Slow vs rapid delivery rate shock wave lithotripsy for pediatric renal urolithiasis: a prospective randomized study

Which frequency is better for pediatric shock wave lithotripsy? Low intermediate or high: A systematic review and meta-analysis

Background

To explore the optimal frequency for pediatric extracorporeal shock wave lithotripsy (ESWL) in the treatment of upper urinary stones.

Methods

A systematic literature search was undertaken using PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials databases to identify eligible studies published before January 2023. Primary outcomes were perioperative efficacy parameters, including ESWL time, anesthesia time for ESWL sessions, success rates after each session, additional interventions needed, and treatment sessions per patient. Secondary outcomes were postoperative complications and efficiency quotient.

Results

Four controlled studies involving 263 pediatric patients were enrolled in our meta-analysis. In the comparison between the low-frequency and intermediate-frequency groups, we observed no significant difference as regards anesthesia time for ESWL session (WMD = −4.98, 95% CI −21.55∼11.58, p = 0.56), success rates after ESWL sessions (first session: OR = 0.02 95%CI −0.12∼0.17, p = 0.74; second session: OR = 1.04 95%CI 0.56∼1.90, p = 0.91; third session: OR = 1.62 95%CI 0.73∼3.60, p = 0.24), treatment sessions needed (WMD = 0.08 95%CI −0.21∼0.36, p = 0.60), additional interventions after ESWL (OR=0.99 95%CI 0.40∼2.47, p = 0.99) and rates of Clavien grade 2 complications (OR = 0.92 95%CI 0.18∼4.69, p = 0.92). However, the intermediate-frequency group may exhibit potential benefits in Clavien grade 1 complications. In the comparison between intermediate-frequency and high-frequency, the eligible studies exhibited higher success rates in the intermediate-frequency group after the first session, the second session and the third session. More sessions may be required in the high-frequency group. With respect to other perioperative, postoperative parameters and major complications, the results were similar.

Conclusions

Intermediate-frequency and low-frequency had similar success rates and seemed to be the optimal frequency for pediatric ESWL. Nevertheless, future large-volume, well-designed RCTs are awaited to confirm and update the findings of this analysis.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022333646.

Complication rate after pediatric shock wave lithotripsy according to Clavien-Dindo grading system: results from a systematic review and meta-analysis of the existing literature

PURPOSE

Shockwave lithotripsy (SWL) is a minimally invasive technique utilized for renal and ureteric stones in children. Despite being considered safe, certain complications have been recorded. We performed this systematic review and meta-analysis to provide a pooled analysis of Clavien-Dindo graded complications after SWL in children.

METHODS

MEDLINE/PubMed, Scopus and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were screened from inception to 12/02/2022 by two authors independently. Only randomized controlled trials providing Clavien-Dindo classification or relevant clinical information were considered eligible. Overall complications were calculated using the aggregate number of each complication divided by the total number of patients in studies with data.

RESULTS

Pooled analysis revealed that from children treated with SWL, 27.7% [95% CI 13.1-49.4] suffered Clavien I complications, 4.9% [95% CI 3.1-7.6] Clavien II complications, 2.7% [95% CI 1.6-4.7] Clavien III complications, 2.3% [95% CI 1.3-4] Clavien IV complications, while no Clavien V complications were recorded. In total, 28.1% [95% CI 15.6-45.3] of children suffered minor complications (Clavien-Dindo I-II), while 3% [95% CI 1.8-5] major complications (Clavien-Dindo III-V). Pooled analysis revealed that 10.7% [95% CI 3.2-30.1] of patients suffered macroscopic hematuria, 7.3% [95% CI 2.1-22.7] pain, 5.5% [95% CI 3.3-9] steinstrasse, 5.3% [95% CI 3-9.3] fever, 2.2% [95% CI 0.8-5.6] sepsis, 1.1% [95% CI 0.3-3.7] urinoma, 1% [95% CI 0.4-2.7] symptomatic hematoma and 1% [95% CI 0.3-2.7] asymptomatic hematoma. Need for re-treatment was 42.6% [95% CI 31.4-54.7] and need for auxiliary procedures was 11.8% [95% CI 8.5-16.1].

CONCLUSION

SWL is an irreplaceable tool for treating urolithiasis in children. Although a minimally invasive technique, parents and children should be adequately informed about the risk of minor/major complications.

Complication rate after pediatric shock wave lithotripsy according to Clavien-Dindo grading system: results from a systematic review and meta-analysis of the existing literature

PURPOSE

Shockwave lithotripsy (SWL) is a minimally invasive technique utilized for renal and ureteric stones in children. Despite being considered safe, certain complications have been recorded. We performed this systematic review and meta-analysis to provide a pooled analysis of Clavien-Dindo graded complications after SWL in children.

METHODS

MEDLINE/PubMed, Scopus and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were screened from inception to 12/02/2022 by two authors independently. Only randomized controlled trials providing Clavien-Dindo classification or relevant clinical information were considered eligible. Overall complications were calculated using the aggregate number of each complication divided by the total number of patients in studies with data.

RESULTS

Pooled analysis revealed that from children treated with SWL, 27.7% [95% CI 13.1-49.4] suffered Clavien I complications, 4.9% [95% CI 3.1-7.6] Clavien II complications, 2.7% [95% CI 1.6-4.7] Clavien III complications, 2.3% [95% CI 1.3-4] Clavien IV complications, while no Clavien V complications were recorded. In total, 28.1% [95% CI 15.6-45.3] of children suffered minor complications (Clavien-Dindo I-II), while 3% [95% CI 1.8-5] major complications (Clavien-Dindo III-V). Pooled analysis revealed that 10.7% [95% CI 3.2-30.1] of patients suffered macroscopic hematuria, 7.3% [95% CI 2.1-22.7] pain, 5.5% [95% CI 3.3-9] steinstrasse, 5.3% [95% CI 3-9.3] fever, 2.2% [95% CI 0.8-5.6] sepsis, 1.1% [95% CI 0.3-3.7] urinoma, 1% [95% CI 0.4-2.7] symptomatic hematoma and 1% [95% CI 0.3-2.7] asymptomatic hematoma. Need for re-treatment was 42.6% [95% CI 31.4-54.7] and need for auxiliary procedures was 11.8% [95% CI 8.5-16.1].

CONCLUSION

SWL is an irreplaceable tool for treating urolithiasis in children. Although a minimally invasive technique, parents and children should be adequately informed about the risk of minor/major complications.

Scoping review of recent evidence on the management of pediatric urolithiasis: summary of meta-analyses, systematic reviews and relevant randomized controlled trials

This scoping review aimed to evaluate and summarize the recent 10 year pediatric urolithiasis literature with a particular focus on systematic reviews, randomized-controlled trials (RCT) and meta-analysis. The systematic literature search performed on September 1, 2021, restricted to the recent 10 years, focused on pediatric urolithiasis that are RCTs, meta-analysis and systematic reviews. The summarized literature included etiology, diagnostics, medical and surgical management. GRADE criteria are used to evaluate and standardize the reporting of evidence quality. A total of 33 relevant articles were included. The recent high-level studies included topics of genetic and diet association with pediatric stone formation, diagnostic assessment, medical management intervention including medical dissolution and expulsion therapy. The study extended to include the efficacy and safety of extracorporeal lithotripsy, percutaneous nephrolithotomy and retrograde intrarenal surgery. However, evidence quality was ranked "very-low" or "low". Based on the GRADE criteria downgrading of the quality level was due to heterogeneity and low precision. A majority of the RCTs were categorized as having a "high" to "uncertain" risk of bias. The relevant RCTs, meta-analyses and systematic reviews within the past decade are of low quality. Consequently, the research provided no clear evidence-based recommendations for managing pediatric urolithiasis. More rigorous research and high-quality studies are needed to determine the best practices.

Extremely slow, half-number shockwave lithotripsy for ureteral stones

To elucidate and compare the efficacy and safety of the reduced (30 shocks/min with 1200 shocks/session) and standard protocols (60 shocks/min with 2400 shocks/session) of extracorporeal shockwave lithotripsy (SWL) for ureteral stones treatment. This study was a retrospective review of 2410 SWL procedures with reduced or standard protocols (groups R and S) in 1106 patients for ureteral stones between March 2014 and March 2021. The primary outcome was treatment success, defined as the absence of residual fragments on ultrasonography and plain radiography within 30 and 90 days. A multivariate logistic regression and propensity score matching analysis evaluated the association between the reduced protocol and treatment success. This study included 311 and 544 patients in the reduced (R) and standard (S) protocol groups, respectively. The patient's characteristics were comparable, excluding the lithotripter machine. No significant difference was observed between groups R and S in treatment success rates within 30 (63.3 vs. 65.8%, p = 0.50) and 90 days (88.7 vs. 91.5%, p = 0.18). The multivariate analysis indicated no significant association between reduced protocol and treatment success within 30 and 90 days (p = 0.44 and p = 0.68, respectively). Propensity score matching showed no significant difference in the treatment success rates within 30 and 90 days. The Extremely slow, half number protocol outcomes are comparable to those of the standard protocol for treating ureteral stones.

Which frequency is better for pediatric shock wave lithotripsy? Intermediate or low: a prospective randomized study

PURPOSE

Shock wave lithotripsy (SWL) is the first option in the treatment of pediatric kidney stones; however, optimal frequency is still uncertain. The aim of this study was to compare low frequency [60 shocks per minute (SWs/min)] and intermediate frequency [90 SWs/min] in terms of lithotripsy success, complications, cardiac arrhythmia, anesthesia time, secondary procedures, and efficiency quotient (EQ) in children.

METHODS

Seventy-eight consecutive children who received SWL for radiopaque renal stones between July 2016 and January 2020 were randomly divided into two groups: Group 60 (SWL frequency: 60 SWs/min) and Group 90 (SWL frequency: 90 SWs/min). After exclusion (remaining 71 children), Group 60 (n = 38) and Group 90 (n = 33) were compared using univariate analysis.

RESULTS

The median age of children (37 girls, 34 boys) was 5 (1-16) years. Patient demographics and stone features were similar between the groups. Success rate after the last SWL session was 81.6% (n = 31) for Group 60 and 87.9% (n = 29) for Group 90 (p = 0.527). Stone-free rate after the first, second, and third sessions was 42.1%, 18.4%, and 21.1% for Group 60 and 48.5%, 27.3%, and 12.1% for Group 90, respectively. Additional treatment rate was similar between the groups. In Group 60, the EQ was 57.83, and it was 64.07 in Group 90. Median total anesthesia time was significantly longer in Group 60 (74.5 min) than in Group 90 (32 min; p < 0.001).

CONCLUSION

Intermediate frequency and low-frequency pediatric SWL have similar success rates; however, intermediate-frequency SWL has a shorter anesthesia time.

What is the optimal frequency in shock wave lithotripsy for pediatric renal stones? A prospective randomized study

The aim of the study is to compare the effects of varying frequency rates (60, 90, and 120 SWs/min) on the stone free rate and complication rates of pediatric SWL. 75 children with renal stones were divided into 3 groups depending on the SW frequency applied. Group 1. low (60 SWs/min), Group 2. intermediate (90 SWs/min) and Group 3. high (120 SWs/min) frequency. Patient demographics (age, gender, BMI), stone (location, size, laterality), and SWL (total number of sessions, shock waves, anesthesia time) related parameters were documented. Postoperative success, complication rates, and the need for additional interventions were comparatively evaluated. There was no significant difference regarding the patient demographics, stone characteristics, SWL parameters, postoperative complication rates, need for additional interventions as well as efficacy quotient between all (p > 0.05). The stone free rates were significantly lower in cases with high frequency, whereas there was no statistically significant difference between the intermediate and low frequency groups (p > 0.05). Although not statistically significant; low frequency application may be more advantageous than intermediate as lower number of high energy shock waves required which may cause less tissue damage. On the other hand, despite lack of a statistically significant difference, relatively longer anesthesia time may constitute a disadvantage for lower frequency. We believe that considering the growing nature of the child kidney application of low frequency (60 SWs/min) will be advantageous. However, we believe that further studies with larger series of cases are needed to make a clear-cut differentiation between low and intermediate SW applications.

Imaging modalities and treatment of paediatric upper tract urolithiasis: A systematic review and update on behalf of the EAU urolithiasis guidelines panel

BACKGROUND

Prompt diagnosis and treatment of paediatric urolithiasis are required to avoid long term sequelae of renal damage.

OBJECTIVE

To systematically review the literature regarding the diagnostic imaging modalities and treatment approaches for paediatric urolithiasis.

STUDY DESIGN

PubMed, Science Direct, Scopus and Web of Science were systematically searched from January 1980-January 2019. 76 full-text articles were included.

RESULTS

Ultrasound and Kidney-Ureter-Bladder radiography are the baseline diagnostic examinations. Non-contrast Computed Tomography (CT) is the second line choice with high sensitivity (97-100%) and specificity (96-100%). Magnetic Resonance Urography accounts only for 2% of pediatric stone imaging studies. Expectant management for single, asymptomatic lower pole renal stones is an acceptable initial approach, especially in patients with non-struvite, non-cystine stones<7 mm. Limited studies exist on medical expulsive therapy as off-label treatment. Extracorporeal shock wave lithotripsy (SWL) is the first-line treatment with overall stone free rates (SFRs) of 70-90%, retreatment rates 4-50% and complication rates up to 15%. Semi-rigid ureteroscopy is effective with SFRs of 81-98%, re-treatment rates of 6.3-10% and complication rates of 1.9-23%. Flexible ureteroscopy has shown SFRs of 76-100%, retreatment rates of 0-19% and complication rates of 0-28%. SFRs after first and second-look percutaneous nephrolithotomy (PNL) are 70.1-97.3% and 84.6-97.5%, respectively with an overall complication rate of 20%. Open surgery is seldom used, while laparoscopy is effective for stones refractory to SWL and PNL. Limited data exist for robot-assisted management.

CONCLUSIONS

In the initial assessment of paediatric urolithiasis, US is recommended as first imaging modality, while non-contrast CT is the second option. SWL is recommended as first line treatment for renal stones <20 mm and for ureteral stones<10 mm. Ureteroscopy is a feasible alternative both for ureteral stones not amenable to SWL as well as for renal stones <20 mm (using flexible). PNL is recommended for renal stones >20 mm.

Dual-frequency setting for urinary stone fragmentation during shock wave lithotripsy: an in vitro study

Extracorporeal shock wave lithotripsy (SWL) is less invasive compared to the other invasive modalities of stone treatment that are gaining popularity. Hence, methods to improve the efficacy of SWL are desirable. We studied the effectiveness of dual frequency on the efficacy of stone fragmentation, but minimizing treatment time. A phantom 10 mm spherical BegoStone was fragmented in vitro in a kidney model using an electromagnetic lithotripter (Storz MODULITH^®SLX-F2). A total of 78 stones were fragmented each with 3000 shocks at 60 Hz or 120 Hz or a dual frequency (DF) of 60-120 Hz. For the DF setting, the first 1000 shocks were delivered at 60 Hz and the next 2000 at 120 Hz. Total weight and number of significant fragments of > 3 mm (TWSF and TNSF, respectively) and also > 2 mm was measured. Results: The mean TWSF was 0.1, 0.16, and 0.08 g for 60 Hz, 120 Hz, and DF 60-120 Hz, respectively. The TWSF of DF 60-120 Hz was significantly lower than that of 120 Hz (p = 0.02), but same as the 60 Hz (p = 0.32). The mean TNSF of > 3 mm was 2.6, 3.0, and 2.0 for 60 Hz, 120 Hz, and DF 60-120 Hz, respectively, without significant differences between each setting. However, increasing trend of TWSF, TW2 mm and TN2 mm was seen in the order of DF, 60 Hz and 120 Hz (p = 0.019, p = 0.004 and 0.017, respectively). Treatment time for 60 Hz, 120 Hz, and DF 60-120 Hz was 50, 25, and 34 min, respectively. Dual-frequency setting produced effective stone fragmentation compared to the recommended 60 Hz, while decreasing treatment time. DF variation is one other factor that may be tailored for effective stone comminution and needs clinical evaluation.

Reprint - Medical and surgical interventions for the treatment of urinary stones in children: A Cochrane Review

INTRODUCTION

We performed systematic review to assess the effects of different medical and surgical management of urinary stones in children.

METHODS

We performed a comprehensive search using multiple databases (MEDLINE, EMBASE, Cochrane Register of Controlled Trials), trials registries (World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov), and abstract proceedings of major urological and pediatric urology meetings, with no restrictions on the language of publication or publication status, up until December 2017. We included all randomized controlled trials (RCTs) and quasi-RCTs. Two review authors independently assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias in accordance with the Cochrane "Risk of bias" tool. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to GRADE.

RESULTS

We included 14 studies with a total of 978 randomized participants in our review, informing seven comparisons with shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy (regardless of the type of lithotripsy), open stone surgery, and medical expulsive therapy. There was very low quality of evidence in the most comparisons with regards to the effectiveness and adverse events for the treatment of pediatric upper renal tract stone disease.

CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children. There is a critical need for better-quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Medical and surgical interventions for the treatment of urinary stones in children

BACKGROUND

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

OBJECTIVES

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of percutaneous nephrolithotripsy on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

AUTHORS' CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Medical and surgical interventions for the treatment of urinary stones in children

BACKGROUND

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

OBJECTIVES

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

AUTHORS' CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Is mini-percutaneous nephrolithotomy a safe alternative to extracorporeal shockwave lithotripsy in pediatric age group in borderline stones? a randomized prospective study

PURPOSE

The extracorporeal shockwave lithotripsy (ESWL) remains the most common first line of treatment for renal stones in the pediatric population. The purpose of this study is to evaluate and compare the outcomes of the ESWL and mini-percutaneous nephrolithotomy (mini-PCNL).

PATIENTS AND METHODS

A total of 108 patients younger than 12 years of age with 1-2 cm single renal stone (pelvic or calyceal) were randomized into two groups, each containing 54 patients. Patients in group A were subjected to mini-PCNL using 16.5 Fr percutaneous sheath while those in group B underwent ESWL using Dornier Compact Sigma.

RESULTS

The stone-free rate (SFR) after first session was 88.9% (48 cases) and 55.6% (30 cases) for groups A and B, respectively. The difference is highly statistically significant P = 0.006. Two patients (3.7%) in group A needed 2nd session of PCNL, while 18 patients (33.3%)in group B needed a 2nd session, of theses 18 patients six patients needed a 3rd session of ESWL. After the third session of ESWL and second look PCNL the stone-free rates were 92.59% (50 cases) and 88.89% (48 cases) for groups A and B, respectively, (P = 0.639), which is statistically insignificant. The mean hospital stay and fluoroscopy exposure were significantly longer in the mini-PCNL group. The complication rate in groups A and group B were (22.2%) and (14.8%), respectively, which is statistically insignificant (P = 0.484).

CONCLUSIONS

According to Clavien grade of complications mini-PCNL is a safe procedure, and after three session of ESWL, mini-PCNL has a similar stone-free rate with a lower retreatment rate. However, the mini-PCNL has more radiation exposure, and requires a longer hospital stay.

Comparison of intermediate- and low-frequency shock wave lithotripsy for pediatric kidney stones

The aim of the study to compare low and intermediate shock wave frequency rates in terms of success and complications for treating pediatric kidney stones. This retrospective study was performed on 58 consecutive pediatric patients (24 girls, 34 boys) who underwent shock wave lithotripsy (SWL) for kidney stones with an electrohydraulic lithotripter between April 2014 and March 2016. In the first year, all children underwent SWL with a frequency of 90 SWs/min as an intermediate frequency (Group 90), and in the second year all children were treated by SWL using 60 SWs/min as a low frequency (Group 60). The mean age of the patients was 5.87 ± 4.5 years. There were no significant differences in age, gender, stone characteristics and SWL energy level between the groups. Stone-free status was achieved in 14, 6 and 4 children in group 60; and in 10, 6 and 4 children in group 90 after one, two and three sessions, respectively. The stone-free rates were 80 and 74.1% after SWL and 90 and 88.9% after additional treatment in groups 60 and 90, respectively. The total median shock pulses were 2000 and 3600 in groups 60 and 90, respectively (p = 0.115). Efficiency quotients were 51.93 and 44.47 in groups 60 and 90, respectively. The mean total anesthesia times and complication rates did not differ between the groups. The low and intermediate frequency of SWL provided similar stone clearance in pediatric renal stones with similar anesthesia times. However, low SWL tended to need fewer shock pulses (2000/3600) for stone clearance, but the trend was not significant.

Comparison of High, Intermediate, and Low Frequency Shock Wave Lithotripsy for Urinary Tract Stone Disease: Systematic Review and Network Meta-Analysis

OBJECTIVES

To perform a systematic review and network meta-analysis of randomized controlled trials (RCTs) to determine the optimal shock wave lithotripsy (SWL) frequency range for treating urinary stones, i.e., high-frequency (100-120 waves/minute), intermediate-frequency (80-90 waves/minute), and low-frequency (60-70 waves/minute) lithotripsy.

MATERIALS AND METHODS

Relevant RCTs were identified from electronic databases for meta-analysis of SWL success and complication rates. Using pairwise and network meta-analyses, comparisons were made by qualitative and quantitative syntheses. Outcome variables are provided as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Thirteen articles were included in the qualitative and quantitative synthesis using pairwise and network meta-analyses. On pairwise meta-analyses, comparable inter-study heterogeneity was observed for the success rate. On network meta-analyses, the success rates of low- (OR 2.2; 95% CI 1.5-2.6) and intermediate-frequency SWL (OR 2.5; 95% CI 1.3-4.6) were higher than high-frequency SWL. Forest plots from the network meta-analysis showed no significant differences in the success rate between low-frequency SWL versus intermediate-frequency SWL (OR 0.87; 95% CI 0.51-1.7). There were no differences in complication rate across different SWL frequency ranges. By rank-probability testing, intermediate-frequency SWL was ranked highest for success rate, followed by low-frequency and high-frequency SWL. Low-frequency SWL was also ranked highest for low complication rate, with high- and intermediate-frequency SWL ranked lower.

CONCLUSIONS

Intermediate- and low-frequency SWL have better treatment outcomes than high-frequency SWL when considering both efficacy and complication.