MacLennan S. et al., 2025: Updated Systematic Review and Meta-analysis of Extracorporeal Shock Wave Lithotripsy, Flexible Ureterorenoscopy, and Percutaneous Nephrolithotomy for Lower Pole Renal Stones.

Friday, 23 May 2025

380 Hits

Steven MacLennan 1, Oliver Wiseman 2, Daron Smith 3, Kathryn Starr 4, Lorna Aucott 5, Rodolfo Hernández 6, Paul Manson 5, Ruth Thomas 7, Charles Terry Clark 8, Graeme MacLennan 7, Dawn McRae 7, Victoria Bell 7, Seonaidh Cotton 7, Zara Gall 9, Ben Turney 10, Sam McClinton 11
1Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
2Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK.
3Stone and Endourology Unit, University College Hospital, University College Hospitals NHS Foundation Trust, London, UK.
4Warwick Medical School, University of Warwick, Warwick, UK.
5Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
6Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
7Centre for Healthcare Randomised Trials, Health Services Research Unit, Aberdeen, UK.
8Patient Advocate, University of Aberdeen, UK.
9Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK.
10Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
11Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Centre for Healthcare Randomised Trials, Health Services Research Unit, Aberdeen, UK.

Abstract

Lower pole stones (LPSs) frequently cause significant morbidity, necessitating effective intervention strategies. We systematically reviewed the evidence for treatment of LPSs with extracorporeal shock wave lithotripsy (ESWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) previously in 2015. In this update, we have included 16 new randomised controlled trials plus eight from our original review (24 in total). Despite the increase in available trials, the certainty of evidence remains moderate for stone-free rates (SFRs), underscoring the on-going need for more robust trials in this domain. FURS demonstrated superior efficacy in achieving SFRs to ESWL (risk ratio [RR] 1.19, 95% confidence interval [CI] 1.05, 1.35), although the absolute difference remains modest. ESWL may lead to fewer complications, and FURS could result in more unplanned procedures and retreatments. It remains unclear whether there are differences in quality of life and cost estimates vary depending on the country. PCNL offers a marginal yet statistically significant advantage over FURS in terms of SFRs (RR 1.07, 95% CI 1.01, 1.12), but it is unclear whether there are differences in unplanned procedures, retreatments, or complications, and there was conflicting evidence about health status and return to normal activities. SFRs were superior with PCNL to those with ESWL (RR 1.42 95% CI 1.28, 1.58). Unplanned procedures and retreatments were generally fewer for PCNL, and complications were fewer for ESWL. The cost effectiveness of each modality is highly dependent on the health care system and country-specific economic factors. The overall certainty of the evidence remains unchanged, with only moderate improvements in certain domains.

Eur Urol. 2025 Mar 12:S0302-2838(25)00061-2. doi: 10.1016/j.eururo.2025.01.020. Online ahead of print. PMID: 40082136 FREE ARTICLE

Comments 1

Peter Alken on Friday, 23 May 2025 11:00

It has become relatively infrequent for European Urology to publish articles on stones, even though it is the most common urological disease - presumably because it pays less than an article on a topic in which the pharmaceutical industry is directly or indirectly involved. Consequently, the present “Free paper” is an exception.
Maybe the message is important?
Concerning the “classical” facts of the stone business like SFR, procedural time, complications, it barely presents something what the well-informed reader does not yet know – with some small exceptions, like “FURS is more effective than ESWL for SFRs with moderate certainty …Restricting stone size to 10 mm attenuated the effect and was no longer statistically significant. “
So, why is it worth reading?
Today the authors look back at their 2015 systemic review and summarize: “ … the main findings included the paucity and general low certainty of evidence for clinical and cost effectiveness, and scant data on quality of life (QoL).”
And they start their todays look-forward: “We updated our 2015 review because nearly a decade has passed, and more evidence is now available.”
Presenting their results, they limit the significance: “Sensitivity analyses such as restricting to studies with low RoB [Risk of Bias] was not possible in the meta-analysis because almost all studies were at moderate to high RoB.”
And they conclude: “since our 2015 review and this 2024 update, although additional evidence has emerged on the effectiveness of ESWL, FURS, and PCNL for LPSs, the certainty of evidence has generally not improved.”
Concerning costs there are only very few data and, “it is unclear whether this
applies to other countries, since the cost effectiveness of each intervention depends on the health care system. “
And QoL?” The evidence around QoL for all comparisons is scant, very weak,
and inconclusive, possibly due, in part, to different QoL instruments being used in different studies.”
So, the facts that we basically new, are confirmed 10 years later with uncertainty and what we know about our patients and the money we waste is practically non-existing.

So, why is it worth reading? As a stimulus to change the way, we perform and publish clinical research on stones. Because: after 10 years “more evidence is now available.”? NO!

Peter Alken

It has become relatively infrequent for European Urology to publish articles on stones, even though it is the most common urological disease - presumably because it pays less than an article on a topic in which the pharmaceutical industry is directly or indirectly involved. Consequently, the present “Free paper” is an exception. 
Maybe the message is important? 
Concerning   the “classical” facts of the stone business like SFR, procedural time, complications, it barely presents something what the well-informed reader does not yet know – with some small exceptions, like “FURS is more effective than ESWL for SFRs with moderate certainty …Restricting stone size to 10 mm attenuated the effect and was no longer statistically significant. “
 So, why is it worth reading?
Today the authors look back at their 2015 systemic review and summarize: “ … the main findings included the paucity and general low certainty of evidence for clinical and cost effectiveness, and scant data on quality of life (QoL).”
And they start their todays look-forward: “We updated our 2015 review because nearly a decade has passed, and more evidence is now available.”
Presenting their results, they limit the significance: “Sensitivity analyses such as restricting to studies with low RoB [Risk of Bias] was not possible in the meta-analysis because almost all studies were at moderate to high RoB.”
And they conclude: “since our 2015 review and this 2024 update, although additional evidence has emerged on the effectiveness of ESWL, FURS, and PCNL for LPSs, the certainty of evidence has generally not improved.”
Concerning costs there are only very few data and, “it is unclear whether this
applies to other countries, since the cost effectiveness of each intervention depends on the health care system. “
And QoL?” The evidence around QoL for all comparisons is scant, very weak,
and inconclusive, possibly due, in part, to different QoL instruments being used in different studies.”
So, the facts that we basically new, are confirmed 10 years later with uncertainty and what we know about our patients and the money we waste is practically non-existing.

So, why is it worth reading? As a stimulus to change the way, we perform and publish clinical research on stones. Because: after 10 years “more evidence is now available.”? NO!

Peter Alken

It has become relatively infrequent for European Urology to publish articles on stones, even though it is the most common urological disease - presumably because it pays less than an article on a topic in which the pharmaceutical industry is directly or indirectly involved. Consequently, the present “Free paper” is an exception. Maybe the message is important? Concerning the “classical” facts of the stone business like SFR, procedural time, complications, it barely presents something what the well-informed reader does not yet know – with some small exceptions, like “FURS is more effective than ESWL for SFRs with moderate certainty …Restricting stone size to 10 mm attenuated the effect and was no longer statistically significant. “ So, why is it worth reading? Today the authors look back at their 2015 systemic review and summarize: “ … the main findings included the paucity and general low certainty of evidence for clinical and cost effectiveness, and scant data on quality of life (QoL).” And they start their todays look-forward: “We updated our 2015 review because nearly a decade has passed, and more evidence is now available.” Presenting their results, they limit the significance: “Sensitivity analyses such as restricting to studies with low RoB [Risk of Bias] was not possible in the meta-analysis because almost all studies were at moderate to high RoB.” And they conclude: “since our 2015 review and this 2024 update, although additional evidence has emerged on the effectiveness of ESWL, FURS, and PCNL for LPSs, the certainty of evidence has generally not improved.” Concerning costs there are only very few data and, “it is unclear whether this applies to other countries, since the cost effectiveness of each intervention depends on the health care system. “ And QoL?” The evidence around QoL for all comparisons is scant, very weak, and inconclusive, possibly due, in part, to different QoL instruments being used in different studies.” So, the facts that we basically new, are confirmed 10 years later with uncertainty and what we know about our patients and the money we waste is practically non-existing. So, why is it worth reading? As a stimulus to change the way, we perform and publish clinical research on stones. Because: after 10 years “more evidence is now available.”? NO! Peter Alken

Cancel Update Comment