Sahin C et al, 2015: How do the residual fragments after SWL affect the health-related quality of life? A critical analysis in a size-based manner.
Sahin C, Kafkasli A, Cetinel CA, Narter F, Saglam E, Sarica K
Urology Clinic, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
This study aimed at evaluating the possible effects of residual fragments (RF) after shockwave lithotripsy (SWL) on the health-related quality of life (QOL) of the patients on a size-related basis. Eighty six patients with RF after SWL were divided into three groups: Group 1 (n:30 with fragments ≤2 mm), Group 2 (n:21 2-≤4 mm) and Group 3 (n:35 > 4 mm). During a 3-month follow-up, spontaneous passage rates, emergency department visits, mean analgesic required, additional procedures and the QOL were all evaluated. QOL was evaluated using the Short Form-36 survey. Of the 30 patients with fragments ≤2 mm all cases passed the fragments spontaneously. Of the 21 cases with
fragments 2-≤4, however, 76 % were stone free. Last, of the 35 cases with fragments >4 mm, 52 % passed them spontaneously in 3 months. While no patient with fragments ≤2 mm required emergency department visit, 19 % of the cases with fragments 2-≤4 mm and 51.4 % with fragments >4 mm did require this visit. Mean analgesic need (mg) values were higher in cases with larger fragments. Evaluation of the QOL score data in a subgroup comparison base showed that cases with larger fragments had prominently lower scores during both 1- and 3-month evaluation. RF after SWL could pose an impact on the QOL of the cases in a size-related basis. While fragments ≤2 mm had nearly no impact on this aspect larger fragments could significantly affect the QOL.
Urolithiasis. 2014 Oct 2. [Epub ahead of print]
It is welcome with a report on the impact of residual fragments after SWL. Stratification in size-groups with diameter 4 mm interestingly showed that all fragments with diameters 4 mm; a group that based on previous experience should be regarded as having insufficiently disintegrated stones. It is of note that in this group the QoL-score after one month was not much lower than that in the small fragment group. In terms of pain, patients in the 2-4 mm group had the lowest QoL-score. As expected increased need of emergency visits and intervention were observed with increased fragment size.
The authors concluded that QoL issues need to be taken into account when considering how to deal with patients who have residual fragments. They did not, however, specify what should be done. It stands to reason that for patients with fragments >4 mm, repeated SWL (or other stone removing technique) seems a reasonable alternative. But for patients with residuals in the size range 2-4 mm, how necessary is it to proceed with SWL or URS? My assumption is that repeated intervention became necessary because of residual fragments in the ureter. Alternatively the decision of repeated intervention might have been dictated only by the fact that residuals were found in the kidney, because for large fragments intervention obviously was not determined by symptoms. Following a non-invasive procedure it is necessary to calculate with some symptoms during fragment passage.
The message is that QoL aspects are important for the further decisions in both active and conservative directions.
It had been of great interest to learn about the long-term course of patients with asymptomatic residuals in the kidney.