Nephrolithiasis: "Scope," Shock or Scalpel?

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Abstract
Purpose: To evaluate treatment preferences for complex urinary calculi. Materials and Methods: A questionnaire was sent to 174 members of the Minnesota Urological Society. Three case scenarios were presented: a 1.5-cm lower-pole calculus with unfavorable anatomy, a 1.4-cm proximalureteral calculus, and a staghorn calculus. The treatment options offered were extracorporeal shockwave lithotripsy (SWL), ureteral stenting, ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and open surgery. Results: Our survey response rate was 49%. A PCNL for staghorn calculi was more likely to be offered by urologists in metropolitan (100%; P < 0.001) and urban (100%; P = 0.003) settings than rural settings (57%). Whereas only 22% of urban and metropolitan urologists would offer anatrophic nephrolithotomy, 43% of rural urologists would include this among their treatment options. A PCNL was more likely to be offered by urologists trained after 1980 (100%) than by urologists trained before 1980 (81%; P = 0.004). For a large lower-pole calculus with unfavorable anatomy, urologists with >50% managed-care practices were more likely (91%) than urologists with P = 0.034). Whereas 82% of metropolitan urologists would select PCNL, 43% of rural urologists would consider SWL as initial therapy. A URS was more likely to be offered by urologists trained after 1980 (16%) than by urologists trained before 1980 (0; P = 0.044). For a large proximal-ureteral calculus, metropolitan urologists were most likely (64%) to use stents initially (urban 28%; P = 0.014; rural 14%; P = 0.017). Rural urologists were more likely to offer SWL (100%) than were metro urologists (55%; P = 0.024). Conclusions: Initial therapy for nephrolithiasis differs significantly according to geographic location, year of residency completion, and the percentage of managed-care patients in a urologist's practice. Future emphasis should be placed on increasing the availability of endoscopic techniques in rural settings.