Upper Urinary Tract

Percutaneous nephrolithotomy in England:

practice and outcomes described in the Hospital
Episode Statistics database
James N. Armitage, John Withington*†, Jan van der Meulen*‡, David A. Cromwell*,
Jonathan Glass†, William G. Finch§, Stuart O. Irving§ and Neil A. Burgess§
Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge,
*Clinical Effectiveness Unit, The Royal College of Surgeons of England, †Department of Urology, Guy's & St Thomas'
NHS Foundation Trust, ‡London School of Hygiene and Tropical Medicine, London, and §Department of Urology, Norfolk
and Norwich University Hospitals NHS Foundation Trust, Norwich, UK

Objective • There were 595 emergency readmissions in 518 patients

• To investigate the postoperative outcomes of percutaneous
nephrolithotomy (PCNL) in English National Health Service
(NHS) hospitals.
Patients and Methods
• We extracted records from the Hospital Episode Statistics
(HES) database for all patients undergoing PCNL between
March 2006 and January 2011 in English NHS hospitals.
• Outcome measures were haemorrhage, infection within the
index admission, and rates of emergency readmission and
in-hospital mortality within 30 days of surgery.
Results
• A total of 5750 index PCNL procedures were performed in
165 hospitals.
• During the index admission, haemorrhage was recorded in
81 patients (1.4%), 192 patients (3.8%) had a urinary tract
infection (UTI), 95 patients (1.7%) had fever, and 41
patients (0.7%) had sepsis.
(9.0%). Reasons for readmission were varied: 70 (1.2%) with
UTI, 15 (0.3%) sepsis, 73 (1.3%) haematuria, 25 (0.4%)
haemorrhage, and 25 (0.4%) acute urinary retention.
• There were 13 (0.2%) in-hospital deaths within 30 days of
surgery.
Conclusions
• Haemorrhage and infection represent relatively common
and potentially severe complications of PCNL.
• Mortality is extremely rare after PCNL (about one in 400
procedures overall) but almost one in 10 patients have an
unplanned hospital readmission within 30 days of surgery.
• Complications of PCNL may be under-reported in the HES
database and need to be corroborated using other data
sources.
Keywords
percutaneous nephrolithotomy, database, healthcare quality,
surgical outcomes

Introduction Percutaneous nephrolithotomy (PCNL) is a complex

Transparency and public accountability are important drivers
of healthcare improvement in the UK [1]. In the summer of
2013, clinical quality measures and survival rates will be
published by national clinical audits for every consultant
practising in 10 surgical specialties, including urology [2].
Furthermore, in the next 5 years, all doctors in the UK will be
required to undergo revalidation in order to retain their
General Medical Council licence to practise [3]. As part of the
revalidation process, surgeons will be expected to provide data
on their clinical outcomes, which may be derived from either
national or local clinical audits, or from routinely collected
data such as Hospital Episode Statistics (HES) [4,5].
endourological operation. It may be considered a ‘benchmark’
surgical procedure for endourologists and could be used to
support revalidation. In 2010, the British Association of
Urological Surgeons (BAUS) established a national registry for
PCNL. For each operation, the registry captures information
on patient demographics, stone complexity and operating
technique, as well as outcomes such as complications and
stone clearance rates. All surgeons in the UK are able to
submit data to the registry via an online interface, and a
recent analysis of registry data showed safety and effectiveness
outcomes aligned with those reported in other large
contemporary series [6]. Nevertheless, as submission to the
BAUS PCNL registry is voluntary, the patients on whom data

© 2013 The Authors

BJU International © 2013 BJU International | doi:10.1111/bju.12373 BJU Int 2014; 113: 777–782
Published by John Wiley & Sons Ltd. www.bjui.org wileyonlinelibrary.com
Armitage et al.
are submitted may not be representative of all patients
undergoing this procedure in the UK.
Since 1989, details of all admissions to NHS hospitals in
England have been registered in the HES database [4]. Each
patient record includes demographic information as well as
primary and supplementary diagnoses and operations. A
unique identifier links the records for each patient across
different years and across admissions in different hospitals.
HES was initially developed for commissioning and
reimbursement purposes, and currently BAUS uses national
audit databases rather than HES to fulfil the requirement to
collect surgical outcome data that will be made publicly
available [7]; however, HES data may be reliably used to
investigate important clinical healthcare outcomes [8], and are
used by ‘Dr Foster’ [9] to issue reports on the quality and
performance of NHS healthcare providers. Moreover, the
Society for Cardiothoracic Surgery in Great Britain and
Ireland has endorsed the use of clinical databases enriched
through linkage with administrative data sources such as HES
to demonstrate healthcare quality [10].
In the present article, we investigate the outcomes of PCNL
performed in English NHS hospitals using data from HES. We
also consider its potential utility as a data source for national
reports in the future.
Patients and Methods
We extracted HES records for all patients undergoing PCNL
in English NHS hospitals between 21 March 2006 and 31
January 2011. In HES, procedures are coded using the Office
of Population, Censuses and Surveys Classification of Surgical
Operations and Procedures (OPCS), 4th revision, and
diagnoses are coded using the International Classification of
Diseases, version 10 (ICD-10). Since 2006, PCNL has been
recorded in HES using a single OPCS-4 code: M164 [11]. We
identified all elective PCNL procedures for urolithiasis
(ICD-10 code: N20), and excluded emergency procedures and
procedures for which N20 did not appear in any diagnostic
field of either the index or any previous hospital admission
[12]. Where patients had undergone more than one PCNL
procedure, we only included their first procedure in the
analysis. The laterality of the procedures was determined using
ICD-10 codes Z941-3. Using a unique patient identifier in
HES, all previous and subsequent admission records for these
patients were also extracted.
Complications of surgery in the index PCNL admission were
identified using ICD-10 codes in all diagnostic fields. Primary
safety outcomes were haemorrhage complicating a procedure
(ICD-10 T810), UTI (N390), fever (R50) and sepsis (A41).
Procedural fields were used to identify patients who required
angiography (OPCS-4 L434: arteriography of renal artery)
or selective renal artery embolization (OPCS-4 L433:
© 2013 The Authors
778 BJU International © 2013 BJU International
percutaneous transluminal embolization of renal artery) to
control haemorrhage after PCNL.
We defined hospital readmission and in-hospital mortality to
be such events within 30 days of surgery. These could occur
either in the operating hospital or any other English NHS
hospital. Readmissions were defined as either elective or for
unplanned emergency indications. The reason for readmission
was identified, and complications were sought using ICD-10
codes in any of the diagnostic fields. Mortality was identified
in patient records where ‘method of discharge’ was recorded as
death (dismeth = 4).
We calculated the complication rates for PNCL for all patients,
and for specific subgroups. We used the chi-squared test to
assess differences between unadjusted rates. All P values were
two-sided, and those <0.05 were considered to indicate
statistical significance.
We used multivariable logistic regression to examine the
association between the risk of complication and patients’
characteristics (age at admission, sex and comorbidities).
Comorbidities were identified using an updated version of the
Charlson comorbidity score that was specifically developed
for use with administrative data on surgical patients [13]. All
statistical analyses were undertaken using STATA 11.1 software
[14].
Results
Between 21 March 2006 and 31 January 2011, 6783 PCNL
procedures were performed in 165 English NHS hospitals.
Levels of activity varied across hospitals, with 45 performing
>50 procedures, and 10 >100 procedures in the study period.
There were 5750 index PCNL operations. We excluded 698
repeat/contralateral operations, 228 emergency operations and
seven records with incomplete data (missing age or sex). The
100 procedures performed in January 2011 were excluded to
ensure that all index operations had at least 30 days’
follow-up. Among the 5750 PCNL procedures, most patients
were men (55%) and more were left-sided operations (57%)
(Table 1). The most common age group for patients having
PCNL was 56–65 years, comprising almost one quarter of all
procedures. The median (interquartile range) length of
hospital stay was 4 (3–6) days. The mean length of stay
decreased over the study period (Fig. 1) which was
attributable, in part, to the increasing use of day of surgery
hospital admission for PCNL. This increased from less than
one third to almost three quarters of patients in the 5-year
study period (Fig. 2).
Almost one third (31.2%) of patients had at least one
comorbid condition captured by the Charlson score. In all,
14.7% of patients had diabetes and 9.6% had chronic
pulmonary disease. In addition, 29.5% of patients who
underwent PCNL had hypertension, a condition which is not
captured by the Charlson score.
 PCNL practice and outcomes in England

Table 1 Demographic characteristics and outcomes for 5750 elective More than one fifth of patients who underwent PCNL (n =
PCNL procedures in English NHS hospitals between 21 March 2006 and
31 December 2010. 1302) were readmitted within 30 days of hospital discharge.
There were 893 elective admissions in 784 patients (13.6%),
Variable Value for which the most common reasons appear to be ureteric
Sex, n (%) stent removal (291 patients) and lithotripsy or ureteroscopy
Male 3158 (54.9) (109 patients). There were 595 emergency readmissions in 518
Female 2592 (45.1) patients (9.0%): 70 readmissions (1.2%) with UTI, 15 (0.3%)
Age, n (%)
<15 years 120 (2.1) sepsis, 73 (1.3%) haematuria, 25 (0.4%) haemorrhage, and 25
16–25 years 239 (4.2) (0.4%) with acute urinary retention. Table 3 shows the
26–35 years 533 (9.3) relationship between the rate of emergency readmission and
36–45 years 962 (16.7)
46–55 years 1070 (18.6) patient characteristics, and reveals that, after adjusting for
56–65 years 1333 (23.2) other factors, patients with comorbidities were at greater risk
66–75 years 1076 (18.7) of emergency readmission (P = 0.005).
≥76 years 417 (7.3)
Charlson comorbidity index score, n (%)
0 3959 (68.9)
1 1383 (24.1) Discussion
2 320 (5.6)
≥3 88 (1.5) The HES database provides the largest contemporary dataset
Procedure laterality, n (%) for PCNL in England. Haemorrhage and infection represent
Left 2979 (57.2)
Right 2202 (42.3)
relatively common and potentially severe complications of
Bilateral 23 (0.4) PCNL which can be identified in HES using ICD-10 and
Length of hospital stay of index admission, days OPCS-4 codes. Mortality is extremely rare after PCNL (about
Median (interquartile range) 4 (3–6)
Mean 5.2
one in 400 procedures overall) but one in 10 patients have an
Complications during index admission, n (%) unplanned readmission to hospital within 30 days of surgery.
Bleeding 81 (1.4)
UTI 192 (3.3)
Fever 95 (1.7) Methodological Limitations
Sepsis 41 (0.7)
Patients readmitted to hospital within 30 days of surgery, n (%) The HES database is populated with data that are recorded by
Elective 794 (13.6)
specially trained clinical coders using patients’ medical records
Emergency 518 (9.0)
Mortality within 30 days of surgery, n (%) 13 (0.23*) at the time of hospital discharge. Department of Health
initiatives, such as ‘Payment by Results’, which directs
[*Correction added on 26 November 2013, after first online publication: value changed healthcare funding according to clinical coding, have led to
from (2.3) to (0.23).]
improvements in data accuracy. For example, a recent
systematic review that compared HES data with medical case
notes showed that accuracy was improving and concluded that
Overall, 383 patients (6.7%) experienced at least one
routinely collected administrative data were sufficiently robust
complication during their hospital admission for PCNL.
to support their use in clinical research [15]. Furthermore, it is
Haemorrhage was recorded in 81 patients (1.4%), of whom 22
likely that accuracy will improve further with increasing
patients (0.4%) had angiography and 19 (0.3%) had selective
professional clinical engagement with the coding process [16].
embolization. A total of 192 patients (3.3%) had a UTI during
their PCNL admission, 95 patients (1.7%) had fever and 41 Since 2006, PCNL has been recorded in HES using a single
patients (0.7%) had sepsis. There were significant differences OPCS-4 code: M164. The first PCNL procedure was described
between women and men in crude UTI (4.6% v 2.3%, P < in 1973 [17] and the technique was widely adopted into
0.001) and sepsis rates (1.3% v 0.3%, P < 0.001). Table 2 clinical practice in the 1980s [18]. Before 2006, the procedure
describes the relationship between infective complication rates would have been coded variably using a variety of different
and patient characteristics. After adjusting for other factors, OPCS-4 codes. It is not possible, therefore, to reliably
women had significantly higher rates of infective investigate the practice and outcomes of PCNL before 2006.
complications than men (P < 0.001). Moreover, it is conceivable that some healthcare providers will
have continued to record the procedure with codes other than
In-Hospital Mortality and Readmissions to Hospital M164 since its introduction, resulting in some cases being
after PCNL missed in the present analysis.
There were 13 in-hospital deaths (0.2%) within 30 days of The HES database can provide information on comorbidities
PCNL surgery. Of these, five patients (38%) had evidence of a which, along with age and sex, allows some adjustment for
bleeding complication (OPCS-4: T81) and three (23%) had case mix, an essential component of any study that attempts to
sepsis. compare healthcare outcomes; however, it is not possible to

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Armitage et al.

7 Fig. 1 Mean length of hospital stay for patients

having PCNL by admission year.
6

5
Length of stay, mean

0
2006 2007 2008 2009 2010
Year

100 Fig. 2 Proportion of PCNL patients admitted to

hospital on the day of surgery.
90
80
70
≥1 day prior
60 to surgery
Percent

50
40
30 Day of surgery
admission
20
10
0
2006 2007 2008 2009 2010
Year

derive from this database information on stone burden or Table 2 Relationship between any infective complication within the index
admission and patient characteristics for PCNL procedures in English NHS
complexity, or on other relevant patient factors such as renal hospitals between 21 March 2006 and 31 December 2010.
anatomy, or on procedural details, all of which may influence
outcomes. It is also not possible to determine the effectiveness Variable Crude Adjusted 95% CI P
odds odds
of stone clearance from HES, although proxy measures such ratio ratio
as rates of adjunctive procedures could be used to provide
some indirect evidence. Sex
Male 1 1 <0.001
Female 2.25 2.27 1.79–2.88
Comparison with Other Studies and Explanation Age
<15 years 1.23 1.28 0.60–2.75 0.90
of Findings
16–25 years 0.75 0.68 0.34–1.34
26–35 years 1.07 1.02 0.66–1.59
A recent study using publicly available, aggregated HES data
36–45 years 0.91 0.89 0.61–1.30
provided some insight into the management of urolithiasis in 46–55 years 1.06 1.05 0.74–1.50
England [19], but the present study used patient-level data for 56–65 years 1 1
66–75 years 0.95 0.93 0.65–1.64
the first time to investigate the practice and safety outcomes
≥76 years 1.10 1.03 0.64–1.64
of PCNL. Charlson comorbidity index score
0 1 1 0.89
Overall, we found that 328 patients (5.7%) had a UTI, fever or 1 1.10 1.10 0.84–1.44
sepsis recorded during their hospital admission for PCNL, a 2 1.13 1.10 0.67–1.81
≥3 1.08 1.16 0.46–2.93
rate which appears lower than that reported in another large
contemporary series [6,20]; however, infective complications
were responsible for a considerable number of emergency
readmissions and, when these were taken into account, the

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780 BJU International © 2013 BJU International
 PCNL practice and outcomes in England

Table 3 Relationship between risk of emergency readmission and patient example, in the present study, transfusion was recorded in
characteristics for PCNL procedures in English NHS hospitals between 21
March 2006 and 31 December 2010. only 10 patients (0.2%) during their PCNL admission.

Variable Crude Adjusted 95% CI P Mortality after PCNL is a rare complication occurring in only
odds odds 0.2% of patients in the present study. This is similar to the rate
ratio ratio
reported in a recent large database study from the USA (0.2%)
Sex [21]. By contrast to the US study, we were also able to obtain
Male 1 1 0.77 information on readmission rates after PCNL. More than one
Female 0.98 0.97 0.81–1.17
Age
fifth of patients were readmitted to hospital within 30 days of
<15 years 1.67 1.79 1.04–3.11 0.065 PCNL surgery. These readmissions were often for elective
16–25 years 1.40 1.51 0.97–2.33 indications and should not therefore be considered
26–35 years 1.16 1.26 0.89–1.77
36–45 years 0.97 1.02 0.76–1.37
complications; however, there was also a high rate of
46–55 years 0.95 0.98 0.73–1.30 unplanned readmissions after PCNL (9.0%). Further work is
56–65 years 1 1 needed to determine whether specific comorbid conditions or
66–75 years 0.88 0.86 0.64–1.15
≥76 years 0.93 0.87 0.58–1.29
other factors, such as variations in hospital provider volume or
Charlson comorbidity index score practice, influence readmission rates; however, premature
0 1 1 0.005 hospital discharge does not appear to be the cause as
1 1.24 1.31 1.06–1.62
2 1.13 1.24 0.84–1.86
readmission rates were stable across the study period despite
≥3 2.06 2.33 1.29–4.22 reduced length of hospital stay. Furthermore, the mean length
of stay for patients readmitted to hospital was 5.9 days
compared with only 5.2 days for those who were not
overall incidence was ∼8%. It is also possible that infection is readmitted.
under-reported in HES and may be better identified in clinical
studies. For example, clinical coders tend to record UTI only
Implications for Collecting and Reporting PCNL
where it is specifically documented as such in the medical case
Outcome Data
notes or discharge summary. In addition, infection may be
defined variably, making comparisons of infection rates Comprehensive and reliable data are fundamental when
between different studies difficult. For example, some may investigating temporal and geographical variations in the
report postoperative fever (with differing temperature practice and outcomes of PCNL. The present study has
thresholds), while others may use criteria such as systemic highlighted the strengths and weaknesses of HES data.
inflammatory response syndrome to define sepsis after PCNL. Strengths include reliable data on patient demographics,
length of hospital stay, readmission and mortality, as well as
The frequency of bleeding complications found in the present
some information on comorbidities and complications.
study (1.4%) was also lower than that observed in other recent
Deficiencies in the HES data may be addressed through
studies. For example, a large contemporary prospective
linkage with clinical data registries such as the BAUS PCNL
multicentre study reported a 5.7% transfusion rate [6]. The
data registry, where safety outcomes may be corroborated
transfusion rate reported in the prospective BAUS PCNL data
and the dataset enriched with information on stone size and
registry was also slightly higher (2.4%) but, interestingly, the
complexity, other patient factors, procedural information
incidence of selective renal artery embolization was very
and data on clinical effectiveness, such as stone-free rates.
similar (0.4%) to that found in this study (0.3%) [20]. The
Furthermore, periodic referencing to local audits may
lower rate of bleeding reported in the HES database may
help to further instill confidence in the accuracy of these
again reflect incomplete coding of this complication. The
data.
methodology adopted by ‘Dr Foster Intelligence’ [9] to identify
postoperative bleeding, and which is published in their Revalidation by the General Medical Council may encourage
Hospital Guide on healthcare quality, is a little different. more surgeons to engage with the process of recording
The ICD-10 code T811 (shock during or resulting from a complete and accurate data on their outcomes and to
procedure) is used in addition to T810 (haemorrhage and contribute to national datasets. High quality national data will
haematoma complicating a procedure), although an additional ultimately improve the quality of patient care through a
OPCS-4 procedural code must also be present for it to qualify number of mechanisms. Firstly, it will allow important
as a bleeding complication. In the present study, the rate of research questions to be addressed, which as a result will help
renal artery angiography and or embolization may therefore to optimize the care of patients and tailor their treatment
give a better representation of significant postoperative according to individual circumstances. Secondly, it will permit
bleeding. Although OPCS-4 codes for transfusion exist (for reliable comparisons between surgeons or healthcare providers
example, X332: i.v. blood transfusion of packed cells), these are and identify poor performance, which could be rectified if
not used by Dr Foster and appear to be much underused. For necessary. Comparing performance is, however, an emotive

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Armitage et al.
issue for surgeons and must be addressed with sensitivity and
not without appropriate consultation. Lastly, if made publicly
available, these data will empower patients to have greater
involvement in the decisions that directly affect their
management and its outcome.
In conclusion, the present study has shown that HES data may
be used to evaluate outcomes of PCNL. Bleeding and infective
complications can be identified using ICD-10 codes but may
be under-reported. We found a low mortality rate but about
one in 10 patients had an unplanned hospital readmission
within 30 days. Linkage of HES data with those from clinical
registries, such as the BAUS PCNL registry, is needed to
corroborate our findings and provide information on stone
complexity and effectiveness of surgery.
Acknowledgements
We thank the Health and Social Care Information Centre for
providing the HES data used in this study. We also thank Ms
Lynn Copley (Clinical Effectiveness Unit of The Royal College
of Surgeons of England) for her help and support with
accessing and extracting the HES data.
Ethical approval: The study is exempt from UK National
Research Ethics Committee approval as it involved analysis of
an existing dataset of anonymized data for service evaluation.
Conflict of Interest
None declared.
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Correspondence: James N. Armitage, Addenbrooke’s Hospital,
Cambridge University Hospitals NHS Foundation Trust, Hills
Road, Cambridge CB2 0QQ, UK.
e-mail: jim_armitage@hotmail.com
Abbreviations: PCNL, percutaneous nephrolithotomy; HES,
Hospital Episode Statistics; OPCS-4, Office of Population,
Censuses and Surveys Classification of Surgical Operations
and Procedures, 4th revision; ICD-10, International
Classification of Diseases version 10.