EURURO Vol. 72 No. 5

787 860

Platinum Priority – Editorial
Referring to the article published on pp. 772–786 of this issue
Endoluminal versus Extracorporeal Endourology:
Which is Better and at What Cost?
Jacob M. Patterson
a Department of Urology, Royal Hallamshire Hospital, Sheffield, UK; b Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK
In this issue of European Urology, Sarica and colleagues
present the findings of their detailed systematic review
comparing the outcomes and complications of ureteroscopy
(URS) and shockwave lithotripsy (SWL) for management of
upper ureteral stones. As is often the way with such reviews
of the literature, particularly in the field of endourology, the
quality is hampered by the heterogeneity of the reported
trials, studies, and series, specifically with reference to both
treatment strategies and the reporting of outcomes. This
review is no different, declaring in its data analysis
description that meta-analysis of the trials and studies
within would not be appropriate, and highlighting in its
conclusions the dire need for good-quality, well-designed
randomised controlled trials (RCTs) to better answer these
complex questions. Randomised trials between two very
different treatment options are, however, difficult to recruit
to. A large proportion of patients with urolithiasis will have
had recurrent stone-related episodes and therefore have
had previous experiences of treatments and may have
developed preferences for specific treatment modalities.
This may unfortunately influence their desire to be
randomised to a specific treatment within a trial setting.
Outside of a trial setting, all urology treatment centres may
also have a degree of treatment bias depending on the
availability of certain equipment and technologies.
Regarding the evidence, most contemporary urology
guidelines still use a similar data set as used in the
2007 combined American Urological Association (AUA) and
European Association of Urology (EAU) guidelines by
Preminger et al. published in 2007. These guidelines
support the use of either SWL or URS for management of all
ureteral stones, with broad equivalence for all stones
<10 mm in size, and a general trend to superiority of URS
for stones >10 mm. The exception to this relates to upper
ureteric stones, the subject of this review, for which the
combined guidelines suggest that SWL may be superior for
stones <10 mm, and both treatments are significantly less
effective for those >10 mm, but favouring URS. The most
up-to-date EAU guidelines maintain largely the same
views as the 2007 work. The 2007 guidelines, however,
unlike this current systematic review, do not explore in as
much detail the complications of treatment, the outcomes
for specific patient subgroups, and the impact on patients
undergoing each treatment. This is the key added value of
this review, for which the authors should be commended.
Technology moves apace in endourology, with tremen-
dous progress in miniaturisation of ureteroscopes the last
30 yr, as well as the introduction of flexible fibre optic and
latterly digital endoscopes. Improvements for energy
delivery to stones (particularly the increasing use of
holmium lasers), a better understanding of the risks and
benefits of surgical adjuncts, and steady progress in the
technology and techniques for delivering SWL to patients
are further advances. Despite these advances, however, we
still have no robust level 1a evidence for the majority of our
practice, instead relying on continued experiential learning,
the didactic teachings of experts, and a very limited
evidence base. Because of technological advances, it is also
hard for the evidence base to keep up; it is often the case
that by the time a large trial has recruited and reported, the
technology on which its outcomes were based may have
become almost obsolete, potentially also the intended
addition to the evidence base less relevant. For example, one
of the papers within this review compared SWL with URS
ava ilable at
journal homepage:
DOI of original article: .
* Corresponding author. Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road,
Sheffield, S10 2JF, UK. Tel. +44 114 2713324; Fax: +44 114 2711570.
E-mail address: (J.M. Patterson).
0302-2838/© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.