Innovations in Endourologic Stone Surgery: Contemporary Practice Patterns from a Global Survey

Abstract

Objective:

The purpose of this study is to evaluate the current availability of technology for urolithiasis treatment and ureteroscopy (URS). Perioperative practice patterns, availability of ureteroscopic technologies, pre- and poststenting practices, and methods to alleviate stent-related symptoms (SRS) were assessed via a survey of members of the Endourological Society.

Methods:

We distributed a 43-question survey online via the Qualtrics platform to members of the Endourological Society. The survey consisted of questions pertaining to the following topics: general (6), equipment (17), preoperative URS (9), intraoperative URS (2), and postoperative URS (9).

Results:

A total of 191 urologists responded to the survey and 126 completed all questions of the survey (66%). Fifty-one percent (65/127) of urologists were fellowship trained and dedicated an average of 58% of their practice to stone management. In terms of procedures, most urologists performed URS most commonly (68%), followed by percutaneous nephrolithotomy (23%) and extracorporeal shockwave lithotripsy (11%). Ninety percent (120/133) of respondent urologists purchased a new ureteroscope within the last 5 years (16% single-use scopes, 53% reusable, and 31% purchased both). Fifty-three percent (70/132) of the respondents stated that they would be interested in a ureteroscope that can sense intrarenal pressure, with an additional 28% (37/132) stating they would be interested depending on the cost. Seventy-four percent (98/133) of responders purchased a new laser within the last 5 years, and 59% (57/97) changed their lasering technique due to the new laser. Urologists are performing primary ureteroscopy for obstructing stones in 70% of cases, and prefer prestenting patients for subsequent URS in 30% (on average after 21 days). Seventy-one percent (90/126) of responders insert a ureteral stent after uncomplicated URS, which is removed, on average, after 8 days in uncomplicated cases and 21 days after complicated URS. Most urologists give analgesics, alpha-blockers, and anticholinergics for SRS and <10% prescribe opioids.

Conclusion:

Our survey revealed urologists' eagerness for the early adoption of novel technologies and adherence to conservative practice patterns focused on patient safety.

Introduction

The pace of technological advance is accelerating in medicine, particularly in endourology. Advances in laser technologies, ureteroscopes, and preoperative optimization of patients provide opportunities to improve care for kidney stone patients. However, information relating to the uptake and availability of newer advanced ureteroscopic technologies among endourologic surgeons worldwide is currently unknown and has not been recently documented.

Since the 1990s, the Holmium:Yttrium Aluminum Garnet (Ho:YAG) laser has been the gold standard of laser lithotripsy in the field of Urology.¹ However, following U.S. Food and Drug Administration (FDA) approval in 2019, the thulium fiber laser (TFL) has attracted attention among endourologists due to various special physical characteristics in preclinical settings, among which is the ability to render a target stone to fine dust with its ability to operate at higher frequencies compared to Ho:YAG.² Recently published clinical data showed significantly higher stone-free rates (SFR) and shorter operative times in favor of TFL compared to Ho:YAG and these significantly shorter operative times could decrease the financial cost per case.^3,4

Single-use flexible ureteroscopes (su-fURS) are another recent endourologic innovation. They were developed to overcome the limitations of reusable flexible ureteroscopes (re-fURS), including high costs related to ureteroscopy (URS) maintenance, acquisition, processing, sterilization, and repairs. Since the introduction of the first su-fURS in 2015, the ureteroscope market is expanding with an increasing number of su-fURS from various companies globally.⁵

With the global increase in the incidence of kidney stone disease, a subsequent rise in endoscopic stone therapies is evident.⁶ Hence, perioperative patient optimization is crucial. Several preoperative measures have been proposed to improve patient outcomes and reduce adverse events associated with routine URS. For instance, preprocedural administration of alpha-blockers or ureteral stent placement to improve surgical outcomes have been a subject of debate. Recent clinical trials have shown a lower need for intraoperative ureteric dilation and a lower rate of grade II ureteric injuries in patients who received preoperative alpha-blockers.^7,8 Furthermore, a systematic review and meta-analysis by Fahmy et al. concluded that preoperative stenting was associated with a significantly lower risk of complications, mainly ureteral injury, and increased SFR.⁹ However, pre- and postoperative stenting could contribute to patients suffering from stent-related symptoms (SRS).

Studies have shown that >80% of patients experience at least one bothersome symptom due to an indwelling ureteral stent.¹⁰ Various international guidelines for URS do not recommend routine stenting after uncomplicated URS;^11,12 however, most urologists worldwide routinely place ureteral stents following URS. In a global survey on stent placement after URS, 55.4% of urologists stented patients after routine URS for ureteral stones and 71% for kidney stones in >75% of cases.¹³

This study aimed to assess the current availability and distribution of technologies in endourology, as well as practice patterns of perioperative measures taken, including pre- and postoperative stenting, and actions taken to alleviate SRS in these patients.

Materials and Methods

In October 2022, an online survey pertaining to new technologies in urolithiasis management, perioperative use of ureteral catheters, and measures to alleviate SRS were distributed to members of the Endourological Society. All of the >1300 members were contacted via email and invited to participate in the survey, which was developed through iterative discussion among the authors, which included six urologists who routinely perform endoscopic stone surgery in high-volume centers. The survey was online from October 22nd, 2022 to December 5th, 2022. We aimed to identify uptake in areas pertaining to recent advances in endourology. To ensure digital security, the web-based questionnaire software Qualtrics (Provo, Utah, USA) was used to generate the survey. A total of 43 questions across 5 domains were asked: demographics (6), equipment including laser technologies (17), preoperative URS (9), intraoperative URS (2), and postoperative URS (9). The questionnaire can be found in the Supplementary Data.

Statistical anlaysis was performed with SPSS 28.0.1.0 (IBM, Armonk, New York, USA). We used t-tests to compare means of utilization of each treatment modality (URS, extracorporeal shockwave lithotripsy [SWL] and percutaneous nephrolithotomy [PCNL]) between fellowship-trained and nonfellowship-trained urologists. The statistical significance level was set at p < 0.05.

Results

General

The survey was distributed via email to all 1300 members of the Endourological Society and a total of 191 urologists participated in the survey (i.e., a 14.6% response rate) and 126 completed all questions of the survey (66%). The survey's respondents' demographics and yearly case volume in stone surgery are shown in Table 1. The most commonly performed procedures (by percentage) are URS, PCNL followed by SWL (Fig. 1). URS is the most commonly performed procedure in each region followed by PCNL. Asia and Europe had higher rates of SWL use than other parts of the world (Table 2). We did not observe any statistical difference in chosen treatment modality between fellowship- and nonfellowship-trained urologists (fellowship vs no-fellowship URS: 68.1% vs 67.3% [p = 0.809]; SWL: 10.2% vs 11.3% [p = 0.573]; PCNL: 24.3% vs 25.4% [p = 0.637]).

FIG. 1.

Percentage of URS, SWL, and PCNL used by survey respondents for upper tract calculi. PCNL = percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS = ureteroscopy. Color images are available online.

Table 1.

Demographics and Case Volumes of Survey Respondents

Dedication to stone management (median, range)	60% (2–100%)
Fellowship training in Endourology
Yes	51.2% (65/127)
1-Year Endourological Society accredited	11.8% (15/127)
1-Year Non-Endourological Society accredited	12.6% (16/127)
2-Year Endourological Society accredited	18.1% (23/127)
2-Year Non-Endourological Society accredited	8.7% (11/127)
Years passed since graduation from fellowship (mean ± SD)	12 Years (±8.61 years)
Regional distribution of respondent urologists
North America	31.7% (40/126)
Europe	28.6% (36/126)
South America	15.1% (19/126)
Southeast Asia	12.7% (16/126)
East Asia	5.6% (7/126)
Africa	4% (5/126)
Central America	1.6% (2/126)
Oceania	0.7% (1/126)
Yearly case volume in stone surgery (n; %)
<100	14.2% (18/127)
100–251	38.6% (49/127)
251–500	24.4% (31/127)
501–750	7.0% (9/127)
751–1000	7.9% (10/127)
>1000	7.9% (10/127)

SD = standard deviation.

Table 2.

Regional Disparities in Interventional Stone Therapy

	North America (n = 40)	Europe (n = 36)	Asia (Southeast and East) (n = 23)	South America (n = 19)	Africa (n = 5)	Central America (n = 2)	Oceania (n = 1)
SDI	0.86	0.808	0.673	0.655	0.548	0.626	0.452
Dedication to stone management (mean)	57.7%	59.6%	60.1%	70.0%	47.4%	40%	40.0%
Fellowship training in Endourology	73.8%	47.2%	30.4%	42.1%	40%	0%	100%
Preferred treatment modalities for upper tract calculi
% of patients treated with URS	73.4%	68.1%	52.9%	72.4%	69.6%	80.0%	85.0%
% of patients treated with SWL	6.9%	12.7%	18.1%	4.6%	8.0%	5.0%	5.0%
% of patients treated with PCNL	21.3%	22.8%	32.4%	23.1%	22.4%	15.0%	10.0%
Availability of scopes
Mean no. of flexible URS available	6	6	5	3	2	2	2
Mean no. of semirigid/rigid URS available	4	6	4	4	2	2	2
% of cases performed with single-use URS	34.5%	24.2%	42.8%	23.1%	26.2%	35.5%	80.0%

PCNL = percutaneous nephrolithotomy; SDI = Socio-Demographic Index; SWL = extracorporeal shockwave lithotripsy; URS = ureteroscopy.

Equipment

Table 3 summarizes information on availability and repair cost of URS. Ninety-one percent (120/133) of responders stated that they had purchased new ureteroscopes within the last 5 years (16% single-use scopes, 53% reusable, and 31% purchased both). Of the urologists, 59.5% (78/131) preferred the reusable scopes over the single-use URS. However, 78% (103/132) of survey participants would be satisfied using only single-use URS if cost was not a barrier.

Table 3.

Availability and Repair Cost of Ureteroscopes

	Mean (±SD)
No. of flexible URS available	5 (±3.46)
No. of semirigid/rigid URS available	4 (±3.27)
No. of repairs flexible URS in 2021	5 (±8.59)
Average of estimated cost for the repair of the flexible URS per urologist in 2021 (in USD)	17,934 (±28,152.93)
Average number of repairs for reusable semirigid/rigid URS per urologist in 2021	4 (±13.19)
Average of estimated cost for the repair of the semirigid/rigid URS per urologist in 2021 (in USD)	5977 (±10,792.63)
Percentage of URS cases performed with single-use URS	31% (±33.01%)

SD = standard deviation.

Fifty-three percent (70/132) stated that they would be interested in a ureteroscope that can sense intrarenal pressure, and 28% (37/132) were interested but expressed concerns regarding the cost of the product stating that they would use it if they were affordable within their system. Different power Holmium:Yttrium Aluminum Garnet (Ho:YAG) lasers were available in the following percentages: 29.6% (50/169) <30 W, 15.4% (26/169) 31–99 W, and 23.7% (40/169) ≥100 W. Thirteen percent (22/169) of respondent had access to Ho:YAG with MOSES™ and 18.3% (31/169) had the TFL.

Seventy-four percent (98/133) of urologists had purchased a laser in the last 5 years, and 59% (57/97) changed their lasering technique and practice due to the new laser (i.e., fragmenting/basketing to dusting or vice versa). Fifty-eight percent (76/131) of responders are planning to invest in a new laser in the next 5 years. Of urologists, 56.6% (43/76) are interested in purchasing a TFL, 25% (19/76) in Holmium MOSES, 22.4% (17/76) in a ≥ 100 W Holmium laser, 14.5% (11/76) in a Thulium:YAG laser, and 8% (6/76) in a Holmium laser with a wattage of 31–99 W.

Fifty-three percent (69/130) of responders use single-use laser fibers, and 21% (13/62) of urologists who do not use single-use fibers would like to use them in the future.

Ureteroscopy

Urologists prefer primary URS for obstructing stones in 70% of the cases, and insertion of a ureteral stent for subsequent URS in 30% of the cases. Detailed information on answers regarding the preoperative management of stone patients can be found in Table 4. The most commonly used laser for lithotripsy was the Ho:YAG (69.5%; 89/128), followed by the TFL (16.4%; 21/128), the Holmium MOSES laser (12.5%; 16/128), and other lasers at 1.6% (2/128). Of responders, 69.8% (90/129) stated that they use a mix of dusting and fragmenting and basketing, 20.9% (27/129) only dust the stones, and 9.3% (12/129) only fragment and basket the stones.

Table 4.

Answers Pertaining to Ureteroscopy

	Mean (±SD)
Percentage of primary URS (no prior stenting)	70% (±25.5)
Percentage of delayed URS (after prestenting)	30% (±25.1)
Time between prestenting and URS	21 days (±16.5)
Percentage of urologists performing URS as day-case surgery	62% (80/129)
Mean length of hospital stay	1.7 days (±1.1 days)
Treatment preference in case of emergency (obstructing ureteral stone)
Primary URS	60.2% (77/128)
Stenting with delayed URS	37.5% (48/128)
Nephrostomy tube and subsequent treatment	2.5% (3/128)
Percentage of urologists that use a kidney scoring system	21.9% (28/128)
Percentage of urologists who prescribe alpha-blockers before URS	31.8% (41/129)
Percentage of urologists who give preoperative antibiotics before URS	93.8% (121/129)
Percentage of urologists who give antibiotics postoperatively after URS (>24 hours)	45.7% (59/129)
Duration of postoperative antibiotic treatment	5 days (±2.3 days)

When respondents were asked about their maximal allotted time limit for a routine URS procedure, the mean time was 88 minutes (standard deviation [SD] ±39.8 minutes; median 90 minutes, range 5–210 minutes).

When asked for their minor complication rate (Clavien-Dindo I&II), urologists estimated to experience a mean rate of minor complications of 15% (SD ±10.6%; median 10%, range 1%–60%). The major complication rate (Clavien-Dindo III&IV) was estimated to be 3% on average (SD ±3.4%; median 2%, range 0–20%). Of urologists, 71.4% (90/126) insert a stent after uncomplicated URS and 62.1% (82/132) of stents are removed cystoscopically by the urologist (Table 5).

Table 5.

Answers Pertaining to Postoperative Ureteroscopy

Postoperative URS
Preferred drainage after uncomplicated URS
Tubeless	28.6% (36/126)
Mono-J ureteral stent	5.6% (7/126)
Double-J ureteral stent	58.7% (74/126)
Ureteral catheter as external drainage	7.1% (9/126)
Time interval between uncomplicated URS and stent removal	8 Days (±5.6)
Time interval between complicated URS and stent removal	21 Days (±14.8)
Extraction of ureteral stents
Cystoscopically by urologist	62.1% (82/132)
Self-extraction by patient (string extraction)	19.7% (26/132)
String extraction by urologist	12.9% (17/132)
Cystoscopically by nurse or other trained staff	4.5% (6/132)
Via magnet by provider	0.8% (1/132)

Urologists stated that, on average, 54% of their patients suffer from SRS (SD ±28.4%; median 55%, range 4%–100%).

Postoperatively, 87% (110/126) of urologists use alpha-blockers to alleviate SRS. Seventy-nine percent (99/126) use analgesics without opioids, 9.5% (12/126) also use opioids, and 56.3% (71/126) use anticholinergics.

Discussion

Endoscopic stone treatment has increased globally over the last decade, whereas the use of SWL has steadily declined.^14,15 This has been hypothesized to be due to an increase in the availability and proficiency of flexible ureteroscopes, high-powered laser lithotripters, and advances in instrumentation. Similarly, the present study found that a limited number of urologists provide SWL. Almost 36% of urologists stated that they do not offer SWL at all, and 51.3% treat ≤25% of their patients with SWL. In contrast, all of the responders offer URS, 74.1% treat ≥50% of their patients with URS, and 8.6% treat all of their patients with URS.

We observed higher utilization of SWL in Europe (12.7%) and Asia (18.1%) when compared to the Americas (on average 6%), Africa (8%), and Oceania (5%). The Socio-Demographic Index (SDI) of a region might impact the chosen treatment modality because of resource and equipment availability. However, in our presented study, we could not detect a pattern between SDI and chosen stone treatment. The regions with the highest SWL utilization represented the second and third highest SDI overall, however, North America, which had the highest SDI, had a relatively lower SWL utilization. Taken together, this suggests that other factors may be influencing treatment decisions.

The Ho:YAG laser has been the dominant laser technology for the past three decades until the recent emergence of the TFL. Because of its laser physics characteristics, the TFL has a compact physical footprint, lower energy consumption, and uses a standard electrical outlet. Furthermore, the production of low peak power, less retropulsion, and high frequency make the TFL an excellent dusting laser.² In our survey, 58% of the urologists are planning to invest in a new laser. Of this group, 56.6% of them are interested in purchasing TFL, while 25% would prefer the Holmium MOSES. Holmium with MOSES has also been shown to provide excellent dusting capability with less retropulsion.¹⁶ More than half (59%) of the participants who purchased a new laser within the last 5 years have changed their lithotripsy technique and stone extraction technique due to the new laser.

Hence, a shift in laser technology could change routine practice and subsequently the overall outcomes of stone patients. Also, the reusability of the laser fibers might influence the choice of the appropriate laser as 21% of the respondents who currently utilize disposable fibers would consider using reusable ones in the future. Further head-to-head studies of Holmium with MOSES against TFL will determine which technology is better. In reality, it will likely be that both are suitable for laser dusting and fragmentation and that both technologies will have their own strengths and weaknesses.

The introduction of su-fURS in 2015 aimed to solve the problems and disadvantages associated with re-fURS such as high acquisition costs and repair costs, and ureteroscope repurposing while offering similar performance.¹⁷ Moreover, a published report showed cultured pathogens in 12.1% of reusable scopes even after high-level disinfection.¹⁸ However, Davis et al. reported that the carbon footprint of su-fURS and re-fURS are comparable.¹⁹ From an economic standpoint, the cost of fURS is mainly related to the volume of procedures performed and the level of training. A systematic review by Talso et al. showed that re-fURS is more cost-effective than disposable scopes in high-volume centers. At the same time, other reports found partial cost overlapping per case when reusable scopes were compared to single-use scopes.²⁰

From a clinical perspective, a recent systematic review and meta-analysis found no differences between disposable and reuseable scopes regarding SFR, operative times, lengths of hospital stay, and complication rates.²¹ Among 91% of responders who purchased new scopes recently, 16% purchased su-fURS, while 31% acquired both reusable and disposable scopes. If cost is not a barrier, 78% of the urologists would be interested in single-use URS.

The American Urological Association (AUA) and European Association of Urology (EAU) guidelines on urolithiasis do not recommend routine stenting before URS to facilitate dilation of the ureter and improve outcomes of URS (“prestenting”).^11,12 In our study, urologists perform primary URS (no prestenting) on average in 70% of their cases and delayed URS (after prestenting) in 30% of cases. Prestenting has been shown to significantly reduce the risk of ureteral wall injuries for patients treated with URS and ureteral access sheath. However, these potential benefits are countered by the detrimental effects that ureteral stents have on the patient's quality of life due to stent-related symptoms.^22
–24 In addition, prestenting did not prove to be cost-effective and did not yield higher SFR.^25,26 The mean time between ureteral stent insertion and delayed URS was 21 days in our survey.

While improved ureteral access could be driving this, other possibilities include concerns for infection, inability to access the ureter requiring stenting and secondary procedure, or on-call stents placed by nonendourologists and subsequent referral. However, 37.5% of respondents prefer stenting and delayed URS for obstructing ureteral stones, which is in line with the percentage observed. Sixty-two percent of respondent urologists perform URS as a day-case surgery and many of those who do not offer day-case surgery stated institutional policies for keeping patients overnight after URS. Participating urologists stated that the average time limit for a URS session was 88 minutes. This result is in line with findings from a large database from Japan, where more than 12,000 URS cases were analyzed, and operative times ≥90 minutes were significantly associated with an increased incidence and severity of adverse events.²⁷

Only 21.9% of responders use a kidney stone scoring system (e.g., Guy's, STONE nephrolithometry, CROES) regularly.

Alpha-blockers are a mainstay in the noninvasive treatment of ureteral stones as they reduce ureteral muscle tone and peristalsis and facilitate stone expulsion.²⁸ However, the preoperative use of alpha-blockers to improve intraoperative outcomes and the stone-free status of patients undergoing URS have been the subject of debate.²⁹ In a systematic review and meta-analysis published in 2020, Alsaikhan et al. concluded that the preoperative administration of alpha-blockers reduced the need for ureteral dilation, increased the SFR of patients, and reduced operative time.³⁰ However, the included RCTs suffered from small sample sizes, heterogenous ureteroscope sizes, differences in length of administration of alpha-blockers preoperatively, and underreported side effects. Two ongoing studies that address this topic have been identified, but both are not recruiting at the time of preparation of this article (NCT04602403 and NCT05197088).

Urologists stated that, in their opinion, 54% of stented patients suffer from SRS. However, the range was 4% at the low end up to 100% at the high end.

Strengths

With the presented study, we provide a comprehensive insight into contemporary practice patterns regarding various modalities to treat urinary calculi, pre- and postoperative stenting routines as well as utilization and availability of modern ureteroscopes and laser technologies on a global scale. Furthermore, we were able to collect data on subjective complication rates after URS and preferred pain management strategies from urologists dealing with stone disease.

Limitations

The endourologic society is the premier urologic society encompassing endourology, robotics, and focal surgery with more than 1300 members. However, only 191 urologists responded to our survey representing approximately <15% of all members. Also, the fact that members of the Endourological society are a distinct group of experts and enthusiasts with broad knowledge in the field might have biased the results as general urologists who treat stones might be underrepresented. Their stone management practice could differ from the way urolithiasis is managed by society members.

Also, we did not stratify for stone size when we surveyed the members on surgical interventions for stone disease, although stone size might be the most crucial factor to decide whether to perform SWL, URS, or PCNL.

In addition, we did not ask about the specific country in which urologists are currently pracitising, but rather the region with designated answers. This limited our analysis regarding SDI and disparities in utilization of different stone treatment modalities.

The global COVID-19 pandemic had detrimental effects on the well-being of patients with urolithiasis as many interventions had to be postponed due to shortages in operating room capability and staffing. In many countries, these effects have repercussions on the daily practice, even today. However, we did not query on the effect the COVID-19 pandemic had on the choices made regarding reusable vs singe-use ureteroscopes. The concern about the spread of the virus might have influenced urologists to prefer single-use ureteroscopes over reusable ones.

Our study showed that <30% of urologists omit postoperative stenting in uncomplicated URS cases, hence, identifying a practice pattern that could be improved as it is not recommended by the current guidelines and stents have a detrimental effect on the quality of life in patients with stone disease. Further studies on ureteral physiology are warranted to better understand the pathophysiologic changes caused by ureteral stents and to identify biomarkers and potential drug targets to alleviate SRS.

Conclusion

This study shows urologists' eagerness to adopt technologic advancements in the field of endourology and confirms current global treatment trends with high utilization of URS and the departure from SWL. New laser technology has affected practice for many endourologists. Stenting is still frequently used routinely after URS and opioids are used by <10% of respondent urologists. The future of endourology is bright with new and upcoming technologies.

Footnotes

Acknowledgments

We thank Michele Paoli and Debra Caridi from the Endourology Society for their help with disseminating the survey to its members. We thank all participants of this survey for their contribution.

Authors' Contributions

R.H. and A.H.: project development, data analysis, and article writing; V.K.F.W., K.C.K., T.Z., and C.M.F.: project development, data analysis, and article editing; A.R. and D.L.: project development and article editing. B.H.C.: project development, data analysis, supervision, and article editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Roman Herout and Alina Reicherz were funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)—447437311; 447617010.

Supplementary Material

Supplementary Data

Abbreviations Used

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