Skenazy Jason, Ercole Barbara, Lee Courtney, Best Sara, Fallon Elizabeth, Monga Manoj
Veterans Administration Health Care Systems and the Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
J Endourol. 2005 Jan-Feb;19(1):45-9. doi: 10.1089/end.2005.19.45.
To evaluate treatment preferences for complex urinary calculi.
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.
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 <50% managed-care practices (65%) to select PCNL for such stones (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).
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.
评估复杂尿路结石的治疗偏好。
向明尼苏达泌尿外科学会的174名成员发送了一份调查问卷。给出了三种病例情况：一枚1.5厘米的下极结石且解剖结构不利、一枚1.4厘米的近端输尿管结石以及一枚鹿角形结石。提供的治疗选择包括体外冲击波碎石术（SWL）、输尿管支架置入术、输尿管镜检查（URS）、经皮肾镜取石术（PCNL）和开放手术。
我们的调查回复率为49%。与农村地区（57%）相比，大城市（100%；P<0.001）和城市（100%；P=0.003）的泌尿外科医生更倾向于为鹿角形结石提供经皮肾镜取石术。虽然只有22%的城市和大城市泌尿外科医生会提供无萎缩性肾切开取石术，但43%的农村泌尿外科医生会将其纳入治疗选择。1980年后接受培训的泌尿外科医生（100%）比1980年前接受培训的泌尿外科医生（81%；P=0.004）更倾向于提供经皮肾镜取石术。对于一枚解剖结构不利的大下极结石，管理式医疗业务占比超过50%的泌尿外科医生（91%）比管理式医疗业务占比低于50%的泌尿外科医生（65%）更有可能选择经皮肾镜取石术治疗此类结石（P=0.034）。虽然82%的大城市泌尿外科医生会选择经皮肾镜取石术，但43%的农村泌尿外科医生会考虑将体外冲击波碎石术作为初始治疗方法。1980年后接受培训的泌尿外科医生（16%）比1980年前接受培训的泌尿外科医生（0；P=0.044）更倾向于提供输尿管镜检查。对于一枚大的近端输尿管结石，大城市的泌尿外科医生最有可能（64%）首先使用支架（城市为28%；P=0.014；农村为14%；P=0.017）。农村泌尿外科医生比大城市泌尿外科医生（55%；P=0.024）更倾向于提供体外冲击波碎石术（100%）。
肾结石的初始治疗因地理位置、住院医师培训完成年份以及泌尿外科医生业务中管理式医疗患者的比例而有显著差异。未来应重点提高农村地区内镜技术的可及性。
