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Wang Z. et al., 2020: Effects of diuretic administration on outcomes of extracorporeal shockwave lithotripsy: A systematic review and meta-analysis

Wang Z, Bai Y, Wang J.
Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.

Abstract

The present systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted for investigating the effect of diuretics on the outcomes of shockwave lithotripsy (SWL) for the treatment of urinary stones. We performed searches of PubMed, Web of science, Embase, EBSCO, and Cochrane library databases from inception to November 2019. RCTs were selected for assessing the effects of diuretics on fragmentation and clearance of urinary stones. The search strategy and study selection process were performed in accordance with the PRISMA guidelines. Four RCTs were included in the meta-analysis. Overall, intervention groups experienced significant improvements in fragmentation compared with the control groups (risk ratio [RR] = 1.14, 95% confidence interval [CI] = 1.05-1.03, P = 0.02). However, stone clearance did not significantly differ between the intervention and control groups (RR = 1.23, 95% CI = 0.97-1.56, P = 0.08). The total numbers of shocks and sessions required were significantly reduced by the use of diuretics. Diuretics significantly enhance stone fragmentation for patients undergoing SWL. However, the improvement in stone clearance appears to be insignificant.

PLoS One. 2020 Mar 5;15(3):e0230059. doi: 10.1371/journal.pone.0230059. eCollection 2020. PMID:32134993
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Comments 1

Hans-Göran Tiselius on Thursday, May 07 2020 08:15

Early observations indicated that one prerequisite for SWL stone disintegration was the presence of fluid between the stone and the surrounding tissues [1]. The question whether fluid irrigation or high diuresis is of clinical value during SWL has remained without a definite answer during the past 35 years. The title of this article therefore invited to reading.
In this systematic review and meta-analysis, the authors were not able to include more than four RCTs carried out on a relatively small number of patients. I was particularly interested to see if this analysis revealed a beneficial effect of diuresis on treatment of stones in the kidney. The reason for this special focus is that a randomized comparison of patients treated with SWL for ureteral stones with high diuresis or without, that we published some years ago [2], did not demonstrate different outcome. Unfortunately, in the current report, only one RCT included stones in the kidney and more than half of their patients also had ureteral stones.
The interpretation of this review is hampered by shortage of information. Although all patients most likely received furosemide intravenously, only two mentioned infusion of fluid during treatment (3000 and 500 mL). How efficient the diuresis was is difficult to know because urine volumes were reported in only one of the studies.
The bottom-line is that the fragmentation of stones was slightly but significantly better when SWL had been carried out with furosemide; 93% vs. 81%.
This article cannot give an answer to the question whether high diuresis improves disintegration of stones in the kidney. According to the results in this summary, it seems possible that high diuresis can be of value when treating stones in the ureter. Such an approach might result in reduced rate of re-treatments. Another advantage is that the early appearance of haematuria indicates disintegration. It is for this purpose necessary with a bladder catheter, but whether bladder catheters were used in these four RCT-studies is not mentioned.
In view of the high stone-free rate after the first SWL session for ureteral stones, high diuresis might be less attractive. It might, however, be worthwhile to consider this therapeutic trick in the case repeated SWL is necessary.

References
1. Mueller SC, Wilbert D, Thueroff JW, Alken P
Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings.
J Urol. 1986 Apr;135(4):831-4.
2. Tiselius HG, Aronsen T, Bohgard S, Fredriksson M, Jonason EM, Olsson M, Sjöström K
Is high diuresis an important prerequisite for successful SWL-disintegration of ureteral stones?
Urol Res. 2010 Apr;38(2):143-6. doi: 10.1007/s00240-009-0241-1. Epub 2009 Dec 8.

Hans-Göran Tiselius

Early observations indicated that one prerequisite for SWL stone disintegration was the presence of fluid between the stone and the surrounding tissues [1]. The question whether fluid irrigation or high diuresis is of clinical value during SWL has remained without a definite answer during the past 35 years. The title of this article therefore invited to reading. In this systematic review and meta-analysis, the authors were not able to include more than four RCTs carried out on a relatively small number of patients. I was particularly interested to see if this analysis revealed a beneficial effect of diuresis on treatment of stones in the kidney. The reason for this special focus is that a randomized comparison of patients treated with SWL for ureteral stones with high diuresis or without, that we published some years ago [2], did not demonstrate different outcome. Unfortunately, in the current report, only one RCT included stones in the kidney and more than half of their patients also had ureteral stones. The interpretation of this review is hampered by shortage of information. Although all patients most likely received furosemide intravenously, only two mentioned infusion of fluid during treatment (3000 and 500 mL). How efficient the diuresis was is difficult to know because urine volumes were reported in only one of the studies. The bottom-line is that the fragmentation of stones was slightly but significantly better when SWL had been carried out with furosemide; 93% vs. 81%. This article cannot give an answer to the question whether high diuresis improves disintegration of stones in the kidney. According to the results in this summary, it seems possible that high diuresis can be of value when treating stones in the ureter. Such an approach might result in reduced rate of re-treatments. Another advantage is that the early appearance of haematuria indicates disintegration. It is for this purpose necessary with a bladder catheter, but whether bladder catheters were used in these four RCT-studies is not mentioned. In view of the high stone-free rate after the first SWL session for ureteral stones, high diuresis might be less attractive. It might, however, be worthwhile to consider this therapeutic trick in the case repeated SWL is necessary. References 1. Mueller SC, Wilbert D, Thueroff JW, Alken P Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings. J Urol. 1986 Apr;135(4):831-4. 2. Tiselius HG, Aronsen T, Bohgard S, Fredriksson M, Jonason EM, Olsson M, Sjöström K Is high diuresis an important prerequisite for successful SWL-disintegration of ureteral stones? Urol Res. 2010 Apr;38(2):143-6. doi: 10.1007/s00240-009-0241-1. Epub 2009 Dec 8. Hans-Göran Tiselius
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