Shifting Paradigms in Stone Disease: How Geography, Training, and Technology Shape Endourologic Practice Worldwide

Endourology has rapidly evolved, offering increasingly effective and minimally invasive treatments for urolithiasis. Despite evidence-based guidelines from the American Urological Association and European Association of Urology, adherence varies worldwide. This study evaluated international practice patterns and factors influencing treatment decisions.

A 37-question online survey was distributed to Endourology Society members. The questionnaire included demographics, management of common clinical scenarios, technical preferences, and approaches to complex anatomical cases. Data from 300 respondents were analyzed using descriptive statistics and subgroup comparisons stratified by geography, fellowship training, and years in practice. Fisher's exact test defined significance (p < 0.05).

Most respondents did not intervene on asymptomatic 4-6 mm renal stones, particularly in the lower pole. For 6-15 mm stones, retrograde intrarenal surgery (RIRS) was most frequently selected, though extracorporeal shockwave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) were also used depending on location and surgeon background. Stones 15-25 mm were most often managed with 17F PCNL, while stones >25 mm and staghorn calculi were primarily treated with 24-30F PCNL. Notably, a proportion of respondents selected RIRS even for staghorn calculi. U.S. urologists more often used RIRS and balloon dilators, whereas international respondents favored 17F PCNL and Amplatz dilators. Fellowship-trained surgeons reported lower reliance on ESWL and greater use of combined or advanced approaches. Surgeons with fewer than 5 years in practice more frequently chose RIRS, while those with over 15 years often performed PCNL, though they also reported increased RIRS use for 15-25 mm stones.

This large international survey highlights substantial heterogeneity in stone management, shaped by geography, fellowship training, and years in practice. While PCNL remains the cornerstone for complex stones, technological advances are driving a measurable shift toward minimally invasive RIRS. These findings underscore the importance of adaptable, evidence-based guidelines to standardize global practice.