Urology-gained renal access in PCNL rises, with favorable safety

The frequency of urologists obtaining de novo percutaneous access when performing percutaneous nephrolithotomy (PCNL) and the number of cases performed have increased, according to results of a study investigating surgical trends in nephrolithiasis. Furthermore, analyses of patient outcomes after PCNL with access obtained by urologists vs radiologists indicate that urologists are able to perform de novo access in selected patients without compromising safety.

The research, recently reported in an online article, analyzed insurance claims data for kidney stone procedures in adults aged 18 to 64 years.¹ It included nearly 20,000 PCNL procedures that were performed during the study period covering the years 2007 to 2017.

Although urologists performed de novo renal access in just 12.8% of cases in 2007, by 2017, 32.3% of the cases involved urologist performed de novo renal access. Analyses of outcomes of the PCNL procedures with cases stratified by renal access provider type showed that the rate of length of stay longer than 2 days as well as rates of readmission, transfusion, and secondary stone procedures in the 90 days after PCNL were significantly higher in the cases in which access was performed by a radiologist vs a urologist. The rate of embolization was less than 1% for the urologist- and radiologist-gained access groups.

“Urologists learn how to perform PCNL in residency, but the puncture and access are still extremely technically challenging and continue to be done mostly by interventional radiology in many centers,” lead author Ian S. Metzler, MD, MTM, assistant professor of urology at Oregon Health & Science University in Portland, said in an interview with Urology Times®. “We were interested in investigating whether the focus on this aspect of PCNL in training provided by the American Urological Association and other teaching organizations was leading to a practice shift with urologists obtaining their own access.

“Urologist-gained access has the potential to improve outcomes and lower cost for patients with complex stones who require PCNL,” he continued. “Going forward, we hope to continue to study how training efforts are affecting the rates of PCNL access by urologists and investigate the potential health cost savings that can be achieved by avoiding the extra steps of involving interventional radiology.”

Current Procedural Terminology codes were used to determine the provider performing the renal access portion of PCNL procedures. For the purpose of the analysis, renal access was assigned to the radiologist if both a radiologist and urologist claimed a de novo access code. Overall, in 2017, renal access was attributed to the interventional radiologists in 40% of cases, whereas 28% were classified as “unspecified” because either there was no associated de novo renal access code or the code was assigned to a provider other than a radiologist or urologist.

The assessment of outcomes after PCNL considered length of stay all-cause readmissions at 30, 60, and 90 days, along with transfusions, embolization, and secondary stone procedures in the 90-day postoperative period.

The study also confirmed the growing popularity of ureteroscopy (URS) over time and showed that during the study period, URS surpassed extracorporeal shock wave lithotripsy (ESWL) as the most common procedure for stone management. In 2007, SWL accounted for 50% of the analyzed nephrolithiasis procedures, whereas URS accounted for 46.3%, and PCNL was performed in 3.7% of cases. In 2017, 60% of cases were done by URS, ESWL was used in 36.7% of cases, and the PCNL rate was 3.3%.

Reference

1. Metzler IS, Holt S, Harper JD. Surgical trends in nephrolithiasis: increasing de novo renal access by urologists for percutaneous nephrolithotomy. J Endourol. Published online April 5, 2021. doi:10.1089/end.2020.0888