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.

Consensus of multiple national guidelines: agreed strategies for initial stone management during COVID-19.

PURPOSE: To review the existing available information regarding urolithiasis management and the impact of COVID-19 on this, and propose recommendations for management of emergency urolithiasis presentations in the COVID-19 era. METHODS: Review of published guidelines produced by Urological Governing Bodies, followed by the literature review regarding urolithiasis management during the COVID-19 pandemic. RESULTS: Consistent recommendations across guidelines and literature were that urolithiasis with concurrent sepsis or renal failure remains a urological emergency warranting urgent intervention within the pandemic environment. Ureteric stenting and percutaneous nephrostomy are considered equivalent for decompression in this setting, with both ideally to be performed under local anaesthesia where possible to spare ventilators and reduce aerosol-generating procedures. Greater utilization of medical expulsive therapy and dissolution chemolysis may occur during the pandemic, and longer indwelling stent times may be accepted while definite stone clearance is deferred. CONCLUSIONS: Urolithiasis will continue to be a source of emergency presentations requiring urgent intervention during the COVID-19 pandemic. However, it is possible to limit these interventions to decompression of the collecting system in the setting of concurrent obstruction or infection, performed under local anaesthesia to limit use of resources and minimise aerosol-generating procedures, with deferral of definitive management.

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.

National Practice Pattern and Time Trends in Treatment of Upper Urinary Tract Calculi in Korea: a Nationwide Population-Based Study.

Despite high prevalence of upper urinary tract calculi (UUTC), there are few studies regarding patterns of care in Asian populations. We investigated treatment patterns and time trends in patients with newly diagnosed UUTC in Korea using the National Health Insurance database that includes de-identified claims from a random 2% sample of the entire population (> 1 million people). A total of 14,282 patients who received active treatments, including shock wave lithotripsy (SWL), ureteroscopic surgery (URS), percutaneous nephrolithotomy (PNL), and uretero/pyelolithotomy (UPL), for newly diagnosed UUTC between 2003 and 2013 were included. The number of primary and all treated cases of UUTC significantly (43% and 103.3%, respectively) increased over the 10-year period. While patients undergoing SWL, URS, PNL, and UPL as primary treatment increased by 43.7%, 31.9%, 87.5%, and 0%, respectively, the relative proportion undergoing each treatment remained constant over the 10 years (SWL > 90%, URS 4.5% to 7.8%, PNL 0.4% to 1.0%, and UPL < 0.4%, respectively). Multinomial logistic regression analysis showed that age > 40 years (compared to age < 30 years) was significantly associated with URS, PNL, and UPL, rather than SWL, while patients living in urban or suburban/rural areas (compared to metropolitan) were significantly less likely to undergo URS and PNL. In summary, the majority of Korean patients underwent SWL as primary treatment for UUTC, and the predominant use of SWL remained steady over a 10-year period in Korea. Our results will be valuable in examining treatment patterns and time trends in Korean UUTC patients.

Innovations in percutaneous nephrolithotomy.

Technical innovations in all aspects of percutaneous nephrolithotomy have changed the field considerably. The current review is aimed at reporting on the most recent advancements in the field of percutaneous nephrolithotomy. Improvements in CT imaging and the possibility of 3D rendering have dethroned the intravenous pyelogram as gold standard for pre-operative imaging. Where gaining access in the lower pole in prone position with telescopic metal dilators, placing a 30F tract used to be standard, the plethora of alternatives provides the trained surgeon with a large armamentarium to tackle any obstacle. Novel lithotripters appear more efficient than their predecessors and with tubeless PCNL gaining some momentum, ambulatory PCNL is slowly but surely becoming feasible rather than fictional.

[Stone treatment tomorrow and the day after]. / Steintherapie morgen und übermorgen.

Urological and surgical treatment of urinary stones are highly technological and technology-driven disciplines in present-day surgery. German medical engineering has always been recognized for its technical innovations in endoscopic surgery. Current and future trends are indicative of further miniaturization and automation of surgical instruments and assist systems to facilitate endourological procedures as well as improvements in the quality of results and ergonomics. These technologies include, e. g. 3D-tracking to facilitate access to the pelvicaliceal system for percutaneous nephrolithotomy (PNL) or robotic master-slave systems for endourology. The aim of all future stone treatment should be complete stone removal. This could be achieved by improved stone fragmentation ("micron-sized debris") or complete removal of fragments (e. g. using a "stone glue"). Integration of diagnostic procedures and treatments will constitute a key aspect of future developments in medical engineering. Intelligent laser systems may be capable of distinguishing stones from mucosa and artificial surfaces and may be used for immediate stone analysis during surgery. A simpler and faster availability of metabolic ("metabolomics") and genetic ("genomics") diagnostics will help to facilitate and improve individual metaphylaxis, e. g. in patient self-management. Nanotechnology and microrobots that may be used for endoluminal diagnostics and treatment of the urinary tract are already in development.

Innovations in surgical stone disease.

PURPOSE OF REVIEW: Urinary stone disease is a condition characterized by a rich history of surgical innovation. Herein, we review the new ideas, devices and methods that are the cornerstones of contemporary surgical innovation in stone disease, specifically flexible ureteroscopy and percutaneous nephrolithotomy. RECENT FINDINGS: The new ideas being applied to flexible ureteroscopy include extending the boundaries of surgical indications and eliminating the need for intraoperative fluoroscopy. Device advancements include disposable ureteroscopes and flexi semirigid ureteroscopes. Robotic flexible ureteroscopy, the use of magnets and mobile technology applications represent progress in methods of performing flexible ureteroscopy. Three-dimensional computed tomography and printing technology are enhancing percutaneous renal access. Novel image-guided access techniques are improving the accuracy of percutaneous surgery particularly for complex cases. SUMMARY: New ideas, devices and methods are continuing to reshape the landscape of surgical stone treatment and in so doing not only have the potential to improve surgical outcomes but also to cultivate further scientific and technological advancements in this area.

Contemporary Trends in Percutaneous Nephrolithotomy in the United States: 1998-2011.

OBJECTIVE: To examine trends in percutaneous nephrolithotomy (PCNL) using a serial, cross-sectional study design. METHODS: The Nationwide Inpatient Sample, the largest, publicly available, all-payer, inpatient database, was searched to identify patients of any age who underwent PCNL from 1998 to 2011. Annual procedure incidence rates were estimated using the total US Census Bureau populations. RESULTS: Data indicated that 105,180 patients underwent PCNL during the study period. The overall annual rate increased from 17 to 31 per million US adults (P < .001), with significant increases among white (P < .001) and Hispanic (P = .03) patients. Both sexes had significant increases in procedure rates: males increased from 17 to 30 per million adults (P < .001), and females increased from 17 to 32 (P < .001). PCNL among patients younger than 18 years was relatively stable (P = .59), whereas among patients aged 18 to 64 years, the procedure rate increased from 39 to 70 per million adults (P < .001), and patients older than 65 years had a larger increase, from 52 to 113 per million (P < .001). CONCLUSION: The incidence of PCNL in the United States nearly doubled from 1998 to 2011.

New technology in ureteroscopy and percutaneous nephrolithotomy.

PURPOSE OF REVIEW: New developments of retrograde intrarenal and percutaneous endoscopic surgery for nephrolithiasis have significantly enhanced the indications of endourology compared to extracorporeal shock wave lithotripsy. We want to review the most significant new technologies RECENT FINDINGS: New technology to access the renal collecting system includes marker-based tracking with iPAD, laser-guided puncture on (Uro)Dyna-CT, electromagnetic tracking (only experimental), and optical tracking for ultrasound-guided puncture. Miniaturization percutaneous nephrolithotomy has been further extended and classified to Midi-PCNL (20-22F/L), Mini-PCNL (16-18F/M), Ultra/Super-mini-PCNL (12-14F/S), and Micro-PCNL (8-10F/XS). Knowledge of Ho:YAG-laser lithotripsy including power settings for fragmentation (depending on stone composition), dusting (0.5J/20Hz), and popcorn-effect/laser-burst (1J/30Hz) becomes mandatory. Also hydrodynamic mechanisms for retrieval of fragments (active/passive washout, purging, vacuum-cleaner-effect) have gained importance. Improvements of FURS focus on digital-HD-video-technology with post-processing software (NBI/SPIES) providing better resolution and increased optical field, further miniaturization of endoscopes to fit in smaller access sheath (12/14F), additional tip-less Nitinol baskets and graspers, and introduction of a robotic device (Avicenna Roboflex) to improve ergonomics of the procedure. SUMMARY: Based on recent technical developments, percutaneous nephrolithotomy and particularly flexible ureteroscopy will further gain preference in management of urolithiasis compared to ESWL. Endourology may offer a higher rate of primary success with minimal side-effects which could weigh out the slightly higher degree of invasiveness.

Contemporary trends in urinary tract stone surgery, a regional perspective: Auckland, New Zealand.

BACKGROUND: The aim of the study is to assess the contemporary patterns of utilization of various therapeutic options for the management of nephrolithiasis in our tertiary referral institution in Auckland, New Zealand. METHODS: A retrospective audit was conducted for all urinary stone procedures between January 2007 and December 2013. Procedure-related information was collected for each year. All elective and emergency procedures were included. Data were collected on the elective waiting lists for each procedure. RESULTS: A total of 5512 stone-related cases were performed during the study period. Six hundred and fifty-three cases were performed in 2007 compared with 945 in 2013. Total number of percutaneous nephrolithotomy (PCNLs) performed, as well as the proportion of PCNL cases, demonstrated a significant decline from 84 (12.9%) in 2007 to 67 (7.1%) in 2013. While the annual numbers of extracorporeal shock wave lithotripsy (ESWLs) have increased, the percentage of ESWLs performed relative to total stone procedures has declined from 33% to 23% over the last 4 years of this audit. There has been a significant rise in the numbers of rigid and flexible ureteroscopies, with these now being the most utilized procedure. The number of patients awaiting elective procedures declined over the duration of this audit, with an associated improvement in meeting annual demand for treatment of nephrolithiasis from 78% in 2007 to 91% in 2013. CONCLUSIONS: A proportional decline in PCNL and ESWL utilization with a significant increase in flexible and rigid ureteroscopic procedures has been observed over this time and this pattern has been associated with improved adherence to surgical targets despite an increasing number of cases.

[Evolution of urolithiasis treatment over 30 years in a French academic institution]. / Évolution du traitement chirurgical de la lithiase urinaire sur 30ans dans un centre hospitalo-universitaire.

OBJECTIVE: To assess the evolution of the annual number of surgical procedures and the surgical management for urolithiasis. METHODS: A retrospective monocentric study was conducted between 1985 and 2014 in a French academic institution. The study population was divided into four groups: extracorporeal shock wave lithotripsy (SWL), flexible and rigid ureteroscopy (URS), percutaneous nephrolithotomy (PCNL) and open surgery. The annual number of surgical procedures as well as the distribution of each technique was determinated by using the operating records. RESULTS: In all, 23,162 procedures were performed during this period. The annual number of procedures rose from 410 in 1985 to 1071 in 2014, representing a rise of 161%. SWL represented 85.6% (351/410) of all surgeries in 1985 then 21.3% in 2014 (228/1071). In contrast, URS accounted for 4.4% (18/410) of all surgeries in 1985 and rose to 76% (814/1071) in 2014. The number of URS has reached the SWL in 2007 and then became the main surgical treatment. The number of PCNL remained stable during the study period but its proportion decreased due to the increased activity, representing 7.1% (29/410) in 1985 and 2.6% (28/1071) in 2014. Open surgery is rarely practiced and represents currently 0.1%. CONCLUSION: The number of surgical procedures for urolithiasis has more than doubled in 30years. SWL represented the main treatment until 2007 and its number decreased whereas ureteroscopy represents now the most common stone treatment in our institution, PCNL remaining stable. LEVEL OF EVIDENCE: 5.

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.

Percutaneous nephrolithotomy and ureteroscopy in children: evolutions.

The increasing incidence of pediatric stone disease has coincided with significant advances in technology and equipment, resulting in drastic improvements in management. Miniaturization of both ureteroscopes and percutaneous nephrolithotomy (PCNL) equipment has facilitated access to the entirety of the urinary tract and has made ureteroscopy a first-line therapy option along with shock-wave lithotripsy for kidney and ureteral stones. Advances in PCNL have decreased patient morbidity while preserving stone clearance rates. In this review, the advances in operative approach for ureteroscopy and PCNL in children and its applicability to current surgical management of pediatric stone disease are discussed.

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.

Riesgo radiológico y radiación del paciente en la nefrolitotomía percutánea / Radiological risk and radiation of the percutaneous nephrolithotomy patient

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