Dr. Andrew Portis and the HealthEast Kidney Stone Institute (KSI) in St. Paul are trying to revamp the model for treating kidney stones in an effort to eliminate repeat surgeries.
Portis is the chair and medical director of the KSI, which he founded five years ago. He and his colleagues have developed a technique, dubbed the “St. Paul method,” for treating kidney stones. It appears to be more than a quick fix to the problem; instead, it aims for long-term results.
Although Portis describes his procedural innovation as “pretty simple” from a technical perspective, he feels he’s fighting an uphill battle against a treatment process that has such low expectations that failure has nearly become the status quo.
Kidney stone disease is caused when urine contains a high amount of crystal-forming substances like calcium oxalate or uric acid. Those substances form a hard, pebble-like material in a kidney, which then passes through the bladder.
While most small stones can be passed without medical assistance, through urination, the larger stones can sometimes require medical treatment. According to Portis, the most popular form of treatment is called “shock wave lithotripsy,” which targets the stone with noninvasive pressure waves that break it up into tiny pieces, which are then small enough to pass.
Portis has found, however, that the shockwave treatment (or “blast ’em treatment,” as he calls it) can be radically ineffective when the stone is near the bottom of the kidney—success rates for the treatment are just 30 percent and often require repeat surgeries because of incomplete stone clearance.
He thought he could do better. So he established a method that would put the kidney stone treatment process on its head, almost literally.
“We developed a technique where we would put the patient under anesthetic, and then stand them almost on their head, like a 45-degree angle,” Portis describes. “This obviously puts the bottom of the kidney on top so that the bottom part is a straight shot, which allows us to remove the stones from the most accessible place.”
Portis also altered how the actual stones were destroyed once he got to them. “Instead of smashing them into a million pieces, we pretend to be diamond cutters and break them down just small enough so we ourselves can get them out—decreasing the number of stray fragments that are floating around,” Portis explains. “That way, we can actually get the patients clean, with just one surgery.”
The most expensive single element of kidney stone disease is surgical treatment. And the major driver behind the need for multiple surgeries is incomplete stone clearance.
Since Portis has begun completely clearing stones from the patients’ kidneys rather than just breaking them up, the incidence of re-treatment at KSI has dropped to about 5 percent, compared with the national average of nearly 20 percent.
“While a lot of people would say our process is too laborious or fastidious, the results speak for themselves,” says Portis. “By dropping our re-treatment rate and eliminating second and sometimes third treatments, we estimate we save somewhere between $3,000 to $5,000 per case that goes to the operating room.”
The second-most expensive element of kidney stone disease is caused by ER visits. Most patients begin their kidney stone experience in the ER, says Portis, and that’s why he decided to tightly integrate the ER department at HealthEast system with its kidney stone specialty division.
One of the biggest problems in the kidney stone treatment process, according to Portis, is uncertainty—both by the ER doctors and the patients.
“By working closely with our ER department, our specialists are able to quickly decide whether an incoming patient belongs in the hospital or is OK to go home,” says Portis. “We cut out the uncertainty that the ER doctors harbor about kidney stones and were able to cut the admission rate from 20 percent to about 10—and of that 10 percent we know which need to get into the clinic quickly, sometimes the very same day.”
KSI’s increased involvement in the ER department has reduced early repeat ER visits from 10 percent to 4 percent, and Portis estimates that it saves about $1,000 on every patient that presents him- or herself at the ER.
“Our role in the ER is a big part of our patient-centered care model,” Portis says. “Many specialists look at ER patients as, ‘I’m not really involved yet, I have an opening next Tuesday and that’s when I’ll take a look at them,’ but that thought process can result in a big waste of money and time in the long run.”
How It Helps
In November 2013, a 73-year-old man named James visited the ER in Coon Rapids after he experienced a painful episode related to kidney stones.
The ER doctors X-rayed James and quickly told him that the stone would pass on its own, gave him pain medication and sent him on his way. The next day, the stone didn’t pass and the pain got worse, so he visited his local ER. He was told it would pass and was sent on his way. After another week of severe pain and another fruitless visit to his local urologist, James went to see Dr. Andrew Portis.
“Dr. Portis looked at my X-rays, and said ‘You’re not going to pass this on your own, let’s go get ’em,’ ” recalls James. “So one painless surgery later, the very next day in fact, and my stones were gone—not just broken up, but gone entirely.”
How They Did It
The “St. Paul method” is an innovative surgical treatment for kidney stone disease that attempts to completely remove the stone rather than merely breaking it up. This method results in fewer repeat hospital visits for the patient.
Dr. Andrew Portis was initially motivated to develop the technique after an influx of patients from the Hmong community.
“Because of the Hmong patients’ naÃ¯vetÃ© regarding Western medicine, they didn’t take the status quo of a low kidney stone removal success rate as acceptable,” Portis says. “They wanted the stones taken care of and they wanted it done in a single surgery.
“So it was the tough customers from the Hmong community that set us on course to try and fix what most doctors consider to be adequate but is really a very flawed system.”