Endourology and Stones Comparison Between Extracorporeal Shock Wave Lithotripsy and Ureteroscopic Lithotripsy for Treating Large Proximal Ureteral Stones: A Meta-analysis Xin Cui, Fan Ji, Hao Yan, Tong-wen Ou, Chun-song Jia, Xin-zhou He, Wei Gao, Qi Wang, Bo Cui, and Jiang-tao Wu OBJECTIVE
To compare extracorporeal shock wave lithotripsy (ESWL) and ureteroscopic lithotripsy (URSL) in terms of efﬁcacy, complications, and overall efﬁciency in the management of proximal ureteral calculi. ESWL and URSL are the 2 most common modalities for treating ureteral stones. Previous studies and meta-analyses suggest that for stones 10 mm is not as clear. The literature was reviewed in the databases, and resulting reports were screened for relevance. This process yielded 10 articles, which were analyzed in terms of the initial stone-free rate (primary outcome measure) compared between the 2 treatment modalities. Pretreatment rate, operation time, auxiliary procedure rate, and complication rate constituted secondary measures in the analysis. A statistically higher initial stone-free rate was demonstrated for URSL compared with ESWL (odds ratio [OR] ¼ 0.349; 95% conﬁdence interval [CI] ¼ 0.183-0.666; P ¼ .001). ESWL showed a statistically higher retreatment rate compared with URSL (OR ¼ 7.192; 95% CI ¼ 4.93410.482; P 10 mm) proximate ureteral stones, URSL tends to be more effective than ESWL, yet without adding signiﬁcant risk. UROLOGY 85: 748e756, 2015. 2015 Elsevier Inc.
rolithiasis is an extremely common health condition, with a reported incidence ranging from 11% to 13% of men and 5.6% to 7.0% of women by the age of 70 years.1,2 Common symptoms of ureteral stones include renal colic, dark or bloody urine, painful urination, nausea, vomiting, and fever. When conservative or medical management fails, the 2 most common treatments are extracorporeal shock wave lithotripsy (ESWL) and ureteroscopic lithotripsy (URSL).3 ESWL uses high-energy sound waves projected from
Xin Cui and Fan Ji contributed equally to this work. Financial Disclosure: The authors declare that they have no relevant ﬁnancial interests. From the Department of Urology, Xuanwu Hospital, Capital Medical University, Beijing, China Address correspondence to: Tong-wen Ou, M.D., Ph.D., Department of Urology, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Beijing 100053, China. E-mail: [email protected]
Submitted: July 31, 2014, accepted (with revisions): November 2, 2014
ª 2015 Elsevier Inc. All Rights Reserved
outside the body through the intervening tissue to break up the stone with no need to insert an instrument through any tissue.2,4 In contrast, URSL depends on a ureteroscope inserted into the affected ureter by way of the urethra and bladder.2,4 In addition to a camera and other operating equipment, a lithotripsy-capable device, such as a laser, is passed through the ureteroscope to breakup the stone.2,4 Frequently cited advantages of ESWL include noninvasiveness, safety, and a lack of need for anesthesia.5 ESWL does not require signiﬁcant surgical skills and can be performed as an outpatient procedure.6 ESWL, however, has a lower success rate compared with ureteroscopic methods, particularly for stones that are large (>1 cm) and proximal, leading to higher rates of retreatment.7e9 Additionally, ESWL is not available in all centers. In contrast, the initial success rate of URSL is higher than that of ESWL.2 However, URSL requires http://dx.doi.org/10.1016/j.urology.2014.11.041 0090-4295/15
considerable surgical skill and anesthesia and is associated with complications such as postoperative bleeding, thrombosis and emboli, infection, and ureteral stricture.2 A limited number of prospective studies comparing ESWL and URSL are available, and most published reports are retrospective in design.10 A recent meta-analysis of several randomized controlled trials (RCTs) suggested that ESWL is safer and has comparable efﬁcacy to URSL for stones 1 cm.2 The aim of the present meta-analysis was to compare ESWL and URSL in terms of efﬁcacy, complications, and overall efﬁciency for the treatment of large proximal ureteral stones.
METHODS Literature Review The literature was reviewed using the method of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.12 Peer-reviewed articles were identiﬁed in MEDLINE, Cochrane, EMBASE, and Google Scholar. The searches were conducted up to May 15, 2014, using the following key phrases: “Proximal ureteral stones;” “proximal ureteral calculi;” “upper ureteral calculi/ureterolithiasis;” “extracorporeal shock wave lithotripsy,” “ESWL;” “ureteroscopy;” and “ureteroscopic lithotripsy.” Other possibly relevant studies were also hand-searched from the reference lists of relevant case report, reviews, and meta-analyses. Reviewers then scanned the resulting reference lists to evaluated relevance. Subsequently, reports were screened for removal of duplicates. Those reports meeting the requirements were evaluated to determine their eligibility. The procedure was carried out by 2 independent reviewers. In cases of disagreement or uncertainty between the 2 reviewers, a third reviewer was consulted.
Selection Criteria Studies from the search were selected into the review if they were RCTs or 2-arm prospective studies. Letters, comments, editorials, and case reports were excluded, as were articles not evaluating primary outcomes and those reporting outcomes in terms of quality of life or cost effectiveness. To be included, reports needed to involve patients with large (1-2.5 cm) proximal ureteric calculi, whereas patients with distal ureteric or small stones (