Newcastle Medical School, Newcastle-upon-Tyne, England.
Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, England.
J Urol. 2021 Sep;206(3):526-538. doi: 10.1097/JU.0000000000001836. Epub 2021 Apr 27.
We assessed the literature around post-treatment asymptomatic residual stone fragments and performed a meta-analysis. The main outcomes were intervention rate and disease progression.
We searched Ovid®, MEDLINE®, Embase™, the Cochrane Library and ClinicalTrials.gov using search terms: "asymptomatic", "nephrolithiasis", "ESWL", "PCNL", "URS" and "intervention." Inclusion criteria were all studies with residual renal fragments following treatment (shock wave lithotripsy, ureteroscopy or percutaneous nephrolithotomy). Analysis was performed using 'metafor' in R and bias determined using Newcastle-Ottawa scale.
From 273 articles, 18 papers (2,096 patients) had details of intervention rate for residual fragments. Aggregate intervention rates for ≤4 mm fragments rose from 19% (20 months) to 22% (50 months), while >4 mm fragments rose from 22% to 47%. Aggregate disease progression rates for ≤4 mm rose from 25% to 47% and >4 mm rose from 26% to 88%. However, there was substantial difference in definition of "disease progression." Meta-analysis comparing >4 mm against ≤4 mm fragments: intervention rate for >4 mm (vs ≤4 mm): OR=1.50 (95% CI 0.70-2.30), p <0.001, I=67.6%, tau=0.48, Cochran's Q=11.4 (p=0.02) and Egger's regression: z=3.11, p=0.002. Disease progression rate for >4 mm: OR=0.06 (95% CI -0.98-1.10), p=0.91, I=53.0%, tau=0.57, Cochran's Q=7.11 (p=0.07) and Egger's regression: z=-0.75, p=0.45. Bias analysis demonstrated a moderate risk.
Larger post-treatment residual fragments are significantly more likely to require further intervention especially in the long term. Smaller fragments, although less likely to require further intervention, still carry that risk. Notably, there is no significant difference in disease progression between fragment sizes. Patients with residual fragments should be appropriately counselled and informed decision-making regarding further management should be done.
我们评估了治疗后无症状残留结石碎片的文献，并进行了荟萃分析。主要结局是干预率和疾病进展。
我们使用搜索词“无症状”、“肾结石”、“ESWL”、“PCNL”、“URS”和“干预”在 Ovid®、MEDLINE®、Embase™、Cochrane 图书馆和 ClinicalTrials.gov 中搜索。纳入标准为所有治疗后有肾内残留碎片的研究（冲击波碎石术、输尿管镜检查或经皮肾镜取石术）。分析使用 R 中的“metafor”进行，使用 Newcastle-Ottawa 量表确定偏倚。
从 273 篇文章中，有 18 篇文章（2096 例患者）详细描述了残留碎片的干预率。≤4mm 碎片的总干预率从 19%（20 个月）上升到 22%（50 个月），而>4mm 碎片的总干预率从 22%上升到 47%。≤4mm 碎片的总疾病进展率从 25%上升到 47%，而>4mm 碎片的总疾病进展率从 26%上升到 88%。然而，“疾病进展”的定义存在很大差异。比较>4mm 与≤4mm 碎片的荟萃分析：>4mm 干预率（与≤4mm 相比）：OR=1.50（95% CI 0.70-2.30），p<0.001，I=67.6%，tau=0.48，Cochran's Q=11.4（p=0.02），Egger 回归：z=3.11，p=0.002。>4mm 碎片的疾病进展率：OR=0.06（95% CI -0.98-1.10），p=0.91，I=53.0%，tau=0.57，Cochran's Q=7.11（p=0.07），Egger 回归：z=-0.75，p=0.45。偏倚分析显示存在中度风险。
较大的治疗后残留碎片更有可能需要进一步干预，尤其是在长期。较小的碎片虽然不太可能需要进一步干预，但仍有这种风险。值得注意的是，碎片大小之间没有明显的疾病进展差异。对于有残留碎片的患者，应进行适当的咨询，并进行进一步管理的知情决策。
