Dong L. et al., 2020: The efficacy and safety of diuretics on extracorporeal shockwave lithotripsy treatment of urolithiasis: A systematic review and meta analysis
Dong L, , Wang F, Chen H, Youyi Lu Y, Zhang Y, Chen L, Cui Y.
Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai.
Department of Urology, Qingdao Third People's Hospital, Qingdao.
Department of Urology, Beijing Tian Tan Hospital, Capital Medical University, Beijing.
Operating Room, The Affiliated YantaiYuhuangding Hospital of Qingdao University, Yantai, Shandong.
Department of Urology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.
The aim of this systematic review and meta-analysis was to demonstrate the efficacy and safety of diuretics on extracorporeal shockwave lithotripsy (SWL) treatment of urolithiasis.
The databases MEDLINE, EMBASE, and the Cochrane Controlled Trial Register of Controlled Trials from January 1980 until November 2019 were searched to identify randomized controlled trials that referred to the use of diuretics on extracorporeal SWL treatment of urolithiasis.
Six randomized controlled trials containing 1344 patients were included in this meta-analysis, which compared diuretics with placebo on extracorporeal SWL treatment of urolithiasis. In the analysis, we found that diuretics on extracorporeal SWL treatment were more effective for the management of urinary stones. Compared with placebo, patients who received diuretics during extracorporeal SWL treatment had significantly higher successful stone clearance rate (Odds ratio; 1.73, 95% confidence interval (CI); 1.35 to 2.21, P < .0001), higher stone fragmentation rate (odds ratio; 2.83, 95% CI; 1.30 to 6.16, P = .009), less average number of sessions per stone (mean difference; –0.13; 95% CI, –0.25 to –0.01, P = .03) and similar average number of shocks per stone (mean difference; –126.89; 95% CI, –394.53 to 140.76, P = .35).
This systematic review and meta-analysis indicates that diuretics during extracorporeal SWL was effective in the management of urolithiasis with lower risk of complications.
Medicine (Baltimore). 2020 Jun 19;99(25): e20602. Doi.10.1097/MD.0000000000020602.PMID: 32569188. FREE ARTICLE
The popularity of using SWL for treating patients with urolithiasis has decreased during recent years while endoscopic solutions are used more commonly.
For successful SWL some tricks might improve the results. One such assisting hand is to administer diuretics to get a high urine flow during the treatment.
In this systematic review the authors were able to identify and refer to six RCTs on combined use of SWL and diuretics. The conclusion was that administration of diuretics increased stone clearance (OR= 1.73) as well as stone fragmentation (OR=2.83) and reduced the number of re-treatments (-0.13). It is not surprising that no difference was recorded in number of shockwaves, because in many centres the treatment is completed in a rather standardized way and the number of shockwaves applied does not directly reflecting the course of stone disintegration.
One important prerequisite for improved results is of course that the diuretic causes high urine flow during the SWL-procedure. It is noteworthy that in only one of the RCTs was saline infused.
I personally have found it especially useful to administer 40 mg of furosemide at the beginning of the SWL procedure and infuse 1000 mL of Ringer acetate under pressure during the approximately 30-40-minute-long treatment. With this arrangement the whole administered volume of fluid will be excreted. This routine requires insertion of a bladder catheter that makes it possible both to confirm the excretion of administered fluid and to detect early haematuria as reflection of stone disintegration.