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

300 endourologists worldwide agree on watching small stones; for large ones, treatment varies by where and when you trained

Journal: Journal of Endourology | Published: 2026-05-24 | Type: Survey/Journal Article | PMID: 42178882 Authors: Singh Z et al. (The Smith Institute for Urology, Hofstra/Northwell; Johns Hopkins) Funding/COI: Not listed for either

Summary

A 37-question survey of 300 Endourology Society members reveals that where a surgeon trained and how long they've been practicing shapes stone treatment decisions as much as the stone itself. The field is measurably shifting toward minimally invasive retrograde intrarenal surgery (RIRS), particularly among U.S.-trained and early-career surgeons, while international and more experienced surgeons still lean on percutaneous nephrolithotomy (PCNL). The most striking data point: a subset of respondents chose RIRS even for staghorn calculi, where guidelines favor PCNL.

Claims

• Most respondents did not intervene on asymptomatic 4-6 mm renal stones, particularly in the lower pole
• RIRS was the most common choice for 6-15 mm stones; ESWL and PCNL also selected based on stone location and surgeon background
• 17F PCNL dominated for 15-25 mm stones; 24-30F PCNL most common for stones >25 mm and staghorn calculi
• A measurable subset chose RIRS for staghorn calculi — outside current guideline recommendations
• U.S. urologists favored RIRS and balloon dilators; international respondents preferred 17F PCNL and Amplatz dilators
• Fellowship-trained surgeons reported less ESWL use and more combined or advanced approaches
• Surgeons with <5 years in practice chose RIRS more often; those with >15 years more often performed PCNL, though they also reported increased RIRS use for 15-25 mm stones

Study Quality

This is a self-reported survey of Endourology Society members — a specialty society that skews toward high-volume, advanced endourologists, not the average community urologist. The 300-respondent sample is reasonable for this type of study, and stratified analysis by geography, fellowship training, and years in practice adds analytical depth. Fisher's exact test is appropriate for the categorical comparisons. The central limitation is that scenario-based surveys consistently overestimate guideline adherence relative to actual practice data — this measures what surgeons say they'd do, not what they do. The response rate is not reported, a standard omission that prevents any assessment of selection bias within the membership.

Red Flags

• Self-selection bias: Endourology Society members are not representative of practicing urologists broadly — findings likely understate real-world variation
• No response rate reported: Cannot evaluate how representative the 300 respondents are of the full membership
• Stated vs. actual practice: Scenario-based surveys capture stated preferences, not real decisions made under OR constraints, equipment availability, and patient complexity
• Funding and COI not disclosed: Unusual omission; RIRS and PCNL equipment manufacturers have material interests in how these practice-patterns stories are framed
• No systematic quantification of guideline deviation: The paper flags RIRS use for staghorn calculi but does not report how many respondents chose it or break it out statistically

Strengths

• International scope with meaningful subgroup stratification across geography, training background, and experience level
• Identifies a concrete, directional finding: RIRS uptake is measurable and increasing even in scenarios where PCNL is guideline-preferred
• Large enough to support Fisher's exact test comparisons across subgroups
• Names a genuine clinical problem — guideline heterogeneity — and offers empirical data on where the variation lives

Verdict

Competent practice-patterns research from a credible group. It documents a real shift in endourologic practice toward RIRS, identifies where that shift is concentrated (U.S. surgeons, early-career practitioners, fellowship-trained urologists), and flags where enthusiasm may be outpacing evidence — most notably, RIRS for staghorn calculi. This won't move guidelines, but it's useful for understanding why two patients with identical stones at different hospitals can receive very different treatments. The missing response rate and undisclosed COI are typical weaknesses of survey research, not disqualifying ones. Worth reading if the gap between what guidelines recommend and what endourologists actually do is a question you care about.