Trends of surgical interventions for nephrolithiasis over the past decade: a population-based analysis
Original Article

Trends of surgical interventions for nephrolithiasis over the past decade: a population-based analysis

Mandy Hsu1, Abdul-Jawad J. Majeed1, Jennifer A. Kane2, Joseph Y. Clark2

1Penn State University College of Medicine, Hershey, PA, USA; 2Department of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA

Contributions: (I) Conception and design: M Hsu, JA Kane, JY Clark; (II) Administrative support: JY Clark; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: M Hsu, AJJ Majeed, JA Kane; (V) Data analysis and interpretation: M Hsu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Joseph Y. Clark, MD. Department of Urology, Penn State Health Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA. Email: jclark13@pennstatehealth.psu.edu.

Background: Nephrolithiasis is common and often requires surgical interventions, which include extracorporeal shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS). As our understanding of nephrolithiasis has evolved, along with technological advances in surgical management, the preferred methods of treatment have evolved. This study aims to describe population-based trends in SWL, PCNL, and URS over the past decade.

Methods: Data were collected on patients aged 18–100 years who received SWL, PCNL, or URS between January 2014 and December 2023 using the TriNetX database. Cohorts were classified by year using Current Procedural Terminology and International Classification of Diseases codes. Basic statistics were conducted utilizing R.

Results: A total of 268,628 records were identified. URS procedures accounted for the majority of procedures in 2014 (59.27%), followed by SWL (33.61%) and then PCNL (7.11%). URS procedures rose to encompass 75.77% (+16.50%) of all procedures in 2023, while SWL dropped to 17.06% (−16.55%). PCNL remained consistent at 7.16% (+0.05%). Within URS, the observed sex ratio favored men between 2014 and 2019, but favored females consistently between 2020 and 2023. The sex ratio for SWL skewed towards men each year, while PCNL showed a female predominance.

Conclusions: URS is even more frequently utilized to surgically manage nephrolithiasis. PCNL and SWL accounted for a smaller proportion of procedures in 2023 compared to 2014, with notable decreases in SWL. In 2020, the proportion of females receiving URS exceeded males, aligning with recent literature suggesting rising stone incidence in females.

Keywords: Nephrolithiasis; percutaneous nephrolithotomy (PCNL); extracorporeal shockwave lithotripsy (extracorporeal SWL); ureteroscopy (URS)

Submitted Feb 09, 2026. Accepted for publication Apr 08, 2026. Published online May 26, 2026.

doi: 10.21037/tau-2026-1-0137

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Key findings

• Between 2014 and 2023, ureteroscopy (URS) use rose from 59.27% to 75.77%. Shockwave lithotripsy (SWL) declined from 33.61% to 17.06% of procedures between 2014 and 2023. Since 2020, more females than males underwent URS for stone disease.

What is known and what is new?

• Adoption of URS has risen, likely due to technological improvements and subsequent studies suggesting greater stone free rates and less need for reintervention compared to SWL. Men have also historically had greater stone burden.

• This study quantifies a shift to use of URS in clinical practice over the past decade, as well as a closing gender gap in stone burden. Female patients are shown to represent an increasing proportion of surgical patients, especially in the past few years.

What is the implication, and what should change now?

• Clinical guidelines currently suggest both URS and SWL as first-line therapy for most stones. Further resources should be allocated to support URS infrastructure and training. Additional research is needed to investigate why females now require more surgical interventions for nephrolithiasis, such as understanding metabolic profiles and stone composition to best optimize prevention and management strategies for both sexes.

Introduction

Nephrolithiasis is a common urologic concern and may often require surgical treatment. It is the second most costly urologic disease when it comes to global healthcare costs (1). The annual number of patients requiring stone procedures has been estimated to be 223,026 among the Medicare population and 149,280 among commercially insured patients in 2019 (2). Surgical management options for kidney stones typically consist of extracorporeal shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), or ureteroscopy (URS).

In a SWL procedure, high-energy shock waves are fired at kidney stones to break them into smaller fragments for easier excretion (3). In a PCNL, a small incision is made in the patient’s back, and through a small tract, kidney stones can be broken up to be excreted or directly removed (3), though this method is considered more invasive and is typically reserved for larger stones. URS is a newer treatment modality, where holmium or thulium fiber lasers are used to fragment or dust kidney stones in modulated pulses (4). These surgical options may be preferentially utilized based on a variety of factors, including stone size and location.

While there are a variety of surgical options to manage kidney stones, there has been a notable shift in the trends of their use over recent years. Though SWL was the predominant method of treatment for kidney stones after its introduction, the invention and incorporation of holmium lasers in URS has made URS a popular option for treating smaller stones (1). Additionally, recent literature has explored changes in the distribution of kidney stone disease burden between men and women, suggesting a closing gender gap in nephrolithiasis incidence, prevalence, and surgical management. Though men have been estimated to have double the risk of developing a first symptomatic kidney stone due to both genetic and lifestyle risk factors (5), multiple studies have shown rising incidence of kidney stones among women of different populations (6,7). Therefore, technological advances, changes in patient population, changing costs, as well as evolving clinical guidelines may be reflected in kidney stone management trends. To further characterize the changing landscape of kidney stone surgical management, this study aims to highlight population-based trends in the use of SWL, PCNL, and URS over the past decade. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0137/rc).

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This is a retrospective observational analysis of data collected on patients aged 18–100 years who received SWL, PCNL, or URS to treat kidney stones between January 2014 and December 2023 using the web-based population research tool TriNetX. This is a global federated health research network providing access to electronic medical records (EMRs) (diagnoses, procedures, medications, laboratory values, genomic information) from large healthcare organizations (HCOs). The TriNetX platform only uses aggregated counts and statistical summaries of de-identified information. No Protected Health Information (PHI) or personal data is made available to the users of the platform.

This database is constantly being updated as patient information is added into the EMR, as well as when data agreements with HCOs expire. At the time of this search on March 30, 2026, the TriNetX database included information on up to 149,174,364 patients in 170 HCOs in the Global Collaborative Network. This collective consists of academic and non-academic medical institutions with multiple inpatient and outpatient facility locations. Ultimately, our queries encompassed information for patients in a maximum of 57 HCOs in the United States.

Using the Query Builder function, cohorts of patients were organized by year, and by using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-10) codes. ICD-10 codes were used to identify patients with a diagnosis of nephrolithiasis, which consisted of the ICD codes N20 (calculus of kidney and ureter), N20.0 (calculus of kidney), N20.1 (calculus of ureter), N20.2 (calculus of kidney with calculus of ureter), N20.9 (urinary calculus, unspecified), and N22 (calculus of urinary tract in diseases classified elsewhere). CPT codes were used to identify surgical procedures used to treat nephrolithiasis. The CPT code used to identify SWL was 50590. The CPT codes used to identify PCNL procedures were 50080 and 50081. Finally, the CPT codes used to identify URS included 52352, 52353, and 52356 (Table 1). Patients were only included if they had an ICD-10 code for nephrolithiasis prior to receiving SWL, PCNL, or URS. For instance, to identify patients who received a SWL to treat nephrolithiasis in 2022, a search query was made for patients that had the CPT code 50590 between January 01, 2022 and December 31, 2022, that had any incidence of the ICD codes used to identify nephrolithiasis on or prior to the instance of SWL. This process was repeated for every year and procedure, culminating in a total of 30 search queries. Afterwards, basic descriptives and frequencies were calculated using the information gathered regarding number of procedures and sex of patients each year.

Table 1

CPT codes used to identify ESWL, PCNL, and URS procedures

CPT code Medical service or procedure
50590 Lithotripsy, extracorporeal shock wave
50080 Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; simple (e.g., stone[s] up to 2 cm in single location of kidney or renal pelvis, nonbranching stones)
50081 Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; complex (e.g., stone[s] >2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy)
52352 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)
52353 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)
52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

CPT, Current Procedural Terminology; ESWL, extracorporeal shockwave lithotripsy; PCNL, percutaneous nephrolithotomy; URS, ureteroscopy.

Statistical analysis

Cochran-Armitage tests were conducted to evaluate if the proportion of female patients undergoing stone surgery changed significantly over the study period utilizing R (version 4.5.3, R Foundation for Statistical Computing, Vienna, Austria). Analyses were performed for all procedures combined and separately for each surgical procedure type. For stratified analyses, a Bonferroni-corrected significance threshold of P<0.017 was applied to account for having three simultaneous comparisons.

Results

A total of 268,628 records were identified as individuals who received a surgical procedure to treat nephrolithiasis between 2014 and 2023. Over this time period, 56,644 SWL procedures (21.09%), 19,680 PCNL procedures (7.33%), and 192,304 URS procedures (71.59%) were conducted.

In 2014, URS procedures accounted for the majority of procedures conducted to treat nephrolithiasis (59.27%). SWL comprised about a third of procedures that year, at 33.61%, while PCNL comprised of 7.11% of procedures. By 2023, URS procedures rose to encompass 75.77% of procedures, a 16.50% rise from 2014. SWL dropped to 17.06% (−16.55%) of procedures in 2023. PCNL was relatively consistent at 7.16% of procedures (+0.05%) by 2023 (Figure 1).

Figure 1 Percentage of overall SWL, PCNL, and URS surgical interventions for nephrolithiasis in 2014–2023. PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.

Within URS procedures, the observed sex ratio favored men between 2014 and 2019, ranging from 1.16 to 1.01 between those years. In 2020, the sex ratio for URS procedures was 0.99, demonstrating for the first time, a higher ratio of females receiving URS compared to males in a year. From 2020 to 2023, the sex ratio for URS procedures consistently favored females, at 0.99, 0.97, 0.95, and 0.93. For SWL procedures, the sex ratio revealed a greater ratio of men receiving SWL each year, ranging from 1.24 in 2014 to 1.12 in 2023. Within PCNL procedures, the sex ratio showed more women than men receiving the surgery each year, fluctuating between 0.86 in 2014, dipping to 0.85 in 2018, and back to 0.87 in 2023. Across all procedures, the sex ratio favored men from 2014 to 2020, starting at 1.16 in 2014 and dropping to 1.02 by 2020. However, between 2021 and 2023, the sex ratio across all procedures consistently showed a higher ratio of women compared to men receiving stone surgeries, ranging from 0.96 to 0.99 (Table 2, Figure 2).

Table 2

Sex ratio (M:F) of URS, SWL, PCNL, and all procedures combined, 2014–2023

Year URS SWL PCNL All procedures
2014 1.16 1.24 0.86 1.16
2015 1.12 1.22 0.86 1.12
2016 1.08 1.16 0.93 1.09
2017 1.04 1.17 0.95 1.06
2018 1.01 1.15 0.85 1.03
2019 1.01 1.18 0.91 1.04
2020 0.99 1.17 0.87 1.02
2021 0.97 1.15 0.89 0.99
2022 0.95 1.18 0.88 0.98
2023 0.93 1.12 0.87 0.96

F, female; M, male; PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.

Figure 2 Linear depiction of sex ratio (M:F) of URS, SWL, PCNL, and all procedures combined, 2014–2023. F, female; M, male; PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.

Cochran-Armitage tests revealed significant changes in the proportion of females receiving stone surgeries across the study period. For all procedures, χ2=194.28 (P<0.001). For SWL, χ2=24.45 (P<0.001). For URS, χ2=150.27 (P<0.001). Findings were not statistically significant for PCNL over the time period (χ2=0.356, P=0.55).

Discussion

Our study found that from 2014 to 2023, URS has only become increasingly used to surgically manage kidney stones. Though URS already encompassed the majority of all procedures conducted to manage nephrolithiasis in 2014, this percentage rose 16.50% by 2023, aligning with other studies suggesting a rise in URS utilization clinically (2,8). This shift in management methods may be attributed to emerging evidence highlighting better clinical outcomes with URS compared to SWL, such as Dasgupta et al.’s randomized control trial showing improved stone clearance outcomes with URS (9). In a 1,282-person cohort study, Fankhauser et al. also found that URS had significantly higher stone-free rates and less need for further intervention compared to SWL, suggesting that URS is a more effective modality than SWL for treating stones up to 20 mm (10). Advances in ureteroscope and laser technology likely contribute as well to the rise of URS and its growing preference over SWL.

URS is consistently recommended as either the first line or second line treatment for ureteral stones. The American Urological Association (AUA) and European Association of Urology (EAU) recommend this for stones both larger and smaller than 10 mm, and either in the proximal or distal ureter. There are no situations in which either organization recommends SWL over URS for urolithiasis (3,11,12). When considering urolithiasis, URS is also regularly recommended as a first line intervention, especially when the stone size is <20 mm. Once larger than 20 mm, the EAU and AUA tend to favor PCNL regardless of the stone’s location, whether it be the upper calyces, middle calyces, renal pelvis, or lower pole (3,11,12). Our findings align with these practice guidelines, demonstrating a consistent percentage of PCNL use over the past decade, but a rise in URS utilization in more recent years.

It is important to note that during the coronavirus disease 2019 (COVID-19) pandemic, many elective procedures were canceled or postponed. SWL is more commonly performed as an elective procedure, while URS is frequently utilized for symptomatic obstructing stones, which may also contribute to the disproportionate reduction in SWL utilization and relative rise in URS. Yet, in our study, these trends have already begun prior to 2020, suggesting that the pandemic may have accelerated rather than initiated this shift in surgical management of stones.

Historically, studies have shown that males had increased stone burden and subsequent treatment. However, recent literature suggests rising stone burden in females. Some studies suggest that the gender gap in kidney stones is closing, with factors such as multiple pregnancies, being of reproductive age, menopause, and female hormone therapy use associated with higher kidney stone prevalence (13,14). Kittanamongkolchai et al. reported increased stone incidence in both men and women over a time frame of three decades between 1984 and 2012, especially so in younger women aged 18–39 years (15). In our study, starting in 2020, the sex ratio consistently favored females for URS and since 2021, for overall surgical procedures, understandably so as URS comprised the majority of procedures in our data. Cochran-Armitage tests also demonstrated statistically significant changes in the proportion of females receiving stone surgeries across all surgical procedures (χ2=194.28, P<0.001), SWL (χ2=24.45, P<0.001), and URS (χ2=150.27, P<0.001), but not PCNL (χ2=0.356, P=0.55). Our findings add to existing literature suggesting increased stone burden in females and provide evidence for increased symptomatic kidney stone burden necessitating surgical management in females. It should also be noted that Kittanamongkolchai’s 2019 study included both symptomatic and asymptomatic stones, with asymptomatic stones in particular rising in incidence (15). These stones are much less likely to necessitate surgical management. Future studies may further investigate differences between the occurrence of asymptomatic stones, stones amenable to medical treatment, and those necessitating surgical management amongst males and females. Though not explored in our analysis, literature exploring factors contributing to increased female stone burden suggests a higher impact of obesity on women compared to men (16,17). Deeper analysis of implicated risk factors may be beneficial. In the meantime, current preventative strategies are not sex-specific but involve metabolic evaluation and targeted strategies such as increased fluid intake, dietary modifications, and sometimes pharmacologic therapies dependent on the metabolic workup (17).

A limitation of this study is that the TriNetX database is constantly updating based on HCO agreements and charted data. Therefore, it is possible that the data obtained may vary slightly depending on the time of data access. This is unfortunately unavoidable given the limitations of the TriNetX database, however, since the database provides information on such a vast number of patients, the overall trends of surgical treatment for kidney stones during this time period can still be appreciated. Similarly, this database is limited in the granularity of data that can be obtained, especially regarding more specific patient demographics, stone characteristics, stone size, stone location, patient body mass index (BMI), surgical indications, potential risk factors, and other potential confounders, limiting this discussion to the relationship between various methods of surgically managing kidney stones and sex. These are all critical factors for clinical decision-making to treat kidney stones and influence which surgical treatments are conducted. Finally, this study does not include information about nephrolithiasis in children and adolescents, an emerging area in the literature regarding kidney stones. Taking into consideration pediatric trends and needs for stone management may yield different conclusions regarding recent trends in the surgical management of kidney stones.

Conclusions

Over the past decade, URS has become increasingly utilized as the method of surgical management for nephrolithiasis. SWL accounted for a smaller proportion of procedures in 2023 compared to 2014, while PCNL remained relatively stable. During this time, there was a statistically significant increase in the ratio of females receiving URS, SWL, or any surgical management for nephrolithiasis overall. Sex ratios showed a female predominance in URS starting in 2020, and in overall surgical treatment starting in 2021, aligning with current literature discussing the closure of the gender gap in kidney stone disease burden. Further research should investigate the risk factors implicated in stone formation, especially among females, as well as factors associated with the development of nephrolithiasis requiring surgical intervention.

Acknowledgments

This abstract has been presented at the American Urologic Association’s 2025 Annual Meeting, April 26–29, 2025, in Las Vegas, Nevada.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0137/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0137/prf

Funding: This work was supported by the Penn State Clinical and Translational Science Institute, which is supported by the National Center for Advancing Translational Sciences, National Institutes of Health (No. UL1 TR002014). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0137/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Hsu M, Majeed AJJ, Kane JA, Clark JY. Trends of surgical interventions for nephrolithiasis over the past decade: a population-based analysis. Transl Androl Urol 2026;15(5):154. doi: 10.21037/tau-2026-1-0137

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