Prospective Randomized Trial of ESWL and PCNL for Lower Pole Nephrolithiasis: Financial and Quality of Life Analysis
Riddell J, Denstedt J, Lingeman J, and the Lower Pole Study Group

The lower pole nephrolithiasis trial is a randomized, prospective, multicenter trial comparing the efficacy of extra-corporeal shock wave lithotripsy (ESWL) to percutaneous nephrolithotripsy (PCNL) as initial treatment of lower pole renal calculi. Complete financial data is available on 76 patients (40 ESWL and 36 PCN L as initial therapy). Hospital costs are calculated for each patient by converting hospital charges to costs by applying cost centre cost to charge ratios (unique to each institution for every fiscal year). Quality of life assessment was carried out pre-operatively, and one and three months post-operatively using a validated SF-36 questionnaire. ESWL is less expensive than PCNL as initial therapy ($2960 vs. $4640), but requires more ancillary treatments to eradicate symptomatic stone burden. When the costs of ancillary treatments are considered, total cost of therapy is comparable ($4540 ESWL vs. $4640 PCNL). Stone free rates are significantly better with PCNL (91% vs. 37%, p<0.01), and these differences increase with increasing stone size. Quality of life analysis shows no significant difference between groups. PCNL is more cost-effective at producing a stone free outcome for lower pole calculi greater than 10mm, and equally effective for smaller stones. This improved cost-effectiveness does not come at the expense of quality of life. These results reinforce the expanding role of PCNL as primary therapy for lower pole calculi.

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