World-wide variation in percutaneous nephrolithotomy practices: evaluation based on training, experience, and region

Percutaneous nephrolithotomy (PCNL) has undergone numerous technological innovations recently that make it even less invasive, but global adoption of these innovations remains unclear. This study sought to compare the effect of region and education on the penetrance of recent advances in PCNL worldwide.

An anonymous 32-item survey was developed and distributed via the Endourological Society's Twitter/X account in November 2023. The survey collected data on participants' geographic region, PCNL volume, fellowship training, and PCNL practices. Descriptive statistics were calculated, and chi-square or Fisher's exact tests were used for comparisons.

Responses were received from 160 PCNL providers worldwide. Respondents were categorized by geography, fellowship training, and procedural volume. Spinal anesthesia was more commonly used by Asian providers (31%, p = 0.001), while supine positioning was notably more common in Europe (76%, p = 0.001). Asian providers favored pneumatic energy (63%), while North American and European providers more frequently used dual energy lithotripters (31-72%) and hemostatic tract agents (p < 0.001). High-volume providers and those with more post-fellowship experience tended to use smaller sheaths, including mini-PCNL. Postoperative imaging practices also varied by region and fellowship-training status.

PCNL practices vary significantly worldwide, influenced by regional, economic, and experiential factors. Our survey indicates a significant shift in practices with 41% of providers using supine position and over 50% doing tubeless PCNL. However, ultrasound access has been slow to gain widespread use with 73% still using predominantly fluoroscopy, similar to prior studies. Further randomized studies are needed to establish the clinical effectiveness of new technologies and to drive standardization of care across geographic and economic barriers.