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Srisubat A et al, 2015: Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones.

Srisubat A, Potisat S, Lojanapiwat B, Setthawong V, Laopaiboon M
Institute of Medical Research and Technology Assessment, Dept of Medical Services, Ministry of Public Health, Tiwanon, Nonthaburi, Thailand

Abstract

BACKGROUND: Stones in the urinary tract are a common medical problem in the general population. At present, the great expansion in minimally invasive techniques has led to the decrease in open surgery. Extracorporeal shock wave lithotripsy (ESWL) has been introduced as an alternative approach which disintegrates stones in the kidney and upper urinary tract through the use of shock waves. Nevertheless, as there are limitations with the success rate in ESWL, other minimally invasive modalities for kidney stones such as percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) are also widely applied. This is an update of a review first published in 2009.
OBJECTIVES: This review aimed to assess the effectiveness and complications of ESWL for kidney stones compared with PCNL or RIRS.
SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register to 3 March 2014 through contact with the Trials' Search
Co-ordinator using search terms relevant to this review.
SELECTION CRITERIA: Randomised controlled trials (RCTs) assessing the use of ESWL compared to PCNL or RIRS for kidney stone
management.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed all the studies for inclusion. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI).MAIN RESULTS: Five studies (338 patients) were included, four studies compared ESWL to PCNL and one compared ESWL with RIRS. Random sequence generation was reported in three studies and unclear in two. Allocation concealment was not reported in any of the included studies. Blinding of participants and investigators could not be undertaken due to the nature of the interventions; blinding of outcome assessors was not reported. Reporting bias was judged to be low risk in all studies. One study was funded by industry and in one study the number of participants in each group was unbalanced.The success of treatment at three
months was significantly greater in the PCNL compared to the ESWL group (3 studies, 201 participants: RR 0.46, 95% CI 0.35 to 0.62). Re-treatment (1 study, 122 participants: RR 1.81, 95% CI 0.66 to 4.99) and using auxiliary procedures (2 studies, 184 participants: RR 9.06, 95% CI 1.20 to 68.64) was significantly increased with ESWL group compared to PCNL. The efficiency quotient (EQ; used to assess the
effectiveness of procedures) higher for PCNL than ESWL; however EQ decreased when stone size increased. Duration of treatment (MD
-36.00 min, 95% CI -54.10 to -17.90) and hospital stay (1 study, 49 participants: MD -3.30 days, 95% CI -5.45 to -1.15) were significantly shorter in the ESWL group. Overall more complications were reported with PCNL, however we were unable to meta-analyse the included
studies due to the differing outcomes reported and the timing of the outcome measurements.One study compared ESWL versus RIRS
for lower pole kidney stones. The success of treatment was not significantly different at the end of the third month (58 participants: RR 0.91, 95% CI 0.64 to 1.30). Mean procedural time and mean hospital stay was reported to be longer in the RIRS group.
AUTHORS' CONCLUSIONS: Results from five small studies, with low methodological quality, indicated ESWL is less effective for kidney stones than PCNL but not significantly different from RIRS. Hospital stay and duration of treatment was less with ESWL. Larger RCTs with high methodological quality are required to investigate the effectiveness and complications of ESWL for kidney stones compared to PCNL if there is any technological progress in the non-invasive elimination of the residual fragments. Moreover, further research is required for the outcomes of ESWL and RIRS in lower and non-lower pole studies including PCNL versus RIRS.

Update of Cochrane Database Syst Rev. 2009;(4):CD007044.
Cochrane Database Syst Rev. 2014 Nov 24;11:CD007044. doi: 10.1002/14651858.CD007044.pub3.

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Comments 1

Hans-Göran Tiselius on Monday, 23 February 2015 09:10

In this Cochran report comparative studies between SWL and PNL and between SWL and RIRS were reviewed and analysed. As expected and recorded in numerous non-randomized studies, stone-free rates were higher in patients treated with PNL than in those treated with SWL. Treatment duration, hospital stay were longer and complications more frequent following PNL. It also is of interest to note that comparative studies between SWL and RIRS did not disclose any significant differences.

The authors conclude that the series of publications analysed generally were of low quality, with ways of presenting the result that did not allow a proper meta-analysis. The conclusion therefore was that there still is a need for carefully designed randomized comparisons. It is possible that by taking into account various determinants of treatment outcome recently analysed [1], might enable a more detailed comparison between the procedures. But with all respect for prospective randomized studies and meta-analyses, I am not certain that such efforts really are worth the efforts. The advantages and disadvantages of different treatment modalities for stone removal are so far reasonably well known and these features need to be carefully considered for the individual patient. A real reason for additional comparative studies probably should await more significant technological advances in the different techniques for stone removal.

Reference
1. Torricelli FC, Marchini GS, Yamauchi FI, Danilovic A, Vicentini FC, Srougi M, Monga M, Mazzucchi E.Impact of renal anatomy on shock wave lithotripsy outcomes for lower pole kidney stones: results from a prospective multifactorial analysis controlled by computed tomography scan.
J Urol. 2014 [Epub ahead of print]

In this Cochran report comparative studies between SWL and PNL and between SWL and RIRS were reviewed and analysed. As expected and recorded in numerous non-randomized studies, stone-free rates were higher in patients treated with PNL than in those treated with SWL. Treatment duration, hospital stay were longer and complications more frequent following PNL. It also is of interest to note that comparative studies between SWL and RIRS did not disclose any significant differences. The authors conclude that the series of publications analysed generally were of low quality, with ways of presenting the result that did not allow a proper meta-analysis. The conclusion therefore was that there still is a need for carefully designed randomized comparisons. It is possible that by taking into account various determinants of treatment outcome recently analysed [1], might enable a more detailed comparison between the procedures. But with all respect for prospective randomized studies and meta-analyses, I am not certain that such efforts really are worth the efforts. The advantages and disadvantages of different treatment modalities for stone removal are so far reasonably well known and these features need to be carefully considered for the individual patient. A real reason for additional comparative studies probably should await more significant technological advances in the different techniques for stone removal. Reference 1. Torricelli FC, Marchini GS, Yamauchi FI, Danilovic A, Vicentini FC, Srougi M, Monga M, Mazzucchi E.Impact of renal anatomy on shock wave lithotripsy outcomes for lower pole kidney stones: results from a prospective multifactorial analysis controlled by computed tomography scan. J Urol. 2014 [Epub ahead of print]
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