Qian S. et al., 2021: Systematic review and meta-analysis of transgluteal versus prone approach to extracorporeal shockwave lithotripsy for patients with distal ureteral stones

Tuesday, 20 July 2021

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Qian S, Liu M, Zhang J, Jiang Q, Gao L.
Department of Urology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China.
Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China.
Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.

Abstract

To explore the effectiveness of transgluteal approach during extracorporeal shockwave lithotripsy (ESWL) for patients with distal ureteral stones compared to the prone approach. A systematic literature search was carried out by two reviewers independently on the basis of three electronic databases up to Aug. 2020. Three randomized controlled trials (RCT) and one cohort studies (CS), with a total of 516 patients, comparing transgluteal approach with prone approach during ESWL for distal ureteral stones were included. The methodological quality of RCT was evaluated by Cochrane collaboration's tools, and the quality of CS and CCS was evaluated by modified Newcatle-Ottawa scale. The weighted mean difference (WMD) and odds ratio (OR) was respectively used to describe results of continuous and dichotomous variables. Pooled data showed that transgluteal approach could significantly improve the rate of stone free after the first treatment [OR = 3.18, 95% confidence interval (CI) 2.19-4.63, p < 0.00001] and the rate of overall stone free (OR = 4.03, 95% CI 2.43-6.69, p < 0.00001). In addition, compared with the prone approach, the transgluteal one could also significantly reduce the rate of ureteroscopy (OR = 0.21, 95% CI 0.12-0.36, p < 0.00001). What's more, complications were rarely reported, which demonstrated a similar safety for two approaches. Our study suggested that, during ESWL for patients with distal ureteral stones, transgluteal approach was a safe and more effective choice than the prone position.
Asian J Surg. 2021 Mar 23:S1015-9584(21)00128-7. doi: 10.1016/j.asjsur.2021.02.021. Online ahead of print. PMID: 33771425 Review.

Comments 1

Hans-Göran Tiselius on Tuesday, 20 July 2021 10:30

In this systematic review a comparison was made between trans-gluteal and prone SWL treatment of stones in the distal ureter. The conclusion was that trans-gluteal treatment was superior to treatment in prone position, with stone-free rates after one session in 75% and 49%, respectively. The overall stone-free rates were 91% and 72%, respectively.

Based on my personal experience of SWL during more than 25 years, I am surprised that ureteroscopy so categorically has been and is recommended for removal of stones in the distal ureter, particularly since treatment of distal ureteral stones with SWL is remarkably successful. In an analysis of 236 SWL treated patients with distal stones 83.2% were successfully treated with only one session. For a final stone-free rate of 97.8% the total number of sessions was only 1.22. Auxiliary gentle and non-anaesthesia requiring procedures, not including any URS were 19% [1]
Out of 1100 SWL treatments reported in that analysis carried out in 2008, 82% were completed in supine position, 17% in prone position and 1% with a combination of these two patient positions.

The results reported in the authors´ article accordingly are in good agreement with my own experience, but it needs to be emphasized that patient positioning during SWL always has to be chosen individually. For that decision it is necessary to consider the stone position in relation to skeletal structures, intestinal gas and the exact shockwave path, This means that although the supine position with trans-gluteal administration of shockwaves is superior in most patients, in others treatment in prone position might be a better alternative.

Reference
1. Tiselius HG. How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008 Feb;22(2):249-55. doi: 10.1089/end.2007.0225.

Hans-Göran Tiselius

Based on my personal experience of SWL during more than 25 years, I am surprised that ureteroscopy so categorically has been and is recommended for removal of stones in the distal ureter, particularly since treatment of distal ureteral stones with SWL is remarkably successful. In an analysis of 236 SWL treated patients with distal stones 83.2% were successfully treated with only one session. For a final stone-free rate of 97.8% the total number of sessions was only 1.22. Auxiliary gentle and non-anaesthesia requiring procedures, not including any URS were 19% [1]
Out of 1100 SWL treatments reported in that analysis carried out in 2008, 82% were completed in supine position, 17% in prone position and 1% with a combination of these two patient positions.

The results reported in the authors´ article accordingly are in good agreement with my own experience, but it needs to be emphasized that patient positioning during SWL always has to be chosen individually. For that decision it is necessary to consider the stone position in relation to skeletal structures, intestinal gas and the exact shockwave path, This means that although the supine position with trans-gluteal administration of shockwaves is superior in most patients, in others treatment in prone position might be a better alternative.

Reference
1.	Tiselius HG. How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008 Feb;22(2):249-55. doi: 10.1089/end.2007.0225.

Hans-Göran Tiselius

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