• 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.


  • 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 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.