Wiesenthal JD et al, 2011: A comparison of treatment modalities for renal calculi between 100 and 300 mm2: are shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy equivalent?
Wiesenthal JD, Ghiculete D, D'A Honey RJ, Pace KT
Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Abstract
BACKGROUND AND PURPOSE: Shockwave lithotripsy (SWL) is considered a standard treatment for patients with upper-tract stones that are less than 10 mm in diameter, whereas stones that are larger than 20 mm are best managed by percutaneous nephrolithotomy (PCNL). The management of stones between these sizes remains controversial. Our purpose was to review our contemporary series of SWL, ureteroscopy (URS), and PCNL outcomes for intermediate-sized upper tract calculi (100-300 mm(2)).
PATIENTS AND METHODS: Analysis was restricted to those patients who were treated for a renal calculus that measured between 100 and 300 mm(2) during a 4-year span. Demographic, stone, patient, treatment, and follow-up data were collected from a prospectively maintained database.
RESULTS: A total of 137 patients were referred with nonstaghorn calculi with an area between 100 and 300 mm(2). Fifty-three (38.7%) patients were treated with SWL, while 41 (29.9%) and 43 (31.4%) underwent ureteroscopy and PCNL, respectively. Mean stone area was higher in the PCNL group (P < 0.001), whereas stone density was higher for patients undergoing SWL (P = 0.002). Single treatment success rates were better for PCNL at 95.3%,vs 87.8% for ureteroscopy and 60.4% for SWL, P < 0.001. When allowing for two SWL treatments, the success rate improved to 79.2%, thus equalizing the success of the three treatment modalities (P = 0.66). Auxiliary treatments were more common after SWL (42.3%; P < 0.01).
CONCLUSIONS: For intermediate-sized upper-tract stones, when allowing for up to two SWL treatments, there was no significant difference between treatment modalities. Thus, SWL is a reasonably successful treatment alternative for patients who are not fit for a general anesthetic or who prefer SWL over competing treatments, provided they accept a potentially higher number of treatments.
J Endourol. 2011 Mar;25(3):481-5. doi: 10.1089/end.2010.0208. Epub 2011 Feb 25
PMID: 21351888 [PubMed - in process]
Comments 1
The study shows that ESWL, URS and PNL for stones between 10 and 30 mm2 are equally effective if secondary ESWL retreatment is regarded as integral part of an ESWL treatment. The selection of the therapeutic procedures was not based on specific diagnostic criteria.
The stones treated with EWSL had the highest density (HU) because Uric acid stones with their low density were treated with PNL or URS. Oral chemolysis with alkalinisation of urine as the least invasive therapy of these stones seems to be forgotten often.
Peter Alken