Most children and adolescents with kidney and ureteral stones are treated with ureteroscopy, despite the uncertainty and equal weight of guideline recommendations for ureteroscopy or shockwave lithotripsy.
To compare stone clearance and patient-reported outcomes among children and adolescents after ureteroscopy or shockwave lithotripsy.
This nonrandomized clinical trial enrolled patients between March 16, 2020, and July 31, 2023, at 31 medical centers in the US and Canada. Patients aged 8 to 21 years with kidney stones, ureteral stones, or both were included. Follow-up was completed on October 15, 2023.
Ureteroscopy or shockwave lithotripsy.
The primary outcome was stone clearance assessed by standardized ultrasonography 6 (±2) weeks after surgery. Using inverse probability weighting and random intercepts for site, stone clearance was evaluated per kidney or ureter using logistic regression and estimated stone clearance rates were generated for each procedure.
This study included 1142 patients (690 females [60.4%]), with a median age of 15.6 years (IQR, 12.6-17.3 years). In terms of race and ethnicity, 41 patients (3.6%) were Black, 130 (11.4%) were Hispanic, and 884 (77.4%) were White. A total of 124 urologists treated 1069 and 197 kidneys or ureters with ureteroscopy and shockwave lithotripsy (n = 953 and n = 189 patients), respectively, with a median stone size of 6.0 mm (IQR, 4.0-9.0 mm). Ureteral stents were placed at time of index surgery for 841 procedures for 767 patients (80.4%) receiving ureteroscopy and for 6 procedures for 5 patients (2.6%) receiving shockwave lithotripsy. Stone clearance occurred in 474 patients who underwent ureteroscopy (71.2% [95% CI, 63.8%-78.5%]) and in 105 patients who underwent shockwave lithotripsy (67.5% [95% CI, 61.0%-74.1%]), a difference that was not statistically significant (risk difference, 3.6% [95% CI, -6.2% to 13.5%]). Compared with shockwave lithotripsy, ureteroscopy resulted in greater pain interference (T-score difference, 5.0 [95% CI, 2.3-7.8]) and urinary symptoms (symptom score difference, 3.9 [95% CI, 1.2-6.7]) 1 week after surgery. Patients who had ureteroscopy missed more school (risk difference, 21.3% [95% CI, 9.7%-32.8%]) and caregivers missed more work (risk difference, 23.0% [95% CI, 11.0%-35.0%]) in the week after surgery.
In this study of 1142 children and adolescents with kidney and ureteral stones, there was no clinically meaningful difference in stone clearance with ureteroscopy vs shockwave lithotripsy. Shockwave lithotripsy was associated with better patient-reported outcomes. These findings raise questions about the preference for ureteroscopy in practice.
ClinicalTrials.gov Identifier: NCT04285658.
JAMA network open. 2025 Aug 01*** epublish ***
Gregory E Tasian, David I Chu, Caleb P Nelson, W Robert DeFoor, Justin B Ziemba, Jing Huang, Xianqun Luan, Michael Kurtz, Christina B Ching, Pankaj Dangle, Anthony J Schaeffer, Renea Sturm, Wayland Wu, Christopher Bayne, Nicolas Fernandez, Michael E Chua, Romano DeMarco, Pamela Ellsworth, Brian Augelli, Jing Bi-Karchin, Rebecca D McCune, Seth Vatsky, Susan Back, Zi Wang, Hunter Beck, Anna Kurth, Laura Kurth, Annabelle Pleskoff, Christopher B Forrest, Jonathan S Ellison, PKIDS Care Improvement Network , Kyle Rove, Scott Sparks, Eric Nelson, Bruce Schlomer, Aaron Krill, Ching Man Carmen Tong, Abby Taylor, Puneeta Ramachandra, Andrew Stec, Pasquale Casale, Douglas Coplen, Nicolette Janzen, Krystal Bagley, Michelle R Denburg, Kimberley Dickinson, Rosemary Laberee, Matt Lorenzo, Antoine Selman-Fermin, Joana Dos Santos, Campbell Grant, Kate Kraft, Bhalaajee Meenakshi-Sundaram
Division of Urology, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania., Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois., Department of Urology, Boston Children's Hospital, Boston, Massachusetts., Division of Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio., Division of Urology, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia., Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia., Department of Pediatric Urology, Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, Ohio., Department of Pediatric Urology, Riley Hospital for Children, Indianapolis, Indiana., Division of Urology, Department of Surgery, University of Utah, Salt Lake City., Department of Pediatric Urology, Mattel Children's Hospital at UCLA, Los Angeles, California., Department of Pediatric Urology, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson University Hospital, New Brunswick, New Jersey., Department of Pediatric Urology, Carilion Children's Pediatric Urology, Roanoke, Virginia., Division of Pediatric Urology, Seattle Children's Hospital, Seattle, Washington., Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada., Division of Pediatric Urology, Department of Urology, University of Florida, Gainesville., Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando., Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania., Patient and Family Research Partners, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania., Department of Pediatrics, Applied Clinical Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania., Division of Pediatric Urology, Department of Urology, Medical College of Wisconsin, Milwaukee., Department of Pediatric Urology, Children's Hospital Colorado, Aurora., Division of Urology, Children's Hospital Los Angeles, Los Angeles, California., Division of Urology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond., Department of Urology, University of Texas Southwestern, Dallas., Department of Urology, Children's National Hospital of Washington, Washington, DC., Department of Urology, University of Alabama, Birmingham., Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee., Division of Urology, Nemours A. I. DuPont Hospital for Children, Wilmington, Delaware., Division of Urology, Nemours Children's Health, Jacksonville, Florida., Division of Urology, Nemours Children's Health, Delaware Valley, Wilmington, Delaware., Division of Urology, St Louis Children's Hospital, St Louis, Missouri., Division of Urology, Texas Children's Hospital, Houston., Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania., Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania., Department of Urology, University of Kentucky, Lexington., Department of Urology, University of Michigan, Ann Arbor., Department of Urology, University of Oklahoma Health Sciences, Oklahoma City.