EURURO Vol. 72 No. 5

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prestenting was more common in patients undergoing
SWL than those undergoing URS (p < 0.01).
3.10. Duration of procedure
A total of eight studies reported on the mean duration of
procedure; one RCT one QRCT , and six NRSs
. The mean duration of procedures ranged
from 36 min to 61 min for SWL and 34 min to 109 min for
URS. Relevant p-values were only provided in two studies
; in one study, the duration of procedure was
significantly longer (p < 0.01) for URS than for SWL but
in the other study there was no statistically significant
difference in the duration of both procedures. Three studies
broke down the duration of procedure into two
groups according to stone size of <10 mm and >10 mm.
Statistical significance was not assessed by any of these
studies, but raw values of mean procedural duration were
greater for URS compared with SWL in one study
regardless of stone size, with completely the opposite
findings in the second study . In the third study the
duration was greater for URS compared with SWL for stones
>10 mm, with the reverse results for stones <10 mm.
3.11. Quality of life
Quality of life was assessed only in one study; Cui et al
and was not statistically significant between the two
treatment modalities.
3.12. Length of hospital stay
Length of stay was reported in four studies; two RCTs
and two NRSs . In all four studies, the mean
length of hospital stay was greater for patients undergoing
URS compared with SWL and in two of the four studies
a p -value was provided, and in both cases, reached
statistical significance.
3.13. Hospital re-admission rates and post-treatment visits
Hospital re-admission rates following treatment were
assessed by one study , and in this study, no patients
in either treatment arm required re-admission. Two studies
looked at emergency department visits after stone man-
agement with higher rates in those treated with
SWL (20% of patients after SWL vs 5% of patients after URS).
The number of post-treatment visits was assessed by
two studies . In the Zhang et al study the
number of post-treatment visits was not significantly
different between the two treatment groups, whereas in
the Parker et al study patients were seen significantly
more often following treatment with SWL than after URS;
2.4 1.2 compared with 1.4 0.8 (p 0.0001).
3.14. Cost analysis
Only three studies looked at cost analysis. According to
Zhang et al , URS was significantly more expensive than
SWL, whereas Parker et al and Wu et al reported
significant higher costs for SWL (p < 0.01 in both studies).
3.15. Quality of evidence assessment
The GRADE quality of evidence for URS versus extracorpo-
real SWL is shown in the evidence profile (Supplementary
Table 3). The overall quality of evidence for SFR at 4 wk,
Grade 3 Clavien-Dindo complications and the need for
secondary procedures were all very low. This indicates that
we are very uncertain about the estimate. The main reasons
were the impact of confounding bias in the observational
studies, as well as small study populations throughout.
Furthermore, the complications and secondary procedures
outcomes had low event rates, heterogeneous estimates of
effect, and wide CIs.
3.16. Evidence synthesis for intragroup (intra-SWL and intra-
URS) comparative studies
3.16.1. Immediate SWL versus delayed SWL
Three studies compared outcomes from immediate SWL
versus those with delayed SWL All three studies
showed higher SGRs when SWL was administered immedi-
ately (within 2 d) rather than if treatment was delayed
(range, 2–7 d) from time of symptom. The difference was
statistically significant in two of the three studies
. One study showed that the mean number of SWL
sessions was higher in patients undergoing delayed SWL
compared with immediate SWL, with a reported p -value of
0.047 provided by one study .
3.16.2. SWL for upper ureteric stones < 1 cm versus 1 cm in
diameter
One study compared SFR using SWL for urinary stones
1 cm compared to SWL for stones >1 cm in diameter
. Subgroup analysis of upper urinary system (UUS)
showed a SFR of 60.8% for stones 1 cm compared to 49.1%
for stones >1 cm albeit not significant (p = 0.496).
3.16.3. SWL with medical expulsion therapy versus SWL alone
Four studies compared the effect of an alpha-blocker on
stone free rates with SWL treatment SFRs were
better with concomitant alpha-blocker use in all four
studies; two of which provided statistically significant p
values . One study looked at the effect of a
calcium-channel blocker on SFRs with SWL treatment
where SFRs were improved with nifedipine administration
(75% compared with 44%, but no p value provided). Mean
analgesic use (diclofenac) was also reduced in patients
receiving nifedipine (p = 0.02). While one study showed
number of SWL sessions needed was not significantly
changed by alpha-blocker administration , another
study showed that patients receiving tamsulosin required
significantly less number of SWL sessions (p = 0.02) .
3.16.4. SWL with diuresis versus SWL alone
Two studies looked at the effect of diuretic treatment
alongside treatment with SWL . Although SFRs were
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