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.

Changing Trends in the Treatment of Nephrolithiasis in the Real World.

INTRODUCTION: Changes in the surgical treatment of nephrolithiasis, owing to recent technical advances and innovations, have made treatments more effective and less invasive. In this retrospective, observational cohort study, we identified the changing trends in the treatment of nephrolithiasis. MATERIALS AND METHODS: We included patients with newly diagnosed nephrolithiasis who received any treatment in the United States, including extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and open surgery, from January 2007 to December 2014. Demographic factors, such as age, sex, region, surgical treatment type, and cost data, were analyzed. RESULTS: The median age of patients at treatment was 52 years, and the ratio of men and women was similar. There were definite changes in the trends of all treatment modalities (p < 0.01). Both the number and percentage tended to increase for RIRS, whereas for SWL, the number increased, but the percentage showed a steady decrease. In PCNL, both number and percentage increased to a minor degree. The overall cost of nephrolithiasis treatments during the study period nearly doubled (from $30,998,726 to $57,310,956). The number of treatments and average cost per treatment increased annually for each treatment modality. RIRS was the least expensive; the other procedures in decreasing order of their mean costs were as follows: SWL, PCNL, and open surgery. CONCLUSIONS: There was a gradual but constant change in treatment trends of nephrolithiasis, with an increasing trend for RIRS and a decreasing trend for SWL. Although PCNL has relatively invasive characteristics, it is still in steady demand.

Contemporary Trends in Utilization and Perioperative Outcomes of Percutaneous Nephrolithotomy in the United States from 2003 to 2014.

PURPOSE: To investigate the contemporary trends and perioperative outcomes of percutaneous nephrolithotomy (PCNL) by using a population-based cohort. MATERIALS AND METHODS: Using the Premier Healthcare Database, we identified 225,321 patients in whom kidney/ureteral calculi were diagnosed and who underwent PCNL at 447 different hospitals across the United States from 2003 to 2014. Outcomes included 90-day postoperative complications (as classified by the Clavien-Dindo system), prolonged hospital length of stay, operating room time, blood transfusions, and direct hospital costs. Temporal trends were quantified by estimated annual percentage change (EAPC) by using least-squares linear regression analysis. Multivariable logistic regression was performed to identify predictors of outcomes. RESULTS: PCNL utilization rates initially increased from 6.7% (2003) to 8.9% (2008) (EAPC: +5.60%, p = 0.02), before plateauing at 9.0% (2008-2011), and finally declining to 7.2% in 2014 (EAPC: -4.37%, p = 0.02). Overall (Clavien ≥1) and major complication (Clavien ≥3) rates rose significantly (EAPC: +12.2% and +16.4%, respectively, both p < 0.001). Overall/major complication and blood transfusion rates were 23.1%/4.8% and 3.3%, respectively. Median operating room time and 90-day costs were 221 minutes (interquartile range [IQR] 4) and $12,734 (IQR $9419), respectively. Significant predictors of overall complications include higher Charlson comorbidity index (CCI) (CCI ≥2: odds ratio [OR] 2.08, p < 0.001) and more recent year of surgery (2007-2010: OR 3.20, 2011-2014: OR 4.39, both p < 0.001). Higher surgeon volume was significantly associated with decreased overall (OR 0.992, p < 0.001) and major (OR 0.991, p = 0.01) complications. CONCLUSIONS: Our contemporary analysis shows a decrease in the utilization of PCNL in recent years, along with an increase in complication rates. Numerous patient, hospital, and surgical characteristics affect complication rates.

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.

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.

An update on percutaneous nephrolithotomy: lessons learned from the CROES PCNL Global Study.

Since its introduction in late 1970's, percutaneous nephrolithotomy (PNL) has undergone an evolution in both equipment and technique. This evolution still continues today in the era of minimally invasive treatment options, and is evidenced by the numerous publications. PNL is generally advantageous in the management of large renal stones (>1.5-2 cm) with high stone-free rates and considerable complication rates. However this technique is especially competing with retrograde intrarenal surgery and laparoscopic techniques. Therefore the CROES Global PNL Study Group prospectively collected data of over 5800 patients managed with PNL worldwide and analyzed the data in detail, producing more than 25 scientific papers. And this update focuses on the lessons learned from the CROES PCNL Global Study.