What Are the Benefits and Harms of Ureteroscopy Compared With

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Platinum Priority – Review – Stone Disease

Editorial by XXX on pp. x–y of this issue

What are the Benefits and Harms of Ureteroscopy Compared with

Shock-wave Lithotripsy in the Treatment of Upper Ureteral

Stones? A Systematic Review

a b,c d e f,g

Tamsin Drake , Nikolaos Grivas , Saeed Dabestani , Thomas Knoll , Thomas Lam ,

g h,i j k l

Steven Maclennan , Ales Petrik , Andreas Skolarikos , Michael Straub , Christian Tuerk ,

m n,

Cathy Yuhong Yuan , Kemal Sarica *

a b

Department of Urology, Royal Bournemouth Hospital, Bournemouth, UK; Department of Urology, Hatzikosta General Hospital, Ioannina, Greece;

c d

Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Ska˚ne

University Hospital, Malmo¨, Sweden; Department of Urology, Sindelfingen-Boeblingen Medical Center, University of Tu¨bingen, Sindelfingen, Germany;

f g h

Department of Urology, Aberdeen Royal Infirmary, Aberdeen, Scotland; Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland; Department

i j

of Urology, Charles University, First Faculty of Medicine, Prague, Czech Republic; Department of Urology, Hospital Ceske Budejovice, Czech Republic; Second

Department of Urology, Sismanoglio Hospital, Athens Medical School, Athens, Greece; Department of Urology, Technical University Munich, Munich,

l m

Germany; Department of Urology, Hospital of the Sisters of Charity, Vienna, Austria; Division of Gastroenterology & Cochrane UGPD Group, Department of

Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada; Department of Urology, Dr. Lutfi Kirdar Research and Teaching Hospital,

Istanbul, Turkey

Article info Abstract

Article history: Context: Extracorporeal shock wave lithotripsy (SWL) and ureteroscopy (URS), with or

without intracorporeal lithotripsy, are the most common treatments for upper ureteric

Accepted April 12, 2017

stones. With advances in technology, it is unclear which treatment is most effective and/

or safest.

Associate Editor:

Objective: To systematically review literature reporting beneﬁts and harms of SWL and

J.-N. Cornu

URS in the management of upper ureteric stones.

Evidence acquisition: Databases including Medline, Embase, and the Cochrane library

Keywords: were searched from January 2000 to November 2014. All randomised controlled trials

(RCTs), quasi-randomised controlled trials, and nonrandomised studies comparing any

Shock wave lithotripsy

subtype or variation of URS and SWL were included. The primary beneﬁt outcome was

Ureteroscopy

stone-free rate (SFR). The primary harm outcome was complications. Secondary out-

Ureteral calculi

comes included retreatment rate, need for secondary, and/or adjunctive procedures. The

Urolithiasis Cochrane risk of bias tool was used to assess RCTs, and an extended version was used to

assess nonrandomised studies. Grading of Recommendations Assessment, Develop-

ment, and Evaluation was used to assess the quality of evidence.

Evidence synthesis: Five thousand-three hundred and eighty abstracts and 387 full-text

articles were screened. Forty-seven studies met inclusion criteria; 19 (39.6%) were RCTs.

No studies on children met inclusion criteria. URS and SWL were compared in 22 studies

(4 RCTs, 1 quasi-randomised controlled trial, and 17 nonrandomised studies). Meta-

analyses were inappropriate due to data heterogeneity. SFR favoured URS in 9/22

studies. Retreatment rates were higher for SWL compared with URS in all studies

but one. Longer hospital stay and adjunctive procedures (most commonly the insertion

of a JJ stent) were more common when primary treatment was URS. Complications were

* Corresponding author. Department of Urology, Dr. Lutﬁ Kirdar Kartal Research and Training

Hospital, Istanbul, Turkey. Tel. +90 216 441 39 00; Fax: +90 216 305 5110.

E-mail addresses: [email protected], [email protected] (K. Sarica).

http://dx.doi.org/10.1016/j.eururo.2017.04.016

Please cite this article in press as: Drake T, et al. What are the Beneﬁts and Harms of Ureteroscopy Compared with Shock-wave

Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol (2017), http://dx.doi.org/10.1016/ j.eururo.2017.04.016

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reported in 11 out of 22 studies. In eight studies, it was possible to report this as a Clavien-

Dindo Grade. Higher complication rates across all grades were reported for URS compared

with SWL. For intragroup (intra-SWL and intra-URS) comparative studies, 25 met the

inclusion criteria. These studies varied greatly in outcomes measured with data being

heterogeneous.

Conclusions: Compared with SWL, URS was associated with a signiﬁcantly greater SFR up to

4 wk but the difference was not signiﬁcant at 3 mo in the included studies. URS was

associated with fewer retreatments and need for secondary procedures, but with a higher

need for adjunctive procedures, greater complication rates, and longer hospital stay.

Patient summary: In this paper, the relative beneﬁts and harms of the two most commonly

offered treatment options for urinary stones located in the upper ureter were reviewed. We

found that both treatments are safe and effective options that should be offered based on

individual patient circumstances and preferences.

The objective of this review was to determine the

1. Introduction

benefits and harms of URS compared with SWL in the

Optimal management of urinary tract stones located in the treatment of upper ureteric stones in children and adults.

proximal part of the ureter has been controversial for a long

period of time, with the clinical introduction of minimally 2. Evidence acquisition

invasive treatment approaches making the decision-

making process more complex than ever [1–3]. Bringing 2.1. Search strategy

the patient(s) to a completely stone-free status with

limited or no morbidity is the ultimate goal, and to achieve We conducted a systematic review in accordance with the

that, in addition to stone (size and location) and patient- Preferred Reporting Items for Systematic Reviews and

related factors (quality of life, length of hospital stay, and Meta-analyses statement [15] and the Cochrane Handbook

analgesic requirement), the surgeon’s experience and the for Systematic Reviews of Interventions [16]. Medline,

availability of particular technologies are the crucial Embase, and Cochrane controlled trials databases and

factors that should be considered on an individual basis. clinicaltrial.gov were searched between January 2000 and

Among the available management alternatives, currently November 2014 for all relevant, English-language publica-

both extracorporeal shock wave lithotripsy (SWL) and tions. This search was supplemented by manually searching

ureteroscopy (URS) are the most commonly applied the reference list of The European Association of Urology

procedures [4,5], with varying success and complication (EAU) Guidelines on Urolithiasis and by discussion with

rates reported in the literature. relevant trialists and organisations. The search strategy is

Because of its noninvasive and practical nature, SWL has published elsewhere [17].

been the preferred therapeutic option [6–8], but its success Following deduplication, two review authors (N.G. and

depends on the location of the treated stone(s), with greater T.D.) independently screened the titles and abstracts of the

success in the management of proximal ureteral calculi. The identified records for eligibility. The full text or abstract

success rates tend to decrease for distal stones, while stones from congress proceedings of all potentially eligible records

treated in an emergency setting have a high success rate, were retrieved and scrutinised independently by two

similar to those treated with delayed lithotripsy [6– review authors using a standardised form, linking together

12]. However, the clinical introduction of URS has signifi- multiple records of the same study. In the case of any

cantly changed the treatment concepts for ureteral stones. As incompletely reported data, study authors were contacted.

a result of the accumulated experience and clinical use of Any disagreements were resolved by discussion or by

thinner and/or flexible instruments, nowadays the vast consulting a third review author (S.D.).

majority of ureteral calculi can be treated with URS as well as

SWL [3,13,14]. 2.2. Types of study design included

The advantage of the endoscopic approach is the adequate

and immediate decompression of the obstruction in one All randomised controlled trails (RCTs) and quasi-random-

session with significantly higher stone-free rates when ised controlled trials (QRCTS) comparing any subtype or

compared with SWL [3,13,14]. Concerning the complications, variation of URS and SWL were included. Comparative

traditionally, ureteroscopic techniques have been associated nonrandomised studies (NRSs) were excluded, unless they

with greater complication rates than SWL (9–11% vs 4%) had more than 10 patients per study arm. Noncomparative

[13]. However, the use of small-calibre, semirigid, and studies (eg, single-arm case series) were excluded. Only

flexible ureteroscopes combined with holmium:ytrrium- studies published from the year 2000 onwards were

aluminium-garnet (Ho:YAG) laser disintegration have im- included to reduce the influence of general changes in

proved the stone-free rates and decreased the risk of severe medical procedures on the results. Furthermore, only

complications. English language studies, either published in peer-reviewed

Please cite this article in press as: Drake T, et al. What are the Beneﬁts and Harms of Ureteroscopy Compared with Shock-wave

Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol (2017), http://dx.doi.org/10.1016/ j.eururo.2017.04.016

EURURO-7347; No. of Pages 15

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journals or abstracts, including those published in congress session was the basis for measuring SFR, but also to find

proceedings, were included. data in studies where multiple SWL sessions were consid-

ered as one package of care before SFR was measured.

2.3. Types of participants included SFR was defined as no stone fragments remaining; if an

alternative definition was used by the trialist (eg, fragments

The population included in our search were male and < 4 mm), data was included but this was recorded as

female adults and children of any ethnicity with a single residual stone fragments rather than stone free (ie, the

radio-opaque stone in the upper ureter (ie, defined as above reviewers had to recode the data). SFR could also, if defined

sacro-iliac junction, or iliac vessel crossing, or as defined by as such by the trialist, be measured as the time taken to

trialists). Recurrent or first-time stone formers were achieve stone-free status, that is, not rates but rather time to

eligible, regardless of whether or not they were symptom- stone-free status.

atic. Pelvic-ureteric junction stones and middle ureteric Secondary outcomes were retreatment rate (ie, more

stones were also included. Patients with or without JJ-stent/ than 1 URS or SWL session according to definitions of

nephrostomy insertion before treatment were allowed, as intervention), need for a secondary procedure (ie, a

were patients with a solitary kidney. All stone sizes and procedure to clear the stone beyond the primary procedure,

compositions were included. including retreatment using the same modality—more than

Studies containing populations with the following 1 URS or SWL session, or other modality, eg, percutaneous

characteristics were excluded: pregnant women, previous nephrolithotomy [PCNL]), need for an adjunctive procedure

open ureteral surgery (eg, ureteric reimplantation, ureter- (ie, a procedure to deal with a postoperative complication or

olithotomy), ureteric stricture, anatomical abnormalities procedures incidental to the stone removal process, eg,

(eg, duplex kidney, pelvic-ureteric junction obstruction, nephrostomy or JJ stent insertion for obstruction). Mean

horseshoe kidney), transplanted kidney, simultaneous length of hospital stay, pain outcomes (as defined by trialist,

treatment of ipsilateral stone in kidney (however, if an eg, analgesic requirements or pain scores), quality of life

incidental stone was present in kidney but not treated, this measures, patient satisfaction measures (as reported by the

was allowed), two or more ipsilateral ureteric stones, trialist), hospital readmission rates, and number of emer-

patients who were anticoagulated or had a coagulopathy, gency department visits were also recorded.

radio-lucent stones, and lower ureteric stones. The primary harm outcome was complications of

treatment (intraoperative and postoperative), to include

2.4. Types of interventions included the incidence of grouped complications according to

severity, for example, Clavien-Dindo, or incidence of ad

For URS, the included interventions were: all subtypes and hoc individual complications such as ureteric injury,

variations including semirigid URS, flexible URS, and with steinstrasse (for SWL only), urosepsis, and urinoma.

ureteroscope sizes ranging from 4.5–10 Ch; additional

sessions (ie, >1) were considered as an outcome. 2.6. Assessment of risks of bias

For SWL, the included interventions were: all subtypes

and variations including electrohydraulic, piezo-electric, Risk of bias was assessed by using the recommended tool in

and electro-magnetic. Two different definitions of the the Cochrane Handbook for Systematic Reviews of Interven-

intervention were used: (1) first definition—only one SWL tions [16]. This includes the assessment of: random

session was allowed, and any additional session was sequence generation, allocation concealment, blinding of

considered as a separate outcome (ie, retreatment); (2) participants and personnel, blinding of outcome assess-

second definition—two to three SWL sessions were allowed ment, incomplete outcome data, selective reporting, and

as preplanned intervention (ie, as a package of care). other sources of bias. Risk of bias in nonrandomised

Studies comparing any URS versus URS, or any URS comparative studies was assessed using all the seven

versus SWL, or any SWL versus SWL were included. Analysis domains above, with an extra item to assess the risk of

of intergroup comparisons (ie, SWL compared with URS) findings being explained by confounding factors. This is a

and intragroup comparisons (ie, SWL compared with pragmatic approach informed by methodological literature

variation of SWL or URS compared with variation of URS) pertaining to assessing risk of bias in nonrandomised

were done separately. studies [18].

A list of the most important potential confounders for

2.5. Types of outcomes measures included harm and benefit outcomes was developed a priori with

clinical content experts (the EAU Urolithiasis Guideline

The primary benefit outcome was: stone-free rate (SFR). For Panel). For each study, we asked whether each prognostic

URS, this was the immediate SFR after treatment. However, confounder was considered, whether the confounder was

allowances were made for studies, which measured this balanced between the intervention and control group, and

outcome at 24 h rather than immediately. For SWL, the 1 mo whether, if necessary, the confounder was controlled for in

stone-free status was measured according to the two analysis. The potential confounding factors prioritised

definitions outlined above. Also, alternative time points for were: stone size, body mass index (BMI) or other measure

measuring SFR were allowed for up to 3 mo. This was done of obesity, stone composition, stone density (ie, Hounsfield

in order to find not only data in studies where one SWL units), type of lithotripsy for URS (ie, laser vs no laser for

Please cite this article in press as: Drake T, et al. What are the Beneﬁts and Harms of Ureteroscopy Compared with Shock-wave

Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol (2017), http://dx.doi.org/10.1016/ j.eururo.2017.04.016

EURURO-7347; No. of Pages 15

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URS), sex (for children only), type of URS (ie, semirigid vs criteria was found. A total of 47 studies were eligible for

flexible), stent versus no stent prior to treatment (for both final inclusion; 22 of these compared URS with SWL. Of

interventions), and number of SWL/URS sessions. Stone these, 18 were full text articles [5,9,11,20–34] and four were

size, BMI, and stone composition were considered the most conference abstracts [35–38].

likely to influence outcomes and are reported in the risk of

bias graph. 3.2. Study and patient characteristics

2.7. Quality of evidence assessment

Of the 22 final studies comparing SWL with URS, four were

RCTs [11,20,21,35], one was a QRCT [22] and 17 [5,9,23–

The Grading of Recommendations Assessment, Develop-

34,36–38] were comparative NRSs. Of the final 25 included

ment, and Evaluation (GRADE) tool [19] was used to assess

comparative intragroup (intra-SWL and intra-URS) studies,

the quality of evidence for URS versus SWL. Quality of

24 were full text articles [7,39–61], and one was a

evidence for critical and important outcomes for decision

conference abstract [62]. There was heterogeneity in study

making were rated on study design, risk of bias, directness,

designs and outcomes measured. Details of all studies and

consistency, and precision [19]. The SFR outcome was rated

baseline characteristics of the participants in the included

as critical for decision making. Four weeks were considered

studies are outlined in Supplementary Table 1.

to be the most appropriate time point on which to GRADE

the quality of evidence because it is a fair trade-off between 3.3. Risk of bias assessment of the included studies

an immediate SFR in the URS arms and allows for a package

of care approach in the extracorporeal SWL arms. Clavien The risk of bias assessment for RCTs and NRSs can be viewed

Grade 3, and need for secondary procedure were rated as in Supplementary Figure 2 and Supplementary Figure 3,

important for decision-making. respectively. In general, there was a low risk of bias for

intergroup RCTs/QRCTs, low to moderate risk of bias for

2.8. Data analysis

intragroup RCTs/QRCTs, while for both intergroup and

intragroup NRSs there was a moderate to high risk of bias

For dichotomous benefit or harm outcomes (eg, SFR or

for included studies. As for confounding factors BMI, stone

complications), we report risk ratios and 95% confidence

size, and stone composition the NRSs had in general high to

intervals (CIs) in forest plots but we did not meta-analyse

very high risks of bias.

these estimates due to heterogeneity in one or several of the

following factors: the study designs, the intervention 3.4. Comparisons of interventions results

schedules and utilisations in both the experimental and

control groups, and the outcome definitions and time- Principal results can be viewed in Table 1, Supplementary

points of measurement. In the results tables, we report Table 2, and in the Forest plots in Figs. 1 and 2.

categorical data (SFR) at available time points up to 3 mo

and reported p values where available. For other categorical 3.5. Evidence synthesis for intergroup comparative studies

outcomes (eg, adverse events) we report proportions. For

continuous outcomes, we report mean difference with 3.5.1. SFR SWL versus URS

standard deviation and/or range and corresponding 95% CIs, All included studies reported SFRs; however, the time points

where available. at which these were measured were heterogeneous. ‘‘Stone-

The primary analysis was per participant randomised. free’’ was defined for the purposes of this review as no stone

For studies with more than two intervention groups, only fragments remaining at the reported time point. Stone-free

the intervention groups relevant to the review were status was measured immediately in four studies [11,29,31,

selected, or where possible, groups were combined to 33], at 1 wk in one study [20], at 2 wk in two studies [21,22], at

enable a single pair-wise comparison. 3 wk in one study [9], at 4 wk in four studies [24,25,30,32], at

We conducted an intention-to-treat analysis, if data 6 wk in one study [27], at 3 mo in six studies [5,9,24,28,30,35],

were available; otherwise an available case analysis was and was unclear in six studies [23,26,34,36–38]. In three of

performed. We did not impute missing data. In the case of the studies two different SFR time points were measured

incompletely reported data, attempts were made to contact within each study [9,24,30].

the relevant authors where possible. As summarised in Fig. 1, achievement of stone-free

status favouring URS reached statistical significance in nine

3. Evidence synthesis studies [22,24,25,29–33,36] of which four were significant

at 4 wk [24,25,30,32]. In the remaining 13 studies [5,9,11,

3.1. Search results 20,21,23,26–28,34,35,37,38] no significant difference was

found between SWL and URS for the treatment of proximal

The study selection process is outlined in the Preferred ureteric stones. There was significant heterogeneity in the

Reporting Items for Systematic Reviews and Meta-analyses lithotripter devices used, their power settings, the modali-

[15] diagram (Supplementary Fig. 1). The initial search ties used for SFR assessment, and the number of shock

returned 5380 abstracts of which 387 were scrutinized for waves delivered among those patients treated with SWL.

eligibility. No study on children fulfilling the inclusion The SFR also varied widely in the studies reporting on

Please cite this article in press as: Drake T, et al. What are the Beneﬁts and Harms of Ureteroscopy Compared with Shock-wave

Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol (2017), http://dx.doi.org/10.1016/ j.eururo.2017.04.016

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Table 1 – Summary of results of intergroup (shock wave lithotripsy [SWL] vs ureteroscopy [URS]) comparative studies

Study ID Treatment Comparator Outcome No. of Value, % (n) p value

patients

Treat Com Treat Com

Manzoor 2013 [20] SWL URS SFR 1 wk 192 192 49.2 (94) 57.8 (111) 0.088

12 mm 44.6 (88) 46.1 (89) 0.88

>12 mm 52 (99) 66.7 (128) 0.019

RTR 40 (77) 11 (21) NR

SP 22 (42) 18 (35) NR

Zhang 2011 [21] SWL URS SFR 2 wk 86 69 89.5 (77) 81.2 (56) 0.138

DHS, mean d 5.5 7.8 <0.001

Post-op visits 1.07 1.09 0.809

CA (total charge $) 460 1395 1.09

Kumar 2010 [35] SWL URS SFR 90 90 82.2(74) 86.6 (78) 0.34

SFR <10 mm 51 51 84.3(43) 86.3 (44) 0.32

SFR 10–20 mm 39 39 79.5(31) 89.7 (35) 0.12

CR 90 90 6.6 (6) 11.1 (10) 0.21

RTR 61.1 (55) 1.1 (1) 0.001

SP 21.1 (19) 17.7 (16) 0.45

Salem 2009 [22] SWL URS SFR 100 100 71 (71) 96 (96) > 0.05

SFR <1 cm 58 52 80 (46) 100 (52) > 0.05

SFR 1 cm 52 48 60 (25) 88 (44) > 0.05

CG 1 100 100 23 (23) 10 (10) NR

CG 2 2 (2) N/A NR

CG 3 29 (29) 17 (17) NR

HER 3 (3) 2 (2) NR

DP, mean min (range) 60.55 (40–75) 34.3 (22–66) NR

RT 22 (22) 0 (0) NR

AP 0 (0) 13 (13) NR

SP 7 (7) 4 (4) NR

EDV 20 (20) 5 (5) NR

Lee 2006 [11] SWL URS SFR 22 20 63.6 (14) 35 (7) NR

SFR 1 session 31.8 (7) N/A NR

SFR 2 sessions 22.7 (5) N/A NR

SFR 3 sessions 4.5 (1) N/A NR

SFR 4 sessions 4.5 (1) N/A NR

CG 1 0 (0) 15 (3) NR

CG 2 9 (2) 35 (7) NR

CG 3 0 (0) 30 (6) NR

UI 0 (0) 30 (6) NR

HER 0 (0) 5 (1) NR

DP, min Æ SD 43.2 Æ 5.0 109.0 Æ 50.0 <0.0001

RTR 31.8 (7) 0 (0) NR

AP 0 (0) 55 (11) NR

SP 22.7 (5) 40 (8) NR

Pain (VAS score), mean Æ SD 1.86 Æ 0.94 4.35 Æ 2.45 <0.0001

DHS, mean days Æ SD 1.8 Æ 0.4 4.7 Æ 2.0 <0.0001

Bhoir 2014 [36] SWL URS SFR Overall 55 65 74.54 (41) 89.23 (58) NR

Cui 2014 [23] SWL URS SFR SWL 1 80 80 77.5 (62) 97.5 (78) 0.018

SFR SWL 2 87.5 (70) 97.5 (78) 0.20

SFR SWL 3 92.5 (74) 97.5 (78) 0.61

DP, mean mins Æ SD 40.0 Æ 10.0 42.5 Æ 11.3 0.29

RTR SWL 1 NR 0(0) NR

RTR SWL 2 15 (12) 0(0) NR

RTR SWL 3 7.5 (6) 0(0) NR

UI 0 (0) 0% NR

HER 20 (16) 2.5 (2) <0.05

VS 6.25 33.75 <0.05

QOL 90 83.75 >0.05

Pain, mean mg tramadol Æ SD 0 (Æ0) 80.5 (Æ31.6) <0.05

Natarajan 2014 [37] SWL URS SFR SWL 1 88 186 34.5 (30) 88.4 (164) >0.05

SFR SWL 2 62.4 (55) N/A NR

SFR SWL 3 86.6 (76) N/A NR

Khalil 2013 [24] SWL URS SFR SWL 1 37 45 56.8 (21) 80 (36) <0.05

SFR 1 mo 67.6 (25) 80 (36) <0.05

SFR 3 mo 78.4 (29) 82.2 (37) >0.05

Mean no. of sessions Æ SD 1.5 Æ 0.8 1.02 Æ 0.15 <0.01

CG I 16.2 (6) 2.2 (1) NR

CG II 2.7 (1) 4.4 (2) NR

CG IIIb 5.4 (2) 6.7 (3) NR

Please cite this article in press as: Drake T, et al. What are the Beneﬁts and Harms of Ureteroscopy Compared with Shock-wave

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Table 1 (Continued )

Study ID Treatment Comparator Outcome No. of Value, % (n) p value

patients

Treat Com Treat Com

YuQing 2011 [38] SWL URS SFR 48 48 83.3 (40) 89.6 (43) 0.008

RTR 54.2 (26) 6.3 (3) <0.001

SP 10.4 (5) 10.4 (5) NR

Bozkurt 2010 [25] SWL URS SFR 1 mo 53 30 69.8 (37) 93.3 (28) < 0.05

UI NR 6.6 (2) NR

Lee 2010 [26] SWL URS SFR 1 session 156 68 36.5 (57) 82.4 (56) <0.05

(at 1 mo)

SFR 2 sessions 65.4 (102) <0.05

SFR 3 sessions 84.6 (132) >0.05

SFR 1 session <10 mm 39.5 (51) 93.8 (45) <0.05

(at 1 mo)

SFR 2 session <10 mm 68.2 (88) <0.05

SFR 3 session <10 mm 87.6 (113) >0.05

SFR 1 session >10 mm 22.2 (6) 55 (11) < 0.05

(at 1 mo)

SFR 2 session >10 mm 51.8 (14) > 0.05

SFR 3 session >10 mm 70.4 (19) >0.05

UI 0 (0) 1.5 (1) 0.02

STER 7.7 (12) 0 (0) NR

US 0 (0) 0 (0) NR

CG 1 12.8 (20) 7.4 (5) NR

CG 3 7.7 (12) 1.5 (1) NR

SP 15.4 (24) 17.6 (12) NR

Pain 12.8 (20) 7.4 (5) 0.26

Izamin 2009 [27] SWL URS SFR 6 wk 30 37 53.3 (16) 67.5 (25) 0.314

SFR 10 mm 11 26 81.8 (9) 84.6 (22) 1.000

SFR >10 mm 19 11 36.8 (7) 27.3 (3) 0.702

AP 30 37 N/A 100 (37) NR

Youssef 2009 [28] SWL URS SFR 3 mo 43 43 83.7 (36) 88.4 (38) 0.80

SFR 10 mm 23 23 87 (20) 87 (20) 1.00

SFR >10 mm 20 20 80 (16) 90 (18) 0.37

CG 3 43 43 4.6 (2) 13.9 (6) 0.10

UI 0 (0) 4.6 (2) NR

STER 2.3 (1) NR NR

RT 65 (28) 2.3 (1) < 0.001

AP 0 (0) 100 (43) NR

SP 16.3 (7) 16.3 (7) 1.000

DHS, mean d (range) NR 2 (1–7) NR

Karlsen 2007 [9] SWL URS SFR 3 wk 33 38 58 (19) 79 (29) 0.061

SFR 3 mo 88 (29) 89 (34) 0.118

RTR 3 (1) 18 (7) NR

CG 3 0 (0) 5 (2) NR

DP, mean min (range) 36.4 (19–50) 57.4 (18–135) NR

UI 0 (0) 5 (2) NR

HER (VAS score), mean Æ SD 0.2 Æ 0.8 1.0 Æ 1.9 0.026

DHS, mean d (range) 0.4 (0–5) 2.5 (1–26) NR

Pain (VAS score), mean (SD) 2.3 (Æ2.2) 2.5 (Æ2.4) 0.800

Stewart 2007 [5] SWL URS SFR 3 mo 27 27 88.9 (24) 81.5 (22) 0.625

RT 25.9 (7) 11.1 (3) 0.219

SP 22.2 (6) 40.7 (11) 0.227

Wu 2005 [29] SWL URS SFR immediate 119 101 63.9 (76) 83.2 (84) NR

SFR SP 1 119 101 100 (119) 99.0 (100) NR

SFR SP 2 119 101 100 (119) 100 (101) NR

SFR immediate >10 mm 51 56 35.2 (18) 76.8 (43) 0.001

SFR after SP 1 >10 mm 51 56 84.3 (43) 92.3 (55) NR

SFR after SP 2 >10 mm 51 56 100 (51) 100 (56) NR

SFR immediate <10 mm 68 45 85.3 (58) 91.1 (41) 0.4

SFR SP1 after <10 mm 68 45 100 (68) 100 (45) NR

SFR SP2 after <10 mm 68 45 N/A N/A NR

DP <10 mm 68 45 43.1 Æ 1.4 39.5 Æ 2.8 NR

Mean min Æ SD

DP >10 mm mean min Æ SD 51 56 49.3 Æ 0.8 75.6 Æ 7.2 NR

AP 119 101 1.7 (2) 63.4 (64) NR

CA <10 mm mean $ Æ SD 68 45 1091 Æ 39 955 Æ 40 0.01

CA >10 mm mean $ Æ SD 51 56 1711 Æ 95 1153 Æ 62 <0.0001

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Table 1 (Continued )

Study ID Treatment Comparator Outcome No. of Value, % (n) p value

patients

Treat Com Treat Com

Fong 2004 [30] SWL URS SFR 1 mo 50 51 50 (25) 80 (41) <0.05

SFR 3 mo 78 (39) 90 (46) NR

DP, mean min (range) 56 (20–105) 25 (5–120) <0.01

RTR 14 (7) 2 (1) <0.01

SP 14 (7) 8 (4) 0.3

CG 1 2 (1) 0 (0) NR

CG IIIb 4 (2) 0 (0) NR

Parker 2004 [31] SWL URS SFR SWL 1 overall 111 109 55 90.8 <0.0001

SFR SWL 1 <10 mm 60 (44) 90 (73) <0.0001

SFR SWL 1 >10 mm 45 (17) 93 (26) <0.0001

DP, mean min Æ SD (range) 50 Æ 17 (19–135) 78 Æ 36 (23–175) NR

<10 mm 59 Æ 28 (20–110) 101 Æ 53 (43–278) NR

>10 mm

SP 45 9 NR

Stent 25.2 (28) 9.2 (10) <0.01

Nephrostomy — 1.8 (2) NR

Post-op visits, mean Æ SD 2.4 Æ 1.2 1.4 Æ 0.8 <0.0001

CG I 40.5 (45) 30.3 (33) NR

CG II 2.7 (3) 4.6 (5) >0.05

CG III 0 (0) 2.8 (3) NR

Pain (colic) 29 (32) 17 (19) 0.05

Initial charge $1000 Æ SD SWL <1 cm 9.4 Æ 2.2 7.6 Æ 3 <0.0001

Initial charge $1000 Æ SD SWL >1 cm 9.7 Æ 2.6 7.3 Æ 3.5 <0.001

Total charge $1000 Æ SD SWL <1 cm 14.9 Æ 7.6 9.2 Æ 4.4 <0.0001

Total charge $1000 Æ SD SWL >1 cm 16.9 Æ 7 10 Æ 7.1 <0.0001

Wu 2004 [32] SWL URS SFR 1 mo 41 39 61 (25) 92.3 (36) 0.003

UI 0 (0) 0 (0) NR

US 0 0 NR

AP N/A 82 (32) NR

SP 39 (16) 7.6 (3) NR

HR 0 (0) 0 (0) NR

EDV 3.3 1.6 NR

Lam 2002 [33] SWL URS SFR SWL 1 >1 cm 20 14 50 (10) 93 (13) NR

SFR SWL 1 <1 cm 35 17 80 (28) 100 (17) NR

SFR immediate 55 31 69.1 (38) 96.8 (30) NR

RTR 1 >1 cm 50 (10) 7 (1) NR

RTR 2 >1 cm 15 (3) 0 (0) NR

RTR 3 >1 cm 5 (1) 0 (0) NR

RTR 1 <1 cm 20 (7) 0 (0) NR

RTR 2 <1 cm 0 (0) 0 (0) NR

RTR 3 <1 cm 0 (0) 0 (0) NR

DP, mean min (range)

stone >1 cm 65.9 (55–100) 48.2 (29–86) NR

Stone <1 cm 55.8 (50–76) 34.6 (24–44) NR

Hammad Ather SWL URS + lithoclast SFR 80 53 92 (73) 75(40) NR

2001 [34]

RTR 21 (17) 18 (9) 0.4570

AP = adjunctive procedure; CA = cost analysis; CG = Clavien Grade; CIRFR = clinically insigniﬁcant residual fragment; CIRFR-B = clinically insigniﬁcant residual

fragment at time point B (time point B being stated within parentheses in mo, but only up to 3 mo); Com = comparator; CR = complication rate; DHS = duration

of hospital stay; DP = duration of procedure; EDV = emergency department visit; HR = hospital readmission; HER = haematuria; n = number of; N/A = not

applicable; NR = not reported; NS = insigniﬁcant p value; MU = mid ureter; QOL = quality of life; Pain: use of painkillers (as speciﬁed by study authors);

RCT = randomised controlled trial; RO = radio-opaque; RTR = retreatment rate; SFR = stone free rate; SFR-B = SFR at time point B (time point B being stated

within parentheses in mo, but only up to 3 mo); SP = secondary procedure; STER = steinstrasse; SWL = shock-wave lithotripsy; TCC = time to complete

clearance; Treat = treatment; UI = ureteric injury; URS = ureteroscopy; UU = upper ureter; VAS = visual analogue scale; VS = voiding symptoms.

SWL-treated patients. The methods of anaesthesia, sizes of one of these studies [20] (which subdivided stones into

ureteroscopes, protocols for postoperative stenting, and those 12 mm and > 12 mm), this breakdown consisted of

method of intracorporeal lithotripsy used in the reported stones >10 mm and stones <10 mm. With regards to

studies also varied. >10 mm sized stones, five studies showed SFR to be

Nine of the studies provided further breakdowns of SFRs superior with URS [20,26,29,31,33], whilst four studies

according to stone size [20,22,26–29,31,33,35]. In all but [22,27,28,35] showed no difference. For the smaller stones

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Fig. 1 – Forest plot (stone free rate of included intergroup studies).

CI = confidence interval; NRS = nonrandomised studies; QRCT = quasi-randomised controlled trial; RCT = randomised controlled trial; SWL = shock wave

lithotripsy; URS = ureteroscopy.

<10 mm, three studies showed SFR to be superior with URS in the forest plot in Fig. 2. Lee et al [11] reported

[26,31,33], whilst five studies showed no difference [22,27– significantly higher complication rates in the URS group

29,35]. compared with the SWL group. The reverse finding was

reported by Salem [22] and Lee et al [26] albeit in both

3.6. Complications studies the higher Clavien-Dindo Grade 3 in the SWL arms

were solely due to stone migration emergency room visits

Complications of treatment were reported on in 14 out of with some requiring JJ stent insertion. The remaining five

22 studies; two RCTs [11,35], one QRCT [22], and nine NRSs studies [9,24,28,30,31] failed to show any significant

[9,23–26,28–33]. In eight of these studies, it was possible to difference in Clavien-Dindo Grade 3 complications. No

group the reported complications into Clavien-Dindo cases of ureteric injury were reported in any patients

Grades [9,11,22,24,26,28,30,31] and grades 3 are reported undergoing SWL, but ureteric injury rates after URS were as

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Fig. 2 – Forest plot (Clavien-Dindo Grade I 3 reported complications in intergroup studies).CI = confidence interval; NRS = nonrandomised studies;

QRCT = quasi-randomised controlled trial; RCT = randomised controlled trial; SWL = shock wave lithotripsy; URS = ureteroscopy.

high as 30% in one study [11]. In other studies, reported 3.8. Need for secondary procedures

ureteric injury rates after URS were much lower at 0–6.6%

[9,23,25,26,29,32]. Secondary procedures were defined as any procedure

Haematuria post-treatment was reported on by four performed to clear the stone, beyond the primary proce-

studies; one RCT [11], one QRCT [22], and two NRSs dure, including retreatment using the same modality. A

[9,23]. Two studies reported associated p values; in one total of 11 studies comparing SWL with URS reported on the

study [9] haematuria rates (assessed according to a visual need for secondary procedures; three RCTs [11,20,35], one

analogue score) were significantly higher after URS than QRCT [22], and eight NRSs [5,26,28,30–32,38]. Overall,

SWL. In the other study [23], rates of gross haematuria between these 11 studies, 880 patients were treated

following treatment were significantly higher after SWL primarily with SWL and 787 patients were treated primarily

than URS, occurring in 20% of patients after SWL, compared with URS. The need for secondary procedures ranged from

with 2.5% of patients treated with URS. 2.6% to 45% in the primary SWL group and 4–50% in the

The rate of steinstrasse following treatment with SWL primary URS group. For patients treated primarily with SWL

was reported on by two studies [26,28] ranging between and URS, respectively, the secondary procedure modalities

2.3% and 7.7%. (eg, SWL, URS, antegrade URS, and ureterolithotomy) varied

Post-treatment voiding symptoms were assessed by one greatly between studies. In two studies [28,38] the need for

study [23] and were significantly more common after secondary procedures was equivalent between the two

treatment with URS (33.7%) compared with SWL (6.2%; treatment modalities. In three studies [5,11,26] the need for

p < 0.05). secondary procedures was greater for URS than for SWL,

Reported rates of pain were assessed by five studies although only one of these [5] provided a p-value which was

[9,11,23,26,31]. Different methods and time points were not statistically significant. In the remaining six studies, the

used to assess the pain. In general, the reported pain levels need for secondary procedures was greater for SWL than

were relatively low. Two studies reported significantly URS, although again, where given, p-values never reached

higher rates of pain after URS [11,23], while the three statistical significance.

remaining studies showed no significant difference in pain

after SWL or URS treatment [9,26,31]. 3.9. Need for adjunctive procedures

3.7. Retreatment rate Adjunctive procedures were defined as procedures needed

to deal with a postoperative complication of the primary

Retreatment was defined as a subsequent intervention for treatment or temporary procedures necessary to perform

the stone disease using the same therapeutic technique as the primary treatment (eg, JJ stent or nephrostomy

the initial treatment. A total of 11 studies reported on placement). A total of seven studies reported on the need

retreatment rates; three RCTs [11,20,35], one QRCT [22], for adjunctive procedures; one RCT [11], one QRCT [22], and

and seven NRSs [5,9,23,30,33,34,38]. Reported retreat- five NRSs [27–29,31,32]. In the majority of cases, this

ment rates were higher for SWL compared with URS in all adjunctive procedure was the insertion of a JJ stent and was

studies but one [9]. Reported rates ranged from 3–61.1% a more common occurrence when primary treatment was

for SWL compared with 0–18% for URS. Altogether, p- URS rather than SWL. Furthermore, in six of the seven

values were only reported in three out of the 11 studies studies [11,22,27–29,32], an adjunctive procedure (inser-

[5,35,38] of which two were statistically significant tion of a JJ stent) was only required in patients who had

(p 0.001) [35,38]. undergone URS rather than SWL. Conversely, in one study

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[31] prestenting was more common in patients undergoing SWL, whereas Parker et al [31] and Wu et al [29] reported

SWL than those undergoing URS (p < 0.01). significant higher costs for SWL (p < 0.01 in both studies).

3.10. Duration of procedure 3.15. Quality of evidence assessment

A total of eight studies reported on the mean duration of The GRADE quality of evidence for URS versus extracorpo-

procedure; one RCT [11], one QRCT [22], and six NRSs real SWL is shown in the evidence profile (Supplementary

[9,23,29,30,32,33]. The mean duration of procedures ranged Table 3). The overall quality of evidence for SFR at 4 wk,

from 36 min to 61 min for SWL and 34 min to 109 min for Grade 3 Clavien-Dindo complications and the need for

URS. Relevant p-values were only provided in two studies secondary procedures were all very low. This indicates that

[11,23]; in one study, the duration of procedure was we are very uncertain about the estimate. The main reasons

significantly longer (p < 0.01) for URS than for SWL [11] but were the impact of confounding bias in the observational

in the other study [23] there was no statistically significant studies, as well as small study populations throughout.

difference in the duration of both procedures. Three studies Furthermore, the complications and secondary procedures

[29,31,33] broke down the duration of procedure into two outcomes had low event rates, heterogeneous estimates of

groups according to stone size of <10 mm and >10 mm. effect, and wide CIs.

Statistical significance was not assessed by any of these

studies, but raw values of mean procedural duration were 3.16. Evidence synthesis for intragroup (intra-SWL and intra-

greater for URS compared with SWL in one study [31] URS) comparative studies

regardless of stone size, with completely the opposite

findings in the second study [33]. In the third study [29], the 3.16.1. Immediate SWL versus delayed SWL

duration was greater for URS compared with SWL for stones Three studies compared outcomes from immediate SWL

>10 mm, with the reverse results for stones <10 mm. versus those with delayed SWL [39–41]. All three studies

showed higher SGRs when SWL was administered immedi-

3.11. Quality of life ately (within 2 d) rather than if treatment was delayed

(range, 2–7 d) from time of symptom. The difference was

Quality of life was assessed only in one study; Cui et al [23] statistically significant in two of the three studies

and was not statistically significant between the two [39,41]. One study showed that the mean number of SWL

treatment modalities. sessions was higher in patients undergoing delayed SWL

compared with immediate SWL, with a reported p-value of

3.12. Length of hospital stay 0.047 provided by one study [41].

Length of stay was reported in four studies; two RCTs 3.16.2. SWL for upper ureteric stones <1 cm versus 1 cm in

[11,21] and two NRSs [9,28]. In all four studies, the mean diameter

length of hospital stay was greater for patients undergoing One study compared SFR using SWL for urinary stones

URS compared with SWL and in two of the four studies 1 cm compared to SWL for stones >1 cm in diameter

[11,21] a p-value was provided, and in both cases, reached [54]. Subgroup analysis of upper urinary system (UUS)

statistical significance. showed a SFR of 60.8% for stones 1 cm compared to 49.1%

for stones >1 cm albeit not significant (p = 0.496).

3.13. Hospital re-admission rates and post-treatment visits

3.16.3. SWL with medical expulsion therapy [44] versus SWL alone

Hospital re-admission rates following treatment were Four studies compared the effect of an alpha-blocker on

assessed by one study [32], and in this study, no patients stone free rates with SWL treatment [42–44,62]. SFRs were

in either treatment arm required re-admission. Two studies better with concomitant alpha-blocker use in all four

looked at emergency department visits after stone man- studies; two of which provided statistically significant p

agement [22,32] with higher rates in those treated with values [42,43]. One study [45] looked at the effect of a

SWL (20% of patients after SWL vs 5% of patients after URS). calcium-channel blocker on SFRs with SWL treatment

The number of post-treatment visits was assessed by where SFRs were improved with nifedipine administration

two studies [21,31]. In the Zhang et al study [21], the (75% compared with 44%, but no p value provided). Mean

number of post-treatment visits was not significantly analgesic use (diclofenac) was also reduced in patients

different between the two treatment groups, whereas in receiving nifedipine (p = 0.02). While one study showed

the Parker et al study [31], patients were seen significantly number of SWL sessions needed was not significantly

more often following treatment with SWL than after URS; changed by alpha-blocker administration [43], another

2.4 Æ 1.2 compared with 1.4 Æ 0.8 (p 0.0001). study showed that patients receiving tamsulosin required

significantly less number of SWL sessions (p = 0.02) [42].

3.14. Cost analysis

3.16.4. SWL with diuresis versus SWL alone

Only three studies looked at cost analysis. According to Two studies looked at the effect of diuretic treatment

Zhang et al [21], URS was significantly more expensive than alongside treatment with SWL [46,47]. Although SFRs were

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equivalent in one study [47], improved SFRs at 3 mo were provided. Finally, a third study [58] compared an EH model

observed when furosemide was administered alongside (HM3) to a more modern EH (LithoTron) model lithotripter

SWL therapy in another study [46] (86.6% vs 58.8%). in a small matched pair analysis. No significant differences

However, p values were not provided in either study. were found (p = 0.08).

3.16.5. SWL in patients with hydronephrosis versus SWL in patients 3.16.11. URS with and without methods for preventing retrograde

without hydronephrosis stone migration

Two studies looked at the effect of SWL on patients with and Two studies looked at stone-free rates with ureteroscopic

without hydronephrosis due to UUS [7,48]. There was no treatment using different methods for preventing retro-

significant difference found in SFR at 3 mo between these grade stone migration during the procedure. The first, a RCT,

two groups in neither study, although one [7] showed a looked at URS with and without a backstop device [60]. SFRs

significant (p < 0.01) longer time to complete stone were high in both groups (93.9% with backstop device

clearance in patients with hydronephrosis. compared to 87.8% without, p-value = 0.7). The second, a

QRCT, looked at URS with and without lubrication jelly

3.16.6. SWL prone versus SWL supine instilled proximal of the stone [61]. SFRs were high in both

Two studies addressed the effect of patient positioning on groups (93.7% with jelly compared with 83.3% without,

treatment outcomes with SWL [49,50]. In one study, there p = 0.384).

was no significant difference in the achieved SFR at 2 wk

[50], whereas in the other study, these rates were improved 4. Discussion

by treating the patient prone rather than supine (90.6% vs

88.3%, p < 0.05) [49]. 4.1. Implications for clinical practice

3.16.7. SWL 60–80 s/min versus SWL 120 s/min Our systematic review demonstrates that URS and SWL are

Three studies looked at whether the administered shock both safe and effective in the treatment of proximal ureteric

rate affected SFRs [51,53,56]. In all studies, SFRs were higher stones. The key observation of this study, that short-term

when shock waves were administered at a slower rate, SFR are better with URS compared with SWL, is perhaps

reaching a statistically significant difference (p < 0.05) in unsurprising given the advantages of direct stone visuali-

one study [53]. One study showed that the mean number of sation that this technique confers, enabling more accurate

SWL sessions required was reduced in patients undergoing delivery of the chosen stone fragmentation modality onto

fast SWL (p = 0.021) [51]. The other study showed that the stone, combined with the ability to actively retrieve

duration of procedure was significantly reduced in patients stones and/or fragments using baskets and forceps after

undergoing fast SWL compared to slow SWL (p < 0.001) stone fragmentation.

[53]. A similar result was reported in one study [56] but no Historically, the success rates associated with uretero-

p-value was reported. scopic treatment of proximal ureteral stones were subopti-

mal compared with the results of other treatment

3.16.8. SWL with and without stenting modalities. In general, the low success rates were attribut-

One study looked at the effect of prestenting on SFRs with able to the inability to reach the stone, inability to fragment

SWL [52]. In this study, high SFRs were seen in both the stone, or cephalad stone migration during treatment.

treatment groups; 86.7% in the nonstented group and 90% in Technological advances such as introduction and down-

the stented group, and there was no statistically significant sizing of the flexible ureteroscopes and the development of

difference in the achieved SFRs. Ho:YAG laser have greatly improved interest and efficacy of

ureteroscopy for proximal ureteral stone treatment. The

3.16.9. SWL under sedation versus under general anaesthesia advent of new technology is inevitably correlated with

One study looked at SFRs in patients undergoing SWL under changes in the treatment of proximal ureteral stones as

sedation, versus under general anaesthesia [59]. Stone-free suggested in International Urological Guidelines over the

rates at 3 mo were higher in those treated under a general last 20 yr. In the 1990s, the recommended first-line therapy

anaesthesia (80% compared with 50%), but no p value was for stones with a diameter <1.0 cm in the proximal ureter

given. was SWL. Ureteroscopy or more invasive PCNL was

recommended for salvage treatment or if SWL was contra-

3.16.10. SWL using different lithotriptors indicated. For stones >1 cm in the proximal ureter, SWL,

Three studies examined different types of SWL lithotriptors URS, or PCNL was recommended as first-line treatment

for UUS [55,57,58]. The first study [55] showed no [63]. The 2007 EAU/American Urological Association Guide-

difference (88% vs 92%, p = 0.245) in SFR between electro- lines for the management of ureteral calculi indicated that

hydraulic (EH) and electromagnetic lithotriptors in treating besides SWL, URS should be considered for stones 10 mm

UUS. The second study [57] compared an EH, electromag- located in the proximal ureter. When stones of this diameter

netic, and a piezoelectric lithotripter to each other in were stratified by stone location, median SFR remained

treating urinary stones. The EH lithotriptor was suggested superior for URS over SWL at all locations. In regards to 10-

in a multivariate analysis to have a better SFR and lower mm proximal ureteral stones, SFR for URS reached 85%

retreatment rate, although p-values for UUS were not compared with 66.5% for SWL. However, for stones

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>10 mm, SFR were comparable for URS and SWL (74% vs needed to overcome several of the limitations of this study.

79%) in the proximal ureter [64]. The current, 2016 Ameri- For example, many of the included studies may be affected

can Urological Association Guidelines state that URS for by selection bias, performance bias, detection bias, and

proximal ureteral stones has a greater SFR in a single outcome-reporting bias. Moreover, despite the moderate

procedure compared with SWL, regardless of stone size statistical heterogeneity of our review, clinical heterogene-

[65,66], albeit the importance of informing patients on the ity can be expected, by including trials using different type

higher morbidity and complications risk compared with of lithotripters/methods of lithotripsy, different follow-up

SWL. All in all, URS can be recommended as the first periods defining SFR, differences in stone size and imaging,

treatment option for proximal ureteral stones >10 mm, but as well as different adjunctive procedures. Furthermore, for

for stones 10 mm the EAU Urolithiasis Guidelines panel five of the included studies, only abstracts were available for

consensus is that either treatment options are viable as first data extraction, which significantly limited the information

choice and should be presented to patients [67]. The and quality of data available for analysis. Even when full

effectiveness of medical expulsive therapy, in particular a- texts were available, there was a lack of adequate and

blockers, as conservative treatment of ureteral stones is reliable evidence for the comparison of URS versus SWL

unproven and the only potential benefit seems to exist for concerning outcomes other than SFR and where it was

distal ureteral stones larger than 5 mm [68]. possible to extract data on the main outcome measures of

Counterbalancing for URS’s higher SFRs, SWL is associ- this study, many studies did not report statistical calcula-

ated with the least morbidity and lower complication rates tions of differences between the two interventional groups.

[65–67]. In this current systematic review, Clavien-Dindo Moreover, available data reported in the literature was not

grade complications were, if reported, less frequent in strong enough to report some certain patient-focused

patients treated with SWL. At the same time, two studies outcomes, for example, analgesic requirement, emergency

[22,26] presented the opposite, pointing out that stone department visits, and quality of life, and cost analysis

migration/steinstrasse requiring decompression with JJ outcomes were poor. Where patient-focused outcomes

stent insertion (ie, making it a Clavien-Dindo Grade were assessed, for example, lower urinary tract symptoms

3 complication) is more frequent in patients treated with or quality of life following treatment [33], validated

SWL. However, it is important to bear in mind that the questionnaires were not used.

quality of evidence is very low. The 2012 Cochrane meta- We assert that increasing the number of well-designed

analysis comparing SWL and URS identified seven random- RCTs focusing mainly on these parameters will ease the

ised controlled studies reporting on all complication rates clinician’s and also patient’s decision making. In order to

and found a significantly lower complication rate for SWL decrease heterogeneity in future studies, consensus is

compared with URS (risk ratio: 0.53, 95% CI: 0.33–0.88, needed regarding the definition and timing of stone free,

p = 0.01) [69]. However, for all patients with ureteral stones, including the imaging modality used for assessing SFR.

when residual fragments are present, especially if initial Moreover, a core outcome set is needed to ensure that the

SWL fails, urologists should offer endoscopic procedures to outcomes, which are of utmost importance for decision

render the patients stone free. Success rates for PCNL and making for all stakeholders including patients, are

URS as secondary procedures after failed SWL are reported reported, defined, and measured consistently [70–72]. This

as 86–100% and 62–100%, respectively [65,66]. will ensure that future trials are efficient and future

Our intragroup comparative studies analysis underlined evidence syntheses are straightforward to perform, com-

several technical modifications leading to higher SWL SFR. municate, and are ultimately useful for decision making by

Despite this improvement, the aforementioned internation- patients, clinicians, and health care policy makers and

al recommendations clearly reflect a trend towards URS as funders.

treatment of proximal ureteral stones regardless of the size

of the stone. However, it is difficult to make a blanket 5. Conclusions

recommendation as to whether all ureteroscopic stone

treatment techniques are better than all SWL machine types This systematic review demonstrates that ureteroscopic

and treatment schedules, for treating all proximal ureteric management of proximal ureteral calculi is associated with

stones, regardless of stone size and other important patient- a significantly greater SFR when compared with SWL at

related factors such as BMI; these variables as well as other 1 mo. Moreover, the rate of retreatment and the need for

confounding factors simply have not been adequately secondary procedures was found to be higher in cases

reported on in the currently available studies and future undergoing SWL. Concerning adjunctive procedures, com-

research should definitely focus on these. Moreover, other plications, and length of hospital stay; however, the

factors such as technological improvements (eg, Ho:YAG ureteroscopic approach was found to be associated with

laser, uretererosope miniaturisation), country policies, higher complication rates along with longer hospitalisa-

capital investment, and the patient’s or surgeon’s prefer- tion periods when compared with SWL. However, the

ence could affect the results of URS and SWL. quality of evidence is very low and it is therefore clear that

As techniques, technologies, and surgeon experience in order to better outline the efficacy, complications, and

continue to evolve, further large, multi-centre, well- other treatment-related parameters of both modalities,

designed RCTs are needed in order to accurately compare further well-designed RCTs with larger sample sizes and

these two treatment modalities. Further research is also consistently reported and defined outcomes are needed.

Please cite this article in press as: Drake T, et al. What are the Beneﬁts and Harms of Ureteroscopy Compared with Shock-wave

Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol (2017), http://dx.doi.org/10.1016/ j.eururo.2017.04.016

EURURO-7347; No. of Pages 15

E U R O P E A N U R O L O G Y X X X ( 2 0 1 7 ) X X X – X X X 13

Author contributions: Kemal Sarica had full access to all the data in the extracorporeal shock-wave lithotripsy for proximal ureteral calculi.

study and takes responsibility for the integrity of the data and the Scand J Urol Nephrol 2007;41:208–13.

accuracy of the data analysis. [8] Ziaee SA, Halimiasl P, Aminshariﬁ A, Shaﬁ H, Beigi FM, Basiri A.

Management of 10-15-mm proximal ureteral stones: uretero-

Study concept and design: Drake, Grivas, Maclennan, Debastani,

scopy or extracorporeal shockwave lithotripsy? Urology 2008;71:

Skolarikos, Tuerk, Knoll, Straub, Seitz, Petrik, Lam, Sarica.

28–31.

Acquisition of data: Yuan, Drake, Grivas.

[9] Karlsen SJ, Renkel J, Tahir AR, Angelsen A, Diep LM. Extracorporeal

Analysis and interpretation of data: Maclennan, Drake, Grivas, Debastani,

shockwave lithotripsy versus ureteroscopy for 5- to 10-mm stones

Sarica.

in the proximal ureter: prospective effectiveness patient-prefer-

Drafting of the manuscript: Drake, Grivas, Maclennan, Debastani, Sarica.

ence trial. J Endourol 2007;21:28–33.

Critical revision of the manuscript for important intellectual content: Drake,

[10] Bagley DH. Expanding role of ureteroscopy and laser lithotripsy for

Grivas, Maclennan, Debastani, Skolarikos, Tuerk, Sarica.

treatment of proximal ureteral and intrarenal calculi. Curr Opin

Statistical analysis: None.

Urol 2002;12:277–80.

Obtaining funding: None.

[11] Lee YH, Tsai JY, Jiaan BP, Wu T, Yu CC. Prospective randomized trial

Administrative, technical, or material support: None.

comparing shock wave lithotripsy and ureteroscopic lithotripsy for

Supervision: Debastani, Tuerk, Sarica.

management of large upper third ureteral stones. Urology 2006;

Other: None.

67:480–4, discussion 4.

[12] Picozzi SC, Ricci C, Gaeta M, et al. Urgent shock wave lithotripsy as

Financial disclosures: Kemal Sarica certiﬁes that all conﬂicts of interest,

ﬁrst-line treatment for ureteral stones: a meta-analysis of

including specific financial interests and relationships and affiliations

570 patients. Urol Res 2012;40:725–31.

relevant to the subject matter or materials discussed in the manuscript (eg,

[13] Yencilek F, Sarica K, Erturhan S, Yagci F, Erbagci A. Treatment of

employment/afﬁliation, grants or funding, consultancies, honoraria, stock

ureteral calculi with semirigid ureteroscopy: where should we

ownership or options, expert testimony, royalties, or patents ﬁled,

stop? Urol Int 2010;84:260–4.

received, or pending), are the following: Knoll: company consultant

[14] Bagley DH, Kuo RL, Zeltser IS. An update on ureteroscopic instru-

(Schoelly, Boston Scientiﬁc, Olympus, Storz Medical), company speaker

mentation for the treatment of urolithiasis. Curr Opin Urol 2004;

honorarium (Karl Storz, Richard Wolf, Olympus, Boston Scientiﬁc, Ibsen),

14:99–106.

trial participation Cook, Coloplast; Straub: company consultant (Richard

[15] Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred

Wolf Endoskope, Knittlingen, Germany), Sanochemia Pharmazeutika AG,

reporting items for systematic reviews and meta-analyses: the

Vienna (Statistik Austria, #674), Porge`s Coloplast. Seitz: company

PRISMA statement. BMJ 2009;339:b2535.

consultant (Astellas), company speaker honorarium (ROWA Wagner

[16] Higgins J, Green S. Cochrane Handbook for Systematic Reviews of

GmbH & Co KG); Petrik: company speaker honorarium (Olympus, Cook),

Interventions Version 5.1.0 [updated March 2011]. London, UK: The

fellowship, travel grants (Astellas Olympus); Lam: company consultant

Cochrane Collaboration; 2011.

(Pﬁzer, GSK, Astellas, Ipsen), company speaker honorarium (Pﬁzer, GSK,

[17] MacLennan S, Grivas N, Drake T, et al. What are the beneﬁts and

Astellas, Ipsen).

harms of ureteroscopy (URS) compared with shock wave lithotripsy

Funding/Support and role of the sponsor: None. (SWL) in the treatment of upper ureteral stones in children and

adults?. York, UK: University of York; 2015.

[18] Reeves B, Deeks J, Higgins J, Wells G. On behalf of the Cochrane Non-

Appendix A. Supplementary data

Randomised Studies Methods Group. Chapter 13: Including non-

randomised studies. Cochrane handbook for systematic reviews of

Supplementary data associated with this article can be

interventions v5022011. London, UK: The Cochrane Collaboration;

found, in the online version, at http://dx.doi.org/10.1016/j. 2011.

eururo.2016.04.035. [19] Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines:

3. Rating the quality of evidence. J Clin Epidemiol 2011;64:401–6.

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Lithotripsy in the Treatment of Upper Ureteral Stones? A Systematic Review. Eur Urol (2017), http://dx.doi.org/10.1016/ j.eururo.2017.04.016