The effect of shock wave lithotripsy and retrograde intrarenal surgery on health-related quality of life in 10-20 mm renal stones: a prospective randomized pilot study

Measuring quality of life in patients with kidney stone disease: is it the future in endourology?

PURPOSE OF REVIEW

Kidney stone disease is recognized to negatively impact quality of life. This pertains to acute episodes, surgical interventions and even during asymptomatic periods. Over time there has been increased attention towards assessing this subjective parameter, including as a determinant of treatment success. Our aim was to evaluate the current status and emerging trends in this field.

RECENT FINDINGS

Patient groups most affected appear to be recurrent stone formers, cystine stone formers, women, younger populations, non-Caucasians and low-income populations. Several stone specific patient reported outcome measures are now available of which, WISQol has been implemented the most in clinical research studies. More invasive interventions such as percutaneous nephrolithotomy impede quality of life to greater extent than alternatives such as shockwave lithotripsy.

SUMMARY

There are certain patient groups who are more vulnerable to the negative impact of kidney stone disease on their quality of life. Urologists can improve patient care by recognizing these particular populations as well as by implemented patient reported outcome measures in their routine clinical practice and when performing research.

Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones

BACKGROUND

Nephrolithiasis is a common urological disease worldwide. Extracorporeal shock wave lithotripsy (ESWL) has been used for the treatment of renal stones since the 1980s, while retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) are newer, more invasive treatment modalities that may have higher stone-free rates. The complications of RIRS and PCNL have decreased owing to improvement in surgical techniques and instruments. We re-evaluated the best evidence on this topic in an update of a Cochrane Review first published in 2014.

OBJECTIVES

To assess the effects of extracorporeal shock wave lithotripsy compared with percutaneous nephrolithotomy or retrograde intrarenal surgery for treating kidney stones.

SEARCH METHODS

We performed a comprehensive search in CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov with no restrictions on language or publication status. The latest search date was 6 December 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs that compared ESWL with PCNL or RIRS for kidney stone treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies, extracted data, and assessed risk of bias. Our primary outcomes were treatment success rate at three months (defined as residual fragments smaller than 4 mm, or as defined by the study authors), quality of life (QoL), and complications. Our secondary outcomes were retreatment rate, auxiliary procedures rate, and duration of hospital stay. We performed statistical analyses using a random-effects model and independently rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 31 trials involving 3361 participants (3060 participants completed follow-up). Four trials were only available as an abstract. Overall mean age was 46.6 years and overall mean stone size was 13.4 mm. Most participants (93.8%) had kidney stones measuring 20 mm or less, and 68.9% had lower pole stones. ESWL versus PCNL ESWL may have a lower three-month treatment success rate than PCNL (risk ratio [RR] 0.67, 95% confidence interval [CI] 0.57 to 0.79; I2 = 87%; 12 studies, 1303 participants; low-certainty evidence). This corresponds to 304 fewer participants per 1000 (397 fewer to 194 fewer) reporting treatment success with ESWL. ESWL may have little or no effect on QoL after treatment compared with PCNL (1 study, 78 participants; low-certainty evidence). ESWL probably leads to fewer complications than PCNL (RR 0.62, 95% CI 0.47 to 0.82; I2 = 18%; 13 studies, 1385 participants; moderate-certainty evidence). This corresponds to 82 fewer participants per 1000 (115 fewer to 39 fewer) having complications after ESWL. ESWL versus RIRS ESWL may have a lower three-month treatment success rate than RIRS (RR 0.85, 95% CI 0.78 to 0.93; I2 = 63%; 13 studies, 1349 participants; low-certainty evidence). This corresponds to 127 fewer participants per 1000 (186 fewer to 59 fewer) reporting treatment success with ESWL. We are very uncertain about QoL after treatment; the evidence is based on three studies (214 participants) that we were unable to pool. We are very uncertain about the difference in complication rates between ESWL and RIRS (RR 0.93, 95% CI 0.63 to 1.36; I2 = 32%; 13 studies, 1305 participants; very low-certainty evidence). This corresponds to nine fewer participants per 1000 (49 fewer to 48 more) having complications after ESWL.

AUTHORS' CONCLUSIONS

ESWL compared with PCNL may have lower three-month success rates, may have a similar effect on QoL, and probably leads to fewer complications. ESWL compared with RIRS may have lower three-month success rates, but the evidence on QoL outcomes and complication rates is very uncertain. These findings should provide valuable information to aid shared decision-making between clinicians and people with kidney stones who are undecided about these three options.

Ureteroscopy in Patients with Urinary Diversion: Outcomes and Lessons Learned from Two European Centres

Background

Ureteroscopy (URS) in patients with urinary diversion is technically challenging. Common difficulties include anastomotic strictures, tortuosity, and failure to cannulate the ureteric orifice. There are few studies reporting outcomes in this special population.

Objective

Our aim was to report outcomes at two tertiary centres in Europe.

Design setting and participants

A multicentre retrospective cohort study was conducted between 2010 and 2022.

Intervention

URS (antegrade and retrograde) procedures carried out in patients with urinary diversions.

Outcome measurements and statistical analysis

Outcomes of interest included success at cannulating the ureteric orifice, stone-free rate (SFR), and complications. A logistic regression analysis was performed to identify potential predictors for success at cannulating the ureteric orifice and success at completing the intended procedure in a single session.

Results and limitations

Fifty patients underwent 72 URS procedures, with most (86%) undergoing a retrograde approach. The majority (82%) of patients had undergone ileal conduit. Wallace was the commonest anastomosis type (64%). Ureteric anastomosis was cannulated successfully in 81% of cases. The most common reason for cannulation failure was the inability to identify the ureteric orifice (11%). A multivariable analysis revealed that an endourologist performing the case was associated with a significantly greater likelihood of cannulation success compared with consultants (odds ratio 25.9, p < 0.001). The mean operative time and hospital stay were 49 min (range: 11-126) and 1 d (range: 0-10), respectively. SFRs were 75% (zero fragments) and 81% (residual fragments ≤2 mm). No intraoperative complications were recorded. The overall postoperative complication rate was 6%. This study is limited by its retrospective status.

Conclusions

Endourological experience increases the likelihood of successful ureteric cannulation and procedural success. A low complication rate can be achieved despite this being a population with often multiple comorbidities.

Patient summary

Patients with previous bladder reconstructive surgery can undergo ureteroscopy with good outcomes. Surgeon experience increases the likelihood of treatment success.

Safety and efficacy of extracorporeal shock wave lithotripsy vs. flexible ureteroscopy in the treatment of urinary calculi: A systematic review and meta-analysis

Objective

This study aims to compare the safety and efficacy of extracorporeal shock wave lithotripsy (SWL) and flexible ureteroscopy lithotripsy (f-URS) in treating urinary tract stones.

Methods

We systematically searched PubMed, Embase, and Cochrane for literature comparing SWL with f-URS. The primary outcomes we focused on were stone-free rate (SFR) and complications; the secondary outcomes were operation time, hospital stay, retreatment rate, number of sessions, and auxiliary procedures rate. We used ReviewManager version 5.4.1 and STATA version 14.2 for meta-analysis.

Results

Seventeen studies with a total of 2,265 patients were included in the meta-analysis, including 1,038 patients in the SWL group and 1,227 patients in the f-URS group. The meta-analysis indicated that patients in the f-URS group had higher SFR than those in the SWL group [odds ratio (OR): 2.00, 95% confidence interval (CI): 1.29–3.12, p = 0.002]. In addition, we found no significant difference in complications (OR: 1.08, 95% CI: 0.85–1.37) between the two treatments. Also, we found that the retreatment rate and the auxiliary procedure rate in the f-URS group were significantly lower than those in the SWL group (OR: 0.08, 95% CI: 0.02–0.24, p &lt; 0.00001; OR: 0.30, 95% CI: 0.11–0.83, p = 0.02). Moreover, the number of sessions in the f-URS group was significantly lower than that in the SWL group [mean difference (MD): −1.96, 95% CI: −1.55 to −0.33, p = 0.003]. However, the operation time and hospital stay in the f-URS group were significantly longer than those in the SWL group (MD: 11.24, 95% CI: 3.51–18.56, p = 0.004; MD: 1.14, 95% CI: 0.85–1.42, p &lt; 0.00001).

Conclusion

For 1–2-cm urinary stones, f-URS can achieve a higher SFR than SWL while having a lower retreatment rate, number of sessions, and auxiliary procedure rate. For urinary stones &lt;1 cm, there was no significant difference in SFR between SWL and f-URS groups. The SWL group has a shorter operative time and hospital stay than the f-URS group.

Are the current nomograms sufficient to predict shockwave lithotripsy outcomes?

INTRODUCTION AND OBJECTIVES

To investigate factors affecting SWL outcomes, validate three current nomograms (Kim JK, Triple D and S3HoCKwave) and compare the predictive ability of the nomograms for SWL outcomes in upper urinary tract stones.

PATIENTS AND METHODS

Medical records of patients with renal and proximal ureteral stones treated with SWL between March 2013 and October 2020 were retrospectively reviewed. Factors affecting SWL success were analyzed with multivariate logistic regression analysis and the three predictive scoring systems compared with the area under the curve (AUC).

RESULTS

A total of 580 patients were included in our study. The overall stone free rate was 61% and 144/580 patients (24.8%) were stone free after one session. In multivariate logistic regression analysis, stone location at upper calyx (OR:2.988; 95%Cl: 1.350-6.612; p = 0.007), middle calyx (OR:3.036; 95%Cl: 1.472-6.258; p = 0.003), and lower calyx (OR:2.131; 95%Cl: 1.182-3.839; p = 0.012), as well as number of stones (OR:1.663; 95%Cl: 1.140-2.425; p = 0.008), maximum diameter of stone (OR:1.156; 95%Cl: 1.098-1.217; p < 0.001) and maximum Hounsfield Unit (OR:1.001; 95%Cl: 1.001-1.002; p < 0.001) were independent risk factors of SWL failure. The AUCs of the Kim JK, Triple D and S2HoCKwave scores for predicting SWL success were 0.678, 0.548, and 0.626 respectively.

CONCLUSIONS

Stone location, number, maximal diameter, and maximum HU were independent predictive factors for SWL outcome in the treatment of upper urinary tract stones. Current nomograms, "Kim JK nomogram", "Triple D score" and "S3HoCKwave score" can predict treatment success after SWL, but all of them have poor discrimination according to AUC analysis.