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.

Contemporary Trends in Percutaneous Nephrolithomy Across New York State: A Review of the Statewide Planning and Research Cooperative System.

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of <0.05. Results: We identified a total of 4576 procedures performed from 2006 to 2014 at a total of 77 hospitals in NYS (Table 1). Total PCNL volume performed across all NYS hospitals increased in the past decade, with the greatest number of procedures performed in 2012 to 2013. Low-volume institutions were more likely to provide care to minority populations (21.4% vs 17.3%, p < 0.001) and those with Medicaid (25.5% vs 21.5%, p < 0.001). High-volume institutions provided care to patients with private insurance (42.1% vs 34.0%, p < 0.001) and had a shorter length of stay (3.3 days vs 4.1 days, p < 0.001). Conclusion: Our data provide insight into the patient demographics of those treated at high-, medium-, and low-volume hospitals for PCNL across NYS. Significant differences in race, insurance status, and length of stay were noted between low- and high-volume institutions, indicating that racial and socioeconomic factors play a role in access to care at high-volume centers.

Contemporary practice patterns associated with percutaneous nephrolithotomy among certifying urologists.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for patients with complex stone burdens. We performed a study to assess the effect of urologist-specific parameters on the use of PCNL-both the access component of the procedure as well as the stone removal. We also examined trends in PCNL utilization over time. METHODS: We analyzed self-reported 6-month case logs submitted to The American Board of Urology (ABU) for urologists who certified or recertified between 2004 and 2013. Surgeons performing PCNL were identified by Current Procedural Terminology coding. Urologist-specific data, including fellowship training, practice type, and practice population, were used to further stratify this cohort. Trends were examined over the study period. RESULTS: A total of 7278 urologists submitted case logs to the ABU between 2004 and 2013. The median ages of the initial certification group, first recertification group, and second recertification group were 36.0, 43.7, and 53 years, respectively. A greater proportion of newly certified urologists performed PCNL (53%) compared with urologists in the first (41%) and second (29%) recertification groups; initially certified urologists were also more likely to be high volume (>10) PCNL surgeons. Urologists with fellowship training were more likely to use PCNL (66%) and be high-volume surgeons (26.4%). PCNL utilization increased significantly during the study period, with 1330 procedures performed in 2004 and 2888 procedures performed in 2012 (117% increase). CONCLUSIONS: Younger and fellowship-trained urologists are the primary users of PCNL; the majority of senior urologists do not perform this operation. Overall, the use of PCNL and urologist-directed access has increased in the previous decade.

Surgeon volume for percutaneous nephrolithotomy is associated with medical costs and length of hospital stay: a nationwide population-based study in Taiwan.

BACKGROUND AND PURPOSE: To investigate the factors associated with outcomes and medical costs for percutaneous nephrolithotomy (PCNL). METHODS: The present study uses a subset of the National Health Insurance Research Database (NHIRD), known as the Longitudinal Health Insurance Database 2005 (LHID 2005), which contains the data of all medical benefit claims from 1997 to 2010 for a subset of 1 million enrollees randomly drawn from the population of 22.72 million persons who were enrolled in 2005. The claims data for all subjects with a diagnosis of urolithiasis who underwent PCNL were analyzed. Hospital and surgeon case volume were classified by quartile. The correlations of all patient, surgeon, and hospital variables with the outcomes and medical costs of PCNL were analyzed by generalized estimating equations. RESULTS: A total of 995 subjects received PCNL. In univariate analysis, PCNL performed by high-volume surgeons (≥12) cost 26% less ($2684 vs $1986) and resulted in a 34.3% shorter hospital stay (6.5 vs 9.9 days) compared with low-volume surgeons (≤3). In multivariate analysis, surgeon volume was a significant predictor for medical cost, length of stay, and intensive care unit transfer but not complications and mortality. CONCLUSIONS: Surgeon volume was associated with lower medical costs and shorter length of stay after PCNL. Surgeon volume, however, was not an independent predictor of complications and mortality. Our findings have important implications for urologists and policymakers with regard to the cost and effectiveness of PCNL.

Current practices in percutaneous nephrolithotomy among endourologists.

OBJECTIVE: To characterize current practices of percutaneous nephrolithotomy (PCNL) among endourologists in relation to practice setting, experience, and fellowship training. METHODS: An Internet survey was administered to active Endourological Society members. Responses were grouped based on demographic information pertaining to setting of practice, number of years practiced, and fellowship training in endourology. PCNL technique details were evaluated and compared by each group. Statistical analysis was performed using SPSS. RESULTS: Two hundred ninety-three completed responses of 2000 were received. There was a significant difference in the experience level among respondents (p < 0.001), with a relatively greater proportion being 11-20 years in practice. The majority of respondents were academic urologists (74%), with 18% being within a group-based private practice. Seventy-seven percent of respondents obtained their own access while 19% had access by interventional radiologists. Sixty-two percent were endourology fellowship trained, and fellows were significantly more likely to obtain their own access (82% vs 71%, p=0.022). Eighty-six percent used the prone position to obtain access, 10% used supine, and 4% used lateral decubitus. An antegrade approach was preferred by 68%, while 18.5% used a retrograde, and 12% used a combined approach. Overall, 76% placed a nephrostomy tube for postoperative drainage; a ureteral stent or catheter was placed in 28% or 11% of respondents, respectively, and only 6 respondents (2%) performed a "tubeless" procedure without any drainage. CONCLUSIONS: The majority of Endourological Society members performing PCNLs who responded obtain their own access, and there is a higher proportion of self-obtained access in fellowship-trained endourologists. Prone positioning is predominant, and more than 75% of respondents leave a nephrostomy tube postoperatively, underscoring that the tubeless approach is rare.

Laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for a solitary renal pelvis stone larger than 3 cm: a prospective cohort study.

To prospectively compare the outcome of laparoscopic pyelolithotomy (LP) versus percutaneous nephrolithotomy (PCNL) in patients with a solitary renal pelvis stone larger than 30 mm. We analyzed demographic and perioperative parameters and intermediate outcome in 30 adults who underwent transperitoneal LP for solitary renal pelvis stone larger than 30 mm (Group I) and compared the results with 30 patients who underwent PCNL (Group II). The two groups were matched for age, sex and stone size (Group I 35.3 ± 7.33 mm, Group II 36.6 ± 7.0 mm; P = 0.47). Mean operative time was significantly longer in LP group (120.5 ± 39.94 min versus 98.1 ± 23.28 min; P = 0.01, 95 % CI 5.43-39.23). Stone-free rate after LP was significantly higher than after PCNL (100 % versus 76.7 %; P = 0.01). On the discharge day, no residual stone was found in LP group, and significant residual stone (mean size 9.8 mm, range 7-15 mm) was found in seven patients (23.3 %) in PCNL group. After the ancillary procedures, the stone-free rates were 100 % in LP and 96.6 % in PCNL group at the end of follow-up. The average overall treatment cost was significantly lower in LP (683.9 USD versus 815.9 USD; P < 0.001). Mean postoperative decreases in hemoglobin was similar in both groups. Given adequate laparoscopic experience, for patients with a solitary renal pelvis stone larger than 3 cm, LP can be considered as an appropriate second choice to PCNL. It can be a potentially cost-effective treatment option in terms of one-session stone-free rate and postoperative complications. However, the potential benefits of LP need to be weighed against the more invasive nature of this procedure.

Quality-of-life assessment after palliative interventions to manage malignant ureteral obstruction.

PURPOSE: Malignancies may cause urinary tract obstruction, which is often relieved with placement of a percutaneous nephrostomy tube, an internal double J nephro-ureteric stent (double J), or an internal external nephroureteral stent (NUS). We evaluated the affect of these palliative interventions on quality of life (QoL) using previously validated surveys. METHODS: Forty-six patients with malignancy related ureteral obstruction received nephrostomy tubes (n = 16), double J stents (n = 15), or NUS (n = 15) as determined by a multidisciplinary team. QoL surveys were administered at 7, 30, and 90 days after the palliative procedure to evaluate symptoms and physical, social, functional, and emotional well-being. Number of related procedures, fluoroscopy time, and complications were documented. Kruskal-Wallis and Friedman's test were used to compare patients at 7, 30, and 90 days. Spearman's rank correlation coefficient was used to assess correlations between clinical outcomes/symptoms and QoL. RESULTS: Responses to QoL surveys were not significantly different for patients receiving nephrostomies, double J stents, or NUS at 7, 30, or 90 days. At 30 and 90 days there were significantly higher reported urinary symptoms and pain in those receiving double J stents compared with nephrostomies (P = 0.0035 and P = 0.0189, respectively). Significantly greater fluoroscopy time was needed for double J stent-related procedures (P = 0.0054). Nephrostomy tubes were associated with more frequent minor complications requiring additional changes. CONCLUSION: QoL was not significantly different. However, a greater incidence of pain in those receiving double J stents and more frequent tube changes in those with nephrostomy tubes should be considered when choosing palliative approaches.

Diffusion of minimally invasive therapy in The Netherlands.

In the context of the European project, the diffusion of 10 selected cases of minimally invasive therapy (MIT) in the Dutch health care system was documented and analyzed. In each case the diffusion pattern resulting from the balance of stimulating and impeding factors is described, and summarized in a matrix framework. Budgetary pressures, lack of evidence on effectiveness and physician conservatism are the most important factors impeding diffusion of MIT. Patient demand, media reporting and presence of medical innovators are important diffusion-stimulating factors. Finally, a judgment is made on the policy implications of these findings, based on a comparison of the extent and speed of the diffusion of each case, the quality of evidence on effectiveness and cost-effectiveness and, in a few cases, existing policies. In most cases, more active policy making, either stimulating or otherwise guiding diffusion, would be desirable.