Tokas T et al, 2016: Uncovering the real outcomes of active renal stone treatment by utilizing non-contrast computer tomography: a systematic review of the current literature.

Friday, 02 June 2017

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Tokas T, Habicher M, Junker D, Herrmann T, Jessen JP, Knoll T, Nagele U; Training Research in Urological Surgery Technology (T.R.U.S.T.)-Group.
Department of Urology and Andrology, General Hospital Hall i.T., Milser Str. 10, 6060, Hall in Tirol, Austria.
Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
Department of Urology and Urooncology, Hannover Medical School (MHH), Hannover, Germany.
Department of Urology, Klinikum Sindelfingen-Böblingen, Sindelfingen, Germany.

Abstract

PURPOSE: To evaluate the stone-free rates (SFRs) and stone clearance rates (SCRs) of extracorporeal shock-wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolitholapaxy (PCNL) according to non-contrast computer tomography (NCCT) findings.
METHODS: Original articles were identified from PubMed. After exclusion of ineligible papers, twenty-three studies with 2494 cases were included in the review.
RESULTS: Six SWL, five RIRS and eight PCNL studies were selected. Additionally, four comparative articles were identified. SWL presents SFRs ranging 35-61.3 % and SCRs for residuals <4 mm being 43.2-92.9 %. RIRS studies report SFRs of 34.8-59.7 % and SCRs for residuals <4 mm ranging 48-96.7 %. Finally, PCNL presents SFRs of 20.8-100 % and SCRs for residuals <4 mm being 41.5-91.4 %. According to the comparative studies, SFRs are 17-61.3 % for SWL, 50 % for RIRS, and 95-100 % for PCNL.
CONCLUSIONS: According to NCCT findings, it seems that PCNL provides better SFRs than ESWL and RIRS. However, further research with comparable and complete preoperative parameters and outcomes could reduce the heterogeneity of current data.

World J Urol. 2016 Oct 13. [Epub ahead of print]

Comments 1

Peter Alken on Friday, 02 June 2017 11:47

This group of authors from different departments in Austria and Germany probably wanted to create some clarity in the publication jungle on different techniques of stone removal.
But a few quotes show that this is a difficult task: “… the absence of high quality comparative trials or reviews and meta-analyses comparing the three modalities is more than apparent.” ”To our knowledge, this is the first systematic review trying to estimate the treatment outcomes based exclusively on CT findings”
”the quality of the different studies varies, with most of them being descriptive, single-arm, retrospective cohorts (LE 4) and only three of them being randomized prospective trials.”
“The current data for active stone treatment characteristics and outcomes remain incomplete and greatly heterogeneous. … future studies should adapt to the suggested standardizations and postoperative NCCT control in order to improve the quality of presented data.”

When the results are assembled in a table with the ranges of SFR and “CIRF” the high variance of data make the persisting confusion obvious:

The figure shows the number and year of publications included in the final analysis (23 of 628)

To include old studies might have been attractive to increase the number in order to come to a valid conclusion. But with the rapidly evolving techniques even an 11 year old study is already outdated
(Pearle MS et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005 Jun;173(6):2005-9) In added it also adds to the confusion because of several other problems: Why would “90% of patients who underwent SWL vs 63% of those who underwent URS would choose to undergo the same procedure again” and why was a SFR of 35% for ESWL and 50%, for URS not significant.
One may also ask why the SFR of RIRS has not significantly increased from the 50% in 2005 to the only 59.2% despite “aggressive manual fragment extraction“ in 2016 (WCE 2016 abstract MP37-9 Lay A, Pearl MS et al. Prospective evaluation of stone free rates by CT after aggressive ureteroscopy)
Sometimes it becomes obvious that a lot of paper is wasted because neither surgery nor reporting is standardized.

When the results are assembled in a table with the ranges of SFR and “CIRF” the high variance of data make the persisting confusion obvious:

[img]http://storzmedical.com/images/blog/Tokas_T1.jpg[/img]

The figure shows the number and year of publications included in the final analysis (23 of 628)

[img]http://storzmedical.com/images/blog/Tokas_T2.jpg[/img]

To include old studies might have been attractive to increase the number in order to come to a valid conclusion. But with the rapidly evolving techniques even an 11 year old study is already outdated
(Pearle MS et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less.  J Urol. 2005 Jun;173(6):2005-9) In added it also adds  to the confusion because of several other problems: Why would “90% of patients who underwent SWL vs 63% of those who underwent URS would choose to undergo the same procedure again” and why was a SFR of 35% for ESWL  and 50%, for URS  not significant.
One may also ask why the SFR of RIRS has not significantly increased from the 50% in 2005 to  the only 59.2% despite “aggressive manual fragment extraction“ in 2016  (WCE 2016 abstract MP37-9 Lay A, Pearl MS et al. Prospective evaluation of stone free rates by CT after aggressive ureteroscopy)
Sometimes it becomes obvious that a lot of paper is wasted because neither surgery nor reporting is standardized.

This group of authors from different departments in Austria and Germany probably wanted to create some clarity in the publication jungle on different techniques of stone removal. But a few quotes show that this is a difficult task: “… the absence of high quality comparative trials or reviews and meta-analyses comparing the three modalities is more than apparent.” ”To our knowledge, this is the first systematic review trying to estimate the treatment outcomes based exclusively on CT findings” ”the quality of the different studies varies, with most of them being descriptive, single-arm, retrospective cohorts (LE 4) and only three of them being randomized prospective trials.” “The current data for active stone treatment characteristics and outcomes remain incomplete and greatly heterogeneous. … future studies should adapt to the suggested standardizations and postoperative NCCT control in order to improve the quality of presented data.” When the results are assembled in a table with the ranges of SFR and “CIRF” the high variance of data make the persisting confusion obvious: [img]http://storzmedical.com/images/blog/Tokas_T1.jpg[/img] The figure shows the number and year of publications included in the final analysis (23 of 628) [img]http://storzmedical.com/images/blog/Tokas_T2.jpg[/img] To include old studies might have been attractive to increase the number in order to come to a valid conclusion. But with the rapidly evolving techniques even an 11 year old study is already outdated (Pearle MS et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005 Jun;173(6):2005-9) In added it also adds to the confusion because of several other problems: Why would “90% of patients who underwent SWL vs 63% of those who underwent URS would choose to undergo the same procedure again” and why was a SFR of 35% for ESWL and 50%, for URS not significant. One may also ask why the SFR of RIRS has not significantly increased from the 50% in 2005 to the only 59.2% despite “aggressive manual fragment extraction“ in 2016 (WCE 2016 abstract MP37-9 Lay A, Pearl MS et al. Prospective evaluation of stone free rates by CT after aggressive ureteroscopy) Sometimes it becomes obvious that a lot of paper is wasted because neither surgery nor reporting is standardized.

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