Emergent Lithotripsy Better for Some Ureteral Stones

ESWL and URS are effective first-line therapies for some ureteral stones in the emergency setting, study suggests.
ESWL and URS are effective first-line therapies for some ureteral stones in the emergency setting, study suggests.

Early rather than delayed lithotripsy is better for patients with symptomatic, obstructing ureteral stones, according to a new study.

“Emergent lithotripsy, either ureteroscopic or extracorporeal, can be offered as an effective and safe treatment for patients with symptomatic ureteral stone,” Riccardo Autorino, MD, of Case Western Reserve University in Richmond Heights, Ohio, and colleagues concluded in Urolithiasis, published online ahead of print.

Dr Autorino' s group evaluated emergent vs delayed lithotripsy in separate systematic reviews and meta-analyses of ureteroscopy (URS) and extracorporeal shock wave lithotripsy (ESWL). An “emergency” procedure occurred variably within 6 to 72 hours of presentation.

Emergent URS performed as well as delayed URS, according to a meta-analysis based on 4 studies (including 1 randomized controlled trial) of 1513 patients. The investigators reported no significant differences in stone-free rate, complication rate, and the need for auxiliary procedures. Stone-free meant the absence of a stone or fragments of 3 mm or less. Emergent ureteroscopy typically is reserved for distal stones, they noted.

Emergent ESWL was associated with more than twice the odds of achieving stone-free status and half the odds of auxiliary procedures compared with delayed ESWL. Again, no differences in rates of complications, such as hematuria or mucosal injury, were observed. “If amenable to ESWL, based on stone and patient characteristics, an emergent approach should be strongly considered,” Dr Autorino and colleagues stated. This meta-analysis involved 6 studies (including 4 randomized trials) of 711 patients. The investigators could not perform sensitivity analyses by stone size and location.

Early treatment of stones with colic is preferable because ureteral edema can develop within 48 hours and interfere with stone clearance, the team suggested. A previous study published in the Journal of Endourology (2010;24:2059-2066) found that treatment after 48 hours is associated with longer clearance of proximal ureteral stones less than 1 cm and higher rates of retreatment and auxiliary procedures. 

Implementing emergent lithotripsy would depend on the availability of URS and ESWL. It is possible that specific machines and technologies affect results. More research is warranted.

Reference

1. Arcaniolo D, De Sio M, Rassweiler J, et al. Emergent versus delayed lithotripsy for obstructing ureteral stones: a cumulative analysis of comparative studies. Urolithiasis. doi: 10.1007/s00240-017-0960-7 [Epub ahead of print]

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