Kallidonis P. et al., 2020: Systematic Review and Meta-analysis Comparing Percutaneous Nephrolithotomy, Retrograde Intrarenal Surgery and Shock Wave Lithotripsy for Lower Pole Renal Stones

Wednesday, 20 May 2020

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Kallidonis P, Ntasiotis P, Somani B, Adamou C, Emiliani E, Knoll T, Skolarikos A, Tailly T.
Department of Urology, University of Patras, Patras, Greece.
European Section of Uro-Technology.
Young Academic Urologist.
Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
Department of Urology, Fundacion Puigvert, University Autonoma of Barcelona, Barcelona, Spain.
Department of Urology, Sindelfingen-Böblingen Medical Centre, University of Tübingen, Sindelfingen, Germany.
2nd Department of Urology, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Department of Urology, Ghent University Hospital, Ghent, Belgium.

Abstract

CONTEXT: The optimal treatment of lower pole stones (LPS) between 1-2cm represents a point of debate among the urologists.

PURPOSE: The aim of the current systematic review and meta-analysis is to provide an answer on which is the most appropriate approach for the management of the LPS with a maximal dimension ≤2cm.

MATERIAL AND METHODS: A systematic review was conducted on PubMed, SCOPUS, Cochrane and EMBASE. The PRISMA guidelines and the recommendations of the EAU Guidelines office were followed. Retrograde intrarenal surgery (RIRS), shock wave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) were considered for comparison. Primary endpoint was the stone-free rate (SFR).

RESULTS: 15 randomized controlled trials (RCTs) were eligible. PCNL and RIRS have higher SFRs in comparison to SWL and require less retreatment sessions. Operative time and complications seem to favor SWL in comparison to PCNL, but this takes place in the expense of multiple SWL sessions. RIRS seems to be the most efficient approach for the management of stones up to 1cm in the lower pole.

CONCLUSION: The pooled analysis of the eligible studies showed that the management of LPS should probably reside to PCNL or RIRS to achieve stone-free status over a short period and minimal number of sessions. For stones smaller than 10mm, RIRS is more efficient in comparison to SWL. The decision between the two approaches (PCNL or RIRS) should be individual, based on the anatomical parameters, the comorbidity and the preferences of each patient.
J Urol. 2020 Mar 9:101097JU0000000000001013. doi: 10.1097/JU.0000000000001013. [Epub ahead of print].

Comments 1

Peter Alken on Wednesday, 20 May 2020 10:30

Systematic reviews are needed from time to time to reliably capture and describe the current situation. But the most interesting systematic reviews and meta-analyses are those presenting a conclusion not matching with what the reader knew and expected.
This is a technically well done systematic review. But one of the conclusion is a little bit disappointing “… the selection of the approach should be based on the anatomy of the patient, the bulk of the stone and experience of the surgeon.”

The authors mention one limit of their review: “… the wide time period that the included studies were conducted (more than 15 years). Thus, instruments, materials and experience with the approaches may have changed over the years. Variation in the size of instruments such as between conventional and mini-PCNL do not represent a limitation since the percutaneous approach remains identical. In a similar fashion, changes in the RIRS equipment took place over the above long period. Consequently, the current quantitative analysis is solid in concept and its results are reliable. “
I do not at all agree to their comment which compares old and fresh apples with fresh and old pears.
Unfortunately the numbers of publications available for a systematic review is usually small and old publication are just included to have enough material for analysis despite the fact that they skew the image: Reference 24 is an old study which I did not like when I have read it 15 years ago: The “lower pole study II” (1) was a valuable prospective and randomized study by a lot of prominent authors comparing ESWL with URS for lower caliceal stones.
19 institutions recruited only 78 patients within 3 ½ years. The bias must have been enormous as 12 of the 19 participants could contribute only 1 to 2 patients. The drop-out rate was 14 %.
The ureteroscopes had a diameter of up to 8,7 Fr and 17 % of the ureters required balloon dilation. 90 % of the patients would have chosen ESWL again compared to 63 % URS. This is simply bad historical stuff not comparable with today’s procedures.

1 Pearle MS, Lingeman JE, Leveillee R, et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005;173(6):2005–2009. doi:10.1097/01.ju.0000158458.51706.56

The authors mention one limit of their review: “… the wide time period that the included studies were conducted (more than 15 years). Thus, instruments, materials and experience with the approaches may have changed over the years. Variation in the size of instruments such as between conventional and mini-PCNL do not represent a limitation since the percutaneous approach remains identical. In a similar fashion, changes in the RIRS equipment took place over the above long period. Consequently, the current quantitative analysis is solid in concept and its results are reliable. “ 
I do not at all agree to their comment which compares old and fresh apples with fresh and old pears.
Unfortunately the numbers of publications available for a systematic review is usually small and old publication are just included to have enough material for analysis despite the fact that they skew the image: Reference 24 is an old study which I did not like when I have read it 15 years ago: The “lower pole study II” (1) was a valuable prospective and randomized study by a lot of prominent authors comparing ESWL with URS for lower caliceal stones.
19 institutions recruited only 78 patients within 3 ½ years. The bias must have been enormous as 12 of the 19 participants could contribute only 1 to 2 patients. The drop-out rate was 14 %.
The ureteroscopes had a diameter of up to 8,7 Fr and 17 % of the ureters required balloon dilation. 90 % of the patients would have chosen ESWL again compared to 63 % URS. This is simply bad historical stuff not comparable with today’s procedures.

1 Pearle MS, Lingeman JE, Leveillee R, et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005;173(6):2005–2009. doi:10.1097/01.ju.0000158458.51706.56

Systematic reviews are needed from time to time to reliably capture and describe the current situation. But the most interesting systematic reviews and meta-analyses are those presenting a conclusion not matching with what the reader knew and expected. This is a technically well done systematic review. But one of the conclusion is a little bit disappointing “… the selection of the approach should be based on the anatomy of the patient, the bulk of the stone and experience of the surgeon.” The authors mention one limit of their review: “… the wide time period that the included studies were conducted (more than 15 years). Thus, instruments, materials and experience with the approaches may have changed over the years. Variation in the size of instruments such as between conventional and mini-PCNL do not represent a limitation since the percutaneous approach remains identical. In a similar fashion, changes in the RIRS equipment took place over the above long period. Consequently, the current quantitative analysis is solid in concept and its results are reliable. “ I do not at all agree to their comment which compares old and fresh apples with fresh and old pears. Unfortunately the numbers of publications available for a systematic review is usually small and old publication are just included to have enough material for analysis despite the fact that they skew the image: Reference 24 is an old study which I did not like when I have read it 15 years ago: The “lower pole study II” (1) was a valuable prospective and randomized study by a lot of prominent authors comparing ESWL with URS for lower caliceal stones. 19 institutions recruited only 78 patients within 3 ½ years. The bias must have been enormous as 12 of the 19 participants could contribute only 1 to 2 patients. The drop-out rate was 14 %. The ureteroscopes had a diameter of up to 8,7 Fr and 17 % of the ureters required balloon dilation. 90 % of the patients would have chosen ESWL again compared to 63 % URS. This is simply bad historical stuff not comparable with today’s procedures. 1 Pearle MS, Lingeman JE, Leveillee R, et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005;173(6):2005–2009. doi:10.1097/01.ju.0000158458.51706.56

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