence: “Open surgery is still performed in 45.5% of the centres, laparoscopy in 32%, but these modalities’ case numbers are low ( less than 10/year/center)”
“The strongest trend we observed is towards PNL as the primary LRS therapy option, with SWL and open surgery as secondary alternatives. … 58.4% of the responders claim having done fewer than 25 PNL procedures in the last 5 years—under 5 a year.”
Who would consider ESWL as a valid, guide-line orientated option to treat large renal stones? How representative were the answers of Urologists who performed