The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (2022)



ORIGINAL ARTICLE
Year : 2001 | Volume : 17 | Issue : 2 | Page : 121-123

The relative cost-effectiveness of PCNL and ESWL for medium sized ( < 2 cms) renal calculi in a tertiary care urological referral centre

Pradeep P Rao, Rasesh M Desai, Ravindra B Sabnis, Snehal H Patel, Mahesh R Desai
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India

Correspondence Address:
Pradeep P Rao
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat
India

Source of Support: None, Conflict of Interest: None

(Video) Relative Role of ESWL, Retrograde Ureteroscopy and PCNL for Urolithiasis


The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (5)Abstract

There is a paucity of cost-effectiveness studies in India comparing PCNL and ESWL in the treatment of renal cal­culi. We are dependent on costing studies from western literature, although the nature of expenses in developed countries is quite different from those in India. This study compares the two procedures with regards to cost-effec­tiveness & efficacy in clearing medium-sized renal calculi ( < 2.0 cms) at our institute. All costs borne by the patient & the institute were taken into account, including equip­ment costs, stay charges & cost of travel incurred, for re­peat visits to the institute. The groups compared had similar stone characteristics & were from our early experience with the two methods. All costing was done at 1998 rates by submitting case sheets to a fresh billing. PCNL, was significantly more efficient at clearing calculi (94% vs 69%) than ESWL, but patients needed hospitalization. The re­quirement of ancillary procedures was significantly less with PCNL than ESWL (1 vs 35) and ESWL was more expensive although the difference was not statistically sig­nificant. High initial cost of a lithotripter along with the need for repeated visits to the hospital for clearance of the calculus contribute to the increased cost of ESWL. PCNL ensures clearance of calculi at a single hospital admission with minimal morbidity.


Keywords:Kidney Stones; SWL; PCNL; Cost-effectiveness; Medium Sized; Indian


How to cite this article:
Rao PP, Desai RM, Sabnis RB, Patel SH, Desai MR. The relative cost-effectiveness of PCNL and ESWL for medium sized ( < 2 cms) renal calculi in a tertiary care urological referral centre. Indian J Urol 2001;17:121-3
(Video) The Horseshoe Kidney and its Implications for Renal Stone Disease

How to cite this URL:
Rao PP, Desai RM, Sabnis RB, Patel SH, Desai MR. The relative cost-effectiveness of PCNL and ESWL for medium sized ( < 2 cms) renal calculi in a tertiary care urological referral centre. Indian J Urol [serial online] 2001 [cited2022 Sep 7];17:121-3. Available from:https://www.indianjurol.com/text.asp?2001/17/2/121/21040
The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (6)Introduction

PCNL and ESWL have revolutionized the manage­ment of renal calculi in the last two decades. There are many western studies comparing these two modalities with regard to cost efficacy & clearance rates. [1],[2],[3] These uniformly state that while PCNL has much higher clear­ance rates, ESWL is more cost-effective for calculi be­low 3.0 cms in size. Would these hold true in an Indian setting as well? So we decided to compare the cost efficacy & clearance rates of PCNL against ESWL for medium sized (

< 2.0 ems) renal calculi at our centre, a tertiary care uro­logical referral hospital.
The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (8)Patients and Methods

The lithrotripter used was the Sonolith 3000 (Technomed), a spark-gap second generation lithotripter, used at a setting of 13 kV (12 kV in children). Shock waves were ECG gated with a frequency of no more than 120 / minute. Stone locali­zation was by ultrasonography and only a few patients re­quired sedo analgesia.

To avoid any bias in patient selection, the PCNL group was drawn up from our early experience (1986-1989), at which time ESWL was not available to us. Hence calculi which would otherwise be treated by ESWL, were treated with PCNL. The first year of experience with ESWL was used as the study group of ESWL. This ensured that the `learning curve' was similar in both the groups.

The criteria for inclusion in the study were patients with renal calculi <2.0 cms in size which were suitable for ESWL. All calculi in the kidney regardless of location were included in this study. All kidneys were normally functioning on IVU. Patients who were planned for combination therapy were ex­cluded from this study. Patients with ureteric calculi who re­quired a push pre-ESWL were also excluded from the study.

77 patients treated with PCNL between 1986 & 1989 and 283 patients treated with ESWL between 1989 & 1990 were compared. The clearance rates, ancillary procedures required to clear calculi and cost of the procedure to the patient were compared. Also assessed were morbidity of the procedure and the dropout rate before the completion of treatment. Pa­tients in the PCNL group received 1-3 treatments, while those in the ESWL group required 1-9 treatments.

(Video) International Alliance of Urolithiasis (IAU) Webinar

The costing for these patients was done at 1998 rates by submitting the case sheets for a fresh billing. The factors taken into account include operative and anaesthesia charges, use of Operating Room and fluoroscopy time and material and stay charges. Also included for the ESWL patients was the cost of travel for additional sittings. Travel costs were calcu­lated for the patient and one relative. There is undoubtedly some amount of `centre effect', which can be attributed to the increased travel cost to the patient as this is a tertiary referral centre. The costs of procedures mentioned in the study were not actually paid by the patient, but that incurred by the hospital in clearing the calculus.

Statistical analysis was done with accumulated data us­ing a stone free (complete clearance) outcome as the end point of analysis.

The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (10)Results

The patient demographics are given in [Table - 1]. The treat­ment data are mentioned in [Table - 2]. Patients lost to fol­low-up were excluded from the analysis.

Of the 77 patients in the PCNL group, 73 were completely cleared, 1 patient required an ureteroscopy & 3 patients were kept under observation for the so-called `clinically insignifi­cant residual fragments'. This gave an effective clearance rate for PCNL of 94.03% (73/77). In the ESWL group, 257 patients were available for analysis of outcome. Of these, 35 patients required a PCNL, for clearance and 44 patients were placed under observation for `clinically insignificant residual fragments'. This gave an effective clearance rate in the ES WL group of 69.3% (178/257).

The re-admission for ancillary procedures (1 vs 35) and average retreatment rate was lower with PCNL than with ESWL (1. 14 vs 2.05). Patients coming for ESWL, espe­cially those from a distance, incurred a significant travel cost while coming for repeated sittings. All the PCNL pa­tients were cleared in a single hospital admission with only one patient requiring 3 stages and 9 requiring 2 stages. When actual costs were computed for the two groups, the average cost to clearance in the PCNL group was Rs. 17,350 and in the ESWL group Rs. 20,347.There was no statistically significant difference between the 2 groups. The results are given in [Table - 3].

1 patient in the PCNL group required a blood transfusion. As this was in our early experience with PCNL, the multi­staged procedures were due to difficulty of access or poor vision due to bleeding. A significant number (35 of 283) of the ESWL patients needed re-admission for clearance by PCNL. The DJ stents placed in this group were removed af­ter 4 weeks. There was no charge for DJ removal.

(Video) 1600 1645 TUES Delivery Physics of SWL Turney, Finch, Roberts, Hanna 1920x1080 FINAL ALL & A

The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (12)Discussion

Nowadays, patients demand treatment with a minimal cost and morbidity in as short a time span as possible.

There is a paucity of cost-effectiveness studies in India comparing the 2 modes of therapy. Economics dictates that once a patient is given ESWL, we are obligated to clear the calculus at minimal extra cost to the patient even if PCNL is required.

The end point of treatment was determined when the patient was stone free on a plain film. We now believe that for a treatment to be regarded as successful, the patient should be stone free on a plain film at the completion of treatment. There is no place for any residual fragment to be regarded as insignificant. So, clearance indicates a `complete clearance' on a plain film at the completion of treatment. Both groups were analyzed as to ancillary pro­cedures required for clearance of calculus, which added to the morbidity and cost of the procedure to the institute and the patient. The cost incurred by the institute of ancil­lary procedures was added to the cost of the procedure. There was no mortality in either group.

What we find when all these factors are considered is that PCNL was clearly more efficient at clearing calculi than ESWL (94% vs 69.3%, p < 0.05), although the PCNL group was from our very early experience. Also, if anything, ESWL is more expensive, even if it is not a statistically significant difference (Rs. 20,345 vs Rs. 17,350). ESWL is still a rela­tively expensive option for many centres in our country and the necessary PCNL expertise is required to clear the calcu­lus in case ESWL is not successful.

We do not believe in giving ESWL for very large stones especially larger than 3 cms. [3] Although nowadays our policy is to give ESWL for stones less than 2 cms, there are a few factors which preclude giving ESWL. [4]

It is difficult to get an unbiased comparison these days, as the stone population going in for ESWL is quite differ­ent from that undergoing PCNL. This is the reason why the early PCNL, group was chosen considering that ESWL was generally not available to us (or to most others in India) at that time. The early experience with ESWL was used to negate the effect of the `learning curve' of the 2 procedures. This learning curve has affected the results of both the pro­cedures in this study. The PCNL group has 10 patients re­quiring multiple stages, while in 1999 a stone of this size would always be cleared in the same sitting. Also the aver­age admission time is much higher in this group than it would be today (8.1 days vs 4 days [1998 figure]). The ESWL group also suffers from this learning curve. The av­erage number of shocks in this study is 3975, while a simi­lar stone size in 1998 gets an average number of 1724 shocks. Also, there area large number of stentnngs (13.41%) while our 1998 figures for similarly sized calculi is lower (6.25%). This is also a reflection on judicious selection of stones these days for ESWL. We prefer not to give ESWL to lower calyceal calculi with an unfavourable PCS con­figuration. [4] ESWL is also avoided for very dense calculi and whenever more sittings are anticipated, especially if the patient lives at a distance from the institute.

(Video) From Open to Minimal Invasive Surgery For Renal Stone Management || Urology ||

The poorer results of ESWL in this study as compared to PCNL are probably due to: i) poor compliance of the patient for repeated sittings leading to a large number of patients being lost to follow-up (9.18%). PCNL is cleared in a single hospital admission thereby follow-up is not essential; ii) ESWL patients required a large number of retreatments (average 2.05) i.e., on an average every pa­tient had to come back for another treatment; iii) ESWL patients had a high re-admission rate (35 patients, for PCNL), while the PCNL group had only one re-admis­sion (for URS). This was similar to that seen in other stud­ies; [1] iv) the initial investment in a lithotripter is very high leading to a higher cost per patient.

The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (14)Conclusions

This is the first study to compare PCNL and ESWL in an Indian setting. This study substantiates the consensus felt by many Indian urologists that ESWL is more expen­sive when all costs are considered. The initial investment in a lithotripter is much higher than that required for PCNL. Although the learning curve for PCNL is steeper, with adequate training at residency level in most centres these days this factor is not felt so acutely. Patient compliance in our country is low (approx 10% lost to follow-up) due to a reduced lack of awareness. Also, any small residual calculus can no longer be considered insignificant for fear of recurrence. Taking all these factors into account, PCNL in our settings is definitely a cost-effective and viable al­ternative to ESWL even for medium-sized renal calculi.

The relative cost-effectiveness of PCNL and ESWL for medium sized (<u> <</u> 2 cms) renal calculi in a tertiary care urological referral centre (16)References

1.Saxby MF, Sorahan T. Slaney P, Coppinger SWV. A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy. Br J Urol 1997; 79: 317-323.
2.Mays N. Relative costs and cost-effectiveness of extracorporeal shock wave lithotripsy versus percutaneous nephrolithotomy in the treatment of renal and ureteric stones. Soc Sci Med 1991; 32: 1401­- 1412.
3.Murray MJ, Chandhoke PS, Berman CJ, Sankey NE. Outcome of extracorporeal shock wave lithotripsy monotherapy for large renal calculi: effect of stone and collecting system surface areas and cost­effectiveness of treatment. J Endourol 1995; 9: 9-13.
4.Sabnis RB, Naik K, Patel SH, Desai MR, Bapat SD. Extracorporeal shock wave lithotripsy for lower calyceal stones: can clearance be predicted? Br J Urol 1997: 80: 853-857.

Tables


[Table - 1], [Table - 2], [Table - 3]
Previous article Next article

FAQs

What is the cost of ESWL? ›

Approximate cost of Extracorporeal shock wave lithotripsy [ESWL] and laser lithotripsy in Bangalore:- Rs. 65,000. Approximate cost of Unilateral Lithotripsy in Bangalore:- Rs. 23,000.

Which is better ESWL or PCNL? ›

PCNL is better than ESWL monotherapy in the eradication of persistent bacteriuria associated with infected stones. PNCL should be used for the treatment of large stones and associated moderate to marked hydronephrosis, as it has a much better clearance rate of residual and infected stone fragments.

What size kidney stone requires PCNL? ›

Percutaneous nephrolithotomy is typically recommended when: Large kidney stones block more than one branch of the collecting system of the kidney. These are known as staghorn kidney stones. Kidney stones are larger than 0.8 inch (2 centimeters) in diameter.

What is the success rate of PCNL? ›

Overall stone free success rate is approximately 80-90% following an initial PCNL and 90-100% following a “second look” procedure.

What size kidney stone requires ESWL? ›

The size and shape of stone, where it is lodged in your urinary tract, your health, and your kidneys' health will be part of the decision to use it. Stones that are smaller than 2 cm in diameter are the best size for SWL.

Is ESWL covered by Medicare? ›

It focuses the shock waves specifically on stones under X-ray visualization, pulverizing them by repeated shocks. ESWL is covered under Medicare for use in the treatment of upper urinary tract kidney stones.

How much does PCNL cost? ›

How Much Does a Kidney Stone Removal (PCNL) Cost? On MDsave, the cost of a Kidney Stone Removal (PCNL) ranges from $11,563 to $17,912. Those on high deductible health plans or without insurance can save when they buy their procedure upfront through MDsave.

Is PCNL a major surgery? ›

In the era of minimally invasive surgery, RIRS and PCNL are two major surgical techniques for removing large renal stones [3], and PCNL has become the standard treatment with which all other approaches should be compared.

What is the recovery time for PCNL surgery? ›

Your doctor may recommend PCNL surgery if you have a large, multiple or complex stones. The surgery lasts one to three hours and typically requires a hospital stay of one to two nights. You should be able to resume normal activities in one to two weeks.

Can PCNL damage kidneys? ›

As an operation requiring kidney puncturing, however, PCNL unavoidably can damage renal function to certain degree. A recent study demonstrates that PCNL is safe and effective for solitary kidney patients and can improve renal function at the post-operative sixth month (4).

At what size can you not pass a kidney stone? ›

Typically, any stone 4 millimeters (mm) or less in length will pass on its own within 31 days. Between 4 mm and 6 mm, only 60 percent will pass without medical intervention, and on average take 45 days to exit your body naturally. Anything bigger than 6 mm will almost always need medical care to help remove the stone.

What should I avoid after PCNL surgery? ›

Avoid heavy lifting (more than 15 lbs.) for 4 weeks after your procedure. Avoid fast stair climbing, long walks and driving for the first 3 weeks. Avoid sexual activity for 2 weeks after the surgery.

Which surgery is best for kidney stones? ›

Ureteroscopy. At NYU Langone, the most common surgery to treat kidney stones is ureteroscopy with Holmium laser lithotripsy. This procedure is used to break up—and often remove—the stone fragments.

Can I drive after PCNL? ›

Technique A small scope (cystoscope) will be inserted through the urethra into the bladder. The stent will be grasped with a small instrument and removed. The procedure usually takes about a minute and is very well tolerated. You may drive home following the procedure.

Is PCNL surgery safe? ›

In complex renal stones, PCNL is a safe and efficient tool in the armamentarium of renal stone management with a relatively low incidence of significant complications. Compared to open surgery, PCNL has the advantages of having a high rate of stone clearance and being cost-effective.

Do you need a stent after ESWL? ›

Not all patients who undergo ESWL will require a ureteral stent. Based upon stone size, location, or presence of any abnormalities in the drainage system of the kidney, placement of a ureteral stent may be required to aid in passive dilation of the ureter to help facilitate passage of stone fragments following ESWL.

Can ESWL damage kidneys? ›

On the downside SWL can cause vascular trauma to the kidney and surrounding organs. This acute SW damage can be severe, can lead to scarring with a permanent loss of functional renal volume, and has been linked to potentially serious long-term adverse effects.

Can a 13 mm kidney stone pass? ›

Kidney stones that are less than 5 millimeters (mm) in size will commonly pass with medical management. Stones that are greater than 10 mm will usually require surgery. Those in between are managed medically first and then surgically if they do not pass.

How long does pain last after ESWL? ›

You may have pain and nausea when the stone pieces pass. This can happen soon after treatment and may last for 4 to 8 weeks. You may have some bruising on your back or side where the stone was treated if sound waves were used. You may also have some pain over the treatment area.

Is ESWL covered by insurance? ›

ESWL treatment is covered under insurance. However, it is not a cash less treatment but the procedure cost is reimbursable.

How long is recovery from ESWL? ›

Many people can fully resume daily activities within one to two days. Special diets are not required, but drinking plenty of water helps the stone fragments pass. Some pain may occur when the fragments pass, which begins soon after treatment and may last for up to four to eight weeks.

How much pain is normal after PCNL surgery? ›

Haotian et al. showed that the incidence of moderate-to-severe postoperative pain after PCNL was about 60%14. It was revealed that our results were similar to Ahmet et al.'s findings which showed that the issue of PCNL-pain during postoperation period has not yet been completely solved15.

How much money does it cost to remove a kidney stone? ›

The cost of kidney stone surgery in India usually starts from Rs. 25,000 and can go up to Rs. 1 lakh. However, the cost of treatment can vary depending on several factors like the type of city, method of kidney stone removal, medical health of the patient, experience of the surgeon, severity of the condition, etc.

Is stent necessary after PCNL? ›

Recent studies in the past decade showed that totally tubeless PCNL without inserting ureter stents and tion rates and safety of use of this technique after multiple access PCNL.

How long does it take to pass stones after ESWL? ›

The stone fragments may pass in within a week but could take up to 4-8 weeks for all fragments to pass.

Can I do exercise after PCNL surgery? ›

Although PCNL is a minimally invasive surgery, you should plan to rest for a week or two after. However, remaining active is important and we advise walking regularly when you can. Do not attempt to do any strenuous exercise or heavy lifting for at least a month.

How is a stent removed after PCNL? ›

JJ Stent (removal of kidney stones) - YouTube

What should eat after PCNL surgery? ›

You may return to your normal diet after surgery. Mild nausea and possibly vomiting may occur in the first 6-8 hours following surgery. This is usually due to the side effects of anesthesia and will resolve soon. We suggest clear liquids and a light meal the first evening following surgery.

How many days rest after kidney stone surgery? ›

While the recovery times vary for each procedure, most patients are fully recovered within six weeks and can resume their normal activities. Many patients feel much better the first week, but care must be taken to assure that healing is complete.

Will removing kidney stones improve kidney function? ›

A stone obstructing the kidney causes renal dysfunction that typically improves or resolves upon removal.

What are the complications of PCNL? ›

The complications following PCNL are infection, hemorrhage, adjacent organ injury, retained stone, loss of kidney function, and death. The Clinical Research Office of the Endourological Society (CROES) conducted two multicenter global studies on the complications following PCNL.

Which anesthesia is given in PCNL? ›

The General Anaesthesia (GA) is the standard modality for PCNL. However, few studies conclude that Spinal Anaesthesia (SA) can be an alternative method of anaesthesia with similar incidence of complications.

What is the quickest a kidney stone can pass? ›

A stone that's smaller than 4 mm (millimeters) may pass within one to two weeks. A stone that's larger than 4 mm could take about two to three weeks to completely pass. Once the stone reaches the bladder, it typically passes within a few days, but may take longer, especially in an older man with a large prostate.

Is it OK to leave a kidney stone alone? ›

Small stones in the kidney may be left alone if they are not causing pain or infection. Some people choose to have their small stones removed. They do this because they are afraid the stone will unexpectedly start to pass and cause pain.

Can you pass a 5 mm kidney stone on your own? ›

The smaller the kidney stone, the more likely it will pass on its own. If it is smaller than 5 mm (1/5 inch), there is a 90% chance it will pass without further intervention. If the stone is between 5 mm and 10 mm, the odds are 50%. If a stone is too large to pass on its own, several treatment options are available.

Which fruit is good after kidney stone surgery? ›

Increase the amount of citrus fruit in your daily diet Citrus fruits and their juices can help reduce or prevent stone formation due to naturally produced citrate. Fruits that are beneficial for people with kidney stones include: Lemons, oranges, and grapefruit.

How much does ESWL cost in India? ›

ESWL cost depends upon multiple factors : Starting price is ₹ 14,250. Average cost is ₹ 55,786. Maximum price is ₹ 88,000.

Can ESWL damage kidneys? ›

On the downside SWL can cause vascular trauma to the kidney and surrounding organs. This acute SW damage can be severe, can lead to scarring with a permanent loss of functional renal volume, and has been linked to potentially serious long-term adverse effects.

Is ESWL treatment painful? ›

However, ESWL is still generally considered to be a painful procedure. This could be caused by shockwaves reaching superficial (skin and muscle) and deeper structures (ribs, nerves and the kidney capsule) [3,4].

Is ESWL successful? ›

The overall success rate of ESWL for treating upper urinary tract stones is 60–95%.

How much does Pcnl surgery cost in India? ›

Percutaneous nephrolithotripsy (PCNL) cost in India – Starts from Rs. Rs. 70,000 and can go up to Rs. 85,000.

Do you need a stent after ESWL? ›

Not all patients who undergo ESWL will require a ureteral stent. Based upon stone size, location, or presence of any abnormalities in the drainage system of the kidney, placement of a ureteral stent may be required to aid in passive dilation of the ureter to help facilitate passage of stone fragments following ESWL.

How much money does it cost to remove a kidney stone? ›

The average cost of Kidney stone removal in India is approximately Rs. 1,29,600. However, the prices may vary depending upon the hospitals in different cities.

How long does pain last after ESWL? ›

You may have pain and nausea when the stone pieces pass. This can happen soon after treatment and may last for 4 to 8 weeks. You may have some bruising on your back or side where the stone was treated if sound waves were used. You may also have some pain over the treatment area.

Are you awake during ESWL? ›

Your provider will not need to make any incisions during a shock wave lithotripsy procedure. But you'll still need some form of anesthesia (pain relief) to keep you comfortable. You may be awake but drowsy or asleep during the procedure.

What should I eat after ESWL? ›

To keep your urine flowing freely and to avoid constipation, drink plenty of fluids during the day (8-10 glasses.) Water is best, but juices, coffee, tea, and soda are all acceptable.

How long does it take to pass stones after ESWL? ›

The stone fragments may pass in within a week but could take up to 4-8 weeks for all fragments to pass.

How long are you in recovery room after lithotripsy? ›

Recovery Time

You will likely be able to resume normal activities within: Two to three days of having an external shock wave lithotripsy procedure or ureteroscopy and laser lithotripsy.

Do you need anesthesia for ESWL? ›

ESWL is an outpatient procedure, but anesthesia is required. You may be given a light sedative or a full general anesthetic, if necessary.

Can you exercise after ESWL? ›

Rest as much as you need to after you go home. You may do your regular activities. But avoid hard exercise or sports for a week. Wait until there is no blood in your urine and the stent is out.

What is the best position to pass a kidney stone? ›

When you have a kidney stone, the priority is to pass it as soon as possible to eliminate the pain. Research indicates that the best position to lay with kidney stones is on the side with the pain. In other words, if the stone is in your left ureter, lie on your left side; if it's in the right ureter, lie on the right.

What are the side effects of ESWL? ›

Known short-term side effects of ESWL are renal hematoma, infectious complications, “steinstrasse” (stone street) blockage caused by remaining stone fragments, renal colic, or regrowth of urinary calculi.

Videos

1. Management of Paediatric Urolithiasis
(European School of Urology)
2. Interventional Uroradiology Hosted by Dr Phil Haslam
(Newcastle University Radiology Society)
3. Webinar: Basic Urology with Limited Resources
(Samaritans Purse International Health Forum)
4. BAUS16 Best Academic Papers
(BAUS TV)
5. Paraneoplastic Syndromes; SRM Partial Nephrectomy; Nephrometry Metastatic Tumours; Immunotherapy TCC
(Master the Medicine)
6. Perspectives on Urological Treatment Procedures During COVID-19
(Dornier MedTech)

Top Articles

Latest Posts

Article information

Author: Nathanial Hackett

Last Updated: 10/07/2022

Views: 6446

Rating: 4.1 / 5 (72 voted)

Reviews: 87% of readers found this page helpful

Author information

Name: Nathanial Hackett

Birthday: 1997-10-09

Address: Apt. 935 264 Abshire Canyon, South Nerissachester, NM 01800

Phone: +9752624861224

Job: Forward Technology Assistant

Hobby: Listening to music, Shopping, Vacation, Baton twirling, Flower arranging, Blacksmithing, Do it yourself

Introduction: My name is Nathanial Hackett, I am a lovely, curious, smiling, lively, thoughtful, courageous, lively person who loves writing and wants to share my knowledge and understanding with you.