Abstract
ABSTRACTPurpose Various surgical options are available for large proximal ureteral stones, such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URSL), percutaneous nephrolithotomy (PCNL) and laparoscopic ureterolithotomy (LU). However, the best option remains controversial. Therefore, we conducted a network meta-analysis comparing various surgical treatments for proximal ureteral stones ≥10mm to address current research deficiencies.Materials and methods We searched PubMed, Ovid, Scopus (up to June 2019), as well as citation lists to identify eligible comparative studies. All clinical studies including patients comparing surgical treatments for proximal ureteral stones ≥10mm were included. A standard network meta-analysis was performed with Stata SE 14 (Stata Corp, College Station, TX, USA) software to generate comparative statistics. The quality was assessed with level of evidence according to the Oxford Centre for Evidence-based Medicine and risk of bias with the Cochrane Collaboration’s Review Manager (RevMan) 5.3 software.Results A total of 25 studies including 2.888 patients were included in this network meta-analysis. Network meta-analyses indicated that LU and PCNL had better stone-free rates and auxiliary procedures. PCNL could result in major complications and severe bleeding. In initial stone-free rate, final stone-free rate, and auxiliary procedures results, SUCRA ranking was: LU> PCNL> URSL> ESWL. In Clavien Dindo score ≥3 complications, SUCRA ranking was: LU> ESWL> URSL> PCNL. In fever, SUCRA ranking was: ESWL> LU> URSL> PCNL. In transfusion, SUCRA ranking was: LU> URSL> ESWL> PCNL. In Cluster analysis, LU had the highest advantages and acceptable side effects. Considering the traumatic nature of PCNL, it should not be an option over URSL. ESWL had the lowest advantages.Conclusions LU have the potential to be considered as the first treatment choice of proximal ureteral stone ≥10mm.
Highlights
Urolithiasis is one of the most common health care burdens in the daily lives of working-age people [1]
Inclusion and exclusion criteria Inclusion criteria: [1] original studies comparing different surgical treatments for proximal ureteral stones; [2] proximal ureteral stones ≥10mm; [3] studies reported in English language; [4] adult patients only; [5] the outcomes should include stone-free rate, auxiliary procedures, transfusion, fever and other complications
25 studies including 2.888 patients were included in this network meta-analysis (Figure-1) [12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36]
Summary
Urolithiasis is one of the most common health care burdens in the daily lives of working-age people [1]. Large ureteral stones above 10mm require further intervention. Due to the long distance, the proximal ureteral stones are not easy to pass, and it is easier to form a stone street. The treatment of large proximal ureteral stones is more difficult. Among various treatments of proximal ureteral stones, such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URSL), percutaneous nephrolithotomy (PCNL) and laparoscopic ureterolithotomy (LU), the best choice remains controversial [3,4,5]. According to the EAU Guidelines, ESWL remains the first line treatment modality for ureteral stones less than 2cm, because of its non-invasive nature [6]. Large impacted proximal ureteral stones could be related with lower stone-free rate. Due to the risk of stone migration, there is still a debate on its efficacy [7]. 3, 4 participants, interventions, comparisons, outcomes, and study design (PICOS)
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