Reviewer's Choice

Javanmard B et al, 2016: Retrograde Intrarenal Surgery Versus Shock Wave Lithotripsy for Renal Stones Smaller Than 2 cm: A Randomized Clinical Trial.

Tuesday, 06 June 2017

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Javanmard B, Kashi AH, Mazloomfard MM, Ansari Jafari A, Arefanian S.
Laser Application in Medical Sciences Research Center, Urology and Nephrology Research Center, Hasheminejad Kidney Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Department of Surgery, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States.

Abstract

PURPOSE: To compare outcomes of retrograde intrarenal surgery (RIRS) with extracorporeal shock wave lithotripsy (SWL) for stones ≤ 2 cm.
MATERIALS AND METHODS: Patients who were diagnosed with kidney stones of ≤ 2 cm underwent RIRS or SWL in a parallel group randomized clinical trial with balanced randomization [1:1] from 2011 to 2014. The primary outcome of interest was stone free rate after a single session intervention. Patients were evaluated by ultrasonography and KUB at 1 and 3 months after the intervention for the presence of residual stone by a radiologist who was blinded to the study.
RESULTS: The stone free rate one month after a single session intervention in the RIRS group was higher than the SWL group (90% versus 75%, P = .03). The success rates after two sessions of RIRS versus SWL were 96.7% versus 88.3% respectively. (P = .08) Patients in the RIRS group had significantly lower postoperative visual analogue pain score compared to the SWL group (5.2 ± 2.8 versus 3.1 ± 2.7, P < .001). Steinstrasse formation and renal hematoma were observed in 4 and one patient in the SWL group versus no patient in the RIRS group. Postoperative hospital stay was significantly shorter in the SWL group (6.7 ± 1.3 versus18.9 ± 4.3 hours, P < .001).
CONCLUSION: The RIRS procedure is a safe treatment option for renal stones of ≤2cm with less pain and higher success rate at first session compared to SWL.&nbsp.

Urol J. 2016 Oct 10;13(5):2823-2828.

Comments 1

Hans-Göran Tiselius on Tuesday, 06 June 2017 13:20

Like several other reports, this article presents excellent results with RIRS compared with SWL. Stone-free rates after one single treatment sessions were 90% and 75% respectively. The results increased to 88% and 97% when repeated sessions were allowed. STI could not be calculated because it is not known in how many patients internal stents were used after RIRS.

There is, however, another observation that needs to be commented. The slightly inferior results with SWL can almost entirely be explained by low stone-free rates for stones located in the lower calyx. When such stones (and multiple stones) were excluded SWL resulted in a stone-free rate of 96%; a level that was almost identical to the 98% obtained with RIRS. The conclusion that should be drawn from this observation is clear. To improve SWL results and make that technique competitive to endoscopic procedure in terms of stone-free rates, it seems necessary to add to SWL a technology that facilitates elimination of gravel from the lower calyx in an efficient and non-invasive way! If this solution means improved methods for inversion/vibration therapy [1] or ultrasound propulsion [2,3] or a combination of such methods remains to be shown. But if nothing is done about this problem SWL will also in the future be described in the literature as a method inferior to endoscopy.

References
1. Lee SW, Chaiyakunapruk N, Chong HY, Liong ML.
Comparative effectiveness and safety of various treatment procedures for lower pole renal calculi: a systematic review and network meta-analysis.
BJU Int. 2015 116(2):252-264 Review
2. Harper JD, Sorensen MD, Cunitz BW, Wang YN, Simon JC, Starr F, Paun M, Dunmire B, Liggitt HD, Evan AP, Focused ultrasound to expel calculi from the kidney: safety and efficacy of a clinical prototype device.
J Urol. 2013;190(3):1090-1095.
3. Connors BA, Evan AP, Blomgren PM, Hsi RS, Harper JD, Sorensen MD, Wang YN, Simon JC, Paun M, Starr F, Cunitz BW, Bailey MR, Lingeman JE. Comparison of tissue injury from focused ultrasonic propulsion of kidney stones versus extracorporeal shock wave lithotripsy.
J Urol. 2014 Jan;191(1):235-41. doi: 10.1016/j.juro.2013.07.087.

There is, however, another observation that needs to be commented. The slightly inferior results with SWL can almost entirely be explained by low stone-free rates for stones located in the lower calyx. When such stones (and multiple stones) were excluded SWL resulted in a stone-free rate of 96%; a level that was almost identical to the 98% obtained with RIRS. The conclusion that should be drawn from this observation is clear. To improve SWL results and make that technique competitive to endoscopic procedure in terms of stone-free rates, it seems necessary to add to SWL a technology that facilitates elimination of gravel from the lower calyx in an efficient and non-invasive way! If this solution means improved methods for inversion/vibration therapy [1] or ultrasound propulsion [2,3] or a combination of such methods remains to be shown. But if nothing is done about this problem SWL will also in the future be described in the literature as a method inferior to endoscopy.

References
1. Lee SW, Chaiyakunapruk N, Chong HY, Liong ML.
Comparative effectiveness and safety of various treatment procedures for lower pole renal calculi: a systematic review and network meta-analysis.
BJU Int. 2015 116(2):252-264 Review
2. Harper JD, Sorensen MD, Cunitz BW, Wang YN, Simon JC, Starr F, Paun M, Dunmire B, Liggitt HD, Evan AP, Focused ultrasound to expel calculi from the kidney: safety and efficacy of a clinical prototype device.
J Urol. 2013;190(3):1090-1095. 
3. Connors BA, Evan AP, Blomgren PM, Hsi RS, Harper JD, Sorensen MD, Wang YN, Simon JC, Paun M, Starr F, Cunitz BW, Bailey MR, Lingeman JE. Comparison of tissue injury from focused ultrasonic propulsion of kidney stones versus extracorporeal shock wave lithotripsy.
J Urol. 2014 Jan;191(1):235-41. doi: 10.1016/j.juro.2013.07.087.

Like several other reports, this article presents excellent results with RIRS compared with SWL. Stone-free rates after one single treatment sessions were 90% and 75% respectively. The results increased to 88% and 97% when repeated sessions were allowed. STI could not be calculated because it is not known in how many patients internal stents were used after RIRS. There is, however, another observation that needs to be commented. The slightly inferior results with SWL can almost entirely be explained by low stone-free rates for stones located in the lower calyx. When such stones (and multiple stones) were excluded SWL resulted in a stone-free rate of 96%; a level that was almost identical to the 98% obtained with RIRS. The conclusion that should be drawn from this observation is clear. To improve SWL results and make that technique competitive to endoscopic procedure in terms of stone-free rates, it seems necessary to add to SWL a technology that facilitates elimination of gravel from the lower calyx in an efficient and non-invasive way! If this solution means improved methods for inversion/vibration therapy [1] or ultrasound propulsion [2,3] or a combination of such methods remains to be shown. But if nothing is done about this problem SWL will also in the future be described in the literature as a method inferior to endoscopy. References 1. Lee SW, Chaiyakunapruk N, Chong HY, Liong ML. Comparative effectiveness and safety of various treatment procedures for lower pole renal calculi: a systematic review and network meta-analysis. BJU Int. 2015 116(2):252-264 Review 2. Harper JD, Sorensen MD, Cunitz BW, Wang YN, Simon JC, Starr F, Paun M, Dunmire B, Liggitt HD, Evan AP, Focused ultrasound to expel calculi from the kidney: safety and efficacy of a clinical prototype device. J Urol. 2013;190(3):1090-1095. 3. Connors BA, Evan AP, Blomgren PM, Hsi RS, Harper JD, Sorensen MD, Wang YN, Simon JC, Paun M, Starr F, Cunitz BW, Bailey MR, Lingeman JE. Comparison of tissue injury from focused ultrasonic propulsion of kidney stones versus extracorporeal shock wave lithotripsy. J Urol. 2014 Jan;191(1):235-41. doi: 10.1016/j.juro.2013.07.087.

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