Tauber V et al, 2015: Efficacy Management of Urolithiasis: Flexible Ureteroscopy versus Extracorporeal Shockwave Lithotripsy.

Friday, 27 November 2015

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Tauber V, Wohlmuth M, Hochmuth A, Schimetta W, Krause FS.
Department of Urology, AKh Linz, Medical Faculty, Linz, Austria.

Abstract

OBJECTIVES: To evaluate the efficacy of flexible ureterscopy (fURS) and extracorporal shockwave lithotripsy (SWL) in the treatment of urolithiasis, complemented by a subgroup analysis of lower pole calyx.
METHODS: Retrospective analysis of patients treated by fURS or SWL was performed by independent variables such as gender, age, nephrolith size, double-J stent (DJ stent) and stone localisation.
RESULTS: Out of 326 patients, 165 were treated by SWL and 161 by fURS. Complete stone removal was achieved by fURS in 83.2% and by SWL in 43.0% (p < 0.001). Asymptomatic behaviour (88-89%) and complication rate (10-11%) were nearly the same in both methods. A higher retreatment rate for SWL was necessary; otherwise, an auxillary DJ stent was performed more often preoperative before fURS. The subgroup analysis of lower pole calyx confirmed these evaluations.
CONCLUSIONS: Complete stone-free removal was almost 8 times higher after fURS compared to SWL. The efficacy of fURS in treatment of urolithiasis is substantially higher than the efficacy of SWL.

Urol Int. 2015 Sep 23. [Epub ahead of print]

Comments 1

Peter Alken on Friday, 27 November 2015 09:45

The data are a little bit difficult to understand:

The authors state: “In case of residual stone fragments, a re-operation was performed on the patients.”
Consequently “A second operation by SWL or fURS was necessary in 9.0% of the cases in group 1 compared to 16.0% in group 2.”
But why was the stone free rate in the ESWL group only 43 % and why were these patients not treated until they were all stone free? And was it meant by 88, 5 % of the ESWL patients were asymptomatic?

Why did 46 % of the ESWL group get a double J stent if the mean stone size was only 7.71 (3–15) mm?
What do the authors mean by “A DJ stent was not required, but performed preoperative as an auxillary procedure in 46.1% of the SWL and in 67.7% of the fURS group. Pre-stenting was done either because of acute colic (ureteral stones were pushed to the kidney) or because the placement of the access sheath was not possible due to strong resistance in the ureter. In that case, a double-J was placed to minimise the risk of ureteral lesions and pre-stented fURS was planned another 2–3 weeks later.”

A Double J stent was placed in 38 % of the lower pole, 40 % of the mid region, 33 % of the upper pole and 67 % of the renal pelvic stones – all because of colics?
Those fURS patients in whom an access sheath could not be placed obviously must have had two procedures under anaesthesia until a successful URS. But the number of these cases is not given

Follow up:
“Those treated with SWL had imaging 2–3 weeks after the procedure and, if residual stones were still detectable, another 6–12 weeks later. Group 2 (fURS) was evaluated 1–4 weeks after the operation. Further follow-up was offered but nonetheless not all patients made use of this probability”
It is not clear at which time the stone free status was determined.

The data are a little bit difficult to understand:

The authors state: “In case of residual stone fragments, a re-operation was performed on the patients.” 
Consequently “A second operation by SWL or fURS was necessary in 9.0% of the cases in group 1 compared to 16.0% in group 2.”
But why was the stone free rate in the ESWL group only 43 % and why were these patients not treated until they were all stone free? And was it meant by 88, 5 % of the ESWL patients were asymptomatic?

Why did 46 % of the ESWL group get a double J stent if the mean stone size was only 7.71 (3–15) mm? 
What do the authors mean by “A DJ stent was not required, but performed preoperative as an auxillary procedure in 46.1% of the SWL and in 67.7% of the fURS group. Pre-stenting was done either because of acute colic (ureteral stones were pushed to the kidney) or because the placement of the access sheath was not possible due to strong resistance in the ureter. In that case, a double-J was placed to minimise the risk of ureteral lesions and pre-stented fURS was planned another 2–3 weeks later.”

A Double J stent was placed in 38 % of the lower pole, 40 % of the mid region, 33 % of the upper pole and 67 % of the renal pelvic stones – all because of colics?
Those fURS patients in whom an access sheath could not be placed obviously must have had two procedures under anaesthesia until a successful URS. But the number of these cases is not given

Follow up:
“Those treated with SWL had imaging 2–3 weeks after the procedure and, if residual stones were still detectable, another 6–12 weeks later. Group 2 (fURS) was evaluated 1–4 weeks after the operation. Further follow-up was offered but nonetheless not all patients made use of this probability”
It is not clear at which time the stone free status was determined.

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