Zilberman DE. et al., 2022: Changing Trends in Surgical Management of Nephrolithiasis among Young Adults: A 15-Year Population-Based Study.

Thursday, 22 December 2022

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Zilberman DE, Erlich T, Kleinmann N, Sabler IM, Neheman A, Verhovsky G.J
Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel.
Department of Military Medicine, Hebrew University of Jerusalem, Jerusalem and the Israel Defense Forces Medical Corps, Ramat Gan 91905, Israel.
Department of Urology, Sackler School of Medicine, Tel-Aviv University, Zerifin 60930, Israel.
Shamir (Assaf Harofeh) Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel.

Abstract

Background: Increases in obesity and diabetes rates among all ages have led to a greater prevalence of nephrolithiasis worldwide. We aimed to explore the changing trends in surgical management of nephrolithiasis in young adults over a 15 year period. Methods: We reviewed medical records of military personnel for information on the diagnosis and care of nephrolithiasis before and during active service between 2007-2021, divided into three 5 year periods: 2007-2011, 2012-2016, and 2017-2021. Demographic, clinical, radiological, and surgical data were retrieved for the analysis of changing trends. Results: The records of 1,117,692 recruits yielded 7383 (0.66%) with stone-related surgeries, of whom 1885 were operated during military service. Their median age was 19.6 years (interquartile range [IQR] 16.8-21.2), 829 (70%) were males, and the cohort's median body mass index was 23.6 (IQR 17.3-26.1). There was a dramatic decline in shock wave lithotripsy (SWL) prevalence (35.1%, 10.4%, and 4.4%, respectively) with a continually increasing prevalence of ureteroscopy (URS)/retrograde intrarenal surgery (RIRS) (62.7%, 88.5%, and 94.6%, p = 0.01). Percutaneous nephrolithotomy (PCNL) procedures have become nearly extinct over time (0.8% in 2017-2021). The number of median-sized stones treated by URS/RIRS increased (7.5 mm, 8.2 mm, and 9.7 mm, p = 0.044), but not those treated by SWL/PCNL. The median length of medical leave for URS/RIRS and PCNL decreased significantly (7 vs. 4 days, p = 0.05 and 10 vs. 6 days, p = 0.036, respectively), with no comparable change for SWL. There was a substantial decline in ancillary procedures in the URS/RIRS groups (9%, 6.8%, and 3.1%, p < 0.01), but not in the SWL/PCNL groups. Conclusions: Advancements in technology and surgical training are leading to the extinction of SWL and the adoption of URS/RIRS as the new standard of care for nephrolithiasis among young adults.
Pers Med. 2022 Aug 21;12(8):1345. doi: 10.3390/jpm12081345. PMID: 36013296. FREE ARTICLE

Comments 1

Hans-Göran Tiselius on Friday, 23 December 2022 09:30

This article might be disappointing reading for the manufacturers of SWL equipment. In the three 5-year periods 2007-2011, 2012-2016 and 2017-2021 a dramatic decrease in use of SWL was recorded: 35%, 10% and 4%, respectively! In contrast URS increased: 62%,89% and 95%. There was also a decreased application of PCNL over the three periods.

This is the only article in which I have seen that the authors have used the expression “near-extinction” of SWL. But although a trend of decreasing SWL can be observed worldwide, the development in this cohort is exceptional.

Further reading, however, disclosed that perhaps the most powerful determinant for this development was problem with function of their Dornier HM3 lithotripter as well as the authors’ erroneous belief that this device only is possible to use with general or regional anesthesia. Obviously, the local health authorities were unwilling to purchase any later generation of lithotripters and in view of these facts, the trend in clinical management of patients with stones is not surprising.

During all three periods the median sizes of stone treated with SWL were surprisingly small: 4.1, 5.1 and 4.9 mm, whereas that of stones referred to URS/RIRS were 7.5, 8.5 and 9.7 mm.

The population of young adults comprised 1.1 million of whom 7383 had undergone stone surgery; 1885 during their military service.

In summary it is unfortunate that the urologists in this specific geographic region are without experience of modern lithotripters and apparently also without knowledge of how to use the Dornier HM3 lithotripter in a modern way. But it stands to reason that if spare parts are not available it is little that can be done!!

Hans-Göran Tiselius

This is the only article in which I have seen that the authors have used the expression “near-extinction” of SWL. But although a trend of decreasing SWL can be observed worldwide, the development in this cohort is exceptional.

Further reading, however, disclosed that perhaps the most powerful determinant for this development was problem with function of their Dornier HM3 lithotripter as well as the authors’ erroneous belief that this device only is possible to use with general or regional anesthesia. Obviously, the local health authorities were unwilling to purchase any later generation of lithotripters and in view of these facts, the trend in clinical management of patients with stones is not surprising.

During all three periods the median sizes of stone treated with SWL were surprisingly small: 4.1, 5.1 and 4.9 mm, whereas that of stones referred to URS/RIRS were 7.5, 8.5 and 9.7 mm.

The population of young adults comprised 1.1 million of whom 7383 had undergone stone surgery; 1885 during their military service.

In summary it is unfortunate that the urologists in this specific geographic region are without experience of modern lithotripters and apparently also without knowledge of how to use the Dornier HM3 lithotripter in a modern way. But it stands to reason that if spare parts are not available it is little that can be done!!

Hans-Göran Tiselius

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