|Year : 2015 | Volume
| Issue : 3 | Page : 190-197
Extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, retrograde intrarenal surgery and ureteroscopic lithotripsy in the treatment of renal and proximal ureteric stones: Are they competitive or complimentary?
Hamed M.H. Eldarawany
Department of Urology, College of Medicine, University of Dammam, and King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia
|Date of Web Publication||3-Aug-2015|
Hamed M.H. Eldarawany
Department of Urology, King Fahd Hospital of the University, P.O. Box 40076, Al-Khobar 31952
Kingdom of Saudi Arabia
Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PCNL), retrograde intrarenal surgery (RIRS), and ureteroscopic lithotripsy (URSL) are now standard methods for the treatment of urinary stones. RIRS is newer compared to the others, and has noticeable promise owing to rapid advancements in endoscopic technology. In this article, a nonsystematic review of the literature was performed to select appropriate evidence-based studies that compare these different lines of stone management regarding the success rate, retreatment rate, auxiliary procedures, and operative complications. Meta-analysis of the collected data is performed using MedCalc for Windows, version 12.1.1. The meta-analysis of the selected papers shows that there is significant difference in stone free rate, retreatment rate, and auxiliary procedures between ESWL cases and the cases treated by other lines of stone management in favor of PCNL, RIRS, and URSL. However, there is no significant difference between the different lines of stone treatment with regard to the operative complication. One of the four methods, ESWL, PCNL, RIRS or URSL, can be the best management choice depending on stone size and location. Stones that do not respond to treatment by one method can be effectively treated by an alternative method. The four methods should be available in any well-equipped stone center, but this idea can change with future advances in technology.
تفتيت الحصوات بالموجات التصادمية أو استخراجها من الكلية عن طريق الجلد، أو تفتيتها بالمنظار تعتبر الأساليب المعتمدة لعلاج الحصوات البولية في الكلى والحالب. يعتبر منظار الحالب والكلية هو أحدث السبل مقارنة بالأساليب الأخرى. في هذه المقالة تم إجراء مراجعة للأبحاث المنشورة والتي تقارن الوسائل المستخدمة في علاج حصوات المسالك البولية من حيث نسبة النجاح، ومعدل إعادة العلاج، والإجراءات المساعدة، والمضاعفات وتعتبرالطرق الأربعة المذكورة ألأسلوب الأمثل للعلاج، اعتمادا على حجم الحصوات ومكان وجودها. ويحبذ أن تكون الطرق الأربعة المستخدمة في علاج حصوات المسالك البولية متوفرة في مراكز العلاج.
Keywords: Lithotripsy, shockwave, stone, ureteroscopy
|How to cite this article:|
Eldarawany HM. Extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, retrograde intrarenal surgery and ureteroscopic lithotripsy in the treatment of renal and proximal ureteric stones: Are they competitive or complimentary?. Saudi J Med Med Sci 2015;3:190-7
|How to cite this URL:|
Eldarawany HM. Extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, retrograde intrarenal surgery and ureteroscopic lithotripsy in the treatment of renal and proximal ureteric stones: Are they competitive or complimentary?. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Jan 26];3:190-7. Available from: https://www.sjmms.net/text.asp?2015/3/3/190/161993
| Introduction|| |
Treatment of urinary stones has shifted dramatically from the conventional open surgery to noninvasive or minimally invasive procedures. Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PCNL), retrograde intrarenal surgery (RIRS), and ureteroscopic lithotripsy (URSL) are now the primary lines of treatment for urinary stones.
Extracorporeal shock wave lithotripsy is a well-recognized standard procedure that is particularly effective with small renal stones (≤20 mm).  It is commonly performed as an out-patient procedure with a low complication rate and requires no anesthesia. Its efficacy can be compromised by obesity, stone density, composition, size, and location in the kidney. ,, The acute angle between the axis of the lower calyx and that of the renal pelvis as well as the length of the lower pole infundibulum can hinder post-ESWL clearance of an already fragmented stone in the lower calyx. 
Percutaneous nephrolithotripsy is effective for stones, irrespective of size or location in the pelvicalyceal system, , but has a higher morbidity and longer hospital stay. , RIRS is rapidly advancing because of continuing remarkable developments in endoscopic technology. Now, RIRS is effective for small stones anywhere in the pelvicalyceal system.  Easy accessibility of the flexible ureteroscope makes RIRS superior to ESWL for lower calyceal stones. , The introduction of small-caliber semi-rigid ureteroscopes as well as lithotripter technology have substantially improved the URSL stone-free rate and decreased the risk of complications. ,,
| Methodology|| |
A nonsystematic review of the literature was performed using PubMed, ScienceDirect, Google and Cochrane Library to assemble appropriate evidence-based reference literature. The search of the management of renal and proximal ureteric stones was done on the following terms : c0 omparison between ESWL and PCNL, for renal stones, ESWL and RIRS for renal stones, and ESWL and URSL for proximal ureteric stones. All types of studies (randomized controlled trials, prospective or retrospective) were selected. Only papers on adult patients and those written in English were incorporated.
Statistical analyses were performed using MedCalc (MedCalc Software, Mariakerke, Belgium) for Windows, version 12.1.1 Dichotomous data were extracted and summarized using odds ratio (OR) with 95% confidence intervals (CIs). If the 95% CI included a value of 1, it was assumed that there was no statistically significant difference between the compared data. Continuous data were extracted as mean and standard deviations and summarized using the mean difference (MD) with 95% CI. If the 95% CI included a value of 0, it was assumed that there was no difference between the groups. A fixed effects model was used by default unless the test of heterogeneity was found significant.
| Results|| |
Extracorporeal shock wave lithotripsy versus percutaneous nephrolithotripsy
Five studies on the treatment of kidney stones compared ESWL to PCNL. Their findings were reviewed and statistically analyzed. ,,,,
In 1992, Carlsson et al. reported the results of ESWL (28 patients) versus PCNL (21 patients) for kidney stones measuring 6-30 mm.  The stone clearance rates (stone fragments ≤4 mm) at the end of the 4 th week were 76% (19/25) after ESWL and 100% (15/15) after PCNL. The mean hospital stay was significantly lower after ESWL (4.1 ± 2.6 days). Hematuria lasted longer after ESWL, while fever was more frequent after PCNL.
The study by Rao et al. compared the outcome of ESWL to PCNL for renal stones ≤20 mm.  Stone clearance was achieved in 178/257 (69%) patients after ESWL and in 73/77 (94%) patients after PCNL. The authors noticed that ESWL was more expensive than PCNL. This was attributed to frequent patient re-visitation for stone clearance by ESWL. Thirty-five patients failed to respond to ESWL and were re-admitted for stone clearance with PCNL adding to the ESWL cost. One patient in the PCNL group required blood transfusion.
In 2001, Albala et al. published their experience with lower calyceal stones treated by either ESWL (52 patients) or PCNL (55 patients).  The stone sizes were ≤30 mm (mean 14.43 mm in the ESWL group, and 13.59 mm in the PCNL group). The overall success rates of ESWL and PCNL were 36.5% and 94.5%, respectively. The success rate was clearly in favor of PCNL, but varied with differences in stone size. It was 63% (12/19) and 100% (20/20) for size ≤10 mm, 23% (6/26) and 93% (26/28) for size 11-20 mm, and 14% (1/7) and 86% (6/7) for size 21-30 mm, for ESWL and PCNL, respectively. Successful results of PCNL were statistically more significant than those of ESWL irrespective of stone size (analysis 1.1.2: Relative risk: 0.39, 95% CI: 0.27-0.56). Stone location in the lower pole was the chief cause of the poor results of ESWL. The authors concluded that lower calyceal stones were better treated by PCNL. In the ESWL group, auxiliary procedures and re-treatment were needed in 10/52 (19.2%) and 5/55 (9.1%) respectively. In the PCNL group, 1/55 (1.8%) patients required auxiliary procedures while 5/55 (9.1%) required re-treatment. The complications following both procedures were minor.
In 2011, Deem et al. studied the outcome of ESWL (12 patients) and PCNL (20 patients) for renal stones of 10-20 mm.  PCNL established a stone-free status in 95% of patients versus 17% in ESWL group at 1-week in plain X-ray films. This dropped to 85% in PCNL group versus 33% in ESWL group after 3 months when assessed by computed tomography (CT)-scan. Auxiliary and re-treatment procedures were more needed in ESWL patients than in PCNL patients.
Wiesenthal et al., in 2011, reviewed 96 patients with big nonstaghorn stones 100-300 mm in size.  Fifty-three patients were treated by ESWL, and 43 by PCNL. Mean stone area was higher in the PCNL group (P < 0.001). Single treatment success rates were significantly better for PCNL than ESWL (95.3 vs. 60.4%). Auxiliary procedures and retreatment were higher for ESWL (42.3% and 9.4%) than for PCNL (7.3% and 0%) respectively.
Extracorporeal shock wave lithotripsy versus retrograde intrarenal surgery
Four studies that compared ESWL to RIRS for the treatment of renal stones were reviewed and statistically analyzed. ,,, In 2011, Wiesenthal et al.  treated 53 patients by ESWL and 41 by RIRS. Single treatment success rates were better for RIRS (87.8%) than ESWL (60.4%), while auxiliary treatments were more required after ESWL (42.3%) than RIRS (9.8%). Five patients (9.4%) who underwent ESWL needed subsequent RIRS for complete stone clearance.
Pearle et al. treated stones (≤10 mm) by ESWL (32 patients) and RIRS (35 patients) in 2005.  Stone-free rates within 3 months were 65% (17/26) for ESWL and 72% (23/32) for RIRS. All patients treated by ESWL and 94% treated by RIRS were discharged on the day of treatment. The complications in both groups were mild and controllable.
El-Nahas et al. treated larger stones (10-20 mm) by ESWL (62 patients) or RIRS (37 patients) in 2012.  The stone-free rate was significantly better after RIRS (86.5%) than ESWL (67.7%) (P = 0.038). The retreatment rate was significantly higher after ESWL (60%) than RIRS (8%) (P < 0.001). RIRS was performed after ESWL to clear significant residual fragments (>4 mm) in 5 patients (8%). However, ESWL was needed to clear significant residual fragments (<10 mm) in 3 patients (8%) after RIRS. RIRS caused more complications (13.5%) than ESWL (4.8%). All were minor, and the differences were not statistically significant.
Wankhade and et al.  evaluated a total of 156 patients with lower calyceal stone 11-15 mm in size, who were divided into 2 equal groups and underwent ESWL or PCNL. The stone clearance rate in the ESWL group (67.95%) was lower than the PCNL group (97.43%). The need for auxiliary procedures was higher in ESWL group (15.38% 12/78). The operative complications were negligible due to the smallness of the calculi.
Extracorporeal shock wave lithotripsy versus ureteroscopic lithotripsy in treatment of proximal ureteric calculi
Seven comparative trials of ESWL and URSL for the treatment of proximal ureteric calculi were evaluated. ,,,,,, Wu et al., reviewed the data of 250 patients with proximal ureteric stone,  149 of whom were treated by ESWL while 101 underwent URSL. The stone burden of the ESWL group (58.7 ± 3.1 mm 2 ) was significantly lower than that of URSL group (108.4 ± 10.0 mm 2 ) (P = 0.000). The initial stone-free rate of the URSL group (83.2%, 84/101) was significantly superior to that of the ESWL group (63.9%, 76/119) (P = 0.001).
A review by Lee et al.,  of 42 patients with a solitary, radiopaque upper ureteral stones 15 mm or more in diameter, who underwent SWL (22 patients) or URSL (20 patients) showed that the mean treatment time and hospital stay were significantly lower in the SWL group (P = 0.000). Of the 22 patients who underwent SWL, 7 patients (31.8%) were stone free after one session, and 7 patients (31.8%) required more than one session. The remaining 8 patients were stone free after auxiliary procedure. In the URSL group, 7 patients (35%) were stone free after a single trial, and 8 patients underwent auxiliary SWL for residual stones. There were greater complications in the URSL group.
In Izamin et al.'s study of a total of 67 patients,  30 patients were treated by ESWL while 37 patients were treated by URSL. The stone free rate was comparable between the two groups (81.8% in ESWL and 84.6% in URSL).
In the Seyed et al., evaluation of 166 patients, 40 had chosen URSL and 126 SWL.  The 3 months stone-free rate was not significantly lower in URSL group (72.5%) than the SWL group (78.6%) (P = 0.42). The mean operative time and post-procedural complication rates were comparable between the two groups.
In the Youssef et al. series,  43 matched pairs of patients were compared. The success rate was 83.7% for SWL and 88.4% for URS (P = 0.8). The retreatment rate was significantly greater in the SWL group than in the URS group (65% vs. 2.3%, respectively; P = 0.001). The need for auxiliary procedures was the same in the two groups (16.3%). The complication rate was 14% in the URS group and 4.7% in the SWL group.
Manzoor et al.,  evaluated 398 patients (divided into two equal groups) with 10-15 mm proximal urteric stone treated by ESWL or URSL. The success rate was 49.2% for ESWL and 57.8% for URS (P = 0.008). The re-treatment rate was higher in ESWL group than in the URS group (40% vs. 11%), 22% of the patients in the ESWL group required auxiliary treatment as against 18% of the patients in URSL group.
In the Cui et al. study,  160 patients who underwent ESWL (80 patients) or URSL (80 patients) for a single radiopaque ureteral stone (8-15 mm) were evaluated. Cui et al. concluded that there was a similarity in stone clearance rate and treatment time between the two procedures, although the overall procedural time, analgesia requirement and total cost were significantly different.
The data of the comparative studies between ESWL and PCNL are summarized in [Table 1]. Meta-analysis revealed that the stone free rate was significantly higher for PCNL than ESWL [Figure 1] (OR: 13.232, 95% CI: 7.235-24.198, P < 0.001). There was significantly more retreatment numbers after ESWL than PCNL (OR: 0.105, 95% CI: 0.0435-0.253, P < 0.001), and more auxiliary procedures for ESWL than PCNL (OR: 0.0866, 95% CI: 0.0344-0.218, P < 0.001). However, there was no significant difference between the two groups for complications (OR: 2.181, 95% CI: 1.025-4.643, P = 0.043).
|Figure 1: Stone free rates after extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotripsy (PCNL) for renal stones. The stone free rate in 3 months is signifi cantly higher for PCNL than ESWL (odds ratio: 13.232, 95% confi dence interval: 7.235-24.198, P < 0.001).|
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|Table 1: The data of different studies comparing ESWL versus PCNL for renal stones|
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The data of the comparative studies between ESWL and RIRS are summarized in [Table 2]. Meta-analysis showed that the stone free rate for RIRS was significantly higher than ESWL (OR: 2.862, 95% CI: 1.580-5.185 P = 0.001). Retreatment numbers were significantly higher with ESWL [Figure 2] (OR: 0.134, 95% CI: 0.0605-0.297, P < 0.001). The auxiliary procedures for ESWL significantly exceeded those following RIRS (OR: 0.306, 95% CI: 0.145-0.647, P = 0.002). The operative complications were insignificantly more common in the RIRS group (OR: 2.383, 95% CI: 0.958-5.929, P = 0.062). There was no significant difference between ESWL and RIRS with regard to the operative time (standardized MD: 0.0343, 95% CI: −0.286-0.355, P = 0.833).
|Figure 2: Retreatment after extracorporeal shock wave lithotripsy (ESWL) versus retrograde intrarenal surgery for renal stones. Retreatment numbers is signifi cantly higher with ESWL (odds ratio: 0.134, 95% confi dence interval: 0.0605-0.297, P < 0.001).|
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|Table 2: The data of different studies that compare ESWL versus RIRS for renal stones|
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The data of the trials that compared treatments by ESWL and URSL of proximal ureteric calculi are summarized in [Table 3]. Meta-analysis showed the success rate to be significantly higher with URSL (OR: 1.924, 95% CI: 1.469-2.519, P < 0.001). Retreatments were significantly more common in the ESWL group (OR: 0.230, 95% CI: 0.158-0.334, P < 0.001), but auxiliary treatments were insignificantly higher in ESWL (OR: 0.860, 95% CI: 0.605-1.221, P = 0.399). The rate of complications was found to be significantly higher in the URSL group [Figure 3] (OR: 1.734, 95% CI: 1.223-2.457, P = 0.002).
|Figure 3: The complication rate is signifi cantly higher in ureteroscopic lithotripsy group than extracorporeal shock wave lithotripsy group (odds ratio: 1.734, 95% confi dence interval: 1.223-2.457, P = 0.002).|
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|Table 3: The data of different studies that compare ESWL versus URSL for proximal ureteric stones|
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Owing to the nonrandomized design of most of the reviewed studies in this article, there is a risk of bias in the results of both the studies and the meta-analysis.
| Discussion|| |
Few studies have compared the results of ESWL, PCNL, and RIRS (for kidney stones) and between ESWL and URSL (for ureteric stones). Meta-analysis was done in three of these studies by Srisubat et al. in 2009;  (2 on ESWL vs. PCNL, , and 1 on ESWL vs. RIRS).  The current review included these as well as other studies published between 1992 and 2014. Five studies were on ESWL versus PCNL, ,,,, and four studies on ESWL versus RIRS. ,,, The criteria used by Srisubat et al. included success rate, retreatment rate, auxiliary treatment, and complications.  They concluded that PCNL and RIRS had higher stone-free success rates with lower auxiliary or retreatment rates than ESWL.
The current review also included 7 papers that compared ESWL and URSL for ureteric stones. ,,,,,, In his meta-analysis study, Xu et al.  included 13 papers that compared ESWL to URSL for ureteric stone. He pointed out that there were significant differences of stone free rate P < 0.0001 in favor of URSL group, the retreatment rate was significantly higher in the ESWL group (P = 0.004) hospital stays in URS group were also significantly longer (P = 0.004). Xu et al., also indicated that ESWL had significantly lower postoperative complications (P = 0.40) and operation time (P = 0.002) than URS.
According to the American Urological Association Nephrolithiasis Clinical Guideline Panel in 2007 for the treatment of ureteral calculi,  stone-free rates were somewhat higher with URSL (93%) than with ESWL (87%) for treating stones of <10 mm in diameter. The difference was even more pronounced in stones larger than 10 mm in diameter (86%, and 67% respectively). Ureteroscopic management of ureteral calculi also required a lower median number of procedures compared to ESWL regardless of stone size.
Stone clearance was defined as absence of stone fragments or the presence of residual stones ≤3-4 mm. ,,, Stone clearance after treatment increases with time because of the passage of fragments with urine. However, this was not the case in some studies where the clearance after PCNL dropped from 100% after 4 weeks to 94% after 1-year in one study,  and from 95% after 1-week to 85% 3 months later in another.  This post-traumatic increase in stone volume could be explained by new stone growth over small retained residual fragments. Alternatively, it could be a technical imaging error. Deem S et al. used plain X-ray films after 1-week and CT-scan after 3 months. Missed fragments of significant volume in plain X-ray films can pose potential complications. 
Technological advances of the equipment used are designed to improve their functional performance and reduce the risk of possible complications. Advances utilized in the new second generation electromagnetic ESWL machines reduced the risks of exposure to radiation. However, they also reduced the focal area for stone fragmentation with an increased risk of compromised stone clearance. However, technological advancements in PCNL and RIRS are making them safer and more effective in stone clearance.
Recent improvements in flexible and semi-rigid ureteroscopy as well as the development of ureteroscope devices have facilitated RIRS/URSL performance and reduced the incidence of complications. They include the development of small nitinol baskets (as small as F1.5) improved ureteral access sheaths, production of highly deflectable small caliber flexible ureteroscopes with a chip on the tip of the camera, and improved intracorporeal lithotripters. ,
Stone size and location are important defining factors for treatment selection. PCNL has the highest stone clearance regardless of size or location. It can achieve up to 100% clearance for small kidney stones (≤1 mm), 94% for size 10-20 mm, and 89% for bigger stones (>20 mm).  ESWL and RIRS are effective with small kidney stones, but lag behind PCNL in clearance. , The lower calyx poses a challenge for the treatment of stones by ESWL. The clearance of small stones (≤30 mm) in the lower calyx by ESWL was significantly less (37%) than the clearance of bigger stones (100-300 mm) in the renal pelvis or in other calyces (60.4%). , RIRS yields best results with small stones (≤2 mm), even if in the lower calyx. However, the need for continuous maximum deflection of the flexible ureteroscope to reach the lower calyx increases the risk of failure of the deflecting mechanism. This can be avoided if the stone is in a more accessible location. 
The remarkable technologic advances in flexible ureteroscopy in recent years have largely made it possible to target kidney stones in unusual positions such as horseshoe kidneys by RIRS.  RIRS has also proved to be preferable over ESWL and PCNL for the treatment of kidney stones in patients with coagulopathy with no reports on significant bleeding after the treatment. 
Complications of ESWL, PCNL, URSL, and RIRS are generally few, minor, and easily controlled in experienced hands. The complications most observed are urinary tract infections and steinstrasse with ureteral obstruction after ESWL, bleeding and atelectasis during percutaneous access for PCNL, and ureteral injury during URSL and RIRS. ,,
Extracorporeal shock wave lithotripsy has the highest failure rate in stone clearance even with multiple sessions. , However, it remains the most popular because of its safety, noninvasiveness and the fact that it is an out-patient procedure.
| Conclusions|| |
Percutaneous nephrolithotripsy followed by RIRS (for renal stone) and URSL (for ureteric stone) achieve higher stone clearance, lower retreatment rate, and lower auxiliary treatment rate than ESWL. ESWL is superior for being noninvasive, an out-patient procedure and with less complication rates. PCNL obtains the best results irrespective of stone size or location. However, it has a higher potential of complications with a long hospital stay. Both ESWL and RIRS are particularly effective with small renal stones, and RIRS can clear fragmented stones from the lower calyx more effectively than ESWL. At the present time, the three treatment methods (ESWL, PCNL, and RIRS) for renal stones, and the two treatments methods (ESWL and URSL) for ureteric stones are both competitive and complementary. These conclusions may change in the future with advances in the technology in the different lines of treatment.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]