Tsai SH. et al., 2020: Comparison of the efficacy and safety of shockwave lithotripsy, retrograde intrarenal surgery, percutaneous nephrolithotomy, and minimally invasive percutaneous nephrolithotomy for lower-pole renal stones: A systematic review and network meta-analysis
Tsai SH, Chung HJ, Tseng PT, Wu YC, Tu YK, Hsu CW, Lei WT.
Department of Urology, Cheng Hsin General Hospital.
School of Medicine, National Yang-Ming University.
Department of Urology, Taipei Veterans General Hospital.
WinShine Clinics in Specialty of Psychiatry.
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taoyuan.
Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei.
Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung.
Division of Allergy, Immunology, Rheumatology Disease, Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan.
Abstract
BACKGROUND:
Shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and minimally invasive PCNL are currently therapeutic options for lower-pole renal stones (LPS). However, the optimal treatment for LPS remains unclear. A comprehensive evaluation of the efficacy and safety of each intervention is needed to inform clinical decision-making. This study aimed at assessing the efficacy and safety of different interventions for LPS.
METHODS:
PubMed, Embase, ScienceDirect, ClinicalKey, Cochrane Library, ProQuest, Web of Science, and ClinicalTrials.gov were searched from inception to December 6th 2018. Only randomized controlled trials (RCTs) including the patients treated for LPS were included. The frequentist models of network meta-analysis were used to compare the effect sizes. The primary outcome was stone free rate, and the secondary outcomes were overall complication rate, major complication rate, retreatment rate, and auxiliary procedure rate.
RESULTS:
This study included 13 RCTs comprising 1832 participants undergoing 6 different interventions, including RIRS, PCNL, Mini-PCNL, Micro-PCNL, SWL, and conservative observation. PCNL had the best stone free rate (odds ratio [OR] = 3.45, 95% confidence interval [CI] = 1.30-9.12), followed by Mini-PCNL (OR = 2.90, 95% CI = 1.13-7.46). Meta-regression did not find any association of the treatment effect with age, sex, and stone size. Although PCNL tended to exhibit a higher complication rate, the difference of complication rate among various interventions did not achieve a statistical significance. SWL was the less effective and associated with higher retreatment rate compared with PCNL, Mini-PNCL, and RIRS.
CONCLUSIONS:
PCNL was associated with the best stone free rate for LPS regardless of age, sex, and stone size. Each treatment achieved a similar complication rate compared with the others. Future large-scale RCTs are warranted to identify the most beneficial management for renal stones at a more complicated location.
Medicine (Baltimore). 2020 Mar;99(10):e19403. doi: 10.1097/MD.0000000000019403. PMID: 32150088 Free Article
Comments 1
In this study the authors compared SWL, RIRS, standard PCNL, mini-PCNL and micro-PCNL by performing a systematic review and meta-analysis. Only lower pole stones were considered. No own results were included.
A summary of the reported stone-free rates (SFR) extracted from the article is shown below.
The results are like those found in the literature.
The authors conclusion was that “further large-scaled RCTs are warranted” for larger or complicated stones. It is possible that such studies can be used for fine-tuning the most appropriate indication for RIRS. It is unlikely, however, that additional studies including SWL will give us important information unless new methods for shockwave delivery with increased stone disintegration or improved techniques for non-invasive fragment elimination become available.
Hans-Göran Tiselius