Abstract
Background
Lower pole kidney stones typically have poor rates of spontaneous clearance from the body. Some studies have suggested that diuresis, percussion and inversion therapy could be beneficial for people with lower pole kidney stones following shock wave lithotripsy. There is however controversy about the relative benefits, harms, and efficacy of these interventions for the management of lower pole kidney stones.
Objectives
To identify the benefits and harms of percussion, diuresis, and inversion therapy to facilitate the passage of lower pole kidney stones following shock wave lithotripsy.
Search methods
We searched the Cochrane Renal Group's specialised register up to 27 November 2013 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review.
Selection criteria
All randomised controlled trials (RCTs) and quasi‐RCTs looking at the benefits and harms of percussion, diuresis, and inversion therapy for aiding passage of lower pole kidney stones following shock wave lithotripsy were sought for assessment. The first phases of randomised cross‐over studies were also eligible for inclusion.
Data collection and analysis
Two authors independently assessed study quality and extracted data. Results were expressed as relative risk (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CI).
Main results
We identified two small studies (177 participants) for inclusion and analysis. One study (69 participants) compared percussion, diuresis and inversion therapy following shock wave lithotripsy versus observation‐only after shock wave lithotripsy. This study reported significantly higher stone‐free rates in the intervention group (RR 0.62, 95% CI 0.47 to 0.82) and a significant reduction in stone burden (MD ‐3.30, 95% CI ‐3.58 to ‐3.03) compared to the observation‐only group. They reported no significant differences in complication rates (RR 3.00, 95% CI 0.12 to 76.24).
The second study (108 participants) compared percussion, diuresis, and inversion therapy plus shock wave lithotripsy with shock wave lithotripsy therapy alone. This study reported significantly higher stone‐free rates in the intervention group (RR 0.36, 95% CI 0.17 to 0.80) and a significant reduction in stone burden (MD ‐0.30, 95% CI ‐0.04 to ‐0.56) compared to the control group. They reported no significant differences in complication rates (RR 2.54, 95% CI 0.10 to 63.72).
For both studies selection bias was unclear; there was high risk of bias for performance bias; and detection, attrition and reporting bias were low.
Authors' conclusions
Limited evidence from two small studies indicated that percussion, diuresis, and inversion therapy may be safe and effective therapies to assist clearance of lower pole kidney stone fragments following shock wave lithotripsy. Methodological quality in both studies was assessed as moderate. Further well‐designed and adequately powered studies are required to inform clinical practice.
Keywords: Humans, Diuresis, Diuretics, Diuretics/administration & dosage, Drainage, Drainage/methods, Drinking Water, Drinking Water/administration & dosage, Furosemide, Furosemide/administration & dosage, Head‐Down Tilt, Kidney Calculi, Kidney Calculi/therapy, Patient Positioning, Patient Positioning/methods, Percussion, Percussion/methods, Randomized Controlled Trials as Topic
Plain language summary
Can percussion, diuresis, and inversion therapy improve outcomes for people with lower pole kidney stones following shock wave lithotripsy?
Lower pole kidney stones are challenging to treat effectively. Many people with lower pole kidney stones undergo shock wave lithotripsy to break up stones so they can be passed from the body in the urine. In some cases, stone fragments can be retained, and these can be difficult to eliminate. Better techniques are needed to help people pass small lower pole kidney stones or fragments that remain following shock wave lithotripsy.
We found two small studies that investigated effectiveness and safety of percussion (striking or tapping the body, usually using a device called a percussor), diuresis (therapy to increase urine flow), and inversion therapy (placing the patient at an inverted angle) for treating lower pole kidney stones.
Although the evidence we found suggested that percussion, diuresis, and inversion therapy may help the passage of lower pole kidney stones after shock wave lithotripsy, this finding was based on very limited evidence of moderate quality. Further studies investigating these treatments in more people are needed to confirm any observed benefits or harms.
Background
Description of the condition
Kidney stones are relatively common: prevalence is 2% to 3% in the general population (Poch 2009), but the relative incidence of lower pole kidney stones is difficult to estimate. Lingeman 1994 reported that incidence of lower pole kidney stones treated had increased from 2% in 1984 to 48% in 1991; Murphy 2001 proposed that the observed increase was related to the increased availability of lithotriptors since the mid 1980s which meant that more lower pole kidney stones were now treated.
Although many investigators have reported that residual stone fragments commonly localise to lower pole calyces following shock wave lithotripsy, regardless of where in the kidney the stone was originally located, Cass 1998 indicated that increased reports of lower pole kidney stones may have been influenced by factors such as reporting and publication bias. Cass 1998 reported that the incidence of lower pole kidney stones had remained relatively stable at 30% to 36% since 1990.
Shock wave lithotripsy is widely regarded as the gold standard treatment for kidney stones less than 2 cm diameter. Benefits are that it is a non‐invasive procedure, requires minimal anaesthesia, and has a high level of patient acceptance (Honey 2008; Kekre 2008; Lin 2008; Raman 2008; Srisubat 2009). However, due to their anatomical location and difficulties in clearance after shock wave lithotripsy (Honey 2008; Kekre 2008; Raman 2008), stones located at the lower pole calyces continue to pose clinical challenges. Stone‐free rates for lower pole stones following shock wave lithotripsy have been reported at 44% to 59% (Lin 2008; Lingeman 1994). When outcomes were stratified by stone size (less than 1 cm diameter, 1 cm to 2 cm, and more than 2 cm), stone‐free rates after one shock wave lithotripsy treatment were 74%, 56% and 33% respectively.
Description of the intervention
Poor stone clearance rates among patients with lower pole kidney stones following shock wave lithotripsy have prompted investigators to improve techniques to facilitate their passage. Several studies have demonstrated that the gravity‐dependent position of the lower calyces appear to be a major factor inhibiting clearance of lower pole kidney stones. Furthermore, it has been found that postural drainage could be beneficial in the postoperative management of lower pole kidney stones (Brownlee 1990; McCullough 1989).
How the intervention might work
Positioning and degree of inversion are thought to influence postural drainage of lower pole kidney stones. An oblique axis in the kidneys means that the upper pole lies posterior to the lower pole. Patients therefore need to be inverted to more than 30° to position the collecting system below the horizontal plane. This counteracts the effect of gravity on lower pole kidney stones and assists their passage using gravitational force (Albanis 2009; Chiong 2005; Pace 2001). Shock wave lithotripsy shatters kidney stones into fine fragments which are passed from the body in urine. Therapies that increase urine flow, such as diuretics and high volume fluid therapy can help to flush out stone fragments to enhance efficacy (Nuss 2005). Percussion therapy transmits pressure and vibrates renal system structures to help discharge stone fragments in the increased flow of urine (Albanis 2009; Pace 2001).
Why it is important to do this review
Limited evidence has suggested that percussion, diuresis, and inversion therapy may be beneficial for patients with residual stones after shock wave lithotripsy (Chiong 2005; Pace 2001). Conversely, Rodrigues 1991 found that controlled inversion therapy did not improve results for people who underwent shock wave lithotripsy for lower pole kidney stones; and Albanis 2009 found that diuresis and 12° inversion did not significantly improve stone‐free rates.
Therapeutic uncertainty warranted a systematic review to assess the effectiveness, safety and complications of percussion, diuresis, and inversion therapy for lower pole kidney stones following shock wave lithotripsy.
Objectives
This review looked at the benefits and harms of percussion, diuresis and inversion therapy for the passage of lower pole kidney stones after shock wave lithotripsy.
Methods
Criteria for considering studies for this review
Types of studies
All randomised controlled trials (RCTs) and quasi‐RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at the benefits and harms of percussion, diuresis and inversion therapy for passage of lower pole kidney stones after shock wave lithotripsy. The first phases of randomised cross‐over studies were also eligible for inclusion.
Types of participants
Inclusion criteria
Patients aged 18 years and over with lower pole kidney stones following shock wave lithotripsy were included.
Exclusion criteria
Patients with ureteral stents in situ, pregnant women, and children with kidney stones were excluded.
Types of interventions
Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Percussion and diuresis therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Percussion and inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Diuresis and inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Percussion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Diuresis therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Percussion, diuresis, and inversion therapy plus shock wave lithotripsy versus shock wave lithotripsy alone.
Types of outcome measures
Primary outcomes
Success: Stone‐free. No visible residual stones, documented with plain abdominal radiography, intravenous urography, or computerised tomography, one, three, and six months after initial therapy
Effectiveness: Stone burden reduction after treatment, documented with plain abdominal radiography, intravenous urography, or computerised tomography before initial therapy, one, three, and six months after initial therapy.
Secondary outcomes
Retreatment for residual stones documented during follow‐up.
Mean procedure time from initiation of therapy until the end of therapy.
Length of hospitalisation for initial therapy.
Days off work. Time in hospital and at home for therapy complications.
Serious adverse effects of the intervention such as renal colic documented during and after therapy.
Search methods for identification of studies
Electronic searches
We searched the Cochrane Renal Group's Specialised Register up to 27 November 2013 through contact with the Trials' Search Co‐ordinator using search terms relevant to this review.
The Cochrane Renal Group’s Specialised Register contains studies identified from sources.
Monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL)
Weekly searches of MEDLINE OVID SP
Handsearching of renal‐related journals and the proceedings of major renal conferences
Searching of the current year of EMBASE OVID SP
Weekly current awareness alerts for selected renal journals
Searches of the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.
Studies contained in the Specialised Register are identified through search strategies for CENTRAL, MEDLINE, and EMBASE based on the scope of the Cochrane Renal Group. Details of these strategies, as well as a list of handsearched journals, conference proceedings and current awareness alerts, are available in the specialised register section of information about the Cochrane Renal Group.
See Appendix 1 for search terms used in strategies for this review.
Searching other resources
Reference lists of clinical practise guidelines, review articles and relevant studies.
Letters seeking information about unpublished or incomplete studies to investigators known to be involved in previous studies.
Data collection and analysis
Selection of studies
The search strategy described was used to obtain titles and abstracts of studies relevant to the review. Titles and abstracts were screened independently by two authors who discarded studies that were not applicable; however, studies and reviews that might include relevant data or information on studies were retained initially. The same two authors independently assessed retrieved abstracts and, if necessary the full text, to determine which studies satisfied our inclusion criteria.
Data extraction and management
Data extraction was carried out independently by two authors using standard data extraction forms. Studies reported in languages other than English and Chinese were translated before assessment. Where more than one publication of one study existed, reports were grouped together and the publication with the most complete data was included. Where relevant outcomes were only published in earlier versions, these data were used. Any discrepancies between published versions were to be highlighted. Any further information required from the original author was requested by written correspondence and any relevant information obtained in this manner was included in the review. Disagreements were resolved in consultation with a third author.
Assessment of risk of bias in included studies
The following items were assessed using the risk of bias assessment tool (Higgins 2011) (see Appendix 2).
Was there adequate sequence generation (selection bias)?
Was allocation adequately concealed (selection bias)?
-
Was knowledge of the allocated interventions adequately prevented during the study (detection bias)?
Participants and personnel
Outcome assessors
Were incomplete outcome data adequately addressed (attrition bias)?
Are reports of the study free of suggestion of selective outcome reporting (reporting bias)?
Was the study apparently free of other problems that could put it at a risk of bias?
Measures of treatment effect
For dichotomous outcomes (success, effectiveness, retreatment, serious adverse effects), results were expressed as risk ratio (RR) with 95% confidence intervals (CI). Where continuous scales of measurement were used to assess the effects of treatment (mean procedure time), the mean difference (MD) was used, or the standardised mean difference (SMD) if different scales had been used.
Unit of analysis issues
The first phases of cross‐over studies were eligible for inclusion.
Dealing with missing data
Missing data relevant to this review were to be sought from authors where necessary. Evaluation of important numerical data such as screened, randomised patients as well as intention‐to‐treat, as‐treated and per‐protocol population was carefully performed. Attrition rates, such as drop‐outs, losses to follow‐up and withdrawals were investigated. Issues of missing data and imputation methods (e.g. last‐observation‐carried‐forward) were critically appraised (Higgins 2011).
Assessment of heterogeneity
Heterogeneity was analysed using a Chi² test on N‐1 degrees of freedom, with an alpha of 0.05 used for statistical significance and with the I² test (Higgins 2003). I² values of 25%, 50% and 75% corresponded to low, medium and high levels of heterogeneity.
Assessment of reporting biases
If sufficient studies were identified, we planned to check for publication bias using funnel plots of between‐treatment effect and its precision on individual studies. If asymmetric funnel plots with statistically significant publication bias were found, we planned to examine its effect on the meta‐analysis conclusion using sensitivity analyses. However, these analyses were not undertaken because an insufficient number of studies were included in this review.
Data synthesis
Data were pooled using the random‐effects model but the fixed‐effect model was also analysed to ensure robustness of the model chosen and susceptibility to outliers.
Subgroup analysis and investigation of heterogeneity
Subgroup analysis was to be used to explore possible sources of heterogeneity (e.g. participants, interventions and study quality). Heterogeneity among participants could be related to age and kidney stone size. Heterogeneity in treatments could be related to prior agents used, and the agent, dose and duration of therapy. Adverse effects were tabulated and assessed with descriptive techniques, as they were likely to be different for the various agents used. Where possible, the risk difference with 95% CI was calculated for each adverse effect, either compared to no treatment or to another agent. There were insufficient studies to permit subgroup analyses.
Sensitivity analysis
Sensitivity analyses were performed to explore the influence of the following factors on effect size.
Repeating the analysis excluding unpublished studies.
Repeating the analysis taking account of risk of bias.
Repeating the analysis excluding any very large studies to establish how much they dominate the results.
Repeating the analysis excluding studies using the following filters: diagnostic criteria, language of publication, source of funding (industry versus other), and country.
There were insufficient studies to permit sensitivity analyses.
Results
Description of studies
Results of the search
Of the 11 reports of 10 studies identified, two met our inclusion criteria. We excluded two studies that were not RCTs, and seven that investigated interventions other than percussion, diuresis, and inversion therapy for lower pole kidney stones (Figure 1).
1.
Study flow diagram
Included studies
Two studies (177 participants) were included (Chiong 2005; Pace 2001). One study was conducted in Singapore (Chiong 2005) and the other in Canada (Pace 2001).
Chiong 2005 (108 participants) conducted a single‐blind, prospective study of patients with lower pole kidney stones 2 cm diameter or less following shock wave lithotripsy. The intervention group underwent a median of four sessions of percussion, diuresis, and inversion therapy one to two weeks after each shock wave lithotripsy session. Additional percussion, diuresis, and inversion therapy was provided for those with documented radiologic residual stone fragments at one month or following additional shock wave lithotripsy within the three month study period. Therapy involved 500 mL of water drunk 30 minutes before treatment; positioning in a prone Trendelenburg position at 45º, and continuous 10 minute manual mechanical percussion over the flank. The control group underwent shock wave lithotripsy only.
Pace 2001 (69 participants) conducted a single‐blind, prospective, cross‐over study in people with lower pole kidney stones 4 mm diameter or less at three months after shock wave lithotripsy. The intervention group received 20 mg furosemide followed by inversion to at least 60° and 10 minutes of flank percussion with a mechanical chest percussor weekly for three weeks or until stone‐free. The control group underwent observation‐only for four weeks. Of the 34 participants in the control group, 28 crossed‐over to undergo mechanical percussion and inversion therapy after completing the observation period.
Excluded studies
We excluded eight studies (nine reports); one was not a RCT (Albanis 2009), and seven investigated interventions unrelated to the management of lower pole kidney stones after shock wave lithotripsy (Arrabal‐Martin 2006; Azm 2002; De Sio 2008; Falahatkar 2008; Goktas 2000; Ulmann 1984; Zomorrodi 2008).
Risk of bias in included studies
Please refer to Figure 2 and Figure 3.
2.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Allocation
Sequence generation and allocation concealment was unclear in both included studies.
Blinding
Performance bias
Both included studies were single‐blinded only to the radiologist, and therefore performance bias was considered to be at high risk of bias.
Detection bias
Outcome assessments were blinded, and lack of blinding elsewhere was unlikely to introduce bias, they were considered to be at low risk of bias.
Incomplete outcome data
Pace 2001 and Chiong 2005 reported that eight and three participants respectively were lost to follow‐up. Intention‐to‐treat analyses were reported in both included studies, and were therefore considered to be at low risk of bias in terms of reporting incomplete outcome data.
Selective reporting
Primary outcome data were reported in both studies, and assessed as low risk of bias.
Other potential sources of bias
Chiong 2005 was assessed as being free of other potential sources of bias. Inadequate reporting meant that it was unclear whether Pace 2001 was free of other potential sources of bias.
There were too few studies included in this review to assess publication bias using a funnel plot.
Effects of interventions
Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention following shock wave lithotripsy
Stone‐free rate
Pace 2001 reported significantly higher stone‐free rates in the intervention group compared with the observation‐only group (Analysis 1.1: RR 0.62, 95% CI 0.47 to 0.82).
1.1. Analysis.
Comparison 1 Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention following shock wave lithotripsy, Outcome 1 Stone‐free rate.
Stone burden reduction
Pace 2001 reported a significant reduction in stone burden in the intervention group compared to the observation‐only group (Analysis 1.2: MD ‐3.30, 95% CI ‐3.58 to ‐3.03).
1.2. Analysis.
Comparison 1 Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention following shock wave lithotripsy, Outcome 2 Stone burden reduction.
Complications
Pace 2001 reported that one treatment group participant experienced an episode of renal colic. No serious adverse events were reported, and there were no significant differences between groups (Analysis 1.3: RR 3.00, 95% CI 0.12 to 76.24). Chiong 2005 did not report complications.
1.3. Analysis.
Comparison 1 Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention following shock wave lithotripsy, Outcome 3 Complications.
Percussion, diuresis, and inversion plus shock wave lithotripsy therapy versus shock wave lithotripsy only
Stone‐free rate
Chiong 2005 reported significantly higher stone‐free rates in the intervention group compared with control group participants (Analysis 2.1: RR 0.36, 95% CI 0.17 to 0.80).
2.1. Analysis.
Comparison 2 Percussion, diuresis, and inversion plus shock wave lithotripsy therapy versus shock wave lithotripsy alone, Outcome 1 Stone‐free rate.
Stone burden reduction
Chiong 2005 reported a significant reduction in stone burden in the intervention group (Analysis 2.2: MD ‐0.30, 95% CI ‐0.04 to ‐0.56).
2.2. Analysis.
Comparison 2 Percussion, diuresis, and inversion plus shock wave lithotripsy therapy versus shock wave lithotripsy alone, Outcome 2 Stone burden reduction.
Complications
Chiong 2005 reported that one treatment group participant developed a small subcapsular haematoma after shock wave lithotripsy, and found the therapy painful. There was no significant difference between groups (Analysis 2.3: RR 2.54, 95% CI 0.10 to 63.72).
2.3. Analysis.
Comparison 2 Percussion, diuresis, and inversion plus shock wave lithotripsy therapy versus shock wave lithotripsy alone, Outcome 3 Complications.
Other interventions
We did not find any studies investigating the following interventions.
Percussion and inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Diuresis and inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Percussion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Diuresis therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Inversion therapy following shock wave lithotripsy versus no intervention or placebo following shock wave lithotripsy
Discussion
Summary of main results
Although results of our review suggested percussion, diuresis, and inversion therapy to be a safe and effective therapy for lower pole kidney stones after shock wave lithotripsy, the evidence base was limited: only two small RCTs were identified; and data could not be pooled and meta‐analysed because controls differed.
Chiong 2005 (108 participants) investigated percussion, diuresis, and inversion therapy plus shock wave lithotripsy therapy versus shock wave lithotripsy only. This study found that percussion, diuresis, and inversion therapy plus shock wave lithotripsy therapy outcomes were more advantageous than shock wave lithotripsy therapy only in terms of stone‐free rates and reduction of stone burden, without increasing complication rates.
Pace 2001 (69 participants) reported that percussion, diuresis, and inversion therapy could significantly improve stone‐free rates and reduce stone burden compared with the observation‐only group, without increasing complication rates.
Overall completeness and applicability of evidence
Management of lower pole kidney stones less than 1 cm diameter continue to pose a clinical challenge. Currently, there is no standard adjunctive therapy to facilitate fragment passage. A small body of evidence suggested that percussion, diuresis, and inversion therapy may be worthwhile to aid passage of lower pole kidney stone fragments following shock wave lithotripsy.
Interventions varied in the two included studies. Pace 2001 compared participants who underwent adjuvant therapy of percussion, diuresis, and inversion therapy following shock wave lithotripsy with control group participants who were observed for four weeks following lithotripsy. Chiong 2005 compared participants who underwent percussion, diuresis and inversion therapy plus shock wave lithotripsy with those who were treated with shock wave lithotripsy therapy alone. The included studies presented results pertaining to stone‐free rate, stone burden reduction, and complications; no studies provided data on retreatment, mean procedure time, length of hospitalisation, or days off work. Chiong 2005 reported stone burden reduction rates as mean and range only, and did not calculate 95% confidence intervals or standard deviation.
These limitations meant that data could not be pooled for meta‐analysis.
Quality of the evidence
Overall, evidence indicated that percussion, diuresis, and inversion therapy were effective and safe to aid passage of lower pole kidney stone fragments following shock wave lithotripsy. However, evidence was limited by small sample sizes and data were methodologically flawed. Evidence should therefore be interpreted cautiously.
The included studies were blinded only to participating radiologists, leading us to assess treatment allocation concealment quality as unclear. Attrition bias and reporting bias were deemed as low risk. Chiong 2005 appeared to be free of other potential sources of bias, but insufficient reporting meant that this was unclear in Pace 2001.
Evidence plausibility overall was not robust. Meta‐analyses could not be conducted because the included studies did not investigate standardised interventions. We were therefore unable to derive a definitive conclusion concerning the efficacy and safety of percussion, diuresis and inversion therapy for lower pole kidney stones.
Potential biases in the review process
Review results were limited by the small number of included studies, limited sample sizes, and lack of consistency of interventions investigated (Chiong 2005; Pace 2001). Planned construction and interpretation of funnel plots could not be conducted to assess for publication bias. Although both studies reported positive outcomes in stone‐free rates and reduction of stone burden, a possible source of bias could be failure to publish small negative studies (publication bias) or unfavourable outcomes. Reporting of randomisation methods was unclear in both studies (Chiong 2005; Pace 2001).
Agreements and disagreements with other studies or reviews
Honey 2008 reported on patients with lower pole kidney stones at least two weeks after shock wave lithotripsy. Patients were placed in a prone Trendelenberg position at 60º to 70º, received furosemide 20 mg IV immediately before therapy, and underwent 10 minutes of flank percussion using a mechanical chest physiotherapy percussor. Therapy was proposed to be effective in aiding stone fragment passage.
Brownlee 1990 also found that multiple sessions of inversion therapy could confer beneficial effects to pass stone debris in gravity‐dependent calices after shock wave lithotripsy.
Albanis 2009 assessed inversion, hydration, and diuresis therapy in 100 patients with lower pole kidney stones less than 20 mm diameter in a prospective, non‐randomised study. Intervention group participants received one litre of oral fluids one hour before shock wave lithotripsy, furosemide 40 mg IV 10 minutes before lithotripsy, and were placed at 12° inversion during the procedure. Control group participants underwent shock wave lithotripsy only. Stone‐free rates of 83.3% and 71.5% were reported in the intervention and control groups respectively. No statistical significance was observed between groups (P > 0.05) (Albanis 2009).
Rodrigues 1991 reported outcomes among study participants who received adjunctive therapy following shock wave lithotripsy of oral hydration, 60º to 75º inversion, and percussion. Stone‐free status was achieved in 84% of participants who did not receive adjunctive therapy, but the stone‐free rate in those who underwent adjunctive therapy was 64.7%. Rodrigues 1991 concluded that inversion therapy did not improve results of shock wave lithotripsy for lower pole kidney stones.
Authors' conclusions
Implications for practice.
The available evidence suggested that percussion, diuresis, and inversion therapy was well tolerated and could aid passage of lower pole kidney stones following shock wave lithotripsy. This intervention may be a safe and effective adjuvant therapy for lower pole kidney stones after shock wave lithotripsy. However the number of studies identified and participants enrolled were small.
Implications for research.
Our findings were based on a small and methodologically‐flawed evidence base. Further studies are needed to better inform clinical practice. Large‐scale, well‐designed and long‐term studies are needed to ascertain the safety and efficacy of percussion, diuresis, and inversion therapy for lower pole kidney stones after shock wave lithotripsy. The effects of various forms of percussion, diuresis and inversion should be evaluated.
Acknowledgements
We would like to thank the referees and the Cochrane Renal Group.
Appendices
Appendix 1. Electronic search strategies
| Database | Search terms |
| CENTRAL |
|
| MEDLINE (OVID) |
|
| EMBASE (OVID) |
|
Appendix 2. Risk of bias assessment tool
| Potential source of bias | Assessment criteria |
|
Random sequence generation Selection bias (biased allocation to interventions) due to inadequate generation of a randomised sequence |
Low risk of bias: Random number table; computer random number generator; coin tossing; shuffling cards or envelopes; throwing dice; drawing of lots; minimization (minimization may be implemented without a random element, and this is considered to be equivalent to being random). |
| High risk of bias: Sequence generated by odd or even date of birth; date (or day) of admission; sequence generated by hospital or clinic record number; allocation by judgement of the clinician; by preference of the participant; based on the results of a laboratory test or a series of tests; by availability of the intervention. | |
| Unclear: Insufficient information about the sequence generation process to permit judgement. | |
|
Allocation concealment Selection bias (biased allocation to interventions) due to inadequate concealment of allocations prior to assignment |
Low risk of bias: Randomisation method described that would not allow investigator/participant to know or influence intervention group before eligible participant entered in the study (e.g. central allocation, including telephone, web‐based, and pharmacy‐controlled, randomisation; sequentially numbered drug containers of identical appearance; sequentially numbered, opaque, sealed envelopes). |
| High risk of bias: Using an open random allocation schedule (e.g. a list of random numbers); assignment envelopes were used without appropriate safeguards (e.g. if envelopes were unsealed or non‐opaque or not sequentially numbered); alternation or rotation; date of birth; case record number; any other explicitly unconcealed procedure. | |
| Unclear: Randomisation stated but no information on method used is available. | |
|
Blinding of participants and personnel Performance bias due to knowledge of the allocated interventions by participants and personnel during the study |
Low risk of bias: No blinding or incomplete blinding, but the review authors judge that the outcome is not likely to be influenced by lack of blinding; blinding of participants and key study personnel ensured, and unlikely that the blinding could have been broken. |
| High risk of bias: No blinding or incomplete blinding, and the outcome is likely to be influenced by lack of blinding; blinding of key study participants and personnel attempted, but likely that the blinding could have been broken, and the outcome is likely to be influenced by lack of blinding. | |
| Unclear: Insufficient information to permit judgement | |
|
Blinding of outcome assessment Detection bias due to knowledge of the allocated interventions by outcome assessors. |
Low risk of bias: No blinding of outcome assessment, but the review authors judge that the outcome measurement is not likely to be influenced by lack of blinding; blinding of outcome assessment ensured, and unlikely that the blinding could have been broken. |
| High risk of bias: No blinding of outcome assessment, and the outcome measurement is likely to be influenced by lack of blinding; blinding of outcome assessment, but likely that the blinding could have been broken, and the outcome measurement is likely to be influenced by lack of blinding. | |
| Unclear: Insufficient information to permit judgement | |
|
Incomplete outcome data Attrition bias due to amount, nature or handling of incomplete outcome data. |
Low risk of bias: No missing outcome data; reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias); missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups; for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk not enough to have a clinically relevant impact on the intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardized difference in means) among missing outcomes not enough to have a clinically relevant impact on observed effect size; missing data have been imputed using appropriate methods. |
| High risk of bias: Reason for missing outcome data likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups; for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk enough to induce clinically relevant bias in intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardized difference in means) among missing outcomes enough to induce clinically relevant bias in observed effect size; ‘as‐treated’ analysis done with substantial departure of the intervention received from that assigned at randomisation; potentially inappropriate application of simple imputation. | |
| Unclear: Insufficient information to permit judgement | |
|
Selective reporting Reporting bias due to selective outcome reporting |
Low risk of bias: The study protocol is available and all of the study’s pre‐specified (primary and secondary) outcomes that are of interest in the review have been reported in the pre‐specified way; the study protocol is not available but it is clear that the published reports include all expected outcomes, including those that were pre‐specified (convincing text of this nature may be uncommon). |
| High risk of bias: Not all of the study’s pre‐specified primary outcomes have been reported; one or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e.g. subscales) that were not pre‐specified; one or more reported primary outcomes were not pre‐specified (unless clear justification for their reporting is provided, such as an unexpected adverse effect); one or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta‐analysis; the study report fails to include results for a key outcome that would be expected to have been reported for such a study. | |
| Unclear: Insufficient information to permit judgement | |
|
Other bias Bias due to problems not covered elsewhere in the table |
Low risk of bias: The study appears to be free of other sources of bias. |
| High risk of bias: Had a potential source of bias related to the specific study design used; stopped early due to some data‐dependent process (including a formal‐stopping rule); had extreme baseline imbalance; has been claimed to have been fraudulent; had some other problem. | |
| Unclear: Insufficient information to assess whether an important risk of bias exists; insufficient rationale or evidence that an identified problem will introduce bias. |
Data and analyses
Comparison 1. Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention following shock wave lithotripsy.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Stone‐free rate | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected | |
| 2 Stone burden reduction | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3 Complications | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected |
Comparison 2. Percussion, diuresis, and inversion plus shock wave lithotripsy therapy versus shock wave lithotripsy alone.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
|---|---|---|---|---|
| 1 Stone‐free rate | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected | |
| 2 Stone burden reduction | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3 Complications | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected |
Characteristics of studies
Characteristics of included studies [ordered by study ID]
Chiong 2005.
| Methods |
|
|
| Participants |
|
|
| Interventions | Treatment group
Control group
|
|
| Outcomes |
|
|
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Using simple randomization by computer" |
| Allocation concealment (selection bias) | Unclear risk | "Patients were randomized to a control group or SWL plus percussion, diuresis, inversion therapy group using simple randomization by computer" |
| Blinding of participants and personnel (performance bias) All outcomes | High risk | Blinded to the radiologist only |
| Blinding of outcome assessment (detection bias) All outcomes | Low risk | Blinded to the radiologist only |
| Incomplete outcome data (attrition bias) All outcomes | Low risk | ITT analysis reported. 2.7% of randomised patients were lost to follow‐up, however data for all patients were reported |
| Selective reporting (reporting bias) | Low risk | Stone‐free rate and the overall reduction in stone size had been reported. Study protocol was not available |
| Other bias | Low risk | Supported by a National Healthcare Group research grant (Singapore) |
Pace 2001.
| Methods |
|
|
| Participants |
|
|
| Interventions | Treatment group
Control group
|
|
| Outcomes |
|
|
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Patients were randomised with simple block randomisation |
| Allocation concealment (selection bias) | Unclear risk | Patients were randomised with simple block randomisation to treatment group or observation group. |
| Blinding of participants and personnel (performance bias) All outcomes | High risk | Blinded to the radiologist only |
| Blinding of outcome assessment (detection bias) All outcomes | Low risk | "A blinded radiologist adjudicated all films to determine final stone free state" |
| Incomplete outcome data (attrition bias) All outcomes | Low risk | ITT analysis reported, 11.5% of randomised patients were lost to follow‐up, however data for all patients has been reported |
| Selective reporting (reporting bias) | Low risk | Primary outcomes (stone free rate and stone burden reduction rate) were reported. Study protocol was available |
| Other bias | Unclear risk | Source of funding not stated |
ITT, intention‐to‐treat; IVP, intravenous pyelogram; RCT, randomised controlled trial; SWL, shock wave lithotripsy
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
|---|---|
| Albanis 2009 | Not RCT |
| Arrabal‐Martin 2006 | Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones |
| Azm 2002 | Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones |
| De Sio 2008 | Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones |
| Falahatkar 2008 | Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones |
| Goktas 2000 | Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones |
| Ulmann 1984 | Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones |
| Zomorrodi 2008 | Did not assess percussion, diuresis and inversion therapy for passage of lower pole kidney stones |
RCT, randomised controlled trial
Differences between protocol and review
We added 'percussion, diuresis and inversion therapy plus shock wave lithotripsy versus shock wave lithotripsy only' to our list of interventions which was not indicated in the review's protocol.
Contributions of authors
Draft the protocol: LLR, WQ
Study selection: LLR, XY, WQ
Extract data from studies: LLR, LQJ
Enter data into RevMan: LLR, LQJ
Carry out the analysis: LLR, WQ, LQJ
Interpret the analysis: LLR, LZH, XY
Draft the final review: LLR, XY
Disagreement resolution: WQ
Update the review: LLR, WQ
Sources of support
Internal sources
-
Chinese Cochrane Center, China.
Chinese Centre of Evidence‐based Medicine, West China Hospital, Sichuan University, China
External sources
No sources of support supplied
Declarations of interest
None known.
New
References
References to studies included in this review
Chiong 2005 {published data only}
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