Bach T et al, 2016: [Individualized evidence-based interventional stone treatment : One stone, many question marks?]

Wednesday, 21 December 2016

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Bach T, Knoll T.
Urologisches Zentrum Hamburg, Asklepios Klinikum Harburg, Eissendorfer Pferdeweg 52, 21075, Hamburg, Deutschland.
Urologische Klinik, Klinikum Sindelfingen-Böblingen, Sindelfingen, Deutschland.

Abstract

The treatment of urolithiasis is still one of the most frequent tasks in the daily urological practice. Driven by the technological developments, patient demands and also personal experiences of urologists, many interventional treatment options have been established. To identify the most suitable treatment option, it is of utmost importance to consider not only stone size and localization but also the individual situation of the patient and the published evidence, which despite all efforts often lags behind the technical and clinical reality.

Article in German.
Urologe A. 2016 Sep 5. [Epub ahead of print]

Comments 1

Hans-Göran Tiselius on Wednesday, 21 December 2016 12:12

This article is a summary and interpretation of EAU guidelines on the management of patients with urolithiasis. The translated heading is “Individualized evidence based stone treatment”. The general and well recognized conclusion is that the use and usefulness (?) of SWL has decreased continuously during the past 10 years. One of the advantages of URS, that is emphasized, is that stone clearance from the ureter can be effectively accomplished with only one session. The authors make no attempt to critically discuss the current EAU guidelines by also considering advantages of a non-invasive approach. For instance it can be mentioned that 83% of patients with distal ureteral stones had their problem solved with only one SWL session [1]. Also for stones in other segments of the ureter the re-treatment rate was low. Less than 24% of patients with ureteral stones (in that analysis) required repeated SWL sessions. The need of stenting before or after URS is another point that deserves to be accounted for.

It is possible that URS (RIRS), in experts’ hands, is better than SWL for clearing the lower calyces, but in a recent Editorial Comment, MS Pearle quoted CT-results and was concerned about the common occurrence of residual fragments also after URS!

Although endoscopic instruments have been subject to an amazing technical development and probably associated with a reduced rate of complications, the advantages of SWL, carried out in an optimal way, should not be forgotten. It seems wise to reconsider the usefulness of SWL. It is in no way clear that excessive and continuous miniaturization of instruments for invasive treatment is the best choice for the patients. For SWL the low complication rate, the lower cost, outpatient procedure with administration of only analgesics and sedatives, are factors worthwhile to remember and consider.

References
1. Tiselius HG.
How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal
of ureteral stones?
J Endourol. 2008; 22:249-255.

2. Pearle MS.
Is Ureteroscopy as Good as We Think?
J Urol. 2016 Apr;195(4P1):823-824.

It is possible that URS (RIRS), in experts’ hands, is better than SWL for clearing the lower calyces, but in a recent Editorial Comment, MS Pearle quoted CT-results and was concerned about the common occurrence of residual fragments also after URS!

Although endoscopic instruments have been subject to an amazing technical development and probably associated with a reduced rate of complications, the advantages of SWL, carried out in an optimal way, should not be forgotten. It seems wise to reconsider the usefulness of SWL. It is in no way clear that excessive and continuous miniaturization of instruments for invasive treatment is the best choice for the patients. For SWL the low complication rate, the lower cost, outpatient procedure with administration of only analgesics and sedatives, are factors worthwhile to remember and consider.

References
1. Tiselius HG.
    How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal   
    of ureteral stones?
    J Endourol. 2008; 22:249-255.

2. Pearle MS.
    Is Ureteroscopy as Good as We Think?
    J Urol. 2016 Apr;195(4P1):823-824.

This article is a summary and interpretation of EAU guidelines on the management of patients with urolithiasis. The translated heading is “Individualized evidence based stone treatment”. The general and well recognized conclusion is that the use and usefulness (?) of SWL has decreased continuously during the past 10 years. One of the advantages of URS, that is emphasized, is that stone clearance from the ureter can be effectively accomplished with only one session. The authors make no attempt to critically discuss the current EAU guidelines by also considering advantages of a non-invasive approach. For instance it can be mentioned that 83% of patients with distal ureteral stones had their problem solved with only one SWL session [1]. Also for stones in other segments of the ureter the re-treatment rate was low. Less than 24% of patients with ureteral stones (in that analysis) required repeated SWL sessions. The need of stenting before or after URS is another point that deserves to be accounted for. It is possible that URS (RIRS), in experts’ hands, is better than SWL for clearing the lower calyces, but in a recent Editorial Comment, MS Pearle quoted CT-results and was concerned about the common occurrence of residual fragments also after URS! Although endoscopic instruments have been subject to an amazing technical development and probably associated with a reduced rate of complications, the advantages of SWL, carried out in an optimal way, should not be forgotten. It seems wise to reconsider the usefulness of SWL. It is in no way clear that excessive and continuous miniaturization of instruments for invasive treatment is the best choice for the patients. For SWL the low complication rate, the lower cost, outpatient procedure with administration of only analgesics and sedatives, are factors worthwhile to remember and consider. References 1. Tiselius HG. How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008; 22:249-255. 2. Pearle MS. Is Ureteroscopy as Good as We Think? J Urol. 2016 Apr;195(4P1):823-824.

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