Sonmez G. et al., 2020: Comparison of the effects of four treatment techniques commonly used in ureteral stone treatment on patients' daily physical functioning: An observational, randomized, controlled study
Sonmez G, Demir F, Keske M, Karadag MA, Demirtaş A.J.
Department of Urology, Erciyes University, Kayseri, Turkey.
Department of Urology, Kayseri City Hospital, Kayseri, Turkey.
Objective: To investigate the effect of four different techniques used in the treatment of ureteral stones on patients' daily physical functioning and quality of life (QoL).
Materials and methods: Patients who underwent ureterorenoscopy (URS)-with or without double j stenting (DJS)- and Extracorporeal shock wave lithotripsy (ESWL) were divided into four groups: Group I: ESWL (n=29), Group II: URS (n=43), Group III: URS + 4.8 Fr DJS (n=39), Group IV: URS + 6 Fr DJS (n=42), and Group V: Control (n=30). Short Form-36 (SF-36) was administered to each participant both preoperatively and 14 days after operation. Based on the SF-36 results, the changes in patients' physical functioning and QoL were evaluated.
Results: Ureteral stone treatment was performed in 202 patients. Of these, 153 patients who underwent a successful ESWL or URS procedure in the first attempt were included in the study. Success rates in the first session were 53.7% (29/54) and 83.8% (124/148) for ESWL and URS, respectively (p <0.001). All the four groups were similar with regard to age, gender, body mass index (BMI), stone size, preoperative physical functioning and QoL. However, although postoperative physical functioning, role limitations due to physical health, and energy/fatigue scores were similar in Group I, III, and IV, they were significantly higher in Group II. No major complication associated with ESWL or URS occurred in any patient. However, in Group 2, DJS was inserted in three (7.7%) patients in the early postoperative period (within the first 48 h) due to renal colic attacks secondary to ureterovesical junction mucosal edema.
Conclusion: Ureterorenoscopy without DJS seems to be the most advantageous technique in the treatment of ureteral stones in terms of daily physical functioning and QoL. However, it should be noted that patients undergoing URS may require postoperative emergency stenting, though rarely.
Endourol. 2020 Sep 16. doi: 10.1089/end.2020.0659. Online ahead of print. PMID: 32935564
An interesting study, which is important because it looks at outcome from a patients view.
The randomisation seems to be skewed. However, it reflects how patients would normally be handled: “Patients with radiopaque stones in the middle and upper segments of the ureter were offered either ESWL or surgical treatment. Patients choosing surgical treatment were assigned to the treatment groups sequentially one by one. However, patients with non-radiopaque or lower ureteric stones were directly referred to surgery and were assigned to the treatment groups sequentially one by one.
In fact randomisation lead to an uneven distribution of cases: “The most common stone location was upper ureter (82.8%) in ESWL patients and was lower ureter in unstented URS patients.”
It would have been nice to know how many patients were in two of the exclusion groups: 1) failure of the first URS procedure (due to failure to reach the stone or the presence of residual stones requiring a second session), and 2) failure in the first ESWL procedure. Like this, one could have got an additional look into real life.
Postprocedural pain scores in any of the URS groups where higher than in the ESWL group, regardless of the stent size used.
The authors mention one limitation of the study: The groups were small.
Another drawback is the use of the SF-36 Quality of Life questionnaire, which is unspecific. There is a Turkish version of the Wisconsin Stone Quality of Life questionnaire (WISQOL), a disease-specific health-related quality of life (HRQOL) instrument to specifically assess the impact of urolithiasis on patients (https://urology.wisc.edu/research/wisqol/).