Endoscopic Combined Intrarenal Surgery: best practices and future perspectives.

INTRODUCTION: Endoscopic Combined Intrarenal Surgery (ECIRS) has emerged as a promising technique for the management of large and complex kidney stones, potentially offering advantages over traditional Percutaneous Nephrolithotomy (PCNL). This study aims to evaluate best practices, outcomes, and future perspectives associated with ECIRS. MATERIALS AND METHODS: A comprehensive PubMed search was conducted from 2008 to 2024, using MESH terms and the following key words: "ECIRS" and "Endoscopic Combined Intrarenal Surgery" The search yielded 157 articles, including retrospective cohort studies, two randomized controlled trials (RCTs), and four meta-analyses comparing ECIRS with PCNL. Most important findings were summarized regarding indications, patient positioning, kidney access, tract size, surgical outcomes, and complications. RESULTS: ECIRS demonstrated higher stone-free rate, lower complication rate, and a reduced need for multiple procedures compared to traditional PCNL. Additionally, ECIRS has the potential to integrate new technologies to further enhance outcomes. CONCLUSION: ECIRS demonstrates significant advantages in the management of large kidney stones. Future research should focus on well-designed RCTs to provide robust evidence of its efficacy, safety, and cost-effectiveness, potentially establishing ECIRS as the first option treatment for complex kidney stones.

Vulnerability to Financial Toxicity From Stone Surgery.

INTRODUCTION: Financial toxicity has been described in stone formers; however, little is understood regarding its causes and how it may relate to stone surgery. We therefore aimed to longitudinally describe markers of financial strain in stone formers from the preoperative to postoperative time points. METHODS: A prospective cohort study was conducted from January 2022 to April 2023. Patients were enrolled in the waiting area prior to undergoing elective ureteroscopy or percutaneous nephrolithotomy. Participants completed The Commonwealth Fund's Biennial Health Insurance Survey at this time point and at 30 days postoperatively. Items were preselected from the survey to capture markers of financial strain due to health care costs. RESULTS: One hundred nine participants were enrolled. White (70%), college-educated (62%), and privately insured (72%) patients comprised the majority of participants. Despite these traditionally protective sociodemographic features, 42% of patients reported some marker of financial strain at the preoperative time point. Patients with Medicaid reported even higher financial stress (67%). Furthermore, 46% of patients did not know their deductible amount. Response rate was low at 30 days postoperatively (35%) but suggested some patients were experiencing new financial strains. CONCLUSIONS: This paper shows that a significant proportion of stone patients are already displaying markers of financial strain from health care bills even prior to surgery as well as poor understanding of the costs they may incur. This makes them vulnerable to experiencing financial toxicity postoperatively and emphasizes the importance of understanding all contributing factors when developing future strategies to intervene in financial toxicity.

Efficacy and Economy of Two-Stage Percutaneous Nephrolithotomy for Complex Renal Calculi

Objectives: To evaluate the efficacy and cost effectiveness of two-stage percutaneous nephrolithotomy (PCNL) in complex renal calculus disease. : The clinical data of 106 patients who underwent two-stage PCNL at the Second Affiliated Hospital of Kunming Medical University from January 2017 to May 2022 were analyzed. In order to select more accurate timing and strategies to reduce costs and surgery risk in two-stage PCNL patients, different parameters were measured—including the preoperative urinary tract infection, intraoperative bleeding, operative time, postoperative stone clearance and treatment costs. Patients were divided intogroup A and group B according to different timings of two-stage PCNL operation. Group A included patients who under wenttwo-stage PCNL during their period of hospitalization 5 to 9 days after the one-stage PCNL. Group B comprised patients whowere re-hospitalized for two-stage PCNL 29 to 35 days after the one-stage PCNL. Results: There were statistically significant differences in the influence of stone diameter and operation time in intraoperative blood loss of PCNL in 106 patients (p < 0.001). Compared with one-stage PCNL, the intraoperative hemoglobin loss and hematocrit loss means of patients with two-stage PCNL were decreased, the stone diameter mean of was smaller, and the mean operative time was diminished (p < 0.001). There were no significant differences in the hemoglobin loss, hematocrit loss and stone clearance rate means between group A and group B (p > 0.05). The urinary tract infection rate in group A was lower than the one in group B, and the average treatment cost was lower than the one in group B (p = 0.006, p < 0.001, respectively). (AU)

Cost analysis between mini-percutaneous nephrolithotomy with and without vacuum-assisted access sheath.

PURPOSE: To perform a cost analysis between vacuum-assisted percutaneous nephrolithotomy (vmPCNL) and minimally invasive PCNL (MIP) and explore potential predictors of costs associated with the procedures. METHODS: We analyzed data from 225 patients who underwent vmPCNL or MIP at a single tertiary referral academic center between January 2016 and December 2020. We collected patients' demographics, peri-and postoperative data and detailed expense records. After propensity score matching, 108 (66.7%) vmPCNL and 54 (33.3%) MIP procedures were analyzed. Descriptive statistics assessed differences in clinical and operative parameters. Univariable and multivariable linear regression models tested the association between clinical variables and costs. RESULTS: Operative time (OT) was shorter for vmPCNL, and the use of additional instruments to complete litholapaxy was more frequent in MIP (all p ≤ 0.01). Length of stay (LOS) was longer for MIP patients (p = 0.03) and the stone-free (SF) rate was higher after vmPCNL (p = 0.04). The overall instrumentation cost was higher for vmPCNL (p < 0.001), but total procedural costs were equivalent (p = 0.9). However, the overall cost for the hospitalization was higher for MIP than vmPCNL (p = 0.01). Univariable linear regression revealed that patient's comorbidities, OT, any postoperative complication and LOS were associated with hospitalization costs (all p < 0.001). Multivariable linear regression analysis revealed that LOS and OT were associated with hospitalization costs (all p < 0.001), after accounting for vmPCNL procedure, patients' comorbidities, and complications. CONCLUSION: vmPCNL may represent a valid option due to clinical and economic benefits. Shorter OT, the lower need for disposable equipment and the lower complication rate reduced procedural and hospitalization costs.

Cost-effectiveness of Retrograde Intrarenal Surgery, Standard and Mini Percutaneous Nephrolithotomy, and Shock Wave Lithotripsy for the Management of 1-2cm Renal Stones.

OBJECTIVE: To perform a cost-effectiveness evaluation comparing the management options for mid-size (1-2cm) renal stones including percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shockwave lithotripsy (SWL). METHODS: A Markov model was created to compare cost-effectiveness of PCNL, mini-PCNL, RIRS, and SWL for 1-2cm lower pole (index patient 1) and PCNL, RIRS, and SWL for 1-2 cm non-lower pole (index patient 2) renal stones. A literature review provided stone free, complication, retreatment, secondary procedure rates, and quality adjusted life years (QALYs). Medicare costs were used. The incremental cost-effectiveness ratio (ICER) was compared with a willingness-to-pay(WTP) threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS: At 3 years, costs for index patient 1 were $10,290(PCNL), $10,109(mini-PCNL), $5,930(RIRS), and $10,916(SWL). Mini-PCNL resulted in the highest QALYs(2.953) followed by PCNL(2.951), RIRS(2.946), and SWL(2.943). This translated to RIRS being most cost-effective followed by mini-PCNL(ICER $624,075/QALY) and PCNL(ICER $946,464/QALY). SWL was dominated with higher costs and lower effectiveness. For index patient 2, RIRS dominated both PCNL and SWL. For index patient 1: mini-PCNL and PCNL became cost effective if cost ≤$5,940 and ≤$5,390, respectively. SWL became cost-effective with SFR ≥75% or cost ≤$1,236. On probabilistic sensitivity analysis, the most cost-effective strategy was RIRS in 97%, mini-PCNL in 2%, PCNL in 1%, and SWL in 0% of simulations. CONCLUSION: For 1-2cm renal stones, RIRS is most cost-effective. However, mini and standard PCNL could become cost-effective at lower costs, particularly for lower pole stones.

The clinical and cost effectiveness of surgical interventions for stones in the lower pole of the kidney: the percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole kidney stones randomised controlled trial (PUrE RCT) protocol.

INTRODUCTION: Renal stones are common, with a lifetime prevalence of 10% in adults. Global incidence is increasing due to increases in obesity and diabetes, with these patient populations being more likely to suffer renal stone disease. Flank pain from stones (renal colic) is the most common cause of emergency admission to UK urology departments. Stones most commonly develop in the lower pole of the kidney (in ~35% of cases) and here are least likely to pass without intervention. Currently there are three technologies available within the UK National Health Service to remove lower pole kidney stones: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureterorenoscopy (FURS) with laser lithotripsy. Current evidence indicates there is uncertainty regarding the management of lower pole stones, and each treatment has advantages and disadvantages. The aim of this trial is to determine the clinical and cost effectiveness of FURS compared with ESWL or PCNL in the treatment of lower pole kidney stones. METHODS: The PUrE (PCNL, FURS and ESWL for lower pole kidney stones) trial is a multi-centre, randomised controlled trial (RCT) evaluating FURS versus ESWL or PCNL for lower pole kidney stones. Patients aged ≥16 years with a stone(s) in the lower pole of either kidney confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) and requiring treatment for a stone ≤10 mm will be randomised to receive FURS or ESWL (RCT1), and those requiring treatment for a stone >10 mm to ≤25 mm will be randomised to receive FURS or PCNL (RCT2). Participants will undergo follow-up by questionnaires every week up to 12 weeks post-intervention and at 12 months post-randomisation. The primary clinical outcome is health status measured by the area under the curve calculated from multiple measurements of the EuroQol five dimensions five-level version (EQ-5D-5L) questionnaire up to 12 weeks post-intervention. The primary economic outcome is the incremental cost per quality-adjusted life year gained at 12 months post-randomisation. DISCUSSION: The PUrE trial aims to provide robust evidence on health status, quality of life, clinical outcomes and resource use to directly inform choice and National Health Service provision of the three treatment options. TRIAL REGISTRATION: ISRCTN: ISRCTN98970319. Registered on 11 November 2015.

Evaluation of day-care versus inpatient mini-percutaneous nephrolithotomy: a propensity score-matching study.

Day-care percutaneous nephrolithotomy (day-PCNL) is being performed more routinely, however, safety remains a concern. The purpose of this study was to compare the complication rate, readmission rate and medical cost saving between day-PCNL and inpatient-PCNL. A protocol for day-PCNL was applied. A retrospective review of 86 patients planned day-PCNL by one surgeon were conducted. Using propensity matching, 86 inpatients (minimum 2-day post-operative stay) treated with the same procedure were matched. For each cohort, 14-day occurrence of complications and unplanned readmissions were recorded and compared. More than 80% of patients had multiple or staghorn stones in both groups. There were no significant differences between stone-free rate, operative time, multiple-tracts use, hemoglobin drop (each p > 0.05). Day- PCNL has a higher tubeless rate (60.8% vs. 24.4%, p < 0.001) and were less costly (mean 2732 vs. 3828 dollars) compared with inpatient PCNL. Within 14 days post-operatively, 10 day-care patients (11.6%) and 13 inpatients (15.1%) experienced complications, with no difference in rate or severity. Four patients (4.6%) required full admission (longer than 24 h) and two patents needed readmission in day-PCNL group. Day-care PCNL was more cost-effective than in-patients PCNL, with no significant difference in complications along with very low unplanned readmission during the postoperative period of 14 days. Therefore, day-care PCNL is a cost-effective choice in selected patients.

Percutaneous nephrolithotomy versus flexible ureteroscopy in terms of cost-effectiveness in patients with 10-30 mm renal stones.

PURPOSE: Kidney stones are one of the most common urological problems. When deciding on the method of treatment for this common disease, the cost of the procedure should also be taken into consideration. MATERIALS AND METHODS: We performed a retrospective analysis of 55 patients who underwent percutaneous nephrolithotomy and 75 patients who underwent retrograde intrarenal surgery between January 2016 and November 2018. Until operative success was achieved, all additional surgical procedures, extracorporeal shock wave lithotripsy procedures, and interventional procedures required to resolve complications were recorded. Total cost was compared between the percutaneous nephrolithotomy and retrograde intrarenal surgery groups. RESULTS: No significant difference was found between the percutaneous nephrolithotomy and retrograde intrarenal surgery groups in terms of gender, mean age, stone side, stone localization and stone surface area. The total cost of 55 patients that underwent percutaneous nephrolithotomy was calculated as US$14.766 after the first operation, and the total cost of 75 patients that underwent retrograde intrarenal surgery was determined to be US$46.627. The mean cost per patient was calculated US$320 ± US$186 for percutaneous nephrolithotomy and US$749 ± US$242 for retrograde intrarenal surgery (p < 0.001). CONCLUSIONS: Percutaneous nephrolithotomy is a lower-cost and successful method in the surgical treatment of 1-3 cm stones, but the serious complications involved in this operation should be kept in mind.

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.

Assessing Cost-Effectiveness of New Technologies in Stone Management.

Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease.

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.

Propensity Score-Matched Analysis Comparing Retrograde Intrarenal Surgery with Percutaneous Nephrolithotomy for Large Stones in Patients with a Solitary Kidney.

PURPOSE: To evaluate the clinical efficacy, safety, and cost of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) in the treatment for large renal stones in patients with a solitary kidney. PATIENTS AND METHODS: In this study, 117 patients with a solitary kidney who had undergone PCNL or RIRS for renal stones larger than 2 cm between January 2010 and December 2016 were retrospectively evaluated. The patients' demographic data, clinical characteristics, and perioperative outcomes were collected through a review of their medical records. Forty-three patients treated with PCNL were compared to 43 patients treated with RIRS by propensity score-matched analysis. The stone-free rate, retreatment rate, complication rate, and efficacy quotient (EQ) were assessed in both groups. RESULTS: Initial stone-free rate of the PCNL group after a single procedure was significantly higher compared with the RIRS group (74.42% vs 34.88%, p < 0.001), whereas there was no significant difference in the final stone-free rate after repeated procedures (90.70% vs 88.37%, p = 0.713). PCNL had a significantly lower retreatment rate than RIRS (16.28% vs 63.79%, p < 0.001), and the PCNL group underwent fewer procedures than the RIRS group (p < 0.001). Thus, PCNL group had a higher EQ (78.00% vs 53.52%). Although cost per procedure of PCNL was significantly higher compared with RIRS (p < 0.001), the total costs were comparable. Complication rate of RIRS was lower compared with PCNL with no statistical significance (p = 0.193), and acute kidney injury rates were also comparable (PCNL vs RIRS: 13.95% vs 6.98%, p = 0.533). CONCLUSIONS: With fewer repeated surgical procedures, higher EQ, and comparable total costs, PCNL is recommended as the first choice for the treatment of large renal calculi in patients with a solitary kidney. As for specific indications such as anticoagulant drugs, RIRS is a safer choice with fewer complications and acceptable final stone-free rate.

The Effect of Physician Specialty Obtaining Access for Percutaneous Nephrolithotomy on Perioperative Costs and Outcomes.

OBJECTIVE: To evaluate the impact of the specialty (urologist vs radiologist) of the physician obtaining percutaneous renal access (RA) on perioperative outcomes, complications, and costs of percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: We used data from a national hospital discharge database to identify patients undergoing PCNL between 2003 and 2015. Procedure codes related to RA were linked to physician specialty. We examined patient demographics, Charlson comorbidity index, postoperative complications, length of stay (LOS), and direct hospital costs, as well as hospital and surgeon characteristics stratified by specialty of the physician obtaining RA. A multivariable regression model was created adjusting for potential confounders. RESULTS: We identified 40,501 patients undergoing PCNL between 2003 and 2015. Urologists obtained access in 17.0% of cases. RA by urologists was associated with a lower 90-day complication rate (5.0% vs 8.3%, p < 0.001) and lower rates of prolonged hospitalization ≥4 days (22.5% vs 42.1%, p < 0.001). On multivariable analysis, RA by urologists was associated with lower rates of any complication (Clavien 1-5) (odds ratios [OR] 0.70, p ≤ 0.001), shorter LOS (OR 0.67, p < 0.001), and lower direct hospital costs (OR 0.65, p < 0.001). CONCLUSION: In the United States, radiologists obtain percutaneous RA in the majority of PCNLs. Access by urologists is associated with lower overall complications, shorter hospitalizations, and lower direct hospital costs. Coding errors and absence of stone complexity information may limit the cogency of our findings and requires further investigation.

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.

Ultrasound Guidance Reduces Percutaneous Nephrolithotomy Cost Compared to Fluoroscopy.

OBJECTIVE: To examine the cost factors associated with ultrasound and fluoroscopic guidance for percutaneous nephrolithotomy (PCNL) and to determine which method can be performed at a lower cost per case. METHODS: A cost comparison study was performed utilizing clinical data from a prospectively maintained research database. We included the most recent 33 consecutive ultrasound-guided PCNL cases in 2016 and the most recent 40 consecutive fluoroscopy-guided PCNL cases before the operative surgeon transitioned to ultrasound guidance in May 2014. The total operative time and clinical outcomes were examined. Costs were extracted from the institution accounting systems and given a uniform multiplier to protect institutional financial reporting confidentiality. Comparisons were made using the Student t test and the chi-squared test. RESULTS: After excluding outliers, 71 PCNL procedures were included in the analysis. Demographic data and stone characteristics were not different between ultrasound-guided and fluoroscopy-guided groups. However, the mean operative time for ultrasound-guided PCNL was significantly shorter (99.8 ± 27.0 vs 144.9 ± 55.1 minutes, P < .05). When capital equipment costs were included, the mean total cost per case of ultrasound-guided PCNL was approximately 30% less than fluoroscopy-guided PCNL (simulated costs with a uniform multiplier; $5258.90 ± 957.12 vs $7508.60 ± 1163.83, P < .05). Postoperative clinical outcomes were comparable between the 2 groups. CONCLUSION: When capital costs are included, ultrasound-guided PCNL can produce comparable clinical outcomes to fluoroscopy-guided procedures at a lower cost to the institution. Shorter operative time drives significant savings with the adoption of ultrasound guidance, which may be magnified with increasing case volume. Using ultrasound imaging during PCNL may be more cost-effective compared to fluoroscopy and warrants further study.