Yuri P et al, 2018: Meta-analysis of Optimal Management of Lower Pole Stone of 10 - 20 mm: Flexible Ureteroscopy (FURS) versus Extracorporeal Shock Wave Lithotripsy (ESWL) versus Percutaneus Nephrolithotomy (PCNL).
Yuri P, Hariwibowo R, Soeroharjo I, Danarto R, Hendri AZ, Brodjonegoro SR, Rasyid N, Birowo P, Widyahening IS.
Division of Urology, Department of Surgery, Faculty of Medicine Universitas Gadjah Mada - Sardjito Hospital, Yogyakarta, Indonesia.
BACKGROUND: the optimal management of lower calyceal stones is still controversial, because no single method is suitable for the removal of all lower calyceal stones. Minimally invasive procedures such as extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureteroscopy (fURS) are the therapeutic methods for lower calyceal stones. The aim of this study was to identify the optimal management of 10-20 mm lower pole stones.
METHODS: a meta-analysis of cohort studies published before July 2016 was performed from Medline and Cochrane databases. Management of 10-20 mm lower pole stone treated by fURS, ESWL and PCNL with follow-up of residual stones in 1-3 months after procedure were include and urinary stone in other location and size were excluded. A fixed-effects model with Mantzel-Haenzel method was used to calculate the pooled Risk Ratio (RRs) and 95% Confidence Interval (CIs). We assessed the heterogeneity by calculating the I2 statistic. All analyses were performed with Review manager 5.3. RESULTS: we analized 8 cohort studies. The stone free rate from 958 patients (271 PCNL, 174 fURS and 513 ESWL), 3 months after operation, was 90.8% (246/271) after PCNL; 75.3% (131/174) after fURS; and 64.7% (332/513) after ESWL. Base on stone free rate in 10-20 mm lower pole stone following management, PCNL is better than fURS (overall RR was 1.32 (95% CI 1.13 - 1.55); p<0.001 and I2=57%) and ESWL (overall risk ratio 1.42 (95% CI 1.30 - 1.55); p=<0.001 and I2 = 85%). But, if we compare between fURS and ESWL, fURS is better than ESWL base on stone free rate in 10-20 mm lower pole stone management with overall RR 1.16 (95% CI 1.04 - 1.30; p=0.01 and I2=40%).
CONCLUSION: percutaneus nephrolithotomy provided a higher stone free rate than fURS and ESWL. This meta-analysis may help urologist in making decision of intervention in 10-20 mm lower pole stone management.
Acta Med Indones. 2018 Jan;50(1):18-25.
This article is one of several examples of the popularity and ease on how modern computerized tools can be used to carry out systematic reviews and meta-analyses. In this case a comparison was carried out between SWL, URS and PCNL for treatment of stones (10-20 mm) in the lower calyx. As expected from previously reported results of comparisons between these non-invasive and low-invasive procedures, the best stone-free rate (91%) was recorded for PCNL. The stone-free rates for URS and SWL were 75% and 65%, respectively.
Data on stone composition, average stone size and lower calyx anatomy were not included.
For SWL there is no information provided on the experience or skill of the operator, neither is there any information on the treatment strategy.
There are insufficient data for calculation of stone treatment index (STI).
For every patient treated with modern methods for stone removal there has to be a balance between the desired end-point and the efforts required to get there. Such conclusions cannot be drawn from the data in this article. But the minor difference in stone-free rates between URS and SWL deserves to be noted.