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Setthawong V. et al.,2023: Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones.

Setthawong V, Srisubat A, Potisat S, Lojanapiwat B, Pattanittum P. 
Department of Surgery, Lerdsin Hospital, Department of Medical Services, Ministry of Public Health, Bangkok, Thailand.
Department of Surgery, College of Medicine, Rangsit University, Bangkok, Thailand.
Institute of Medical Research and Technology Assessment, Dept of Medical Services, Ministry of Public Health, Nonthaburi, Thailand.
Bhumirajanagarindra Kidney Institute, Bangkok, Thailand.
Department of Surgery, Chiangmai University, Chiangmai, Thailand.
Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.

Abstract

Background: Nephrolithiasis is a common urological disease worldwide. Extracorporeal shock wave lithotripsy (ESWL) has been used for the treatment of renal stones since the 1980s, while retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) are newer, more invasive treatment modalities that may have higher stone-free rates. The complications of RIRS and PCNL have decreased owing to improvement in surgical techniques and instruments. We re-evaluated the best evidence on this topic in an update of a Cochrane Review first published in 2014.

Objectives: To assess the effects of extracorporeal shock wave lithotripsy compared with percutaneous nephrolithotomy or retrograde intrarenal surgery for treating kidney stones.

Search methods: We performed a comprehensive search in CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov with no restrictions on language or publication status. The latest search date was 6 December 2022.

Selection criteria: We included randomized controlled trials (RCTs) and quasi-RCTs that compared ESWL with PCNL or RIRS for kidney stone treatment.

Data collection and analysis: Two review authors independently classified studies, extracted data, and assessed risk of bias. Our primary outcomes were treatment success rate at three months (defined as residual fragments smaller than 4 mm, or as defined by the study authors), quality of life (QoL), and complications. Our secondary outcomes were retreatment rate, auxiliary procedures rate, and duration of hospital stay. We performed statistical analyses using a random-effects model and independently rated the certainty of evidence using the GRADE approach.

Main results: We included 31 trials involving 3361 participants (3060 participants completed follow-up). Four trials were only available as an abstract. Overall mean age was 46.6 years and overall mean stone size was 13.4 mm. Most participants (93.8%) had kidney stones measuring 20 mm or less, and 68.9% had lower pole stones. ESWL versus PCNL ESWL may have a lower three-month treatment success rate than PCNL (risk ratio [RR] 0.67, 95% confidence interval [CI] 0.57 to 0.79; I2 = 87%; 12 studies, 1303 participants; low-certainty evidence). This corresponds to 304 fewer participants per 1000 (397 fewer to 194 fewer) reporting treatment success with ESWL. ESWL may have little or no effect on QoL after treatment compared with PCNL (1 study, 78 participants; low-certainty evidence). ESWL probably leads to fewer complications than PCNL (RR 0.62, 95% CI 0.47 to 0.82; I2 = 18%; 13 studies, 1385 participants; moderate-certainty evidence). This corresponds to 82 fewer participants per 1000 (115 fewer to 39 fewer) having complications after ESWL. ESWL versus RIRS ESWL may have a lower three-month treatment success rate than RIRS (RR 0.85, 95% CI 0.78 to 0.93; I2 = 63%; 13 studies, 1349 participants; low-certainty evidence). This corresponds to 127 fewer participants per 1000 (186 fewer to 59 fewer) reporting treatment success with ESWL. We are very uncertain about QoL after treatment; the evidence is based on three studies (214 participants) that we were unable to pool. We are very uncertain about the difference in complication rates between ESWL and RIRS (RR 0.93, 95% CI 0.63 to 1.36; I2 = 32%; 13 studies, 1305 participants; very low-certainty evidence). This corresponds to nine fewer participants per 1000 (49 fewer to 48 more) having complications after ESWL.

Authors' conclusions: ESWL compared with PCNL may have lower three-month success rates, may have a similar effect on QoL, and probably leads to fewer complications. ESWL compared with RIRS may have lower three-month success rates, but the evidence on QoL outcomes and complication rates is very uncertain. These findings should provide valuable information to aid shared decision-making between clinicians and people with kidney stones who are undecided about these three options.
Database Syst Rev. 2023 Aug 1;8(8):CD007044. doi: 10.1002/14651858.CD007044.pub4. PMID: 37526261 Review.

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Comments 1

Hans-Göran Tiselius on Thursday, 01 February 2024 10:00

The authors have updated the recommendations for stone removal in children by summarizing current literature data. It is of note that this article is written in Turkey in which country stones among children are particularly common.
Although it is mentioned initially that treatment of this group of patients require full metabolic and urological examination, only surgical aspects are presented in the current publication.
It is clear that the need of open surgery is very limited, whereas modern techniques such as SWL, PNL and URS dominate. Of these procedures, SWL is the least invasive and most applied method. This is true at least for stones with a size up to 2 cm in diameter. The indication for SWL-treatment of ureteral stones is said to be best for those located in the proximal ureter, but the reason for that is not explained. Important is that fragment passage is facilitated by the powerful ureter in children. This property also shows that stenting is unnecessary and in fact stenting might counteract stone-clearance.
URS is described in more detail than SWL and it is obvious that the authors are more attracted by endoscopy than by SWL. But the risk of ureteral perforation with URS is emphasized. Ureteral avulsion is mentioned, but it is important to note that this complication never occurs with SWL.
RIRS is suggested as treatment for lower pole stones, but whether this approach really is necessary is doubtful because of the mobility of children that will allow high fragment passage after SWL.
Large stones preferably were treated with PNL, but it needs to be mentioned that a recent report showed great success with SWL in children with stones > 20 mm [1]
Miniaturization of instruments as mini, ultra-mini, etc. has increased the use of PNL, particularly following the introduction of super-mini PNL.
For bladder stones suprapubic cysto-lithectomy seems to be an excellent procedure.
Although SWL still is the major tool for stone removal, tis article gives more information on endoscopic methods. Nevertheless, the safety of SWL with limited number of shock waves and low energy is valuable for avoiding kidney damage.
The conclusion of this report is that SWLK still is the first choice in most children with stones.

References
1. Mohamed ER, Elmogazy HM, Zanaty AK, Elsharkawi AM, Riad AM, Badawy AA.Extracorporeal shock wave lithotripsy for treatment of large pediatric renal pelvic stone burden more than 2 cm. J Pediatr Urol. 2023 Jun 20:S1477-5131(23)00245-0. doi: 10.1016/j.jpurol.2023.06.017. Online ahead of print.PMID: 37414650

Hans-Göran Tiselius

The authors have updated the recommendations for stone removal in children by summarizing current literature data. It is of note that this article is written in Turkey in which country stones among children are particularly common. Although it is mentioned initially that treatment of this group of patients require full metabolic and urological examination, only surgical aspects are presented in the current publication. It is clear that the need of open surgery is very limited, whereas modern techniques such as SWL, PNL and URS dominate. Of these procedures, SWL is the least invasive and most applied method. This is true at least for stones with a size up to 2 cm in diameter. The indication for SWL-treatment of ureteral stones is said to be best for those located in the proximal ureter, but the reason for that is not explained. Important is that fragment passage is facilitated by the powerful ureter in children. This property also shows that stenting is unnecessary and in fact stenting might counteract stone-clearance. URS is described in more detail than SWL and it is obvious that the authors are more attracted by endoscopy than by SWL. But the risk of ureteral perforation with URS is emphasized. Ureteral avulsion is mentioned, but it is important to note that this complication never occurs with SWL. RIRS is suggested as treatment for lower pole stones, but whether this approach really is necessary is doubtful because of the mobility of children that will allow high fragment passage after SWL. Large stones preferably were treated with PNL, but it needs to be mentioned that a recent report showed great success with SWL in children with stones > 20 mm [1] Miniaturization of instruments as mini, ultra-mini, etc. has increased the use of PNL, particularly following the introduction of super-mini PNL. For bladder stones suprapubic cysto-lithectomy seems to be an excellent procedure. Although SWL still is the major tool for stone removal, tis article gives more information on endoscopic methods. Nevertheless, the safety of SWL with limited number of shock waves and low energy is valuable for avoiding kidney damage. The conclusion of this report is that SWLK still is the first choice in most children with stones. References 1. Mohamed ER, Elmogazy HM, Zanaty AK, Elsharkawi AM, Riad AM, Badawy AA.Extracorporeal shock wave lithotripsy for treatment of large pediatric renal pelvic stone burden more than 2 cm. J Pediatr Urol. 2023 Jun 20:S1477-5131(23)00245-0. doi: 10.1016/j.jpurol.2023.06.017. Online ahead of print.PMID: 37414650 Hans-Göran Tiselius
Monday, 20 May 2024