Abstract
Introduction
The age of peak incidence for stone disease is 20-40 years, although stones are seen in all age groups. There is a male to female ratio of 3:2.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions for stone removal in people with asymptomatic kidney stones? What are the effects of interventions for the removal of symptomatic renal stones? What are the effects of interventions to remove symptomatic ureteric stones? What are the effects of interventions for the management of acute renal colic? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodic drugs, extracorporeal shockwave lithotripsy, intravenous fluids, NSAIDs, opioids, oral fluids, percutaneous nephrolithotomy, and ureteroscopy.
Key Points
Kidney stones develop when crystals separate from the urine and aggregate within the kidney papillae, renal pelvis, or ureter.
The age of peak incidence for stone disease is 20-40 years, although stones are seen in all age groups. There is a male to female ratio of 3:2.
The evidence is somewhat sparse regarding the best treatments for people with asymptomatic kidney stones.
Extracorporeal shockwave lithotripsy may reduce the need for further invasive surgery, although the evidence is not sufficient for us to know this for certain.
We didn't find any evidence assessing percutaneous nephrolithotomy or ureteroscopy in people with asymptomatic kidney stones.
Percutaneous nephrolithotomy seems as effective as extracorporeal shockwave lithotripsy in removing symptomatic kidney stones less than 30 mm in diameter, but it is more invasive and associated with more complications.
People with larger stones are likely to take longer to pass stone fragments after extracorporeal shockwave lithotripsy, and so in these cases percutaneous nephrolithotomy may be a more suitable option. However, the field is advancing rapidly so RCT evidence is not always applicable to current practice.
We didn't find any information from RCTs about ureteroscopy or open nephrolithotomy for the removal of symptomatic kidney stones.
Open nephrolithotomy has been largely superseded by percutaneous nephrolithotomy in resource-rich countries.
For people with symptomatic ureteric stones, ureteroscopy seems to increase overall stone-free rates and decrease the time needed to become stone free compared with extracorporeal shockwave lithotripsy, although lithotripsy is associated with lower failure and complication rates.
We found no evidence examining ureterolithotomy (either open or laparoscopic) in people with symptomatic ureteric stones.
About this condition
Definition
Nephrolithiasis is the presence of stones within the kidney; urolithiasis is a more general term for stones anywhere within the urinary tract. Urolithiasis is usually categorised according to the anatomical location of the stones (i.e. renal calyces, renal pelvis, ureteric, bladder, and urethra). Ureteric urolithiasis is described further by stating in which portion (proximal, middle, or distal) the stone is situated. This review assesses the effects of treatments only for the removal of asymptomatic or symptomatic renal and ureteric stones. It excludes pregnant women, in whom some diagnostic procedures and treatments for stone removal are contraindicated, and people with significant comorbidities (including severe cardiovascular and respiratory conditions) who may be at increased risk when having general anaesthesia. Diagnosis: Diagnosis is usually based on clinical history, supported by investigations with diagnostic imaging. One third of all kidney stones become clinically evident, typically causing pain (often severe in nature), renal angle tenderness, haematuria, or digestive symptoms (e.g. nausea, vomiting, or diarrhoea). The onset of pain is usually sudden, typically felt in the loin, and radiating to the groin and genitalia (scrotum or labia). People are typically restless, find the pain excruciating, and describe it as the worst pain ever experienced. The cause and chemical composition of a stone may have some bearing on its diagnosis, management, and particularly on prevention of recurrence. Although the choices for surgical management in general remain the same for all types of stone disease, the recognition of a specific cause, such as recurrent infection with a urease-producing organism for struvite stones, or cysteinuria for cysteine stones, will inform further management. Differential diagnosis: Bleeding within the urinary tract may present with identical symptoms to kidney stones, particularly if there are blood clots present within the renal pelvis or ureter. Other differential diagnoses include urinary tract infection (and indeed the 2 conditions may coexist), analgesic abuse, and alternative retroperitoneal pathology (e.g. abdominal aortic aneurysm). Patients with papillary cell necrosis (which may occur in diabetes or sickle cell disease) may present with renal colic.
Incidence/ Prevalence
The age of peak incidence for stone disease is 20-40 years, although stones are seen in all age groups.The male predominance of stone disease may be decreasing, with recent reports of male to female ratio being approximately 3:2. In North America, calcium oxalate stones (the most common variety) have a recurrence rate of 10% at 1 year and 35% at 5 years after the first episode of kidney stone disease.
Aetiology/ Risk factors
Kidney stones develop when crystals separate from the urine and aggregate within the kidney papillae, renal pelvis, or ureter. The most common type of stones are calcium-containing stones, which are usually formed of calcium oxalate, and less commonly of calcium phosphate. Other metabolic stones include uric acid, cysteine and xanthine stones. In contrast, there are infective stones, or "struvite" stones, which contain a mixture of magnesium, ammonium, and phosphate, and are associated with urease-forming organisms such as Klebsiella or Proteus species. General predisposing factors for stone formation include dehydration, lifestyle, geographical location (dry arid climate), as well as some specific risk factors. These may include anatomical/structural abnormalities (e.g. pelviureteric junction obstruction, urinary diversion surgery, horseshoe kidney, calyceal diverticulum), underlying metabolic conditions (e.g. cystinuria, oxaluria, gout), certain drugs, and urease-producing infective organisms.
Prognosis
Most kidney stones pass within a few days with expectant treatment (including adequate fluid intake and analgesia). Others may take longer to pass and the observation period can be extended to 3-4 weeks where appropriate. Ureteric stones less than 5 mm in diameter will pass spontaneously in about 90% of people, compared with 50% of ureteric stones between 5 mm and 10 mm. Expectant (conservative) management is considered on an individual basis in people with stones that are asymptomatic, very small, or both (although stone size may not correlate with symptom severity), and in people with significant comorbidities, in whom the risks of treatment may outweigh the likely benefits. Stones may migrate regardless of treatment or after treatment for their removal, and may or may not present clinically once in the ureter. Stones blocking the urine flow may lead to hydronephrosis and renal atrophy. They may also result in life-threatening complications including urinary infection, perinephric abscess, or urosepsis. Drainage of an infected obstructed kidney is a medical emergency, and may result in death if left untreated. Infection may also occur after invasive procedures for stone removal. Some of these complications may cause kidney damage and compromised renal function. Eventually, 10-20% of all kidney stones need treatment.
Aims of intervention
To render people free of stones; and to prevent the development of the complications of stone disease, with minimal adverse effects.
Outcomes
Stone-free rate (proportion of people becoming stone free, assessed radiologically); time to becoming stone free (duration of passing stone fragments); treatment failure (defined as no change in the stone, or the presence of large stone fragments, even if asymptomatic); complication rate of kidney stone disease (including sepsis, obstructive renal failure, hydronephrosis, and perinephric abscess); complication rate of renal and ureteric surgery including renal and ureteric trauma, sepsis, haemorrhage, and death; adverse effects of treatment. Pain management outcomes: Requirement of additional pain relief; readmission to hospital.
Methods
Clinical Evidence search and appraisal May 2008. The following databases were used to identify studies for this systematic review: Medline 1966 to May 2008, Embase 1980 to May 2008, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2008, Issue 2. An additional search was carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language and containing more than 50 individuals of whom more than 80% were followed up. There was a minimum length of follow-up of 3 months required to include studies of surgical interventions; there was no minimum follow-up length for medical treatments. We included all studies described as "open", "open label", or not blinded. In addition we use a regular surveillance protocol to capture harms alerts from organisations such as the US FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).
Table.
GRADE evaluation of interventions for Kidney stones
| Important outcomes | Removal of stones, time to becoming stone free, treatment failure, pain, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of interventions for stone removal in people with asymptomatic kidney stones? | |||||||||
| 1 (228) | Removal of stones | Extracorporeal shockwave lithotripsy v expectant management | 4 | 0 | 0 | 0 | 0 | High | |
| 1 (228) | Need for invasive procedure | Extracorporeal shockwave lithotripsy v expectant management | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for low event rate and incomplete reporting of results |
| What are the effects of interventions for the removal of symptomatic renal stones? | |||||||||
| 1 (128) | Removal of stones | Extracorporeal shockwave lithotripsy v percutaneous nephrolithotomy | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (67) | Removal of stones | Extracorporeal shockwave lithotripsy v ureteroscopy | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 2 (280) | Removal of stones | Extracorporeal shockwave lithotripsy using 60 shocks per minute v 120 shocks per minute | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (79) | Removal of stones | Percutaneous nephrolithotomy v open nephrolithotomy | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (79) | Postoperative recovery | Percutaneous nephrolithotomy v open nephrolithotomy | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| What are the effects of interventions to remove symptomatic ureteric stones? | |||||||||
| 1 (100) | Removal of stones | Extracorporeal shockwave lithotripsy v expectant management (mid- or distal ureteric stones) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 5 (732) | Removal of stones | Extracorporeal shockwave lithotripsy v ureteroscopy (mid- or distal ureteric stones) | 4 | 0 | –1 | –1 | 0 | Low | Consistency point deducted for heterogeneity of RCTs. Directness point deducted for inclusion of some people with upper ureteric stones |
| 1 (100) | Removal of stones | Extracorporeal shockwave lithotripsy v conservative management (proximal ureteric stones) | 4 | –2 | 0 | 0 | 0 | Moderate | Quality points deducted for sparse data and incomplete reporting of results |
| 23 (at least 1494) | Removal of stones | Alpha-blockers v placebo | 4 | 0 | –1 | 0 | 0 | Moderate | Consistency point deducted for heterogeneity among RCTs. |
| What are the effects of interventions for the management of acute renal colic? | |||||||||
| 1 (112) | Pain | NSAIDs v placebo | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for uncertain generalisability of interventions and outcomes |
| 1 (80) | Recurrent episodes of renal colic | NSAIDs v placebo | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for uncertain generalisability of interventions and outcomes |
| 1 (192) | Pain | Antispasmodic drugs v placebo | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for uncertain generalisability of intervention and outcome |
Type of evidence: 4 = RCT; 2 = Observational.Consistency: similarity of results across studies.Directness: generalisability of population or outcomes.Effect size: based on relative risk or odds ratio.
Glossary
- High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
- Hydronephrosis
Dilatation of the renal pelvis and calyces, with or without dilatation of the ureter, which may result from an obstruction within the renal tract.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Perinephric abscess
Abscess lying within Gerota's fascia.
- Staghorn calculus
A stone lying in the renal pelvis and extending into at least two calyceal groups.
- Steinstrasse
A collection of stone fragments within the ureter. On x-ray, such collections have the appearance of a cobbled street, hence the term steinstrasse, in German meaning “street of stone”.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Ranan DasGupta, Imperial College Healthcare Trust, London, UK.
Jonathan Glass, Guy's Hospital, London, UK.
Jonathon Olsburgh, Guy's Hospital, London, UK.
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