Elsevier

European Urology

Volume 76, Issue 3, September 2019, Pages 352-367
European Urology

Review – Stone Disease
Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel

https://doi.org/10.1016/j.eururo.2019.06.018Get rights and content

Abstract

Context

Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment.

Objective

To assess the efficacy (primary outcome: stone-free rate [SFR]) and morbidity of BS treatments.

Evidence acquisition

This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970–2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with ≥10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Evidence synthesis

A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p = 0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference [MD] 0.82 d, p < 0.00001) and procedure duration (MD 9.83 min, p < 0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74 min, p < 0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases; QoE was very low.

Conclusions

Current available evidence indicates that TUCL is the intervention of choice for BSs in adults and children, where feasible. Further high-quality research on the topic is required.

Patient summary

We examined the literature to determine the most effective and least harmful procedures for bladder stones in adults and children. The results suggest that endoscopic surgery is equally effective as open surgery. It is unclear whether stone size affects outcomes. Shock wave lithotripsy appears to be less effective. Endoscopic treatments appear to have shorter catheterisation time and convalescence compared with open surgery in adults and children. Transurethral surgery, where feasible, appears to have a shorter hospital stay than percutaneous surgery. Further research is required to clarify the efficacy of minimally invasive treatments for larger stones and in young children.

Introduction

Despite constituting only approximately 5% of all urinary tract stones [1], bladder stones (BSs) are responsible for 14% of hospital admissions [2] and 8% of urolithiasis-related deaths in developed nations [3]. BSs are more prevalent in men and in developing countries 3, 4, 5. BSs have a bimodal age distribution: incidence peaks at 3 4, 6 and 60 yr [4]. BSs may cause lower urinary tract symptoms, infections, pain, and haematuria, and have been associated with bladder cancer [8].

BSs can be classified as primary, secondary, and migratory [9]. Primary or endemic BSs occur in the absence of other urinary tract pathologies, typically seen in children in areas with a diet lacking animal protein, poor hydration, and recurrent diarrhoea [10]. Secondary BSs occur in the presence of other urinary tract abnormalities, including bladder outlet obstruction, neurogenic bladder dysfunction, chronic bacteriuria, foreign bodies including catheters, bladder diverticulae, and bladder augmentation or urinary diversion. Migratory BSs form in the upper urinary tract [9].

Although open cystolithotomy (CL) is the traditionally accepted treatment modality [8], minimally invasive treatments have widely been adopted to reduce hospital stay and convalescence. However, it is unclear whether these treatments may compromise stone-free rates (SFRs) and what morbidity they may expose patients to 7, 8. We present the first systematic review that addresses benefits and harms of procedures used to remove BSs in either adults or children.

Section snippets

Search strategy

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [11] and the Cochrane Handbook for Systematic Reviews of Interventions [12]. Medline, Embase, and Cochrane controlled trials databases and clinicaltrial.gov were searched between January 1970 and February 2019 for relevant English-language publications.

The published a priori protocol includes the search strategy [13]. Following deduplication, two review

Description of the included studies

A total of 2742 abstracts were screened and 59 full-text articles were assessed: 27 articles on 25 studies were included with 2340 patients: 1526 adults and 814 children. Reasons for exclusion are listed in Fig. 1.

Study characteristics

Characteristics of the included studies are listed in Supplementary Table 1. Twenty studies on adults were included: nine RCTs and 11 NRSs; two studies compared four interventions, and four studies compared three interventions. Five studies in children were included: one RCT and four

Discussion

This study provides the first ever systematic review and meta-analyses on the treatment of BSs, and has informed the first national or international guideline on BSs [41]. Complete removal of a stone constitutes the most important outcome when evaluating the efficacy of any stone treatment. Our results indicate that SWL was less effective than endoscopic or open surgery in both adults and children in terms of SFR, although the QoE was low or very low. An RCT on small (<2 cm) BSs in adults found

Conclusions

This systematic review demonstrates that endoscopic, transurethral, and percutaneous BS treatments are associated with comparable SFRs, but with a shorter operation and catheterisation duration as well as a shorter length of hospital stay, compared with open CL, in both adults and children. SWL appears to offer an inferior SFR when compared with other procedures, but offers the shortest duration of hospital stay. In adults, TUCL using an instrument with continuous flow (eg, a nephroscope or a

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