Surgical Trends In Nephrolithiasis: Increasing De Novo Renal Access By Urologists For Percutaneous Nephrolithotomy

Purpose: Percutaneous nephrolithotomy (PCNL) has wide variability in the methods of renal access. In many centers, this is done as a separate nephrostomy procedure by interventional radiology, while other urologists gain initial access themselves during the PCNL. We aimed to characterize these trends to confirm the need for continued training in this aspect of PCNL.Methods: Using MarketScan insurance claims, we examined surgical volume for ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and PCNL during 2007-2017. For PCNL, current procedural terminology (CPT) codes were used to identify the provider performing the de novo renal access over time. We stratified postoperative outcomes for PCNL by provider type.Results: From 2007 to 2017, the annual proportion of PCNL procedures peaked at 4.5%, with a recent decline in 2016 and 2017 to 3.2%. URS steadily increased from 46.3% to 60.0% of procedures, and SWL mirrored that change with a decrease from 50.0% to 36.7%. Within 19,743 PCNLs, there was a notable increase from 12.8% to 32.3% in the number of procedures with urologists performing de novo renal access. Most cases (40.0%) still had a de novo access code assigned to a radiologist. Length-of-stay, readmission, transfusion, and secondary stone procedure rates were higher in the radiologist-gained access PCNLs.Conclusions: URS has surpassed SWL as the most common stone procedure. While the proportion of PCNLs has remained fairly stable over the last decade, urologists obtaining their own de novo access have increased substantially. Continued outreach efforts focused on urologist-obtained access may further increase this proportion and improve outcomes for PCNL.