Burr J et al, 2015: Is flexible ureterorenoscopy and laser lithotripsy the new gold standard for lower pole renal stones when compared to shock wave lithotripsy: Comparative outcomes from a University hospital over similar time period.
Burr J, Ishii H, Simmonds N, Somani BK.
University Hospital Southampton NHS Trust, Department of Urology, Southampton, United Kingdom.
INTRODUCTION: Renal lower pole stones pose difficulty in management due to anatomical variation, stone size, hardness and patient demographics. Flexible ureterorenoscopy and laser lithotripsy (FURSL) and shock wave lithotripsy (SWL) are preferred for stones 1-2 cm in size. We wanted to compare the outcomes of FURSL and SWL for lower pole stones during the same time period.
MATERIAL AND METHODS: All patients who were treated for lower pole stones with FURSL and SWL during a 19-month period were included. The stone free rate (SFR) was defined as ≤3 mm fragments on follow-up imaging or stone free endoscopically. Data was recorded in an excel spreadsheet with SPSS version 21 used for statistical analysis.
RESULTS: A total of 161 lower pole procedures were done (93 SWL and 63 FURSL). The mean stone size for SWL (7.4 mm; range: 4-16 mm) was significantly smaller than for FURSL (13.4 mm; 4-53 mm). The mean operating time and hospital stay for FURSL was 65 minutes (range: 30-160 minutes) and 0.5 days (range: 0-7 days) respectively. The SFR was significantly better (p <0.001) for FURSL (n = 63, 93%) compared to SWL (n = 23, 25%). There were 4 (6%) complications (3 Clavien II and 1 Clavien I) in the FURSL group (2 urosepsis, 1 UTI and 1 stent pain). Three patients in the SWL group (Clavien I) were readmitted with renal colic but there were no other complications.
CONCLUSIONS: FURSL for lower pole stones seems to be a much better alternative than SWL with a high SFR even for larger stones and seems to be the new gold standard for lower pole stone management.
Cent European J Urol. 2015;68(2):183-6. doi: 10.5173/ceju.2015.509. Epub 2015 Mar 9. FREE ARTICLE
A 23 % SFR of ESWL for lower pole stones reflects a non-adequate patient selection and treatment technique and 2 cases of urosepsis in the FURSL group reflect an injudicious use of the latter. (Donaldson J F et al. Systematic review and meta-analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower-pole renal stones. Eur Urol. 2015 Apr;67(4):612-6;
Srisubat A et al. Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones.
Cochrane Database Syst Rev. 2014 Nov 24; 11: CD007044.)
The authors state in the discussion section:
“Another limitation is that the SFR of our SWL procedures was far lower than the normal expected range, which might be due to the use of a mobile lithotripter and our definition of SFR. In our study we did not look specifically at the reasons for failure of SWL including the stone density, infundibular length, width and infundibulopelvic angle. As most of the failed SWL patients then underwent FURSL with successful outcome, these factors seem to be less important for FURSL in the management of lower pole stones.”
What is the reader supposed to learn from “under-standard” performance?