Optimal management of large proximal ureteral stones (> 10 mm): A systematic review and meta-analysis of 12 randomized controlled trials

INTERNATIONAL JOURNAL OF SURGERY

卷:80

Review

Lai, Shicon^1,2,3,4,5  Jiao, Binbin^4,5,6  Diao, Tongxiang^1,2,3,7  Seery, Samuel^8,9  Hu, Maolin^1,2,3,7  Wang, Miao^1,2,3,4,5  Hou, Huimin^1,2,3  Wang, Jianye^1,2,3,4,5  Zhang, Guan^4,5,6  Liu, Ming^1,2,3,4,5 

[1] Beijing Hosp, Dept Urol, Beijing 100730, Peoples R China

[2] Natl Ctr Gerontol, Beijing 100730, Peoples R China

[3] Chinese Acad Med Sci, Inst Geriatr Med, Beijing 100730, Peoples R China

[4] Peking Union Med Coll, Grad Sch, Beijing 100730, Peoples R China

[5] Chinese Acad Med Sci, Beijing 100730, Peoples R China

[6] China Japan Friendship Hosp, Dept Urol, Beijing 100029, Peoples R China

[7] Peking Univ, Sch Clin Med 5, Beijing, Peoples R China

[8] Chinese Acad Med Sci, Sch Humanities & Social Sci, Beijing 100730, Peoples R China

[9] Peking Union Med Coll, Beijing 100730, Peoples R China

关键词: Extracorporeal shockwave lithotripsy (ESWL);    Large proximal ureteral stones (LPUS);    Laparoscopic ureterolithotomy (LU);    Percutaneous nephrolithotomy (PCNL);    Systematic review and meta-analysis;    Ureteroscopic lithotripsy (URL);   

DOI  :  10.1016/j.ijsu.2020.06.025

来源: Elsevier

【 摘 要 】

Objectives: To develop an evidence base to guide clinicians treating adults with large proximal ureteral stones (LPUS) greater than 10 mm. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library was conducted to identify randomized controlled trials (RCT) concerning different LPUS management techniques including laparoscopic ureterolithotomy (LU), percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URL) up until March 2020. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement when searching and determining inclusion. All included articles were quality assessed and the data analyses were conducted with Review Manager (5.3). Results: 12 RCTs involving 1416 patients met our eligibility criteria and were analyzed. Of these participants, 44.6% (n = 632) underwent URL, 25.5% (n = 361) PCNL, and 29.9% (n = 423) LU. Pooled analysis revealed that URL had a significantly lower stone-free rate (SFR) compared to PCNL and LU (both with p < 0.05). URL had a significantly higher ureteral injury rate compared to LU (Relative risk (RR) = 5.27, 95% confidence interval (CI) 1.52 to 18.22, p = 0.009) and PCNL (RR = 4.11, 95% CI 1.03 to 16.34, p = 0.04). However, no significant differences were found between PCNL and LU in terms of SFR or overall complications, both with p > 0.05. URL initially costs less than PCNL (Weighted mean difference (WMD) -597.35US$, 95% CI -823.10 to -371.60, p < 0.00001), but being less effective creates greater demand for repeat or ancillary treatments compared to LU (RR 15.65, 95% CI 2.11-116.12, p = 0.007) and PCNL (RR 8.86; 95% CI 3.19-24.60; p < 0.00001). Conclusions: Both PCNL and LU appear more effective and safer than URL for LPUS; although, LU has higher risk of urine leakage and is more likely incur trauma which requires additional support. However, caution must be taken because this recommendation is based upon a very limited number of clinical studies, and even fewer comparing flexible ureteroscopic technologies. Further prospective real-world studies or RCTs comparing flexible URL, LU and PCNL are required, as well as an in depth analysis of the hidden costs involved in unsuccessful URL treatments.

【 授权许可】

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