Department of Urology, Royal Bournemouth Hospital, Bournemouth, UK.
Department of Urology, Hatzikosta General Hospital, Ioannina, Greece; Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
Eur Urol. 2017 Nov;72(5):772-786. doi: 10.1016/j.eururo.2017.04.016. Epub 2017 Apr 26.
Extracorporeal shock wave lithotripsy (SWL) and ureteroscopy (URS), with or without intracorporeal lithotripsy, are the most common treatments for upper ureteric stones. With advances in technology, it is unclear which treatment is most effective and/or safest.
To systematically review literature reporting benefits and harms of SWL and URS in the management of upper ureteric stones.
Databases including Medline, Embase, and the Cochrane library were searched from January 2000 to November 2014. All randomised controlled trials (RCTs), quasi-randomised controlled trials, and nonrandomised studies comparing any subtype or variation of URS and SWL were included. The primary benefit outcome was stone-free rate (SFR). The primary harm outcome was complications. Secondary outcomes included retreatment rate, need for secondary, and/or adjunctive procedures. The Cochrane risk of bias tool was used to assess RCTs, and an extended version was used to assess nonrandomised studies. Grading of Recommendations Assessment, Development, and Evaluation was used to assess the quality of evidence.
Five thousand-three hundred and eighty abstracts and 387 full-text articles were screened. Forty-seven studies met inclusion criteria; 19 (39.6%) were RCTs. No studies on children met inclusion criteria. URS and SWL were compared in 22 studies (4 RCTs, 1 quasi-randomised controlled trial, and 17 nonrandomised studies). Meta-analyses were inappropriate due to data heterogeneity. SFR favoured URS in 9/22 studies. Retreatment rates were higher for SWL compared with URS in all studies but one. Longer hospital stay and adjunctive procedures (most commonly the insertion of a JJ stent) were more common when primary treatment was URS. Complications were reported in 11 out of 22 studies. In eight studies, it was possible to report this as a Clavien-Dindo Grade. Higher complication rates across all grades were reported for URS compared with SWL. For intragroup (intra-SWL and intra-URS) comparative studies, 25 met the inclusion criteria. These studies varied greatly in outcomes measured with data being heterogeneous.
Compared with SWL, URS was associated with a significantly greater SFR up to 4 wk but the difference was not significant at 3 mo in the included studies. URS was associated with fewer retreatments and need for secondary procedures, but with a higher need for adjunctive procedures, greater complication rates, and longer hospital stay.
In this paper, the relative benefits and harms of the two most commonly offered treatment options for urinary stones located in the upper ureter were reviewed. We found that both treatments are safe and effective options that should be offered based on individual patient circumstances and preferences.
体外冲击波碎石术（SWL）和输尿管镜检查术（URS），联合或不联合腔内碎石术，是治疗输尿管上段结石的最常用方法。随着技术的进步，哪种治疗方法最有效和/或最安全尚不清楚。
系统评价 SWL 和 URS 治疗输尿管上段结石的疗效和安全性。
从 2000 年 1 月至 2014 年 11 月，检索 Medline、Embase 和 Cochrane 图书馆等数据库。纳入比较 URS 和 SWL 任何亚型或变异的随机对照试验（RCT）、准随机对照试验和非随机研究。主要疗效结局为结石清除率（SFR）。主要不良结局为并发症。次要结局包括再次治疗率、需要辅助或附加治疗率。采用 Cochrane 偏倚风险工具评估 RCT，采用扩展版评估非随机研究。采用推荐评估、制定与评价分级（Grading of Recommendations Assessment, Development, and Evaluation）评估证据质量。
筛选了 5380 篇摘要和 387 篇全文，47 项研究符合纳入标准，其中 19 项（39.6%）为 RCT。无符合纳入标准的儿童研究。22 项研究比较了 URS 和 SWL（4 项 RCT、1 项准随机对照试验和 17 项非随机研究）。由于数据异质性，不适合进行荟萃分析。9/22 项研究中 SFR 有利于 URS。所有研究均显示 SWL 的再次治疗率高于 URS，但有一项研究除外。初次治疗为 URS 时，住院时间较长且需要辅助治疗（最常见的是 JJ 支架置入）。11/22 项研究报告了并发症。8 项研究中可以采用 Clavien-Dindo 分级报告。所有等级的并发症发生率均高于 SWL。对于组内（SWL 内和 URS 内）比较研究，25 项符合纳入标准。这些研究在测量结果方面差异很大，数据存在异质性。
与 SWL 相比，URS 在治疗后 4 周内的结石清除率显著提高，但在纳入的研究中，3 个月时的差异无统计学意义。URS 与较少的再次治疗和需要辅助治疗有关，但需要更多的辅助治疗，并发症发生率更高，住院时间更长。
本文回顾了治疗输尿管上段结石的两种最常用治疗方法的相对疗效和安全性。我们发现，这两种治疗方法均安全有效，应根据患者个体情况和偏好选择。
