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Medical Policy

Policy Num:      07.001.049
Policy Name:    Percutaneous Nephrostolithotomy and Lithetripsy for Kidney Stones
Policy ID:          [7.001.049]  [Ar / B / M+ / P]  [7.01.30]

Last Review:      September 05, 2019
Next Review:      Policy Archived
Issue:                  9:2019

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Related Policies BCBS: None                                     

Related Policies TSSS: None

Percutaneous Nephrostolithotomy and Lithetripsy for Kidney Stones

Summary

Percutaneous nephrostolithotomy (PCN) is an invasive procedure for removing upper urinary tract stones by means of forceps or wire basket devices. Percutaneous lithotripsy (PCL) is often used to break up large kidney stones to a more manageable size. A nephrostomy tract is first established by using a needle, catheter, dilators, and a nephrostomy tube under fluoroscopic guidance. After this has been accomplished, an endoscope is used to visualize the treatment area while lithotripsy instruments are inserted into the nephrostomy tube to break up the kidney stone.

 Stone fragments are removed by catheter suction, forceps, or a small basket; smaller fragments are sometimes left to pass spontaneously. General or local anesthesia may be appropriate.

Objective

The objective of this review is to outline the indications, contraindications and relevant outcomes of percutaneous nephrostolithotomy when compared to flexible ureteroscopy.

Policy Statements

Percutaneous nephrostolithotomy and lithotripsy are considered medically necessary for treating upper urinary tract kidney stones that are symptomatic and cannot be managed conservatively.

Policy Guidelines

Suitable stones for PCN/PCL therapy are:

·         stones that cannot be fragmented by extracorporeal shock wave lithotripsy or ESWL treatment Failures;

·         stones that are impacted in the ureter;

·         cystine stones;

·         upper urinary tract stones when urinary diversions or obstructions are present;

·         stones greater than 3 cm, which require debulking prior to ESWL; and

·         contraindications to ESWL.

PCN/PCL may be used as an alternative or an adjunct to ESWL for stones in the 2- to 3-cm range.

Benefit Application

BlueCard/National Account Issues

Percutaneous nephrostolithotomy may be performed in two stages, on different days, as follows:

Stage 1—Creation of nephrostomy tract and placement of tube to access stone; and

Stage 2—Disruption of stone and removal of fragments.

With complex stones, adjunctive procedures may be required in some cases (e.g., ESWL or mechanical removal), which may or may not necessitate the creation of a second percutaneous tract.

This procedure is performed as a team effort by a surgeon and radiologist.

Background

Considerable progress has been made in the medical and surgical management of nephrolithiasis over the past 20 years. Approximately 10 to 20 percent of all kidney stones require surgical removal, which is determined based upon the presence of symptoms and the size and location of the stones. Larger stones and proximal ureteral stones are less likely to pass spontaneously Stone removal is also indicated for pain or obstruction or for an infected struvite stone. On the other hand, no specific surgical therapy is required for asymptomatic stones, particularly those that are less than 5 mm in diameter.

Three minimally invasive surgical techniques that significantly reduce the morbidity of stone removal are available: percutaneous nephrolithotomy (PNL), rigid and flexible ureteroscopy and, shock wave lithotripsy (SWL).

These techniques appear to offer comparable success when compared with open renal and ureteral surgery and provide significant advantages in terms of patient morbidity and cost. In addition, improvements in urologic equipment, fluoroscopic technology, and interventional radiologic techniques provide many additional treatment options.

The choice of intervention for stones that are unlikely to pass spontaneously varies with the location and size of the stone. Studies suggest that either SWL or ureteroscopy is a viable option for managing ureteral calculi. SWL is the treatment of choice for most small renal calculi, while PNL is the preferred method of stone removal for larger (>2 cm) renal stones, including staghorn calculi.

regulatory Status

N/A

Rationale

A search of literature was completed through the MEDLINE database for the period of January 1992 through October 1995. The search strategy focused on references containing the following Medical Subject Headings:

- Calculi

- Kidney

- Lithotripsy

- Percutaneous

Research was limited to English-language journals on humans

Percutaneous nephrolithotomy  and open surgery are equally effective for the management of renal stones. In one study of 129 patients with renal calculi, for example, we found that PCN and open renal surgery were associated with a similar success and complication rate [1]. An important difference was that PCN shortened the hospitalization time by 60 percent and allowed the patient to return to work in approximately one week as compared with greater than three weeks after open renal surgery. This less invasive technique is also 40 percent less expensive than open renal surgery.

Percutaneous nephrolithotomy is used most often for larger stones or when other procedures, such as extracorporeal shock wave lithotripsy or uteroscopy, are unsuccessful or not possible.

Percutaneous nephrolithotomy is typically recommended in the following situations:

• Large kidney stones are blocking more than one branch of the collecting system of the kidney (known as staghorn kidney stones)
• Kidney stones are larger than 0.8 inch (2 centimeters) in diameter
• Large stones are in the ureter
• Other therapies have failed

Population Reference No. 1 

Individuals With upper urinary tract kidney stones that are symptomatic and cannot be managed conservatively.   Interventions of interest are: Percutaneous nephrostolithotomy (PCN) / Percutaneous lithotripsy (PCL). Comparators of interest are: Standard of care. Relevant outcomes are: Quality of life, Treatment-related morbidity, Functional outcomes.

Supplemental Information

N/A

Practice Guidelines and Position Statements

American Urological Association Education and Research Inc. Report on the management of staghorn calculi. American Urological Association Education and Research Inc. 2005; reaffirmed 2010.

National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave therapy for refractory Achilles tendinopathy. Interventional Procedures Guidance IPG312. August, 2009. https://www.nice.org/uk/guidance/ipg312. Accessed November 18, 2016. Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. J Urol. 2007;178(6):2418 — 34.

Medicare National Coverage

NCD 230.1: Treatment of kidney stones; effective 1/16/1988. CMS Medicare Coverage Database Web site. https://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=106&ncdver=1&DocID=230.1&bc=gAAAABAAAAAAAA%3d%3d&. Accessed November 22, 2016.

L35627 Extracorporeal Shock Wave Lithotripsy for Musculoskeletal Conditions. CMS Medicare Coverage Database Web site. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=35627&ver=12&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All& KeyWord=lithotripsy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d%3 d&. Accessed November 22, 2016.

References

1.Preminger GM, Clayman RV, Hardeman SW, et al. Percutaneous nephrostolithotomy vs open surgery for renal calculi. A comparative study. JAMA 1985; 254:1054.

2.Meretyk S, Gofrit ON, Gafni O, et al. Complete staghorn calculi: random prospective comparison between extracorporeal shock wave lithotripsy monotherapy and combined with percutaneous nephrostolithotomy. J Urol 1997; 157:780

3.Rana AM, Mithani S. Tubeless percutaneous nephrolithotomy: call of the day. J Endourol 2007; 21:169

4.Preminger GM, Peterson R, Peters PC, Pak CY. The current role of medical treatment of nephrolithiasis: the impact of improved techniques of stone removal. J Urol 1985; 134:6.

5.Preminger GM. Editorial comment. The value of intensive medical management of distal ureteral calculi in an effort to facilitate spontaneous stone passage. Urology 2000; 56:582.

6. Jewett MA, Bombardier C, Menchions CW. Comparative costs of the various strategies of urinary stone disease management. Urology 1995; 46:15.

7. Grasso M, Beaghler M, Loisides P. The case for primary endoscopic management of upper urinary tract calculi: II. Cost and outcome assessment of 112 primary ureteral calculi. Urology 1995; 45:372.

8. Al-Otaibi K, Hosking DH. Percutaneous stone removal in horseshoe kidneys. J Urol 1999; 162:674.

9. Pengfei S, Yutao L, Jie Y, et al. The results of ureteral stenting after ureteroscopic lithotripsy for ureteral calculi: a systematic review and meta-analysis. J Urol 2011; 186:1904.

Codes

Appplicable Modifiers

N/A

Policy History