Changing treatments for primary urolithiasis: impact on services and renal preservation in 16,679 patients in Western Australia

Which has more complications?—Shockwave lithotripsy versus endoscopic treatment of renal calculi with 1‐year follow‐up in an Australian population

Introduction and objectives

Renal calculi are a common medical problem with incidence rates calculated to be approximately 6%‐9% in men & 3%‐4% in women worldwide. Incidence appears to be increasing. This study compares emergency presentations and unplanned readmissions between extracorporeal shock wave lithotripsy (SWL) and pyeloscopic stone treatment in the population of Victoria, Australia after 1‐year follow‐up.

Methods

This is a population study comparing all patients with renal calculi electively treated with SWL to those initially treated with flexible ureteroscopy (URS) in Victoria, Australia. We used data linkage across the state of Victoria to follow patients treated with either modality in a 12 months period (with no urological surgery in the prior 12 months). Each patient's emergency presentations and subsequent re‐admissions were followed up for 1 year after their index treatment to assess for stone complications. We assessed for selection bias between the two patient groups by comparing age, gender, insurance status, geographical location, and comorbidity scores.

Results

We report stone‐related complications for 739 flexible URS and 1317 SWL procedures undertaken across public and private hospitals in Victoria over 12 months. Unplanned emergency presentations within 60‐days of surgery were (22/739) 2.98% for flexible URS patients and (83/1317) 6.30% for SWL patients (P = .001); however, at 12 months, this became 16.23% (120/739) for flexible URS patients and 12.83% (169/1317) for SWL patients (P = .034). Flexible URS patients were more likely than SWL patients to be admitted with 71.76% of flexible URS versus 53.97% of SWL patients requiring an admission at any given emergency presentation (P ≤ .001) within 12 months. On multivariate analysis, both flexible URS ([OR] 1.67, CI 1.23‐2.26, P = .001) and being a public patient ([OR] 3.06, CI 2.24‐4.18, P < .001) significantly increased the likelihood that patients required an unplanned re‐admission within 12 months.

Conclusions

There is work needed to reduce emergency presentations and unplanned re‐admissions after both SWL and flexible URS. At 12‐months follow‐up, unplanned emergency visits and re‐admission rates were significantly more after flexible URS. Symptoms at emergency presentation indicate that better education regarding stent management is needed, especially in the public health care system.

Comparative analysis of direct and indirect costs of two minimally invasive techniques for the treatment of renal/ureteral calculi smaller than 2 cm

OBJECTIVE

To perform a comparative analysis of indirect and direct costs of two minimally invasive techniques (extracorporeal shock wave lithotripsy (ESWL) vs. ureteroscopy with holmium laser (URS/RIRS)) for the treatment of renal/ureteral calculi smaller than 2 cm.

MATERIAL AND METHODS

Prospective, comparative, non-randomized study of 84 patients treated for kidney stones smaller than 2 cm between January and December 2016. Of these, 38 (45.67%) were treated with ESWL (18 renal lithiasis and 20 ureteral lithiasis) and 46 (54.32%) with URS/RIRS (22 renal lithiasis and 24 ureteral lithiasis). A total of 19 (41.3%) patients in the URS/RIRS group and 15 (39.5%) patients in the ESWL group were actively working before treatment. The variables analyzed were sex, age, number and size of lithiasis, time (days) off from work due to treatment, estimate of indirect cost due to labor productivity loss and direct treatment costs including follow-up (total number of procedures, ancillary care, visits and diagnostic tests). The 2015 Wage Structure Survey (INE) was used to estimate the indirect cost. In addition, the «Work Productivity and Activity Impairment» (WPAI) questionnaire was also used to determine the level of perceived productivity loss.

RESULTS

The mean number of sessions until lithiasis resolution was achieved was 2.57 for the ESWL group and 1.04 for the URS. The mean number of days off from work in the URS group was 7.16 days and 3.18 (p = 0.034) in the ESWL group. The total indirect costs resulting from productivity loss were EUR 621.55 and EUR 276.05 for the URS and ESWL, respectively. Direct costs in the ESWL group were EUR 1,382.9 and EUR 2,317.71 in the URS group. The level of work impairment perceived by patients undergoing URS was 18.88% and 21.33% in the ESWL group. The degree of impairment for performing activities of daily living was 24.44% in the URS and 15% in ESWL.

CONCLUSIONS

The ESWL technique requires a higher number of sessions for the resolution of kidney stones under 2 cm, but it has a lower impact on total costs and on the perceived degree of affectation.

Role of Dual-Energy Computed Tomography in Characterization of Ureteric Calculi and Urinary Obstruction

Objective The present study was carried out to assess the accuracy of dual-energy computed tomography (DECT) in the morphological and chemical characterization of ureteric calculi along with the prediction of the grade of urinary obstruction. Methods This was a prospective observational study that included 100 cases with ultrasonography (USG)-diagnosed ureteric calculi that underwent surgery or had spontaneous expulsion of ureteric calculi. At enrolment, DECT was performed for an in vivo evaluation of volume, chemical composition, and grade of obstruction by subjective assessment of the perinephric edema. After surgical intervention, in vitro evaluation of volume was done by fluid displacement followed by infrared spectroscopy (IRS) for chemical composition. DECT findings were compared with the biochemical analysis and degree of obstruction was validated against excretory CT urograms. Sensitivity, specificity, and the positive predictive and negative predictive values of DECT were assessed. Results No significant difference was observed between the mean volume of stones by fluid displacement (65.1±77.61 mm³) and DECT assessment (66.09±81.78 mm³). IRS revealed the composition of stones as hydroxyapatite, uric acid, cysteine, oxalic acid, and mixed type in 48, 23, 15, five, and nine cases. The sensitivity and specificity of DECT for hydroxyapatite, uric acid, cysteine, oxalic acid, and mixed types were 89.6% and 88.5%, 82.6% and 97.5%, 86.7% and 96.5%, 80% and 98.9%, and 88.9% and 98.9%, respectively. On CT urography, a total of 35 had a high-grade and 65 had a low-grade obstruction, whereas DECT revealed high- and low-grade obstructions in 42 and 58 cases. The sensitivity and specificity of DECT for a high-grade obstruction were 94.3% and 86.2%. Conclusions The findings of the study showed that DECT provides comprehensive information regarding the morphological, chemical, and anatomical characterization of ureteric stones.

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.

Evolution of stone management in Australia

What's known on the subject? and What does the study add? There is very little contemporary data regarding stone management in Australia. This study assesses the impact of technological advances on stone management practises, and raises questions as to why there is an increasing rate of intervention for stone disease in Australia. Knowledge of management trends as demonstrated in this paper give individual surgeons a guideline for contemporary practise in this country.

OBJECTIVE

• To examine trends in the operative management of upper urinary tract stone disease in Australia over the past 15 years.

MATERIALS AND METHODS

• The Medicare Australia and Australian Institute of Health and Welfare databases were used to determine the annual number of renal colic presentations and procedural interventions undertaken for stone disease.

RESULTS

• In Australia over the past 15 years, the annual number of procedural interventions for upper urinary tract stones has increased, primarily due to the rising number of endoscopic procedures performed. • During this period, shock wave lithotripsy numbers have remained steady whilst open and percutaneous procedures have been in decline.

CONCLUSION

• The introduction of and subsequent preference for less invasive techniques has changed the management pathway of patients presenting with stone disease in Australia. • Further studies are necessary to determine whether this escalation in endoscopic procedures is due to an increase in the incidence of stone disease, earlier detection, a lower intervention threshold or a higher retreatment rate.

Effects of repeated extracorporeal shock wave on kidney apoptosis of normal and diabetic rat

OBJECTIVE

To assess the effect of repeated extracorporeal shock waves (ESW) on the apoptosis of renal parenchyma in normal and diabetic rats by the caspase-3 expression.

MATERIALS AND METHODS

80 rats were assigned for ESW (Direx Tripter X1(R) - 14 KVA) to one of three groups with 50% rats with diabetes (A) and 50% normal (B) in each: G1 (n = 40): no ESW; G2 (n = 20): one ESW; G3 (n = 20): two ESWin an interval of 14 days. The animals were sacrificed 3 days after the ESW and samples of the renal parenchyma were histologically prepared, stained by the caspase-3 cleavage immunohistochemical method, and the apoptotic index (ApIn) was calculated by computer program Image Pro-Plus V 4,5,1 Media Cybernetics ( ApIn = number of apoptotic cells in the microscopic section / total cells in the microscopic section).

RESULTS

There was no statistical difference in ApIn of normal rats with one ESW (8.4 +/- 0.2) or two ESW (9.1 +/- 0.3) and both were similar to the control group with no ESW (7.9 +/- 0.2). The ApIn of diabetic rats with one ESW (7.4 +/- 0.3) was similar to the normal rats with one or two ESW. On the other hand, the ApIn was statistically higher in diabetic rats with two ESW (11.9 +/- 0.4) than in diabetic rats with one ESW (7.4 +/- 0.3).

CONCLUSIONS

The ApIn of normal rats with a single (2,000 SW) or repeated ESW (4,000 SW) was similar to the control animals without any ESW. In diabetic rats, the repeated ESW (4,000 SW) may result in an additional risk of tissue damage expressed by the higher ApIn.

Australian Hospital Data: Not Just for Funding

Collections of routine, or ‘administrative’, hospital data have many applications in health care and are now recognised as valuable sources of information. In recent decades, administrative data have been seen primarily as funding and billing tools to assist with the reimbursement of hospitals for services provided; this purpose remains the primary focus of the clinical coder workforce. More recently, hospital data have been recognised as valuable resources for a range of health system improvement processes beyond funding. The focus of this paper is to review and demonstrate the diverse uses of administrative data in health services research and quality improvement. By gaining an understanding of how the data are used, we can appreciate the importance of good quality data from the perspective of its multiple uses. This paper describes a sample of the studies conducted in Australia using administrative data in health care improvement.

Public good through data linkage: measuring research outputs from the Western Australian Data Linkage System

OBJECTIVE

To measure the 'public good' by retrieving, collating, reviewing and assessing outputs from projects using information supplied from the Western Australian Data Linkage System (WADLS) during 1995-2003.

METHODS

Using WADLS project application records, all investigators were contacted and requested to submit research outputs for review.

RESULTS

708 outputs comprising journal articles, reports, presentations, conference proceedings, media, theses and other items were reported. During the review, consequential policy reforms in mental health, crystalline silica exposure guidelines and surgical mortality audit were identified. Consequential clinical practice reforms had occurred in laparoscopic, cholecystectomy and acute coronary care.

CONCLUSIONS

Data linkage can make a substantial and quantifiable contribution to population health and policy development.

Management of ureteral obstruction

The most common cause of ureteral obstruction in dogs and cats is ureteral calculi. Common clinical signs associated with ureteral obstruction include abnormalities in urination, persistent urinary tract infection, abdominal pain, vomiting, anorexia, weight loss,and depression or lethargy. Medical management of ureteral obstruction includes fluid diuresis, muscle relaxants, and treatment of azotemia using nephrostomy tubes or hemodialysis. Surgical techniques used to restore patency to the ureter include ureterotomy,partial ureterectomy and ureteroneocystostomy, and ureteral resection and anastomosis. Lithotripsy has been used in dogs to remove ureteral calculi. Renal function can be preserved if complete ureteral obstruction is relieved within several days of onset.

Prognostic factors, pattern of recurrence and survival in a Danish bladder cancer cohort treated with radical cystectomy

A cohort of 248 consecutive patients with bladder cancer undergoing radical cystectomy between 1992 and 98 was retrospectively followed from diagnosis until death. Prognostic factors, pattern of recurrence and survival were analysed. Pathological T and N, angiolymphatic and perineural invasion had an independent prognostic influence on survival. Patients without muscle-invasive tumour (Ta, T1) had a good prognosis, whereas patients with primarily superficial tumour progressing to muscle-invasive tumour had a significantly poorer outcome. Forty-six percent of these patients developed recurrences in the follow-up period, with a median time from recurrence to death of 5 months. The 5-year disease-specific survival for all 248 patients was 57%. Patients with pT4b or N + all died within 3 years. Patients with positive lymph nodes or T4b were not curable with cystectomy alone. Patients with advanced T or with perineural/vessel invasion are in need of improved treatment options. Patients with superficial tumours at high risk of progression should be offered early cystectomy.