Comparison of stone-free rates following shock wave lithotripsy, percutaneous nephrolithotomy, and retrograde intrarenal surgery for treatment of renal stones: A systematic review and network meta-analysis

Abstract

Objectives: To perform a systematic review and network meta-analysis comparing stone-free rates following retrograde intrarenal surgery (RIRS), extracorporeal shock wave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) treatments of renal stones.

Materials and methods: Clinical trials comparing RIRS, SWL, and PCNL for treatment of renal stones were identified from electronic databases. Stone-free rates for the procedures were compared by qualitative and quantitative syntheses (meta-analyses). Outcome variables are shown as risk ratios (ORs) with 95% credible intervals (CIs).

Results: A total of 35 studies were included in this network meta-analysis of success and stone-free rates following three different treatments of renal stones. Six studies compared PCNL versus SWL, ten studies compared PCNL versus RIRS, fourteen studies compared RIRS versus SWL, and five studies compared PCNL, SWL, and RIRS. The quality scores within subscales were relatively low-risk. Network meta-analyses indicated that stone-free rates of RIRS (OR 0.38; 95% CI 0.22-0.64) and SWL (OR 0.12; 95% CI 0.067-0.19) were lower than that of PCNL. In addition, stone-free rate of SWL was lower than that of RIRS (OR 0.31; 95% CI 0.20-0.47). Stone free rate of PCNL was also superior to RIRS in subgroup analyses including ≥ 2 cm stone (OR 4.680; 95% CI 2.873-8.106), lower pole stone (OR 1.984; 95% CI 1.043-2.849), and randomized studies (OR 2.219; 95% CI 1.348-4.009). In rank-probability test, PCNL was ranked as No. 1 and SWL was ranked as No. 3.

Conclusions: PCNL showed the highest success and stone-free rate in the surgical treatment of renal stones. In contrast, SWL had the lowest success and stone-free rate.

Fig 1. Flow diagram of evidence acquisition.

Thirteen studies were ultimately included in the qualitative and quantitative review that used pairwise and network meta-analyses.

Fig 2. Network plots for included studies.

Six studies compared PCNL versus SWL. Six studies reported outcomes between PCNL and RIRS. Eight studies compared outcomes between RIRS and SWL. Four studies demonstrated the comparison for PCNL, SWL, and RIRS.

Fig 3. Pairwise meta-analysis of success rate in PCNL and RIRS.

Pooled data assessment of stone-free rate between PCNL and RIRS showing a significantly higher stone-free rate with PCNL (OR 2.31; 95% CI 1.45–3.67; P<0.001).

Fig 4. Pairwise meta-analysis of success rate in PCNL and SWL.

Results show that the stone-free rate of PCNL was superior to SWL (OR 7.71; 95% CI 4.08–14.57; P<0.001).

Fig 5. Pairwise meta-analysis of success rate in SWL and RIRS.

Results show that the stone-free rate of SWL was lower than RIRS (OR 60.46; 95% CI 0.30–0.71; P<0.001).

Fig 6

L’Abbe plots of success rate between RIRS and PCNL (A), SWL and PCNL (B) and RIRS and SWL (C). Little heterogeneity was noted in L’Abbe plots.

Fig 7

Radial plots of success rate between RIRS and PCNL (A), SWL and PCNL (B), and RIRS and SWL (C). Little heterogeneity was noted in radial plots.

Fig 8. Network meta-analysis for success rate of RIRS, PCNL, SWL, and node-splitting analyses of inconsistency.

In node-splitting analysis, no inconsistency was demonstrated in direct, indirect, or network comparison.

Fig 9. Net-heat plot for inconsistency.

Net-heat plot showing that there is little inconsistency in whole network analysis of PCNL, SWL, and RIRS.

Fig 10

Funnel plots of success rate between RIRS and PCNL (A), SWL and PCNL (B), and RIRS and SWL (C). There were some publication bias in funnel plots.

Fig 11. Rank-probability test of network meta-analyses.

In the rank-probability test, PCNL was ranked as No. 1 and SWL was ranked as No. 3.