Researchers from the Endourology Disease Group for Excellence research consortium compared the techniques in 152 patients at several stone centers.
The rise of laser lithotripsy has revolutionized the treatment of larger kidney stones, but there’s been a big mystery: Is it better to pulverize the stone into bits and leave them in the kidney (“dusting”) or pull the fragments out via ureteroscope (“basketing”)? Dusting is quicker and possibly less damaging, while basketing gets rid of remnants that could cause trouble later.
Now, a new study, presented at the AUA annual meeting in San Diego, offers insight into the outcomes of both procedures after 4 to 6 weeks. The verdict: “At first blush, there’s not a difference between patients who were dusted or basketed,” said study co-author Mitchell Humphreys, MD, of Mayo Clinic, Phoenix. “I can’t say one is clearly better than the other. This shows that both techniques have a role in stone disease.”
According to Dr. Humphreys, dusting has become a feasible option thanks to the advent of high-powered lasers that offer flexibility in terms of increasing frequency rather than hertz.
“Some people dusted before, but it wasn’t as efficient because you could only take your hertz up so much,” he said. Now, basketing is feasible too, and the question is: Which one is better?
“People who do basketing feel that the patient has a better chance of not having any subsequent stone episodes: ‘If I leave something behind, that will turn into another stone,’ ” Dr. Humphreys said. “Plus, patients like hearing that all the stone is out.”
But proponents of dusting are skeptical that the fragments will become problematic, he said, and they like the potential for savings due to not needing accessory devices such as a ureteroscopic access sheath or basket. And, he said, they like not having to make “trips” in and out of the kidney with the extra risk of damage to the ureter, although Dr. Humphreys said that might be alleviated by the ureteroscopic access sheath.
In the study, Dr. Humphreys, representing the Endourology Disease Group for Excellence research consortium, prospectively enrolled 152 patients at high-volume stone centers with well-established standardized protocols-three dusting sites and five basketing sites.
“Most people do one technique,” Dr. Humphreys said, “and maybe the other in special circumstances.”
Of the subjects, 48% were male and 52% female; all had renal stones measuring between 5 and 20 mm. All received laser lithotripsy, were stented postoperatively, and received an alpha-blocker for 30 days. All underwent KUB and ultrasound imaging within 3 months.
The authors found that the dusting patients had slightly larger stones, and significantly more laser energy was needed to perform dusting versus basketing. Not surprisingly, the basketing procedures took longer, Dr. Humphreys said.
Of the basketing patients, 80.7% were fragment-free compared to 56.1% of the dusting patients at first follow-up.
In terms of these outcomes, the authors found little clinical difference in the impact of the residual fragments. Two dusting patients required reintervention compared with three basketing patients. The readmission rate to hospital or emergency room was 14% to 15% in both groups; postoperative creatinine and stone analyses were the same in both groups.
Three of nine patients who were basketed and had leftover fragments suffered from symptoms, Dr. Humphreys said, and four out of 20 who were dusted and had leftover fragments suffered from symptoms.
“All in all, if you have fragments left, you’ve got a good chance of having symptoms,” he said, “but it made no difference whether you got dusted or basketed, at least in the short term.”
Dr. Humphreys acknowledged that the study doesn’t include a cost analysis because it would be too complex to complete due to the number of different price structures involved. But the authors hope to analyze expenses in the future. Also, he said, long-term analyses still need to be completed.
What should urologists take from the research?
“For patients who are dusted, it’s quicker, you can attack bigger stones, and you have no increased risk of complications,” he said. “But you’re leaving fragments behind, and we don’t know about the long-term consequences.”
In comparison, basketing doesn’t appear to translate to extra benefits in the immediate weeks after procedures, he said.
Dr. Humphreys cautioned that each technique might have value in certain situations.
Patients with narrow ureters and big stones may do better with dusting because it doesn’t pose the risk of repeated trauma from basketing or the need for a ureteroscopic access sheath, he said. And basketing may be best for patients who have a stone that’s easy to get to, very hard, and likely to break into discrete fragments. A patient with a solitary kidney may be another good option for basketing, he said, because it’s especially important to remove fragments and avoid future problems.