Liu LR et al, 2013: Percussion, diuresis, and inversion therapy for the passage of lower pole kidney stones following shock wave lithotripsy
Liu LR, Li QJ, Wei Q, Liu ZH, Xu Y
Department of Urology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China
BACKGROUND: Lower pole kidney stones typically have poor rates of spontaneous clearance from the body. Some studies have suggested that diuresis, percussion and inversion therapy could be beneficial for people with lower pole kidney stones following shock wave lithotripsy. There is however controversy about the relative benefits, harms, and efficacy of these interventions for the management of lower pole kidney stones.
OBJECTIVES: To identify the benefits and harms of percussion, diuresis, and inversion therapy to facilitate the passage of lower pole kidney stones following shock wave lithotripsy.
SEARCH METHODS: We searched the Cochrane Renal Group's specialised register up to 27 November 2013 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.
SELECTION CRITERIA: All randomised controlled trials (RCTs) and quasi-RCTs looking at the benefits and harms of percussion, diuresis, and inversion therapy for aiding passage of lower pole kidney stones following shock wave lithotripsy were sought for assessment. The first phases of randomised cross-over studies were also eligible for inclusion.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed study quality and extracted data. Results were expressed as relative risk (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CI).
MAIN RESULTS: We identified two small studies (177 participants) for inclusion and analysis. One study (69 participants) compared percussion, diuresis and inversion therapy following shock wave lithotripsy versus observation-only after shock wave lithotripsy. This study reported significantly higher stone-free rates in the intervention group (RR 0.62, 95% CI 0.47 to 0.82) and a significant reduction in stone burden (MD -3.30, 95% CI -3.58 to -3.03) compared to the observation-only group. They reported no significant differences in complication rates (RR 3.00, 95% CI 0.12 to 76.24).The second study (108 participants) compared percussion, diuresis, and inversion therapy plus shock wave lithotripsy with shock wave lithotripsy therapy alone. This study reported significantly higher stone-free rates in the intervention group (RR 0.36, 95% CI 0.17 to 0.80) and a significant reduction in stone burden (MD -0.30, 95% CI -0.04 to -0.56) compared to the control group. They reported no significant differences in complication rates (RR 2.54, 95% CI 0.10 to 63.72).For both studies selection bias was unclear; there was high risk of bias for performance bias; and detection, attrition and reporting bias were low.
AUTHORS' CONCLUSIONS: Limited evidence from two small studies indicated that percussion, diuresis, and inversion therapy may be safe and effective therapies to assist clearance of lower pole kidney stone fragments following shock wave lithotripsy. Methodological quality in both studies was assessed as moderate. Further well-designed and adequately powered studies are required to inform clinical practice.
Cochrane Database Syst Rev. 2013 Dec 8;12:CD008569. doi: 10.1002/14651858.CD008569.pub2.
PMID:24318643 [PubMed - in process]
The addition of a regimencomprising percussion, diuresis and inversion in order to clear the lower calyx system from residual fragments is an attractive idea and some promising reports have appeared in the literature.
In this Cochrane report a careful literature analysis was carried out and it was concluded that there were two studies that fulfilled the inclusion criteria. These two randomized reports comprised a total of 177 patients. It was found that percussion, diuresis and inversion resulted in a significantly higher stone free rate and a significant reduction of the stone burden compared with patients who were not given this treatment.
There are some points in these studies that might be of particular interest:
1. In both studies repeated sessions of intervention were carried out during one to two weeks after the SWL procedure.
2. Percussion was continued during 10 minutes.
3. The prone Trendelenburg position was 45- 60º.
4. In both groups diuresis was accomplished by furosemide and/or fluid ingestion.
By introducing a method aiming at non-invasive, non-anaesthesia requiring clearance of lower pole fragments, it might be possible to get a high stone-free rate while maintaining the non-invasive concept of SWL.
This seems to be a therapeutic approach that needs to be further standardized and applied in patients with residuals in the lower calyx. From a technical point of view it is probably most critical to find the position on the body surface where the percussion device should be applied in order to give maximal vibration in the fragment collection.