Trends and patterns of initial percutaneous nephrolithotomy and subsequent procedures among commercially-insured US adults with urinary system stone disease: a 10-year population-based study.

PURPOSE: To describe trends and patterns of initial percutaneous nephrolithotomy (PCNL) and subsequent procedures from 2010 to 2019 among commercially-insured US adults with urinary system stone disease (USSD). METHODS: Retrospective study of administrative data from the IBM® MarketScan® Database. Eligible patients were aged 18-64 years and underwent PCNL between 1/1/2010 and 12/31/2019. Measures of interest for analysis of trends and patterns included the setting of initial PCNL (inpatient vs. outpatient), percutaneous access (1 vs. 2-step), and the incidence, time course, and type of subsequent procedures (extracorporeal shockwave lithotripsy [SWL], ureteroscopy [URS], and/or PCNL) performed up-to 3 years after initial PCNL. RESULTS: A total of 8,348 patients met the study eligibility criteria. During the study period, there was a substantial shift in the setting of initial PCNL, from 59.9% being inpatient in 2010 to 85.3% being outpatient by 2019 (P < 0.001). The proportion of 1 vs. 2-step initial PCNL fluctuated over time, with a low of 15.1% in 2016 and a high of 22.0% in 2019 but showed no consistent yearly trend (P = 0.137). The Kaplan-Meier estimated probability of subsequent procedures following initial PCNL was 20% at 30 days, 28% at 90 days, and 50% at 3 years, with slight fluctuations by initial PCNL year. From 2010 to 2019, the proportion of subsequent procedures accounted for by URS increased substantially (from 30.8 to 51.8%), whereas SWL decreased substantially (from 39.5 to 14.7%) (P < 0.001). CONCLUSIONS: From 2010 to 2019, PCNL procedures largely shifted to the outpatient setting. Subsequent procedures after initial PCNL were common, with most occurring within 90 days. URS has become the most commonly-used subsequent procedure type.

Burden of Urolithiasis: Trends in Prevalence, Treatments, and Costs.

CONTEXT: The recent evolution of management options for urolithiasis has presented a unique dilemma for the modern urologist. A comprehensive understanding of epidemiological trends along with current provider preferences in treating urinary stones would be beneficial. OBJECTIVE: To review trends in the prevalence, treatments, and costs of urolithiasis worldwide. EVIDENCE ACQUISITION: A literature review was performed using the MEDLINE database, the Cochrane Library Central search facility, Web of Science, and Google Scholar between 1986 and 2016. Keywords used for the search were "urolithiasis" and "prevalence; treatment; and cost". EVIDENCE SYNTHESIS: The incidence and prevalence of urinary stones are rising around the world, including regions that have historically had low rates of urolithiasis. Common theories explaining this trend involve climate warming, dietary changes, and obesity. Shockwave lithotripsy (SWL) has been the preferred mode of treatment since its introduction in the 1980s. However, ureteroscopy (URS) has become increasingly popular for small stones regardless of location because of lower recurrence rates and costs. Developing countries have been slower to adopt URS technology and continue to use percutaneous nephrolithotomy at a steady rate. CONCLUSIONS: URS has recently challenged SWL as the treatment modality preferred for small upper urinary tract stones. In some cases it is less expensive but still highly effective. As the burden of stone disease increases worldwide, appropriate selection of stone removal therapies will continue to play an important role and will thus require further investigation. PATIENT SUMMARY: Urinary stones are becoming more prevalent. Recent advances in technology have improved the management of this disease and have decreased costs.

Contemporary Trends of Inpatient Surgical Management of Stone Disease: National Analysis in an Economic Growth Scenario.

PURPOSE: To assess trends in urologic surgical management of upper tract urolithiasis in Brazil over the past 15 years. MATERIALS AND METHODS: The Public Health System of Brazil (SUS) provides health coverage to 47% to 74% of the population. SUS has a longitudinal hospital inpatient database (SIH/SUS). Hospital discharges between January 1,1998 and December 31, 2012 were abstracted from the SIH/SUS. All inpatient hospitalizations for patients of any age with a primary/secondary diagnosis code of N20.x (calculus of kidney or ureter) were abstracted (ICD-9/10). All urolithiasis-related procedure codes were analyzed. The absolute number of procedures/year and the proportion among all techniques were analyzed for Brazil and also separately for the five distinguished regions of the country. Prevalence trends over the studied period were quantified by the estimated annual percent change (EAPC) using the least squares linear regression methodology. Significance was set at P<0.05. RESULTS: The number of surgical interventions for stone disease increased significantly from 10080 to 24713 (+145%; EAPC=1008.1; P<0.001). The most common surgical modalities in 1998 were nephrectomy (n=2918; 29%), ureterolithotomy (n=2361; 23%), and pyelolithotomy (n=1771; 18%). In 2012, ureteroscopy (URS) was the most commonly performed procedure (n=8725; 35%), followed by ureterolithotomy (n=5822; 24%), and nephrectomy (n=3466; 14%). Between 1998 and 2012, percutaneous nephrolithotomy had the highest significant relative increase (+791.8%; EAPC=0.6%; P<0.001), followed by URS (+607%; EAPC=1.78%; P<0.001). Pyelolithotomy showed the most significant decrease (-47.5%; EAPC = -0.91%; P<0.001). All five regions presented a significant positive increase in the EAPC (P<0.001). CONCLUSION: Trends of stone disease surgical management in the public health system of Brazil follow worldwide tendencies toward less invasive treatment modalities.

Extracorporeal shock wave lithotripsy of gallstones revisited: current status and future promises.

The improvement and refinement of extracorporeal shock wave lithotripsy (ESWL) has made this non-invasive treatment modality not only more effective, but also applicable to a larger population of gallstone patients. It can be performed safely on an outpatient basis. Advances in lithotripsy technology have made it possible to fragment stones into very small, sand-like particles (pulverization), which clear the gall-bladder faster than large fragments. Recent studies provide evidence that adjuvant bile acids may not be necessary in most cases in which pulverization is achieved. Good gall-bladder emptying appears both to promote the clearance of gallstones after ESWL and to decrease their recurrence. Although generally found to be more expensive than surgery if bile acids are used, ESWL should be cost-effective, as bile acids may not be necessary in all patients. Elderly patients with radiolucent, solitary and less than 30 mm gallstones can particularly benefit from lithotripsy.

The dynamics of innovation in minimally invasive therapy.

The emergence of minimally invasive therapy (MIT), which provides alternatives to major open-surgery procedures, is affecting all aspects of medical care delivery. In the present environment of resource and cost constraint in health services, an uncommon consensus among patients, physicians, providers, and payers has evolved regarding the rapid acceptance of this area of medical intervention, an acceptance that, in turn, is stimulating further innovation. This paper discusses the dynamics of medical innovation and analyzes these forces in the context of three minimally invasive therapies: percutaneous transluminal coronary angioplasty, extracorporeal shock wave lithotripsy, and laparoscopic cholecystectomy. The different experiences of the United States and Europe are used to illustrate how scientific, medical, economic, and regulatory factors affect both the rate and direction of technological change in minimally invasive therapy.

Minimally invasive therapy: the French case study.

The diffusion in France of the 10 selected technologies is quite different, depending on the technology. Some are 'ancient', widely diffused and stabilized techniques, such as arthroscopy for knee surgery and lithotripsy for bladder stones. Others are very new but quickly disseminating technologies, such as laparoscopic cholecystectomy, and others, especially those based on lasers, have only a restricted diffusion related in some cases to a lasting skepticism of most physicians. It is therefore not possible to draw a common sketch that would apply to 'minimally invasive surgery in France' as a whole. Nevertheless, it is possible to stress some common points which characterize the dissemination of innovation in the French health care system since the 1980s. These include the lack of methods available to health authorities to control medical innovation; the organizational and financial constraints on health care institutions, restricting their ability to adapt to changing circumstances; a limited judicial response in the face of potentially dangerous technologies; the high degree of freedom that medical practitioners have in adopting innovations; the weakness of French industry; and the important and sometimes destructive role the media play in diffusion of health care innovations.

Going mobile.

The high cost of ESWL and MRI have created a strong market for mobile units that can be shared by several health-care facilities. Recent modifications in the design of this technology make it convenient to use in mobile vans. Other modalities are being used in mobile vans primarily to service small hospitals.

[Development of the indications for extra-corporeal lithotripsy and the impact of organizational methods on the indications]. / Evolution des indications de la lithotripsie extra-corporelle et impact du mode d'organisation sur les indications.

A technology assessment of ESWL for renal stones has been conducted. The development of lithotripsy during the early phase of diffusion of the technique was studied retrospectively for 1985 and 1986. This study permitted the comparison of lithotripsy practice in Paris with that in Lyon. Results show that the proportion of small (less than 10 mm) stones increased from 39% at the beginning of the period to 60% at the end in Paris and simultaneously from 41% to 53% in Lyon. The location of the calculi treated by ESWL changed significantly over the period, but only in Paris where the number of caliceal stones went from 62% to 38% and that of ureteral stones from 1% to 8%. Neither the number of stones treated during one ESWL session, nor the length of hospital stay, changed significantly during the first years of use of this treatment. However, if one excludes hospital stays of more than 15 days, the average hospital stay in Paris decreased where as the opposite was observed in Lyon. The impact of the organization of ESWL users upon medical practice is obvious in relation to the size of stones: in Lyon, where one team provides ESWL therapy for all hospital urology departments, treatment practice is more homogeneous than in Paris and more closely a resembles the international consensus.

The coming battle over gallstones. How will surgeons, gastroenterologists, and radiologists fare?

The standard treatment of symptomatic gallstones--initial patient evaluation, confirmation of the presence of stones by diagnostic imaging, and surgical removal of the gallbladder (cholecystectomy)--has become institutionalized in modern medical practice. In recent years alternative treatments have been developed, but none has dislodged cholecystectomy from its preeminent position. Should a new therapy, extracorporeal shock-wave biliary lithotripsy, prove to be broadly successful, it could profoundly change the future workloads of general surgeons, gastroenterologists, and radiologists, the three specialists most likely to have significant roles in providing this new treatment.