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JU INSIGHT Flexible Ureteroscopy vs Extracorporeal Shock Wave Lithotripsy for Renal Stones in Pediatric Patients

By: Robert Geraghty, BMedSc, BSc, PGCert, MRCS, Freeman Hospital, Newcastle Upon Tyne, United Kingdom; Riccardo Lombardo, PhD, FEBU, Sapienza University of Rome, Italy; Cathy Yuan, MD, MSc, PhD, McMaster University, Hamilton, Ontario, Canada; Niall Davis, FRCS, Beaumont Hospital and Royal College of Surgeons in Ireland (RCSI), Dublin; Lazaros Tzelves, MD, MSc, PhD, FEBU, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Greece; Ales Petrik, PhD, České Budějovice Hospital, Czechia; Helene Jung, MD, PhD, Hospital Lillebaelt, University of Southern Denmark, Odense; Giovanni Gambaro, MD, PhD, Ospedale Maggiore, Verona, Italy; Thomas Tailly, MD, MSc, FEBU, University Hospital of Ghent, Belgium; Andreas Neisius, MD, Bruederkrankenhaus Trier, Johannes Gutenberg University Mainz, Germany; Andreas Skolarikos, MD, PhD, FEBU, National and Kapodistrian University of Athens, Greece; Bhaskar Somani, DM, FEBU, FRCS (Urol), University Hospital Southampton NHS Foundation Trust, United Kingdom | Posted on: 15 Dec 2023

Geraghty R, Lombardo R, Yuan C, et al. Outcomes of flexible ureteroscopy vs extracorporeal shock wave lithotripsy for renal stones in pediatric patients: A European Association of Urology Urolithiasis Guidelines systematic review and meta-analysis. J Urol. 2023;210(6):876-887.

Study Need and Importance

Within the European Association of Urology guidelines the current recommended first-line treatment for pediatric patients with kidney stones less than 2 cm is extracorporeal shock wave lithotripsy (ESWL). However, as ureteroscopic technology improves and scopes become miniaturized there is increasing interest in using flexible ureteroscopy (FURS) to treat these patients, given the reportedly higher success rates. The European Association of Urology Urolithiasis Guidelines Panel therefore undertook a systematic review and meta-analysis of the available evidence comparing FURS to ESWL in pediatric patients with renal stones < 2 cm.

What We Found

There were 6 studies meeting inclusion criteria (3 randomized trials and 3 prospective cohorts). Meta-analyses comparing FURS to ESWL were limited to randomized controlled trials (Figure). The meta-analysis demonstrates that FURS has a significantly higher stone-free rate than ESWL, with no difference in complication rate or fluoroscopy exposure time, albeit with associated significantly higher operative times and hospital stay.

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Figure. A, Forest plot of meta-analysis (MA) outcomes for continuous outcomes. B, Forest plot of MA outcomes for binary outcomes. CI indicates confidence interval; MD, mean difference; RR, relative risk.

Limitations

These findings should be caveated by the poor evidence base this review is based on, with several metrics having only 1 to 2 studies available for analysis. This is reflected in the high overall risk of bias as well as the GRADE (Grading of Recommendations Assessment, Development, and Evaluations) analysis, which found that only the result for stone-free status had a high certainty of being true. The remaining factors were mostly low certainty.

Interpretation for Patient Care

Given the paucity of evidence, neither treatment modality can be recommended over the other, and further randomized trials are needed in this population.

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