Study Of Minimally Invasive Treatment Of Ureteral Calculi: Systematic Review And Randmized Control Trials

Background and Objective：Minimally invasive treatment of ureteral stones includes extracorporeal shock wavelithotripsy (ESWL)、 ureteroscopic lithotripsy (URL)、 percutaneous nephrolithotomylithotripsy (PCNL)、 retroperitoneal laparoscopic ureterolithotomy(RPLU), etc. Thesetreatments of ureteral stones in different locations have the advantages and disadvantagesrespectively. Cochrane Collaboration and The American Urological Association KidneyStone Treatment Guidelines(AUA) systematically evaluated the treatment of ureteral calculione after another. Cochrane Collaboration showed that URL had the higher stone clearancerate than ESWL with relatively more complications and longer hospitalization. AUA alsoconsidered URL could get higher stone clearance rate，and had more advantage in thetreatment of lower ureteral stones. But for upper ureteral stones, AUA did not give apreferential treatment method clearly. Thus, how to choose the treatment method forureteral stones in different locations still remains controversial both at home and abroad. Inthis study, we conducted the evidence-based medical research about minimally invasivetreatment of ureteral stones in different locations，and provided evidence-based medicinefor the choice of ureteral calculi treatment. Meanwhile，we compared the safety andefficacy of flexible ureteroscopic lithotripsy (F-URS) with mini-percutaneousnephrolithotomy (MPCNL) for proximal ureter stones in a prospective randomized manner.We aimed to provide further evidence for the treatment of upper ureteral calculi.Materials and Methods:In order to conduct the systematic review, articles were searched from the abstractdatabases, such as MEDLINE, EMBASE, Cochrane Library and CBMDisc, and full-textdatabases, such as PUBMED，CNKI and CQVIP，et al. In addition, we tracked down thereference lists of papers related to this review．Time limited from January1995toDecember2012. All the included studies were randomized controlled trials which compared different ways of treatment of ureteral calculi. Indexes about the initial and overall stoneclearance rate, repeat treatment, mean operating time, postoperative complications, hospitalstay、VAS were extracted and Meta Analysis was done using the software RevMan5.1provided by Cochrane Collaboration.In our randomized controlled trials,120patients were randomized in equal number totwo treatment groups, flexible ureteroscopic lithotripsy（F-URS）and mini-percutaneousnephrolithotomy (MPCNL). The two groups were well matched for age, sex, stone size.Achievement ratio of operation, time of operation, hospital stay, postoperative visualanalogue scale (VAS) scores, stone clearance rate and complications were comparedbetween the two groups. Date analysis was done using the software SPSS16.0，P<0.05wasconsidered statistically significant.Results:Fifteen studies met inclusion criteria. Meta-analysis showed that for the treatment ofdistal ureteral stones，the stone-free rate in URS group was significantly higher than that inESWL group，and the re-treatment rate in URS group was significantly lower. There was nodifference between the2modalities in the risk of complications and the time of operation.For proximal ureteral stones，there was no difference in stone-free rate、postoperativecomplications and re-treatment rate in ESWL group and URS group，but ESWL group hadshorter operative times than URS group. Contrastive analysis showed that the stone-freerate in PCNL group was significantly higher than that in URS group in the treatment ofproximal ureteral stones with no difference in complications、 operative time andre-treatment rate.In our randomized controlled trials, the initial stone clearance rate of F-URS andMPCNL was68.33%and95.0%respectively, and the difference was significant (P＜0.05).The clearance rate of the two groups three months after operation was96.67%and98.33%respectively, and the difference between the two groups was insignificant (P＞0.05). Theoperating time of F-URS group and MPCNL group was35.33±11.57min and53.75±17.31min respectively, the average hospital stay after operation was3.05±0.62days and5.43±1.84days respectively, and the average visual analogue scale (VAS) score on firstpostoperative day was1.70±1.37and3.68±1.57. These indicators were significantlydifference between the two groups (P＜0.05). The average hemoglobin drop of F-URS group and MPCNL group was14.25g/L and15.32g/L, the difference was insignificant. Thecomplications of F-URS group and MPCNL group was6.67%and8.33%and there wasno difference between the two groups (P＞0.05) too.Conclusions:Through the systematic review, we know that for the treatment of lower ureteral stones,URS has much higher stone clearance rate and lower rate of re-treatment than SWL. SoURS is recommended as preferred method for lower ureteral stone in clinical practice. Therandomized controlled trial results show that for proximal ureteral calculi，there is nosignificantly difference between F-URS and MPCNL in long-term calculi clearance rate,but F-URS is more security and has shorter postoperative hospital stay. In the departmentwhich has flexible ureteroscope, F-URS should be choosed as the preferred treatment forthese stones.