Operations and Performance Management Office, Fourth Affiliated Hospital, China Medical University, Shenyang, Liaoning, China.
Departments of Urology.
Int J Surg. 2023 May 1;109(5):1481-1488. doi: 10.1097/JS9.0000000000000394.
The efficacy and safety of minimally invasive nephrolithotomy (MPCNL) versus retrograde intrarenal surgery (RIRS) was assessed for lower calyceal (LC) stones.
Our team conducted a systematic literature search up to December, 2022, using PUBMED, EMBASE and the Cochrane Library. The study was registered in PROSPERO, CRD 42021247197. Randomized controlled trials evaluating the efficacy and safety of MPCNL versus RIRS for LC stones were collected. Heterogeneity among the studies was assessed using the χ 2 test based on the Q and I2 tests. Pooled effect sizes were calculated using a fixed model if I2 is less than 50%; otherwise, a random-effects model was chosen. The primary outcomes were the 3-month stone-free rate (3SFR) and total complications, while the secondary outcomes were the operating time, hospital stay, haemoglobin reduction, bleeding, postoperative fever and complications with the Clavien-Dindo system. A subgroup analysis of 10-20 mm LC stones was also designed.
A total of 7 peer-reviewed trials comprising 711 patients were identified. No statistical differences were observed in the heterogeneity results of the 3SFR or total complications ( P >0.1, I2 < 50%). Compared with RIRS, MPCNL had an unfavourable safety profile, resulting in total complications [odds ratio (OR): 1.87 (95% CI: 1.05, 3.33); P =0.03], haemoglobin reduction [OR: 0.81 (95% CI: 0.15, 1.47); P =0.02] and complications with Grade I [OR: 5.52 (95% CI: 1.34, 22.83); P =0.02] but an improved efficacy and 3SFR [OR: 2.43 (95% CI: 1.48, 3.97); P =0.0004]. As for the 10-20 mm LC stones, compared with RIRS, MPCNL also had an unfavourable safety profile, resulting in total complications [OR: 2.47 (95% CI: 1.20, 5.07); P =0.01], complications with Grade I [OR: 4.97 (95% CI: 0.99, 25.01); P =0.05] and an increased hospital stay [OR: 2.46 (95% CI: 2.26, 2.66); P =0.00001] but an improved efficacy and 3SFR {OR: 3.10 (95% CI: 1.61, 5.99); P =0.0008]. The efficacy effect of MPCNL and safety effect of RIRS were nearly equal for both stones sized less than 20 mm (number needed to treat = 17, number needed to harm = 20) and stones sized 10-20 mm (number needed to treat = 20, number needed to harm = 13). No statistical difference was found between the MPCNL and RIRS groups for the rest of outcomes.
Both MPCNL and RIRS are safe and effective management methods. Moreover, compared with RIRS, MPCNL had an unfavourable safety profile but improved efficacy for LC stones of ≤20 mm or 10-20 mm, and the differences were statistically significant. The relative profit of efficacy of MPCNL was similar to the relative profit of safety of RIRS.
评估微创经皮肾镜取石术（MPCNL）与逆行肾内手术（RIRS）治疗下盏结石的疗效和安全性。
我们的团队进行了系统的文献检索，截至 2022 年 12 月，使用了 PUBMED、EMBASE 和 Cochrane 图书馆。该研究在 PROSPERO 中进行了注册，CRD42021247197。收集了评估 MPCNL 与 RIRS 治疗下盏结石疗效和安全性的随机对照试验。使用基于 Q 和 I2 检验的 χ 2 检验评估研究之间的异质性。如果 I2 小于 50%，则使用固定模型计算合并效应大小；否则，选择随机效应模型。主要结局是 3 个月结石清除率（3SFR）和总并发症，次要结局是手术时间、住院时间、血红蛋白减少、出血、术后发热和 Clavien-Dindo 系统并发症。还设计了 10-20mm 下盏结石的亚组分析。
共纳入 7 项高质量的随机对照试验，包括 711 名患者。3SFR 或总并发症的异质性结果无统计学差异（P >0.1，I2 < 50%）。与 RIRS 相比，MPCNL 的安全性较差，导致总并发症[优势比（OR）：1.87（95%置信区间：1.05，3.33）；P =0.03]、血红蛋白减少[OR：0.81（95%置信区间：0.15，1.47）；P =0.02]和 I 级并发症[OR：5.52（95%置信区间：1.34，22.83）；P =0.02]增加，但疗效和 3SFR 提高[OR：2.43（95%置信区间：1.48，3.97）；P =0.0004]。对于 10-20mm 下盏结石，与 RIRS 相比，MPCNL 的安全性也较差，导致总并发症[OR：2.47（95%置信区间：1.20，5.07）；P =0.01]、I 级并发症[OR：4.97（95%置信区间：0.99，25.01）；P =0.05]和住院时间延长[OR：2.46（95%置信区间：2.26，2.66）；P =0.00001]，但疗效和 3SFR 提高[OR：3.10（95%置信区间：1.61，5.99）；P =0.0008]。对于直径小于 20mm 的结石（需要治疗的数量=17，需要伤害的数量=20）和直径为 10-20mm 的结石（需要治疗的数量=20，需要伤害的数量=13），MPCNL 和 RIRS 对结石的疗效效果几乎相等，安全性效果也几乎相等。对于其余结局，MPCNL 组和 RIRS 组之间没有统计学差异。
MPCNL 和 RIRS 都是安全有效的治疗方法。此外，与 RIRS 相比，MPCNL 安全性较差，但对直径≤20mm 或 10-20mm 的下盏结石疗效提高，差异有统计学意义。MPCNL 的疗效相对获益与 RIRS 的安全性相对获益相似。
