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Ureteroscopy vs Shockwave Lithotripsy to Remove Kidney Stones in Children and Adolescents: A Nonrandomized Clinical
Gregory E Tasian1,2, David I Chu3, Caleb P Nelson4
1Division of Urology, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Insights
Ureteroscopy and shockwave lithotripsy show similar stone clearance in children. Shockwave lithotripsy offers better patient outcomes, questioning the common preference for ureteroscopy in pediatric kidney stone treatment.
Area of Science:
- Pediatric Urology
- Nephrology
- Surgical Outcomes
Background:
- Ureteroscopy is the predominant treatment for pediatric kidney and ureteral stones.
- Guideline recommendations for ureteroscopy versus shockwave lithotripsy are not definitive.
- Evidence comparing these treatments in pediatric populations is limited.
Purpose of the Study:
- To compare stone clearance rates between ureteroscopy and shockwave lithotripsy in children and adolescents.
- To evaluate patient-reported outcomes, including pain and functional recovery, after each procedure.
- To inform clinical practice regarding the optimal treatment strategy for pediatric urolithiasis.
Main Methods:
- A nonrandomized clinical trial involving 1142 patients (aged 8-21 years) across 31 medical centers.
- Patients underwent either ureteroscopy or shockwave lithotripsy for kidney or ureteral stones.
- Primary outcome was stone clearance assessed by ultrasonography at 6 weeks post-procedure.
Main Results:
- No statistically significant difference in stone clearance between ureteroscopy (71.2%) and shockwave lithotripsy (67.5%).
- Ureteroscopy was associated with significantly greater pain interference and urinary symptoms one week post-surgery.
- Patients undergoing ureteroscopy missed more school, and caregivers missed more work compared to shockwave lithotripsy.
Conclusions:
- Ureteroscopy and shockwave lithotripsy demonstrate comparable efficacy for stone clearance in pediatric patients.
- Shockwave lithotripsy is associated with superior patient-reported outcomes and faster return to daily activities.
- Findings challenge the current preference for ureteroscopy, suggesting shockwave lithotripsy as a viable alternative.
Importance:
Most children and adolescents with kidney and ureteral stones are treated with ureteroscopy, despite the uncertainty and equal weight of guideline recommendations for ureteroscopy or shockwave lithotripsy.
Objective:
To compare stone clearance and patient-reported outcomes among children and adolescents after ureteroscopy or shockwave lithotripsy.
Design, Setting, And Participants:
This nonrandomized clinical trial enrolled patients between March 16, 2020, and July 31, 2023, at 31 medical centers in the US and Canada. Patients aged 8 to 21 years with kidney stones, ureteral stones, or both were included. Follow-up was completed on October 15, 2023.
Interventions:
Ureteroscopy or shockwave lithotripsy.
Main Outcomes And Measures:
The primary outcome was stone clearance assessed by standardized ultrasonography 6 (±2) weeks after surgery. Using inverse probability weighting and random intercepts for site, stone clearance was evaluated per kidney or ureter using logistic regression and estimated stone clearance rates were generated for each procedure.
Results:
This study included 1142 patients (690 females [60.4%]), with a median age of 15.6 years (IQR, 12.6-17.3 years). In terms of race and ethnicity, 41 patients (3.6%) were Black, 130 (11.4%) were Hispanic, and 884 (77.4%) were White. A total of 124 urologists treated 1069 and 197 kidneys or ureters with ureteroscopy and shockwave lithotripsy (n = 953 and n = 189 patients), respectively, with a median stone size of 6.0 mm (IQR, 4.0-9.0 mm). Ureteral stents were placed at time of index surgery for 841 procedures for 767 patients (80.4%) receiving ureteroscopy and for 6 procedures for 5 patients (2.6%) receiving shockwave lithotripsy. Stone clearance occurred in 474 patients who underwent ureteroscopy (71.2% [95% CI, 63.8%-78.5%]) and in 105 patients who underwent shockwave lithotripsy (67.5% [95% CI, 61.0%-74.1%]), a difference that was not statistically significant (risk difference, 3.6% [95% CI, -6.2% to 13.5%]). Compared with shockwave lithotripsy, ureteroscopy resulted in greater pain interference (T-score difference, 5.0 [95% CI, 2.3-7.8]) and urinary symptoms (symptom score difference, 3.9 [95% CI, 1.2-6.7]) 1 week after surgery. Patients who had ureteroscopy missed more school (risk difference, 21.3% [95% CI, 9.7%-32.8%]) and caregivers missed more work (risk difference, 23.0% [95% CI, 11.0%-35.0%]) in the week after surgery.
Conclusions And Relevance:
In this study of 1142 children and adolescents with kidney and ureteral stones, there was no clinically meaningful difference in stone clearance with ureteroscopy vs shockwave lithotripsy. Shockwave lithotripsy was associated with better patient-reported outcomes. These findings raise questions about the preference for ureteroscopy in practice.
Trial Registration:
ClinicalTrials.gov Identifier: NCT04285658.
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