Summary
- Ten years ago the main treatments for renal stones were open surgery and medical therapy. Since then, radical changes have occurred with the introduction of percutaneous nephrolithotomy (PCN), extracorporeal shock wave lithotripsy (ESWL) and transurethral procedures using lithotripsy.
- It remains true that not all cases of kidney stones require intervention.
PCN
- While PCN can be used to remove most kidney and upper ureteral stones, its main role, when ESWL is available, is in the preliminary debulking of large or staghorn stones, and in the removal of cystine stones which are often resistant to ESWL.
- In Australia, public hospital stays following PCN are longer (eight to twelve days) than those reported overseas (three to nine days).
ESWL
- ESWL has made a major impact on renal stone treatment, and is being used to treat 80 to 90 per cent of stones in several other countries. It is used to treat the majority of renal stones and many ureteral stones.
- Several issues relating to its use and effects are still being debated, in particular the possibility of ESWL leading to renal hypertension in some cases, and its use in the treatment of staghorn and very large stones.
- In Australia, ESWL (where available) has replaced many open surgical operations and some transurethral procedures. Australian experience with ESWL is similar to that overseas in terms of factors such as length of hospital stay, complications, number of shocks per session and energy levels.
- Recent advances in lithotripters include features such as multipurpose treatment tables, stone localisation alternatives and improvements in patient positioning, rather than significant changes in the technology itself. A number of different units are now available, with capital costs ranging from $430,000 (excluding localisation device) to $2.2m.
- Fewer referrals have come to the two public hospital ESWL units in Sydney and Melbourne from the country than from the surrounding metropolitan areas. Even fewer cases have come from interstate, with practically none travelling east from Western Australia.
- Recent and pending acquisitions are expected to result in at least three ESWL units in Sydney, and one in each of Melbourne, Brisbane and Perth. These six units would be able to treat the estimated national caseload of 4,800 to 6,400 with capacity to spare, although ·problems of access and equitable distribution would need to be addressed.
Transurethral procedures
- Laser ureteroscopy is a new technology with much wider application than either electrohydraulic or ultrasonic ureteroscopy, although it is more costly. Developments in ureteroscopes have increased the potential usage of lasers in this application.
- Most ureteral stones can be treated, and indications are still evolving. Information on morbidity, mortality; success rates and cost-effectiveness is still limited.
- Several suitable laser-based systems are available, with capital costs in the range $250,000 to $380,000.
Open surgery
• Levels of open surgery for renal stones in Australia are considerably higher than those reported for other countries which have ESWL.
Costs and savings
- Hospital costs per patient (including machine costs) for ESWL depend on the type of lithotripter, re-treatment rate and patient throughput ($1,860 to $3,000). ESWL is still the least costly method .of treating stones.
- Open surgery is the most expensive method of treating stones ($4,962 to $6,062).
- PCN is expensive on the basis of the average length of public hospital stay ($6,450). For uncomplicated cases with shorter stays, costs drop to $3,700 to $4,750 per patient.
- The cost of transurethral procedures depends on the method of stone fragmentation or extraction, and on patient throughput; costs are relatively low at $2,591 to $2,949 per patient.
- The introduction of ESWL to Australia has resulted in an estimated annual saving to the health care system of approximately $3.9m, according to the model used in this report.
Health outcomes
- ESWL has few complications, and patients normally return to usual activities within a week.
- Convalescence following PCN or transurethral procedures is usually longer at one to two weeks.
- The reduction in convalescence periods due to ESWL has reduced post-treatment illness by an estimated 69 person years a year in Australia, a significant saving from the point of view of both patients and employers.
- Complications of laser ureteroscopy relate mainly to ureteroscopy, and decrease as the operator becomes more experienced.
- Open surgery is associated with longer periods of convalescence (four to six weeks), with higher morbidity and with some mortality.
- The long-term effects of ESWL on renal hypertension, the growing kidney, and the ovaries (when used on mid ureteral stones) are not yet established.
Recommendations and suggestions
The Committee:
- does not support any further increase in the number of ESWL units in Australia beyond those needed to provide a realistic distribution of services between States without generating significant over-capacity. This would imply no more than seven ESWL units in Australia;
- urges caution in treating patients with high numbers of shocks, high energy levels, or several treatment sessions in quick succession, until the question of whether or not ESWL leads to hypertension is resolved;
- suggests that State governments should address the issue of ensuring equitable access to ESWL;
- sees a need for further investigation of the use of PCN in Australia, in particular the long hospital stays associated with its use, and its application in combination with ESWL;
- considers that the level of open surgery for kidney stones in Australia remains unacceptably high;
- considers there is a need for further data on laser ureteroscopy, including comparison with ESWL for the treatment of ureteral stones;
- suggests that laser ureteroscopy might prove to be an effective way of treating many ureteral stones in Australia.