Practice patterns of methodologies for treatment of renal and ureteral stones
Mohummad M. Siddiqui, MD1, Stephen D. Adlard, BS1, Robin O. Cleveland, PhD2, Stephen P. Dretler, MD1, Dianne E. Sacco, MD1.
1Massachusetts General Hospital, Boston, MA, USA, 2Boston University, Boston, MA, USA.
There has been substantial technology advances in the field of endourology for the treatment of renal and ureteral calculi. Although the approaches such as percutaneous ultrasonic lithotripsy (PUL), ureteroscopic retrograde, and external shock wave lithotripsy (ESWL) have remained as the major approaches, significant changes in the quality of the instruments have taken place. This has likely resulted in changing practice patterns of endourologists in the treatment of stone disease. Here we review the changing practice patterns for the treatment of stone disease at the Massachusetts General Hospital.
A review of case volume per billing data was performed of all patients with a primary diagnosis of renal or ureteral stone between 1995 and 2008. Procedures of interest were ureteroscopic management of stone disease, ESWL, and percutaneous ultrasonic lithotripsy. A total of 7 attending surgeons performed these procedures over the 13 year period. Operating room records were also consulted to correlate any changes in technology with potential periods when practice volume and patterns may have shifted.
A total of 3401 ESWL procedures, 3539 laser lithotripsy, and 680 PULs were performed at Massachusetts General Hospital over a 13 year period for a total of 7620 cases. The case volumes were plotted in figure 1. Of note, significantly more ESWLs were performed than ureteroscopies or PULs for management of stone disease during the years 1995-2000 at a relatively constant rate. ESWL volume began to drop and ureteroscopic management volume has steadily increased between 2000 and 2004. After 2004, ureteroscopic management of stone disease has been used at the MGH in greater frequency than ESWL which has dropped drastically in volume which is now almost the same volume as PUL. The ratio of Ureteroscopic management : ESWL has changed from 0.6 to 6.3 over this 13 year period. PUL volume has remained relatively constant. Interestingly, the loop ureteroscope was introduced at MGH in 1995 and the significantly improved flexible X2 scope was later introduced in March 2003 around the time that ureteroscopic management has superseded ESWL.
Ureteroscopy and namely laser lithotripsy of renal and ureteral stones has increasingly become a first line modality for stone treatment over ESWL. This is regardless of even suitability of the stone disease for treatment by ESWL. Although there are admittedly many confounders in this study including changing population demographics and changing surgeons, we believe that technology changes, improving efficacy of the procedure, and improving complication rates are substantial influences that have affected the changing practice patterns. This study was performed to provide some data that validates what many surgeons at our center already suspected that the primary modalities used in treatment of ureteral and renal stones is changing. As technology continues to improve, it may be worthwhile to expound on these findings and assess ESWL vs laser lithotripsy vs PUL as primary treatments for the different presentations of stone disease.