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Comparative Study
. 2020 Mar;99(10):e19403.
doi: 10.1097/MD.0000000000019403.

Comparison of the efficacy and safety of shockwave lithotripsy, retrograde intrarenal surgery, percutaneous nephrolithotomy, and minimally invasive percutaneous nephrolithotomy for lower-pole renal stones: A systematic review and network meta-analysis

Sheng-Han Tsai  1   2 , Hsiao-Jen Chung  2   3 , Ping-Tao Tseng  4 , Yi-Cheng Wu  5 , Yu-Kang Tu  6 , Chih-Wei Hsu  7 , Wei-Te Lei  8
Affiliations
Comparative Study

Comparison of the efficacy and safety of shockwave lithotripsy, retrograde intrarenal surgery, percutaneous nephrolithotomy, and minimally invasive percutaneous nephrolithotomy for lower-pole renal stones: A systematic review and network meta-analysis

Sheng-Han Tsai et al. Medicine (Baltimore). 2020 Mar.

Abstract

Background: Shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and minimally invasive PCNL are currently therapeutic options for lower-pole renal stones (LPS). However, the optimal treatment for LPS remains unclear. A comprehensive evaluation of the efficacy and safety of each intervention is needed to inform clinical decision-making. This study aimed at assessing the efficacy and safety of different interventions for LPS.

Methods: PubMed, Embase, ScienceDirect, ClinicalKey, Cochrane Library, ProQuest, Web of Science, and ClinicalTrials.gov were searched from inception to December 6th 2018. Only randomized controlled trials (RCTs) including the patients treated for LPS were included. The frequentist models of network meta-analysis were used to compare the effect sizes. The primary outcome was stone free rate, and the secondary outcomes were overall complication rate, major complication rate, retreatment rate, and auxiliary procedure rate.

Results: This study included 13 RCTs comprising 1832 participants undergoing 6 different interventions, including RIRS, PCNL, Mini-PCNL, Micro-PCNL, SWL, and conservative observation. PCNL had the best stone free rate (odds ratio [OR] = 3.45, 95% confidence interval [CI] = 1.30-9.12), followed by Mini-PCNL (OR = 2.90, 95% CI = 1.13-7.46). Meta-regression did not find any association of the treatment effect with age, sex, and stone size. Although PCNL tended to exhibit a higher complication rate, the difference of complication rate among various interventions did not achieve a statistical significance. SWL was the less effective and associated with higher retreatment rate compared with PCNL, Mini-PNCL, and RIRS.

Conclusions: PCNL was associated with the best stone free rate for LPS regardless of age, sex, and stone size. Each treatment achieved a similar complication rate compared with the others. Future large-scale RCTs are warranted to identify the most beneficial management for renal stones at a more complicated location.

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Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Flowchart of the systematic review and network meta-analysis.
Figure 2
Figure 2
(A) Network structure of the network meta-analysis of stone free rate. The lines between nodes represented of direct comparisons, and the size of each circle is proportional to the number of participants in each intervention. The thickness of the lines is proportional to the number of trials connected to the network. (B) Forest plot of the network meta-analysis of stone free rate. It indicates better stone-free rate by interventions than controls when effect size >1.
Figure 3
Figure 3
(A) Network structure of network meta-analysis of overall complication rate. (B) Forest plot of network meta-analysis of overall complication rate.
Figure 4
Figure 4
(A) Network structure of network meta-analysis of major complication rate. (B) Forest plot of network meta-analysis of major complication rate.
Figure 5
Figure 5
(A) Network structure of network meta-analysis of retreatment rate. (B) Forest plot of network meta-analysis of retreatment rate.
Figure 6
Figure 6
(A) Network structure of network meta-analysis of auxiliary procedure rate. (B) Forest plot of network meta-analysis of auxiliary procedure rate.
Figure 7
Figure 7
(A) Overview of risk of bias. (B) Detailed risk of bias in each study.
See this image and copyright information in PMC

References

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