Singh Z. et al., 2026: Shifting Paradigms in Stone Disease: How Geography, Training, and Technology Shape Endourologic Practice Worldwide.

Singh Z, Ashkezari A, Smith A, Srinath M, Tabib C, Rai A, Hoenig D, Smith A, Aro T, Okeke Z.
J Endourol. 2026 Jul;40(7):786-794. doi: 10.1177/08927790261451453. Epub 2026 May 24.

Abstract

Introduction: Endourology has rapidly evolved, offering increasingly effective and minimally invasive treatments for urolithiasis. Despite evidence-based guidelines from the American Urological Association and European Association of Urology, adherence varies worldwide. This study evaluated international practice patterns and factors influencing treatment decisions.

Methods: A 37-question online survey was distributed to Endourology Society members. The questionnaire included demographics, management of common clinical scenarios, technical preferences, and approaches to complex anatomical cases. Data from 300 respondents were analyzed using descriptive statistics and subgroup comparisons stratified by geography, fellowship training, and years in practice. Fisher's exact test defined significance (p < 0.05).

Results: Most respondents did not intervene on asymptomatic 4-6 mm renal stones, particularly in the lower pole. For 6-15 mm stones, retrograde intrarenal surgery (RIRS) was most frequently selected, though extracorporeal shockwave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) were also used depending on location and surgeon background. Stones 15-25 mm were most often managed with 17F PCNL, while stones >25 mm and staghorn calculi were primarily treated with 24-30F PCNL. Notably, a proportion of respondents selected RIRS even for staghorn calculi. U.S. urologists more often used RIRS and balloon dilators, whereas international respondents favored 17F PCNL and Amplatz dilators. Fellowship-trained surgeons reported lower reliance on ESWL and greater use of combined or advanced approaches. Surgeons with fewer than 5 years in practice more frequently chose RIRS, while those with over 15 years often performed PCNL, though they also reported increased RIRS use for 15-25 mm stones.

Conclusions: This large international survey highlights substantial heterogeneity in stone management, shaped by geography, fellowship training, and years in practice. While PCNL remains the cornerstone for complex stones, technological advances are driving a measurable shift toward minimally invasive RIRS. These findings underscore the importance of adaptable, evidence-based guidelines to standardize global practice.

Comment Hans-Göran Tiselius

How urologists in a world-wide perspective select methods for stone removal in unclear. Most reports are based on comparative studies between different procedures. To get more information on this matter the authors sent a survey to members of the Endourological Society. Answers were received from 300 respondents. The result disclosed a considerable variation for which by several different factors played a role.

For the interested reader a lot of data can be found in this article. I have emphasized the essential points. Although RIRS more commonly was used for 6-15 mm stones, SWL was not uncommon for stones in the upper calyces and renal pelvis, whereas lower calyx stones of this size most commonly was treated invasively with RIRS.

The dominance of RIRS for stones measuring 15-25 mm was obvious with use of SWL in only 5.3-11 %. For stones larger than 25 mm PCNL was most used (70 - 75%). RIRS in 7–17 % and SWL only in 0.7–2 %. Although SWL apparently was used for both 4-6 mm stones and 6-15 mm stones, RIRS dominated for 15-25 mm stones.

For lower calyx stones 6-15 mm RIRS more commonly was chosen than SWL (≈64% vs ≈26%) For upper and pelvic stones the difference was less pronounced (≈69% vs ≈48%)

There is a lot of information in this article which it does not make sense to repeat, but one important point is that young colleagues preferred RIRS before SWL. This is an important observation that needs due attention and that to some extent explains the diminishing role of SWL. Geographic location, fellowship training and years in urology practice played an important role for selection of stone removing method. So did also the lack of straightforward recommendations in guidelines.

Hans-Göran Tiselius