Shock wave lithotripsy vs ureteroscopy: variation in surgical management of kidney stones at freestanding children's hospitals

Abstract

Purpose: Although shock wave lithotripsy has long been considered the gold standard for treatment of kidney stones in children, ureteroscopy has become increasingly common. The factors determining procedure choice at individual centers are unclear. We sought to identify patient and hospital factors associated with the choice between shock wave lithotripsy and ureteroscopy.

Materials and methods: We searched the Pediatric Health Information System hospital database to identify patients with renal calculi who underwent inpatient or outpatient shock wave lithotripsy or ureteroscopy between 2000 and 2008. We used multivariate regression to evaluate whether procedure type was associated with hospital level factors, including treating hospital, region, size and teaching status, or patient level factors, including age, race, gender and insurance type.

Results: We identified 3,377 children with renal stones, of whom 538 (16%) underwent surgery (shock wave lithotripsy in 48%, ureteroscopy in 52%). Procedures in 445 patients at hospitals performing both procedures were included. The relative proportion of ureteroscopy increased during the study period (24% from 2000 to 2002 vs 50% from 2006 to 2008, p=0.0001). Procedure choice was not significantly associated with patient age (p=0.2), gender (p=0.1), race (p=0.07), insurance (p=0.9), hospital size (p=0.6) or teaching status (p=0.99). Procedure choice varied significantly by geographical region (p=0.05), regional population (p=0.002) and stone location (p<0.0001). On multivariable analysis controlling for stone location, gender and treatment year the treating hospital was still highly associated with procedure choice.

Conclusions: There is wide variation in procedure choice for children with kidney stones at freestanding children's hospitals in the United States. Treatment choice depends significantly on the hospital at which a patient undergoes treatment.