WCE 2018: The Best Treatment for 10-20mm Renal Stones: A Pilot Randomized Controlled Trial of Extracorporeal Shock Wave Lithotripsy, Ureterorenoscopy, and Percutaneous Nephrolithotomy

Paris, France (UroToday.com) Urolithiasis represents a growing proportion of urologic practice given recent data suggesting an up trending prevalence of this issue in the last decade. Three different techniques for managing urolithiasis, Extracorporeal shock wave lithotripsy (SWL), Ureterorenoscopy (URS), and percutaneous nephrolithotomy (PCNL), each have advantages and disadvantages. There is concern that SWL and URS while both being less invasive than PCNL, do not achieve high enough stone-free rates especially for stones greater than 1 cm. There are currently no randomized control trials comparing these three techniques in terms of outcomes for treating stone disease. The authors in this study attempt to pilot one of the first designs of this kind specifically for patients with stones 10-20mm in size.

Bailie et al. assessed outcomes on 31 patients each of which were randomized to one of the three treatment modalities. Treatments were performed as necessary until adequate stone-free status was achieved, which was assessed through post-treatment CT scan. Stone free rates (SFR) were 60%, 55%, and 80% for SWL, URS, and PCNL, respectively (p = .33). Overall, PCNL treatment resulted in fewer procedures (median = 1) than either SWL or URS (median = 2 for both) (p = .015), with a comparable length of hospital stay (LOS). Complication rate and severity was much higher with SWL (50%) than with either URS (9%) or PCNL (20%) (p = .019).

The presenter for this session was not able to address differences in stone composition, which may influence the appropriateness of these techniques in certain patients. However, this study presents compelling evidence that SWL is an inadequate method for treating large stone disease due to its higher complication rates and relatively low stone-free rate. This adds to the growing body of literature discouraging the use of SWL for large stone burden. PCNL, on the other hand, may be the most appropriate treatment modality given it comparable LOS, higher SFR, and fewer incidences of follow up procedures.

Presented by: John Bailie, Monash Health, Melbourne
Co-Authors: Shekib Shahbaz, Ivor Berman, Matthew Hong, Philip McCahy

Written by: Max Towe, medical writer for UroToday.com at the 36th World Congress of Endourology (WCE) and SWL - September 20-23, 2018 Paris, France