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He Z. et al., 2019: Does the presence or degree of hydronephrosis affect the stone disintegration efficacy of extracorporeal shock wave lithotripsy? A systematic review and meta-analysis

He Z, Yin S, Duan X, Zeng G.
Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Kangda Road 1, Haizhu District, Guangzhou, 510230, Guangdong, China.
Guangzhou Institute of Urology, Guangzhou, China.
Guangdong Key Laboratory of Urology, Guangzhou, China.
Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Kangda Road 1, Haizhu District, Guangzhou, 510230, Guangdong, China.
Guangzhou Institute of Urology, Guangzhou, China.
Guangdong Key Laboratory of Urology, Guangzhou, China.

Abstract

The aim of this study was to determine whether the presence or degree of hydronephrosis (HN) affects the stone disintegration efficacy of shock wave lithotripsy (SWL). A comprehensive literature search using PubMed, Embase, Cochrane Library, and Web of Science was conducted to retrieve relevant studies. Risk ratios (RRs) and mean differences (MDs) with corresponding 95% confidence intervals (CIs) were calculated for comparisons of outcomes of interest. In total, seven comparative studies with 2033 patients were included. Overall results indicated no significant difference in stone-free rate (SFR) and retreatment rate between two groups. Subgroup analysis further revealed: (1) compared with moderate or severe HN, non-HN SWL brought significantly lower retreatment rate (RR 0.67, 95%CI 0.52-0.87, P = 0.002 and RR 0.55, 95%CI: 0.40-0.76, P = 0.0003, respectively) and shorter clearance time (MD - 3.80, 95%CI - 5.81 to - 1.79, P = 0.0002 and MD - 5.93, 95%CI - 10.29 to - 1.57, P = 0.008, respectively); (2) SWLs performed without stone-induced HN or with artificial HN were associated with significantly higher SFR (RR 1.11, 95%CI 1.04-1.18, P = 0.001 and RR 0.93, 95%CI 0.87-0.99, P = 0.02, respectively); (3) non-HN SWL brought significantly higher SFR than HN group when treating proximal ureteral stones (RR 1.14, 95%CI 1.04-1.24, P = 0.005). Generally, SWLs performed with HN were shown to offer similar stone disintegration efficacy to those without HN. However, it seemed preferable to perform SWL: (1) without severe to moderate HN or stone-induced HN; (2) with artificial HN; (3) without HN when treating proximal ureteral stones.
Urolithiasis. 2019 Oct 12. doi: 10.1007/s00240-019-01165-7. [Epub ahead of print]

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Comments 1

Hans-Göran Tiselius on Sunday, March 15 2020 08:35

The problem dealt with in this systematic review and meta-analysis is to which extent the presence of hydronephrosis (HN) affects stone disintegration. Already by looking at the individual studies it is evident that there are two entirely different causes of HN, One group of patients had HN because of outflow obstruction and the other group had HN by methods aiming at an increased fluid space around the stone(s).

Accordingly, when these two prerequisites are considered, HN associated with obstruction can be assumed to result in stone impaction, difficulties to conclude on stone disintegration and in any case often reason for both repeated treatment and slow clearance, This is a problem that is well recognized clinically.

Artificial HN apparently was better and when the two groups of patients were compared SFRs were 78% and 91%.
There are two lessons learnt from this review: Firstly, that HN caused by outflow obstruction is associated with less favorable outcome of SWL. Secondly, and highly interesting, HN artificially induced can favorably affect the outcome.
It is necessary to make this distinction and from a clinical point of view it seems reasonable that when HN is established by bladder filling or by intravenous fluid infusion and diuretics, these are methods that might result in improved SWL outcome.
Moreover, it seems reasonable to avoid diuretic regimen when treating patients with impacted stones at least as long as the obstruction has not been handled by inserting a stent or ureteral catheter.
I agree with the authors that high quality studies accounting for the factors mentioned above are necessary.

The problem dealt with in this systematic review and meta-analysis is to which extent the presence of hydronephrosis (HN) affects stone disintegration. Already by looking at the individual studies it is evident that there are two entirely different causes of HN, One group of patients had HN because of outflow obstruction and the other group had HN by methods aiming at an increased fluid space around the stone(s). Accordingly, when these two prerequisites are considered, HN associated with obstruction can be assumed to result in stone impaction, difficulties to conclude on stone disintegration and in any case often reason for both repeated treatment and slow clearance, This is a problem that is well recognized clinically. Artificial HN apparently was better and when the two groups of patients were compared SFRs were 78% and 91%. There are two lessons learnt from this review: Firstly, that HN caused by outflow obstruction is associated with less favorable outcome of SWL. Secondly, and highly interesting, HN artificially induced can favorably affect the outcome. It is necessary to make this distinction and from a clinical point of view it seems reasonable that when HN is established by bladder filling or by intravenous fluid infusion and diuretics, these are methods that might result in improved SWL outcome. Moreover, it seems reasonable to avoid diuretic regimen when treating patients with impacted stones at least as long as the obstruction has not been handled by inserting a stent or ureteral catheter. I agree with the authors that high quality studies accounting for the factors mentioned above are necessary.
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