title: Nephrolithiasis: "scope," shock or scalpel?
abstract: OBJECTIVE
  To evaluate treatment preferences for complex urinary calculi.
  
  
  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 <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).
  
  
  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.
authors.affiliation: Veterans Administration Health Care Systems and the Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Skenazy
authors.forename: Barbara
authors.initials: B
authors.lastname: Ercole
authors.forename: Courtney
authors.initials: C
authors.lastname: Lee
authors.forename: Sara
authors.initials: S
authors.lastname: Best
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Fallon
authors.forename: Manoj
authors.initials: M
authors.lastname: Monga
mesh_terms: D003657:Decision Making; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D007669:Kidney Calculi / Q000628:therapy*; D008096:Lithotripsy / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends; D008910:Minnesota; D009403:Nephrostomy, Percutaneous / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data / Q000639:trends; D012189:Retrospective Studies; D012955:Societies, Medical; D011795:Surveys and Questionnaires; D014572:Urology