Extracorporeal Shockwave Lithotripsy Compared with Ureteroscopy for the Removal of Small Distal Ureteral Stones

Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi

BACKGROUND

Ureteral stones frequently cause renal colic, and if left untreated, can lead to obstructive uropathy. Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy, with or without intracorporeal lithotripsy, are the most common interventions used to treat ureteral stones. ESWL treatment is less invasive than ureteroscopy, but has some limitations such as a high retreatment rate, and is not available in all centres. Recent advances in ureteroscopy have increased success rates and reduced complication rates.

OBJECTIVES

To examine evidence from randomised controlled trials (RCTs) on the outcomes of ESWL or ureteroscopy in the treatment of ureteric calculi.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), CINAHL, Clinicaltrials.gov, Google Scholar, reference lists of articles and abstracts from conference proceedings, all without language restriction.

SELECTION CRITERIA

RCTs that compared ESWL with ureteroscopic retrieval of ureteric stones were included in this review. Study participants were adults with ureteric stones requiring intervention. Published and unpublished sources were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed study quality, risk of bias, and extracted data. Statistical analyses were performed using the random-effects model. Results were expressed as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous data, both with 95% confidence intervals (CI).

MAIN RESULTS

Seven RCTs (1205 patients) were included in the review. Stone-free rates were lower in patients who underwent ESWL (7 studies, 1205 participants: RR 0.84, 95% CI 0.73 to 0.96) but re-treatment rates were lower in ureteroscopy patients (6 studies, 1049 participants: RR 6.18, 95% CI 3.68 to 10.38. ESWL-treated patients had less need for auxiliary treatment (5 studies, 751 participants: RR 0.43, 95% CI 0.25 to 0.74; fewer complications (7 studies, 1205 participants: RR 0.54, 95% CI 0.33 to 0.88); and shorter length of hospital stay (2 studies, 198 participants: MD -2.55 days, 95% CI -3.24 to -1.86).Three studies adequately described the randomisation sequence, three studies were unclear on how they randomised, while one study had a high risk of selection bias. All the studies had an unclear risk of performance bias and detection bias, while all had a low risk of attrition bias, reporting bias, or other sources of bias identified.

AUTHORS' CONCLUSIONS

Compared with ESWL, ureteroscopic removal of ureteral stones achieves a greater stone-free state, but with a higher complication rate and longer hospital stay.

Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi

BACKGROUND

Ureteral stones frequently cause renal colic, and if left untreated, can lead to obstructive uropathy. Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy, with or without intracorporeal lithotripsy, are the most common interventions used to treat ureteral stones. ESWL treatment is less invasive than ureteroscopy, but has some limitations such as a high retreatment rate, and is not available in all centres. Recent advances in ureteroscopy have increased success rates and reduced complication rates.

OBJECTIVES

To examine evidence from randomised controlled trials (RCTs) on the outcomes of ESWL or ureteroscopy in the treatment of ureteric calculi.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), CINAHL, Clinicaltrials.gov, Google Scholar, reference lists of articles and abstracts from conference proceedings, all without language restriction.

SELECTION CRITERIA

RCTs that compared ESWL with ureteroscopic retrieval of ureteric stones were included in this review. Study participants were adults with ureteric stones requiring intervention. Published and unpublished sources were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed study quality, risk of bias, and extracted data. Statistical analyses were performed using the random-effects model. Results were expressed as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous data, both with 95% confidence intervals (CI).

MAIN RESULTS

Seven RCTs (1205 patients) were included in the review. Stone-free rates were lower in patients who underwent ESWL (7 studies, 1205 participants: RR 0.84, 95% CI 0.73 to 0.96) but re-treatment rates were lower in ureteroscopy patients (6 studies, 1049 participants: RR 6.18, 95% CI 3.68 to 10.38. ESWL-treated patients had less need for auxiliary treatment (5 studies, 751 participants: RR 0.43, 95% CI 0.25 to 0.74; fewer complications (7 studies, 1205 participants: RR 0.54, 95% CI 0.33 to 0.88); and shorter length of hospital stay (2 studies, 198 participants: MD -2.55 days, 95% CI -3.24 to -1.86).Three studies adequately described the randomisation sequence, three studies were unclear on how they randomised, while one study had a high risk of selection bias. All the studies had an unclear risk of performance bias and detection bias, while all had a low risk of attrition bias, reporting bias, or other sources of bias identified.

AUTHORS' CONCLUSIONS

Compared with ESWL, ureteroscopic removal of ureteral stones achieves a greater stone-free state, but with a higher complication rate and longer hospital stay.

Extracorporeal shockwave lithotripsy vs ureteroscopy as first-line therapy for patients with single, distal ureteric stones: a prospective randomized study

OBJECTIVE

To compare extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy (URS) as first-line treatments for patients with distal ureteric stones.

PATIENTS AND METHODS

In all, 273 patients with single, monolateral, radiopaque, distal ureteric stones of 0.5-1.5 cm were enrolled in a prospective randomized trial. Patients were randomized to undergo ESWL (137) or URS (136). The electromagnetic Modulith SLX lithotripter (Storz Medical, Switzerland) was used for ESWL and a semi-rigid ureteroscope was used for URS. Patients in both groups were compared for overall stone-free rates (SFRs), re-treatment rates, need for auxiliary procedures and complication rates. A subgroup analysis was performed in both groups according to stone size of ≤1 cm and >1 cm.

RESULTS

Patients in the ESWL group achieved a 92.70% overall SFR with a 44.88% re-treatment rate and an 11.02% auxiliary procedure rate. Complications occurred in 15.32% of patients treated with ESWL. Patients in the URS group achieved a 94.85% overall SFR with a re-treatment rate of 7.75% and an auxiliary procedure rate of 18.60%. Complications occurred in 19.11% of patients treated with URS. In the ESWL group, the need for re-treatments and for auxiliary procedures as well as the incidence of complications was significantly higher in patients with stones of >1 cm. In patients with stones of ≤1 cm treated with ESWL the need for re-treatments and for auxiliary procedures as well as the incidence of complications was significantly lower than for those treated with URS.

CONCLUSION

In centres where both techniques are available, ESWL should be the preferred treatment for patients with single distal ureteric stones of ≤1 cm and URS should be reserved for patients with stones of >1 cm.

Does stone dimension affect the effectiveness of ureteroscopic lithotripsy in distal ureteral stones?

OBJECTIVE

To investigate whether stone dimension is a restrictive factor for ureterorenoscopic procedures.

MATERIALS AND METHODS

A group of 416 patients who had undergone ureterorenoscopic pneumatic lithotripsy (URS-PL) for lower ureteral stones between January 1999 and June 2006 in our clinic had been evaluated retrospectively. Two hundred and seventy (270, 64.9%) patients were men and 146 (35.1%) were women. The mean age of the patients was 36.61 (+/- 12.43) years. Patients were grouped according to stone dimension; 193 patients with stones smaller than 1 cm being group 1 and 223 patients with stones > or = 1 cm in dimension being group 2. Stone-free rate, operative time and rate of complications of the groups were compared. Pearson's correlation test, chi2 test, Fischer's exact test and Student's t-test were used for the statistical analysis. The p value was accepted as being meaningful if p < 0.05.

RESULTS

For group 1, the mean operative time was 39.19 (+/- 18.33) min. Proximal stone migration in five and false passage formation in three patients was observed. Three patients were stone-free after a second session of URS-PL. The cumulative stone-free rate was 97.4% (188/193). For group 2, the mean operative time was 48.5 (+/- 11.31) min. About 208 (93.27%) patients were stone-free after the first session and an additional eight patients became stone-free after the second session of URS-PL. False passage, ureteral perforation, ureteral avulsion and stricture were observed in four, six, one and one patients, respectively. No proximal stone migration was observed. The cumulative stone-free rate was 96.86% (216/223).

CONCLUSIONS

The effectiveness of ureterorenoscopy (URS) in the treatment of distal ureteral stones was independent of stone dimension. However, the operative time was longer and the rate of perforation was higher in stones with a diameter > or = 1 cm. On the other hand, the migration rate was higher in stones < 1 cm in diameter. Generally speaking, there was no meaningful effect of stone dimension on complication rates.

Efficacy and safety of endoscopic treatment of ureteral stones in pediatric age

Ureteroscopy procedures in pediatric age are becoming more and more common thanks to the availability of smaller caliber instruments, and of improved endoscopic techniques. The efficacy of this procedure in pediatric age is still discussed nowadays. This paper aims at reviewing all cases of ureteral lithiasis treated by ureteroscopy plus intracorporeal lithotripsy (ULT), as well as verifying efficacy and safety of this procedure in pediatric age.

Materials and Methods

From July 2002 to May 2006, 37 patients (26 female, 11 male; mean age 7.4 years; range 2–17) were treated by ULT for ureteral stones: 30 in distal, 4 in middle and 3 in proximal ureter. Median size of stones was 7mm (range 3–13mm). Dilation of the ureteral meatus was necessary in 2 patients only. Endoscopic procedure was similar to adult patients. Outcomes were statistically compared with current literature data.

Results

In 36 (97.3%) out of 37 patients ULT proved successful. All patients having stones in distal (30) and middle (4) ureter were stone-free at the end of treatment. Stone migration into the kidney pelvis occurred in 1 patient with proximal ureter stones (66.7% stone-free rate): an ESWL treatment was therefore performed. 1 case only (2.7%) developed a perioperative complication (stone migration). Hematuria and flank pain in 4 patients (10.8%) were the most common reported post-operative complications. A stone-free state was confirmed at 1 and 3 months for all 36 patients. There was no evidence of ureteral strictures and/or ureteral refluxes.

Conclusions

Smaller caliber ureteroscopes confirmed ULT as the first-choice treatment procedure in children affected by ureteral lithiasis, thanks to its efficacy and safety.

Extra-corporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi

BACKGROUND

Ureteral stones frequently cause renal colic and if left untreated can cause obstructive uropathy. Extracorporeal Shock Wave Lithotripsy (ESWL) and ureteroscopy, with or without intracorporeal lithotripsy, are the two most commonly offered interventional procedures in these patients. ESWL treatment is less invasive but has some limitations such as a high retreatment rate and lack of availability in many centres. Advances in ureteroscopy over the past decade have increased the success rate and reduced complication rates.

OBJECTIVES

To examine evidence from randomised controlled trials (RCTs) on the outcomes of ESWL or ureteroscopy in the treatment of ureteric calculi.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library Issue 2, 2006), MEDLINE (1966 - March 2006), EMBASE (1980 - March 2006), reference lists of articles and abstracts from conference proceedings without language restriction.

SELECTION CRITERIA

RCTs comparing ESWL with ureteroscopic retrieval of ureteric stones were included. Participants were adults with ureteric stones requiring intervention. Published and unpublished sources were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or weighted mean difference (MD) for continuous data with 95% confidence intervals (CI).

MAIN RESULTS

Six RCTs (833 patients) were included. The stone-free rates were lower in the ESWL group (RR 0.84 95% CI 0.73 to 0.96). The retreatment rates were lower but not significant in the ureteroscopy group (RR 3.34 95% CI 0.82 to 13.62). The rate of complications was lower in the ESWL group (RR 0.48 95% CI 0.26 to 0.91). Length of hospital stay was less for ESWL treatment (MD -2.10 95% CI -2.55 to -1.64).

AUTHORS' CONCLUSIONS

Ureteroscopic removal of ureteral stones achieves a higher stone-free state but with a higher complication rate and a longer hospital stay.

Shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective study

We performed a prospective, non-randomised study to determine the appropriate first-line treatment modality for distal ureteral stones. Between 2003 and 2004, a total of 124 patients with distal ureteral calculi were entered into the study (mean age 48 years, 35 women and 99 men). Sixty-two patients were treated with shock wave lithotripsy (SWL) and 62 patients with ureteroscopy (URS). The average stone size was 6.9 mm (3-33 mm) for SWL and 7.2 mm (3-30 mm) for URS. The treatment decision depended on the patients' preference and clinical parameters (i.e. contraindications for anaesthesia). URS was performed under general anaesthesia, using semirigid 8 Fr instruments. SWL was performed under analgo-sedation using a Modulith SLX. Of patients treated with SWL, 84% had a treatment success within 7 days, 98% after URS. These results show a significant success (P=0.005) in favour of URS. The average in-patient stay after SWL was 3 days and for URS 4 days (not significant). The results show a high efficacy and a low complication rate for both modalities. The attained stone-free rate shows a significant advantage for primary URS.