Complex stone treatment advances, but reimb remains a challenge

Advances in endoscopic and laser technologies improve treatment efficiency for large and multiple stones

Focus shifts to complex cases rather than simple stones... procedure time and repeat procedures are key considerations

Reimbursement limited for expensive single-use devices... selective coverage and post-market evaluation proposed

Treatment for urinary stones is evolving beyond extracorporeal shock wave lithotripsy to increasingly incorporate endoscopic and laser technologies, but a gap remains between the clinical need for new technologies and their use on site.

Large or multiple stones, as well as stones that are anatomically difficult to access, can prolong procedure times and increase the likelihood of repeat procedures. This is why technologies that minimize stone movement and improve fragmentation efficiency are necessary.

Dailypharm spoke with Woojin Bang, Professor of Urology at Hallym Sacred Heart Hospital (Insurance Affairs Director of the Korean Urological Association), about changes in urinary stone treatment and policy measures needed to improve access to new technologies.

Beyond stone removal to recurrence prevention... management tailored to underlying causes becomes more important

Woojin Bang, Professor of Urology at Hallym Sacred Heart Hospital

Urinary stones are notorious for causing severe pain, but treatment does not end simply because the pain subsides. In patients with urinary tract infections or underlying conditions such as diabetes, infection may even progress to sepsis.

Professor Bang said, “There is a widespread perception that urinary stones are a condition for which patients seek medical attention only when they experience pain. Many patients also underestimate the condition, believing that ‘drinking plenty of water will flush them out,’ ‘beer will help,’ or ‘shock wave treatment will take care of everything.’”

More recently, treatment has evolved beyond simply removing stones. Physicians increasingly analyze stone composition and conduct metabolic testing to identify underlying causes before recommending individualized drug therapy and lifestyle modifications. Given the high recurrence rate, post-treatment management is becoming an increasingly important part of care.

Treatment varies depending on the size and location of the stone and whether pain or infection is present. Small stones may pass spontaneously with medication, while extracorporeal shock wave lithotripsy or ureteroscopic stone removal may be considered when pain cannot be controlled, or the stone is too large to pass naturally.

Professor Bang said, “In general, spontaneous passage can be expected for stones measuring around 4–5 mm, but active treatment is often considered once the stones exceed 5 mm. For stones of 1 cm or larger, multiple sessions of shock wave treatment may be required, so endoscopic treatment is being increasingly used.”

An option to address the limitations of endoscopic treatment... a role in complex stone cases

Endoscopic procedures involve directly visualizing stones and fragmenting and removing them using a laser or other device. Although stone-free rates are relatively high, stones may be pushed back toward the kidney during surgery, making removal more difficult and, in some cases, necessitating another procedure.

In the past, when an upper ureteral stone migrated into the kidney, surgery sometimes had to be discontinued because no endoscope was available to follow it. The introduction of flexible ureteroscopes has made it possible to track migrated stones, but stones in difficult-to-access locations or multiple stones scattered across different sites can still pose a substantial treatment burden.

One option available to physicians in these cases is Boston Scientific’s MOSES technology. It uses two laser pulses: the first creates a pathway for energy transmission through water, while the second delivers energy to the stone. The technology is designed to reduce retropulsion and improve fragmentation efficiency.

Bang said, “With MOSES technology, stones tend to remain near the laser fiber, reducing the need to continually chase them during fragmentation. Clinical studies have reported that stone fragmentation time was reduced by approximately one-third with MOSES.”

Patients who may be considered for the technology include those with stones 1 cm or larger or stones expected to be particularly hard, multiple small stones at different sites, stones in unfavorable locations, or anatomical abnormalities.

Procedure time is another consideration when selecting treatment technology. In urinary stone surgery, irrigation pressure and procedure duration can affect infection risk, so procedures expected to last more than 60 minutes may be divided into multiple sessions.

Bang said, “Trying to remove a large stone in a single prolonged procedure can increase the risk of infection or sepsis. If stones can be removed more quickly and treatment completed in a single procedure, it may help reduce complications and the likelihood of repeat surgery.”

Advances in treatment technology outpace reimbursement... first need to allow selective access

Although mechanisms exist to select patients who need these new technologies, reimbursement remains the biggest barrier to their use.

According to Bang, laser fibers used in urinary stone surgery are expensive single-use devices, but their cost is bundled into the surgical procedure fee rather than reimbursed separately as treatment materials. The actual cost of a dedicated MOSES laser fiber is 7-8 times the relevant procedure fee, making its use financially impractical unless hospitals absorb the loss.

Bang explained, “Even when a technology could benefit patients, it is difficult for it to become established in clinical practice if hospitals lose money every time they use it. One option would be to introduce it selectively for patients with large stones, those at high risk of infection, or those with a high likelihood of requiring repeat surgery.”

Medical societies and physicians are also calling first for a pathway that would allow such technologies to be used, rather than seeking full reimbursement across the board. They propose setting separate fees for expensive treatment materials through mechanisms such as recognized non-covered services or selective reimbursement, and allowing patients who need them to choose these options.

Bang believes that if use itself remains restricted, it will be difficult to accumulate clinical cases and treatment outcomes, leaving insufficient evidence for subsequent cost-effectiveness assessments. He argued that evaluations should consider not only the difference in material costs for a single procedure but also costs across the entire course of treatment, including repeat procedures and complications.

A similar issue exists with single-use flexible ureteroscopes. Reusable scopes are extremely thin and prone to damage, resulting in substantial maintenance and repair costs. Disposable scopes offer advantages in terms of equipment failure and infection control, but their use remains limited because they are not reimbursed separately.

Bang emphasized, “We need to first open a pathway for patients with the greatest need to access new technologies and then accumulate real-world clinical outcomes for subsequent evaluation. What matters is ensuring that patients are not denied access to technologies they may need.”