EURURO Vol. 72 No. 5

783 860

>10 mm, SFR were comparable for URS and SWL (74% vs
79%) in the proximal ureter . The current, 2016 Ameri-
can Urological Association Guidelines state that URS for
proximal ureteral stones has a greater SFR in a single
procedure compared with SWL, regardless of stone size
, albeit the importance of informing patients on the
higher morbidity and complications risk compared with
SWL. All in all, URS can be recommended as the first
treatment option for proximal ureteral stones >10 mm, but
for stones 10 mm the EAU Urolithiasis Guidelines panel
consensus is that either treatment options are viable as first
choice and should be presented to patients . The
effectiveness of medical expulsive therapy, in particular a-
blockers, as conservative treatment of ureteral stones is
unproven and the only potential benefit seems to exist for
distal ureteral stones larger than 5 mm .
Counterbalancing for URS’s higher SFRs, SWL is associ-
ated with the least morbidity and lower complication rates
In this current systematic review, Clavien-Dindo
grade complications were, if reported, less frequent in
patients treated with SWL. At the same time, two studies
presented the opposite, pointing out that stone
migration/steinstrasse requiring decompression with JJ
stent insertion (ie, making it a Clavien-Dindo Grade
3 complication) is more frequent in patients treated with
SWL. However, it is important to bear in mind that the
quality of evidence is very low. The 2012 Cochrane meta-
analysis comparing SWL and URS identified seven random-
ised controlled studies reporting on all complication rates
and found a significantly lower complication rate for SWL
compared with URS (risk ratio: 0.53, 95% CI: 0.33–0.88,
p = 0.01) However, for all patients with ureteral stones,
when residual fragments are present, especially if initial
SWL fails, urologists should offer endoscopic procedures to
render the patients stone free. Success rates for PCNL and
URS as secondary procedures after failed SWL are reported
as 86–100% and 62–100%, respectively .
Our intragroup comparative studies analysis underlined
several technical modifications leading to higher SWL SFR.
Despite this improvement, the aforementioned internation-
al recommendations clearly reflect a trend towards URS as
treatment of proximal ureteral stones regardless of the size
of the stone. However, it is difficult to make a blanket
recommendation as to whether all ureteroscopic stone
treatment techniques are better than all SWL machine types
and treatment schedules, for treating all proximal ureteric
stones, regardless of stone size and other important patient-
related factors such as BMI; these variables as well as other
confounding factors simply have not been adequately
reported on in the currently available studies and future
research should definitely focus on these. Moreover, other
factors such as technological improvements (eg, Ho:YAG
laser, uretererosope miniaturisation), country policies,
capital investment, and the patient’s or surgeon’s prefer-
ence could affect the results of URS and SWL.
As techniques, technologies, and surgeon experience
continue to evolve, further large, multi-centre, well-
designed RCTs are needed in order to accurately compare
these two treatment modalities. Further research is also
needed to overcome several of the limitations of this study.
For example, many of the included studies may be affected
by selection bias, performance bias, detection bias, and
outcome-reporting bias. Moreover, despite the moderate
statistical heterogeneity of our review, clinical heterogene-
ity can be expected, by including trials using different type
of lithotripters/methods of lithotripsy, different follow-up
periods defining SFR, differences in stone size and imaging,
as well as different adjunctive procedures. Furthermore, for
five of the included studies, only abstracts were available for
data extraction, which significantly limited the information
and quality of data available for analysis. Even when full
texts were available, there was a lack of adequate and
reliable evidence for the comparison of URS versus SWL
concerning outcomes other than SFR and where it was
possible to extract data on the main outcome measures of
this study, many studies did not report statistical calcula-
tions of differences between the two interventional groups.
Moreover, available data reported in the literature was not
strong enough to report some certain patient-focused
outcomes, for example, analgesic requirement, emergency
department visits, and quality of life, and cost analysis
outcomes were poor. Where patient-focused outcomes
were assessed, for example, lower urinary tract symptoms
or quality of life following treatment validated
questionnaires were not used.
We assert that increasing the number of well-designed
RCTs focusing mainly on these parameters will ease the
clinician’s and also patient’s decision making. In order to
decrease heterogeneity in future studies, consensus is
needed regarding the definition and timing of stone free,
including the imaging modality used for assessing SFR.
Moreover, a core outcome set is needed to ensure that the
outcomes, which are of utmost importance for decision
making for all stakeholders including patients, are
reported, defined, andmeasured consistently . This
will ensure that future trials are efficient and future
evidence syntheses are straightforward to perform, com-
municate, and are ultimately useful for decision making by
patients, clinicians, and health care policy makers and
funders.
5. Conclusions
This systematic review demonstrates that ureteroscopic
management of proximal ureteral calculi is associatedwith
a significantly greater SFR when compared with SWL at
1 mo. Moreover, the rate of retreatment and the need for
secondary procedures was found to be higher in cases
undergoing SWL. Concerning adjunctive procedures, com-
plications, and length of hospital stay; however, the
ureteroscopic approach was found to be associated with
higher complication rates along with longer hospitalisa-
tion periods when compared with SWL. However, the
quality of evidence is very low and it is therefore clear that
in order to better outline the efficacy, complications, and
other treatment-related parameters of both modalities,
further well-designed RCTs with larger sample sizes and
consistently reported and defined outcomes are needed.
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