McClinton S. et al., 2020: The clinical and cost effectiveness of surgical interventions for stones in the lower pole of the kidney: the percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole kidney stones randomised controlled trial (PUrE RCT) protocol
McClinton S, Starr K, Thomas R, MacLennan G, Lam T, Hernandez R, Pickard R, Anson K, Clark T, MacLennan S, Thomas D, Smith D, Turney B, McDonald A, Cameron S, Wiseman O.
Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK.
Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK.
Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, UK.
5Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK.
St George’s Hospital, London, UK.
Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK.
Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
University College London Hospitals NHS Foundation Trust, London, UK
Oxford University Hospitals NHS Trust, Headley Way, Oxford, UK.
Addenbrooke’s NHS Trust, Hills Road, Cambridge, UK.
Introduction: Renal stones are common, with a lifetime prevalence of 10% in adults. Global incidence is increasing due to increases in obesity and diabetes, with these patient populations being more likely to suffer renal stone disease. Flank pain from stones (renal colic) is the most common cause of emergency admission to UK urology departments. Stones most commonly develop in the lower pole of the kidney (in ~35% of cases) and here are least likely to pass without intervention. Currently there are three technologies available within the UK National Health Service to remove lower pole kidney stones: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureterorenoscopy (FURS) with laser lithotripsy. Current evidence indicates there is uncertainty regarding the management of lower pole stones, and each treatment has advantages and disadvantages. The aim of this trial is to determine the clinical and cost effectiveness of FURS compared with ESWL or PCNL in the treatment of lower pole kidney stones.
Methods: The PUrE (PCNL, FURS and ESWL for lower pole kidney stones) trial is a multi-centre, randomised controlled trial (RCT) evaluating FURS versus ESWL or PCNL for lower pole kidney stones. Patients aged ≥16 years with a stone(s) in the lower pole of either kidney confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) and requiring treatment for a stone ≤10 mm will be randomised to receive FURS or ESWL (RCT1), and those requiring treatment for a stone >10 mm to ≤25 mm will be randomised to receive FURS or PCNL (RCT2). Participants will undergo follow-up by questionnaires every week up to 12 weeks post-intervention and at 12 months post-randomisation. The primary clinical outcome is health status measured by the area under the curve calculated from multiple measurements of the EuroQol five dimensions five-level version (EQ-5D-5L) questionnaire up to 12 weeks post-intervention. The primary economic outcome is the incremental cost per quality-adjusted life year gained at 12 months post-randomisation.
Discussion: The PUrE trial aims to provide robust evidence on health status, quality of life, clinical outcomes and resource use to directly inform choice and National Health Service provision of the three treatment options.
Trial registration: ISRCTN: ISRCTN98970319. Registered on 11 November 2015.
2020 Jun 4;21(1):479. doi: 10.1186/s13063-020-04326-x.PMID: 32498699. FREE ARTICE
This article is a “study protocol” with the aim of comparing cost-effectiveness of SWL, fURS and PCNL for removal of stones in the lower calyx. Randomization will be carried out between SWL and fURS for stone 10 mm and ≤ 25 mm.
This study is reported to be underway since May 2016 with assumed completion September 2020. One important part of the study is the economic evaluation in which resources and costs will be estimated for each participating patient.