Tasian GE. et al., 2025: Ureteroscopy vs Shockwave Lithotripsy to Remove Kidney Stones in Children and Adolescents: A Nonrandomized Clinical Trial.

Gregory E Tasian, David I Chu, Caleb P Nelson, W Robert DeFoor, Justin B Ziemba, Jing Huang, Xianqun Luan, Michael Kurtz, Christina B Ching, Pankaj Dangle, Anthony J Schaeffer, Renea Sturm, Wayland Wu, Christopher Bayne, Nicolas Fernandez, Michael E Chua, Romano DeMarco, Pamela Ellsworth, Brian Augelli, Jing Bi-Karchin, Rebecca D McCune, Seth Vatsky, Susan Back, Zi Wang, Hunter Beck, Anna Kurth, Laura Kurth, Annabelle Pleskoff, Christopher B Forrest, Jonathan S Ellison; PKIDS Care Improvement Network; Kyle Rove, Scott Sparks, Eric Nelson, Bruce Schlomer, Aaron Krill, Ching Man Carmen Tong, Abby Taylor, Puneeta Ramachandra, Andrew Stec, Pasquale Casale, Douglas Coplen, Nicolette Janzen, Krystal Bagley, Michelle R Denburg, Kimberley Dickinson, Rosemary Laberee, Matt Lorenzo, Antoine Selman-Fermin, Joana Dos Santos, Campbell Grant, Kate Kraft, Bhalaajee Meenakshi-Sundaram 
JAMA Netw Open. 2025 Aug 1;8(8):e2525789. doi: 10.1001/jamanetworkopen.2025.25789 FREE TEXT

Abstract

Importance: Most children and adolescents with kidney and ureteral stones are treated with ureteroscopy, despite the uncertainty and equal weight of guideline recommendations for ureteroscopy or shockwave lithotripsy.

Objective: To compare stone clearance and patient-reported outcomes among children and adolescents after ureteroscopy or shockwave lithotripsy.

Design, setting, and participants: This nonrandomized clinical trial enrolled patients between March 16, 2020, and July 31, 2023, at 31 medical centers in the US and Canada. Patients aged 8 to 21 years with kidney stones, ureteral stones, or both were included. Follow-up was completed on October 15, 2023.

Interventions: Ureteroscopy or shockwave lithotripsy.

Main outcomes and measures: The primary outcome was stone clearance assessed by standardized ultrasonography 6 (±2) weeks after surgery. Using inverse probability weighting and random intercepts for site, stone clearance was evaluated per kidney or ureter using logistic regression and estimated stone clearance rates were generated for each procedure.

Results: This study included 1142 patients (690 females [60.4%]), with a median age of 15.6 years (IQR, 12.6-17.3 years). In terms of race and ethnicity, 41 patients (3.6%) were Black, 130 (11.4%) were Hispanic, and 884 (77.4%) were White. A total of 124 urologists treated 1069 and 197 kidneys or ureters with ureteroscopy and shockwave lithotripsy (n = 953 and n = 189 patients), respectively, with a median stone size of 6.0 mm (IQR, 4.0-9.0 mm). Ureteral stents were placed at time of index surgery for 841 procedures for 767 patients (80.4%) receiving ureteroscopy and for 6 procedures for 5 patients (2.6%) receiving shockwave lithotripsy. Stone clearance occurred in 474 patients who underwent ureteroscopy (71.2% [95% CI, 63.8%-78.5%]) and in 105 patients who underwent shockwave lithotripsy (67.5% [95% CI, 61.0%-74.1%]), a difference that was not statistically significant (risk difference, 3.6% [95% CI, -6.2% to 13.5%]). Compared with shockwave lithotripsy, ureteroscopy resulted in greater pain interference (T-score difference, 5.0 [95% CI, 2.3-7.8]) and urinary symptoms (symptom score difference, 3.9 [95% CI, 1.2-6.7]) 1 week after surgery. Patients who had ureteroscopy missed more school (risk difference, 21.3% [95% CI, 9.7%-32.8%]) and caregivers missed more work (risk difference, 23.0% [95% CI, 11.0%-35.0%]) in the week after surgery.

Conclusions and relevance: In this study of 1142 children and adolescents with kidney and ureteral stones, there was no clinically meaningful difference in stone clearance with ureteroscopy vs shockwave lithotripsy. Shockwave lithotripsy was associated with better patient-reported outcomes. These findings raise questions about the preference for ureteroscopy in practice.

Comment Hans-Göran Tiselius

This report is particularly valuable for all those endoscopic enthusiasts who think that SWL is an outdated method for stone removal.
In a non-randomized comparison of 953 URS- and 189 SWL-treatments carried out in children with similar stone situations, the stone-free rates were 71.2% and 67.5%. It is of interest that stents were inserted in 29.9% and 3.2% of URS- and SWL-treated patients. Children treated with SWL had less postoperative pain and less influence on school attendance. More episodes with general anesthesia were required in the URS group.
The basic finding was that there was no clinically meaningful difference in stone clearance between the two groups, but the latter method was associated with better QoL experience.
For the interested reader there are extensive tables with detailed information on the two treatment groups.
This is a top-publication during the period and its content gives valuable support to the use of SWL in children and adolescents.

Hans-Göran Tiselius