Department of Urology, University of Michigan, Ann Arbor, MI, USA.
Department of Urology, University of Michigan, Ann Arbor, MI, USA.
J Pediatr Urol. 2019 Oct;15(5):516.e1-516.e8. doi: 10.1016/j.jpurol.2019.06.006. Epub 2019 Jun 21.
As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children.
The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities.
A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis.
A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4 mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P = 0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P = 0.03) and flank pain (3.6% vs. 10.9%, P = 0.05) and required fewer general anesthetics per treatment (1.2 vs. 2.0, P < 0.01) than those who underwent URS (Figure).
Stone clearance after both the initial and final treatments and need for repeat interventions were similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment support thoughtful utilization of these medications. Limitations of this study include its retrospective nature and the prolonged 20-year time period over which data were collected.
When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.
随着小儿肾结石发病率的上升，了解手术治疗方案的疗效和发病率至关重要。目前，关于比较评估儿童体外冲击波碎石术（SWL）和输尿管镜检查术（URS）结果的相关数据有限。
本研究旨在比较两种治疗方法的结石清除率、30 天内急诊就诊率以及每个结石治疗所需的全身麻醉剂数量。
对 2000 年至 2017 年间接受 URS 或 SWL 治疗的儿童进行了一项多机构回顾性研究。记录并比较了两组的结石清除率、需要再次治疗的情况、麻醉剂数量以及急诊就诊的次数和原因。对年龄、结石位置、结石直径、术前支架置入和术者手术量等因素进行了多变量统计分析，以进行校正分析。
共纳入 84 例 SWL 和 175 例 URS 手术。SWL 的完全结石清除率和最终治疗后结石碎片残留<4mm 的比例分别为 77.0%和 90.8%，URS 分别为 78.5%和 91.7%。两种治疗方法的再次治疗率无显著差异（SWL 为 17.9%，URS 为 18.9%，P=0.85）。SWL 组的尿路感染（0% vs. 5.1%，P=0.03）和腰痛（3.6% vs. 10.9%，P=0.05）急诊就诊率较低，且每个治疗所需的全身麻醉剂数量也较少（1.2 次 vs. 2.0 次，P<0.01）（图）。
两种手术方式初始和最终治疗后的结石清除率和需要重复干预的情况相似。然而，SWL 比 URS 的发病率更低。具体而言，接受 SWL 的患者发生尿路感染和腰痛的急诊就诊率较低，与当前比较文献中的结论一致。此外，SWL 需要的全身麻醉剂较少（2.0 次 vs. 1.2 次），这主要是由于输尿管支架置入和取出的比例较低。关于全身麻醉对神经发育潜在风险的相关数据支持对这些药物的合理使用。本研究的局限性包括其回顾性性质以及数据采集长达 20 年的时间跨度。
在调整混杂因素后，SWL 和 URS 的结石清除率相似。在疗效相当的情况下，应考虑到重复干预的必要性、麻醉的发病率和并发症，将这些因素纳入临床实践。
