EURURO Vol. 72 No. 5

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journals or abstracts, including those published in congress
proceedings, were included.
2.3. Types of participants included
The population included in our search were male and
female adults and children of any ethnicity with a single
radio-opaque stone in the upper ureter (ie, defined as above
sacro-iliac junction, or iliac vessel crossing, or as defined by
trialists). Recurrent or first-time stone formers were
eligible, regardless of whether or not they were symptom-
atic. Pelvic-ureteric junction stones and middle ureteric
stones were also included. Patients with or without JJ-stent/
nephrostomy insertion before treatment were allowed, as
were patients with a solitary kidney. All stone sizes and
compositions were included.
Studies containing populations with the following
characteristics were excluded: pregnant women, previous
open ureteral surgery (eg, ureteric reimplantation, ureter-
olithotomy), ureteric stricture, anatomical abnormalities
(eg, duplex kidney, pelvic-ureteric junction obstruction,
horseshoe kidney), transplanted kidney, simultaneous
treatment of ipsilateral stone in kidney (however, if an
incidental stone was present in kidney but not treated, this
was allowed), two or more ipsilateral ureteric stones,
patients who were anticoagulated or had a coagulopathy,
radio-lucent stones, and lower ureteric stones.
2.4. Types of interventions included
For URS, the included interventions were: all subtypes and
variations including semirigid URS, flexible URS, and with
ureteroscope sizes ranging from 4.5–10 Ch; additional
sessions (ie, >1) were considered as an outcome.
For SWL, the included interventions were: all subtypes
and variations including electrohydraulic, piezo-electric,
and electro-magnetic. Two different definitions of the
intervention were used: (1) first definition—only one SWL
session was allowed, and any additional session was
considered as a separate outcome (ie, retreatment); (2)
second definition—two to three SWL sessions were allowed
as preplanned intervention (ie, as a package of care).
Studies comparing any URS versus URS, or any URS
versus SWL, or any SWL versus SWL were included. Analysis
of intergroup comparisons (ie, SWL compared with URS)
and intragroup comparisons (ie, SWL compared with
variation of SWL or URS compared with variation of URS)
were done separately.
2.5. Types of outcomes measures included
The primary benefit outcome was: stone-free rate (SFR). For
URS, this was the immediate SFR after treatment. However,
allowances were made for studies, which measured this
outcome at 24 h rather than immediately. For SWL, the 1 mo
stone-free status was measured according to the two
definitions outlined above. Also, alternative time points for
measuring SFR were allowed for up to 3 mo. This was done
in order to find not only data in studies where one SWL
session was the basis for measuring SFR, but also to find
data in studies where multiple SWL sessions were consid-
ered as one package of care before SFR was measured.
SFR was defined as no stone fragments remaining; if an
alternative definition was used by the trialist (eg, fragments
< 4 mm), data was included but this was recorded as
residual stone fragments rather than stone free (ie, the
reviewers had to recode the data). SFR could also, if defined
as such by the trialist, be measured as the time taken to
achieve stone-free status, that is, not rates but rather time to
stone-free status.
Secondary outcomes were retreatment rate (ie, more
than 1 URS or SWL session according to definitions of
intervention), need for a secondary procedure (ie, a
procedure to clear the stone beyond the primary procedure,
including retreatment using the same modality—more than
1 URS or SWL session, or other modality, eg, percutaneous
nephrolithotomy [PCNL]), need for an adjunctive procedure
(ie, a procedure to deal with a postoperative complication or
procedures incidental to the stone removal process, eg,
nephrostomy or JJ stent insertion for obstruction). Mean
length of hospital stay, pain outcomes (as defined by trialist,
eg, analgesic requirements or pain scores), quality of life
measures, patient satisfaction measures (as reported by the
trialist), hospital readmission rates, and number of emer-
gency department visits were also recorded.
The primary harm outcome was complications of
treatment (intraoperative and postoperative), to include
the incidence of grouped complications according to
severity, for example, Clavien-Dindo, or incidence of ad
hoc individual complications such as ureteric injury,
steinstrasse (for SWL only), urosepsis, and urinoma.
2.6. Assessment of risks of bias
Risk of bias was assessed by using the recommended tool in
the Cochrane Handbook for Systematic Reviews of Interven-
tions This includes the assessment of: random
sequence generation, allocation concealment, blinding of
participants and personnel, blinding of outcome assess-
ment, incomplete outcome data, selective reporting, and
other sources of bias. Risk of bias in nonrandomised
comparative studies was assessed using all the seven
domains above, with an extra item to assess the risk of
findings being explained by confounding factors. This is a
pragmatic approach informed by methodological literature
pertaining to assessing risk of bias in nonrandomised
studies
A list of the most important potential confounders for
harm and benefit outcomes was developed a priori with
clinical content experts (the EAU Urolithiasis Guideline
Panel). For each study, we asked whether each prognostic
confounder was considered, whether the confounder was
balanced between the intervention and control group, and
whether, if necessary, the confounder was controlled for in
analysis. The potential confounding factors prioritised
were: stone size, body mass index (BMI) or other measure
of obesity, stone composition, stone density (ie, Hounsfield
units), type of lithotripsy for URS (ie, laser vs no laser for
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