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Medical and surgical interventions for the treatment of urinary stones in children: A Cochrane Review.

Introduction

The prevalence rate of urinary tract stones in children in low- to middle-income countries such as Pakistan and Turkey is 5% to 15%, compared with 1% to 5% in high-income countries [1,2]. The manifestation and clinical presentation of urinary stones in children differs from the adult population and can vary with age. Fifty percent of children will present with abdominal pain, 33% with haematuria and 11% with infection. Children under the age of five years most commonly present with blood in the urine, while pain is a more common finding in older children [3].

The most appropriate management strategy in children depends on the size, location and composition of the stone. Shock wave lithotripsy (SWL) is a commonly used for smaller upper urinary tract stones as long as there is adequate drainage of the urinary system below the level of the stone. In children with larger and more complex stone disease percutaneous nephrolithotripsy (PCNL) is widely used. This technique is considered in children with large upper tract stones (1.5 cm or larger). Children with stone size from 4 mm within the ureter or collecting system may be treated by ureterorenoscopy with different contact lithotripsy techniques such as laser, ultrasound, and pneumatic lithotripsy. Open stone surgery may be used in very young children with large stones or in children with a large stone which would require multiple endoscopic procedures and in children with a stone in the presence of congenital anomalies of the urinary system or orthopaedic anomalies. Laparascopic and robotic surgery are becoming more popular in the treatment of various urological conditions requiring a surgical approach but is not yet commonly used in the treatment of paediatric stones [4]. Medical expulsion therapy involves the administration of medications to accelerate and facilitate the spontaneous passage of ureteric stones. Corticosteroids, hormones, nonsteroidal anti-inflammatory agents, calcium-channel blockers and alpha-adrenergic blockers have been used in the conservative management of stone disease. While there are existing systematic reviews that assess the effects of medical expulsive therapy and ureteroscopy, the reviews are less rigorous and include non-randomised controlled trials regardless of study design [5, 6, 7, 8, 9]. Furthermore, none apply the GRADE approach or use the same methodology as Cochrane reviews.

Therefore, we performed the systematic reviews to assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

Methods

Please see the protocol and review published in Cochrane Library for further details on the methods.

Search strategy and selection criteria

The search strategy was developed with the Cochrane Renal Group's Trials Search Coordinator. The latest search was conducted on 31st December 2017 of the Cochrane Central Register of Controlled trials, MEDLINE and Embase. No language limitations were applied. We also searched the references of full articles retrieved for our review to identify any additional studies. To identify unpublished trials or trials in progress, we searched the following sources: ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform Search Portal (apps.who.int/trialsearch/) and the International Standard Randomised Controlled Trial Number registry (controlled-trials.com). We conducted a search of abstract proceedings of major urological and paediatric urology meetings, covering the years 2012 to 2017. We contacted the authors of studies identified as potentially eligible to obtain clarification on missing data.

Two review authors (LB and AA) independently screened all potentially relevant records and classified studies in accordance with the criteria for each provided in the Cochrane Handbook for Systematic Reviews of Interventions [10]. The conflict resolution was performed by a third author (MK) independently. We reviewed randomised controlled trials (RCTs), including pseudo-RCTs.

Types of participants

We included children (aged 0 to 18 years) with upper tract urinary stones confirmed by imaging, who required medical or surgical intervention.

Types of interventions

We have examined and compared shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy (regardless of the type of lithotripsy), open stone surgery and medical expulsive therapy.

Types of outcomes measured

Primary outcomes measured were stone-free rate, serious adverse events or complications of treatment and secondary procedures for residual fragments. Secondary outcomes measured were hospital stay and pain.

Assessment of risk of bias in included studies

Two review authors (LB, AA) independently assessed the risk of bias of each included study on a per outcome basis. We resolved all disagreements by discussion and consensus. We assessed risk of bias using the Cochrane 'Risk of bias' assessment tool. We judged risk of bias domains as 'low risk', 'high risk', or 'unclear risk' and evaluated individual bias items as described in the Cochrane Handbook for Systematic Reviews of Interventions [10].

Data collection and synthesis

Data extraction was carried out independently by two authors (LB and MK) using data extraction forms created in Microsoft Excel. We resolved any disagreements by discussion or, if required, by consultation with a third review author (AA). We combined data from individual studies for meta-analysis where interventions were similar enough.

We expressed dichotomous outcome results (SFR, adverse events and complications after treatment, number of second procedures for residual fragments measuring 4 mm or more as RRs with 95% confidence intervals (CIs). We used the MD where continuous scales of measurement are used to assess the effects of treatment (mean hospital stay, pain scale, pain medication).We summarised data using a random-effects model. We interpreted random-effects meta-analyses with due consideration of the whole distribution of effects.

Heterogeneity was analyzed using a [Chi.sup.2] test on N-1 degrees of freedom with an alpha of 0.05 used for statistical significance and with the [I.sup.2] test [11]. [I.sup.2] values of 25%, 50% and 75% generally correspond to low, medium and high levels of heterogeneity. When we encountered heterogeneity, we attempted to determine possible reasons for it by examining individual study and subgroup characteristics. In the event of excessive heterogeneity unexplained by subgroup analyses, we planned not to report outcome results as the pooled effect estimate in a meta-analysis but to provide a narrative description of the results of each study.

Subgroup and sensitivity analyses

We expected the following characteristics to introduce clinical heterogeneity, and we planned to carry out subgroup analyses with investigation of interactions.

* Size of the kidney stone (less than 10 mm versus 10 mm or more).

* Location of the stone (renal pelvis versus ureter).

Summary of findings tables (SoF)

We presented the overall quality of the evidence (QoE) for each outcome according to the GRADE approach, which takes into account five criteria not only related to internal validity (risk of bias, inconsistency, imprecision, publication bias), but also to external validity, such as directness of results [12].

Results

Search results

We identified a total of 700 references from all searches. After removal of duplicates, we screened the titles and abstracts of 617 records and excluded 597. We screened 20 full-text articles and excluded 5 articles. A total of 14 studies (15 articles) were included in the final review. The flow of studies identified to be included in the review is summarised in a flow chart (Figure 1). Detailed characteristics of included studies are summarised in Table 1.

Participants

The mean age of trial participants ranged from 20.3 months to 11.1 years (with an age range of 0.5 to 17 years). Ethnic groups were not described; however, two studies were conducted in Turkey [22, 24], seven studies in Egypt [17, 19, 21, 23, 25, 27, 28], two studies in Iran [14, 15], one in India [18], one in China [20], and one in Italy [16]. Major exclusion criteria were renal abnormalities and coagulopathy. Inclusion criteria related to stone size and age. In the surgical group, stone size range was 5 mm to 45 mm [14-20]. In the medical therapy group, stone size ranged from 2 mm to 12 mm [22-25, 27], and less than 1 cm [21]. In the medical and surgical intervention group the median stone size was 12 mm (10 mm to 16 mm) [28].

Effects of interventions

Shock wave lithotripsy versus dissolution therapy for intrarenal stones

We found a single study with 87 participants (39 randomised to SWL and 48 to oral citrate) [28]. The follow-up period was three months.

1. Stone-free rate

We are uncertain about the effects of SWL on SFR (RR 1.13, 95% CI 0.90 to 1.41; very low QoE).

2. Serious adverse events or complications of treatment

We are uncertain about the effects of SWL on serious adverse events (RR 1.23, 95% CI 0.08 to 19.05; very low QoE).

3. Secondary procedures for residual fragments

We are uncertain about the effects of SWL on secondary procedures for residual fragments (RR 0.66, 95% CI 0.29 to 1.50; very low QoE).

There were no data for Hospital stay and Pain.

Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones.

We found a single study with 60 participants (30 randomised to slow SWL and 30 randomised to rapid SWL) [19]. The follow-up period was a minimum of one month.

1. Stone-free rate

We are uncertain about the effects of slow SWL on SFR (RR 2.25, 95% CI 1.16 to 4.36; very low QoE).

2. Serious adverse events or complications of treatment

We could not estimate the risk of serious adverse events or complications of treatment due to there being no reported events.

3. Secondary procedures for residual fragments

We are uncertain about the effects of slow SWL on secondary procedures for residual fragments (RR 0.38, 95% CI 0.11 to 1.28; very low QoE).

There were no data for Hospital stay and Pain.

Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones.

We found three studies with 153 participants (75 randomised to SWL and 78 randomised to ureteroscopy) [15-17]. All studies were included in the analyses, except for the outcome 'hospital stay', which included data from 2 studies [15, 17]. While two studies reported the follow-up period two weeks to eight months [15, 16], one [17] did not report the period.

1. Stone-free rate

We are uncertain about the effects of SWL on SFR (RR 0.62, 95% CI 0.43 to 0.88; very low QoE).

2. Serious adverse events or complications of treatment

We are uncertain about the effects of SWL on severe adverse events (RR 0.56, 95% CI 0.12 to 2.58; very low QoE).

3. Secondary procedures for residual fragments

We are uncertain about the effects of SWL on secondary procedures (RR 3.47, 95% CI 1.32 to 9.15; very low QoE).

4. Hospital stay (hours)

We are uncertain about the effects of SWL on hospital stay (MD -10.71, 95% CI - 34.09 to 12.67; very low QoE).

5. Pain

We did not find any data related to pain.

Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones

We found a single study with 221 participants (110 randomised to SWL and 111 randomised to mini-PCNL) [18]. The follow-up period was three months.

1. Stone-free rate

SWL likely has lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate QoE).

2. Serious adverse events or complications of treatment

SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low QoE).

3. Secondary procedures for residual fragments

SWL may increase the need of secondary procedures (RR 2.50, 95% CI 1.01 to 6.20; low QoE).

4. Hospital stay (days)

SWL likely reduces hospital stay (MD -3.40, 95% CI -5.43 to - 1.37; moderate QoE).

5. Pain

We did not find any data related to pain.

Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones

We found a single study with 23 participants (10 randomised to PCNL and 13 randomised to tubeless PCNL) [14]. The follow-up period was one month.

1. Stone-free rate

We are uncertain <Sut the effect of PCNL in SFR (RR 1.16, 95% CI 0.88 to 1.53; very low QoE).

2. Serious adverse events or complications of treatment

We are uncertain about the effect of PCNL on serious adverse events (RR 0.42, 95% CI 0.02 to 9.43; very low QoE).

3. Secondary procedures for residual fragments

We are uncertain about the effect of PCNL on secondary procedures (RR 0.42, 95% CI 0.02 to 9.43; very low QoE).

4. Hospital stay (hours)

PCNL may increase hospital stay (MD 19.16, 95% CI 10.24 to 28.08; low QoE).

5. Pain (dose of morphine: mg/kg)

PCNL likely requires larger doses of morphine (MD 0.08, 95% CI 0.05 to 0.11; moderate QoE).

Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones

We found a single study with 78 participants (38 randomised to PCNL and 40 randomised to tubeless mini-PCNL) [20]. The follow-up period was 12 months.

1. Stone-free rate

PCNL likely results in no difference in SFR (RR 1.03, 95% CI 0.93 to 1.14; moderate QoE).

2. Serious adverse events or complications of treatment

We did not find any data related to serious adverse events.

3. Secondary procedures for residual fragments

There were no reported events.

4. Hospital stay (days)

PCNL likely increases hospital stay (MD 3.14, 95% CI 2.78 to 3.50; moderate QoE).

5. Pain

We did not find any data related to pain.

Alpha-blockers versus placebo with/without analgesics for distal ureteric stones

We found six studies with a different number of participants in each analysis [21, 22, 23-25, 27]. The follow-up period ranged from three to four weeks.

1. Stone-free rate

We included six studies with 335 participants (alpha-blocker 185, placebo with/without analgesics 150) in the analysis for SFR [21, 22, 23-25, 27]. Alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low QoE).

2. Serious adverse events or complications of treatment

There were no serious adverse events or complications in either group.

3. Secondary procedures for residual fragments

We included one study with 39 participants (alpha-blocker 19, placebo with/without analgesics 20) [22]. We are uncertain about the effect of alpha-blockers on secondary procedures (RR 0.53, 95% CI 0.15 to 1.81; very low QoE).

4. Hospital stay

We did not find any data related to hospital stay.

5. Pain

We included two studies with 98 participants (alpha-blocker 51, placebo with/without analgesics 47) [23, 27]. We are uncertain about the effect of alpha-blockers on pain episodes (MD -1.49, 95% CI -3.04 to 0.06; very low QoE).

Subgroup analysis and sensitivity analysis

We were able to perform subgroup analysis only in the comparison of shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy. There was a difference in hospital stay with an MD of 0.00 (95% CI -1.07 to 1.07) in the participants with renal stones [18] versus an MD of-24.00 (95% CI -39.45 to -8.55) in the participants with distal ureteral stones (P = 0.002, [I.sup.2] = 89.2%). However, no differences were found in SFR (P = 0.57, I2 = 0%), Serious adverse events or complications of treatment (P = 0.70, [I.sup.2] = 0%) and Secondary procedures for residual fragments (P = 0.66, [I.sup.2] = 0%).

We could not conduct any sensitivity analyses.

Risk of bias in included studies

Further details on the assessment of Risk of Bias were stated in the review published in Cochrane Library. Assessments of risk of bias are summarised in Figure 2.

Summary of findings tables

We summarised the results in summary of findings tables in accordance with GRADE methodology (Table S3-9).

Discussion

To date, we have not identified any non-Cochrane review that used similar rigorous methodology including a published protocol. However, there were a few reviews for this topic. We identified two systematic reviews assessing ureteroscopy [6, 7] and three systematic reviews assessing medical expulsive therapy [5, 8, 19].

Ishii et al. looked at the effects of ureteroscopic approach. They concluded that the use of ureteroscopy as the first-line surgical management is a safe and highly effective intervention, with a small proportion of the study population having minor complications. Also, Saad et al. compared PCNL to ureterorenoscopy in 38 randomized patients [29]. While they reported no difference in SFR, serious adverse events or complications of treatment and secondary procedures, they reported 43 renal units instead of randomized participants which causes unit of analysis error.

Tian et al. analyzed effects of alpha-blockers (tamsulosin and doxazosin) on stone expulsion rate, stone expulsion time, and treatment-emergent adverse events with four RCTs and one cohort study. The results of the review regarding the stone expulsion rate suggested that adrenergic alpha-antagonists significantly improved the stone expulsion rate compared to the placebo. There was no significant difference between the adrenergic alpha-antagonists and the placebo groups in terms of adverse events. In addition, Glina et al analyzed alpha-1 adrenergic blockers as medical expulsive treatment in children with distal ureterolithiasis with three RCTs in the meta-analysis and concluded that use of an alpha-1 adrenergic blocker is related to a greater incidence of expulsion of ureteral calculi and fewer episodes of pain when compared to ibuprofen.

Although all interventions assessed in this review are used to treat stone disease, the patient populations they apply to vary greatly by stone size and age. This limits any assessments across randomised comparisons. In addition, the definition of the SFR varied across the studies. In some studies, the SFR was accepted if the fragments post-treatment were less than or equal to 4 mm [14, 19, 20], whereas other studies classified SFR as no remaining fragments in the renal tract. The length of follow-up varied between the studies and was generally limited to short-term follow-up of three months or less. There is a need for long-term follow-up data. Regarding the predefined primary and secondary outcomes in this review, half of the studies reported on all primary outcomes (SFR, complications and rate of secondary procedures) [14-18, 19, 20, 28]. Only three studies reported pain [14, 23, 27] as an outcome and five studies reported on hospital stay [14, 15, 17, 18, 20]. We were unable to conduct any of the predefined subgroup analyses except one comparison of SWL versus ureteroscopy. Questions around differential effectiveness and safety of these interventions therefore remain unanswered. A majority of the studies are recent. This is potentially due to the increasing incidence of the nephrolithiasis in children 18 years old and younger [30] and increased recognition of the importance of trials in paediatric urology. The majority of comparisons assessed in this review relate to surgical innovation. With regards to ureterorenoscopes and nephroscopes, there have been recent advancements in terms of miniaturisation, increased functionality (improved scope flexibility) and visualization (introduction of digital scopesO [31]. These recent advances are not captured in this review, given the paucity of trials and limiting applicability. Factors which could have significant impact on the treatment outcomes - such as contributing metabolic abnormalities, stone composition and preoperative renal function - have not been considered in most of the studies. This could have an impact on the choice of treatment modality and treatment outcomes. The applicability of the findings to high-income countries needs consideration as the majority of included studies were conducted in middle- and low-income countries with possible variation in risk factors for stone formation, availability of certain interventions and access to paediatric care.

Although we attempted to conduct a comprehensive search irrespective of language and publication status, it is possible that we missed non-English studies in non-indexed journals. In addition, the reporting quality of most included studies was poor, prompting us to contact the authors for further information. Due to the time-intense nature of this effort, we limited this to one attempt only. Increased efforts may have yielded a better response rate. The focus of this systematic review was direct evidence from randomised trials in paediatric patient populations. Given that the QoE was very low, it is possible that indirect evidence from adult populations or observational studies may have yielded higher quality evidence for at least some comparisons.

References

(1.) Shah AM, Kalmunkar S, Punekar SV, et al. Spectrum of pediatric urolithiasis in Western India. Indian Journal of Pediatrics 1991;58(4):543-9.

(2.) Elsobky E, Sheir KZ, Madbouly K, et al. Extracorporeal shock wave lithotripsy in children: experience using two second-generation lithotripters. BJU International 2000;86(7):851-6.

(3.) Santos-Victoriano M, Brouhard BH, Cunningham RJ 3rd. Renal stone disease in children. Clinical Pediatrics 1998;37(10):583-99.

(4.) Dahm P, Sedrakyan A, McCulloch P. Application of the IDEAL Framework to Robotic Urologic Surgery. European Urology 2014;65(5):849-51.

(5.) Glina FP, Castro PM, Monteiro GG, et al. The use of alpha-1 adrenergic blockers in children with distal ureterolithiasis: a systematic review and meta-analysis. International Brazilian Journal of Urology 2015;41(6): 1049-57.

(6.) Ishii H, Griffin S, Somani BK. Flexible ureteroscopy and lasertripsy (FURSL) for paediatric renal calculi: results from a systematic review. Journal of Pediatric Urology 2014; 10(6): 1020-5.

(7.) Ishii H, Griffin S, Somani BK. Ureteroscopy for stone disease in the paediatric population: a systematic review. BJU International 2015; 115(6):861-73.

(8.) Tian D, Li N, Huang W, et al. The efficacy and safety of adrenergic alpha-antagonists in treatment of distal ureteral stones in pediatric patients: A systematic

(6.) review and meta-analysis. Journal of Pediatric Surgery 2017; 52(2): 360-5.

(9.) Velazquez N, Zapata D, Wang HH, et al. Medical expulsive therapy for pediatric urolithiasis: Systematic review and meta-analysis. Journal of Pediatric Urology 2015;11(6):321-7.

(10.) Higgins JP, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011.

(7.) Available from www.cochrane-handbook.org.

(11.) Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003;327(7414):557-60.

(12.) Guyatt GH, Oxman AD, Vist GE et al. GRADE: what is "quality of evidence" and why is it important to clinicians? BMJ (Clinical Research Ed) 2008;336:995-8

(13.) Barreto L, Jung JH, Abdelrahim A, et al. Medical and surgical interventions for the treatment of urinary stones in children. Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD010784.

(14.) Aghamir SM, Salavati A, Aloosh M, et al. Feasibility of totally tubeless percutaneous nephrolithotomy under the age of 14 years: a randomized clinical trial. Journal of Endourology 2012;26(6):621-4.

(15.) Basiri A, Zare S, Tabibi A, et al. A multicenter, randomized, controlled trial of transureteral and shock wave lithotripsy which is the best minimally invasive modality to treat distal ureteral calculi in children?. Journal of Urology 2010;184(3):1106-9.

(16.) De Dominicis M, Matarazzo E, Capozza N, et al. Retrograde ureteroscopy for distal ureteric stone removal in children. BJU International 2005;95(1): 1049-52.

(17.) Gamal W, Mmdouh A, Sogah. FURS vs Shockwave lithotripsy for treatment of (1-2) cm renal stones in children with a solitary kidney: A prospective randomized study. The Journal of Urology. 2017; 197:578.

(18.) Kumar A, Kumar N, Vasudeva P, et al. A single center experience comparing miniperc and Shockwave lithotripsy for treatment of radiopaque 1-2 cm lower caliceal renal calculi in children: a prospective randomized study. Journal of Endourology/Endourological Society 2015; 29(7): 805.

(19.) Salem HK, Fathy H, Elfayoumy H, et al. Slow versus rapid delivery rate shock wave lithotripsy for pediatric renal urolithiasis: a prospective randomized study. The Journal of Urology 2014;191(5):1370.

(20.) Song G, Guo X, Niu G, et al. Advantages of tubeless mini-percutaneous nephrolithotomy in the treatment of preschool children under 3 years old. Journal of Pediatric Surgery 2015;50(4):655.

(21.) Aldaqadossi HA, Shaker H, SaifelnasrM, et al. Efficacy and safety of tamsulosin as a medical expulsive therapy for stones in children. Arab Journal of Urology 2015;13:107-11.

(22.) Aydogdu O, Burgu B, Gucuk A, et al. Effectiveness of doxazosin in treatment of distal ureteral stones in children. Journal of Urology 2009;182(6):2880-4.

(23.) Elgalaly H, Eliwa A, Seleem M, et al. Silodosin in the treatment of distal ureteric stones in children: A prospective, randomised, placebo-controlled 8. study. Arab Journal of Urology 2017; 15:194-8.

(24.) Erturhan S, Bayrak O, Sarica K, et al. Efficacy of medical expulsive treatment with doxazosin in pediatric patients. Urology 2013;81(3):640-3.

(25.) Fahmy A, Rhasad H, Kamal A, et al. Silodosin for medical expulsive therapy in children with distal ureteral stone: a prospective randomized, placebo-controlled, single blind study. The Journal of Urology. 2017; Vol. 197:1217.

(26.) Mokhless I, Youssif M, Zahran A. Tamsulosin for the management of distal ureteral stones in children: a prospective randomized study [abstract no: S2-2]. 22nd Annual Congress of the European Society for PediatricUrology (ESPU); 2011 Apr 27-30; Copenhagen, Denmark. 2011.

(27.) Mokhless I, Zahran AR, Youssif M, et al. Tamsulosin for the management of distal ureteral stones in children: a prospective randomized study. Journal of Pediatric Urology 2012;8(5):544-8.

(28.) Elderwy A, Kurkar A, Hussein A-M, et al. Dissolution therapy versus shock wave lithotripsy for radiolucent renal stones in children: a prospective study. The Journal of Urology 2014; 191(5): 1491.

(29.) Saad KSM, Youssif ME, Hamdy S, et al. Percutaneous nephrolithotomy vs retrograde intrarenal surgery for large renal stones in pediatric patients: A randomized controlled trial. Source Journal of Urology Dec 2015; 194(6): 1716-20.

(30.) Sas DJ, Hulsey TC, Shatat IF, et al. Incidence of kidney stones in children evaluated in the ER is increasing. The Journal of Pediatrics 2010; 157(1): 132-7.

(31.) Borofsky MS, Shah O. Advances in ureteroscopy. Urologic Clinics of North America 2013;40(1):67-78.

Figures and Tables

Acknowledgement: This article is based on a Cochrane Review published in the Cochrane Database of Systematic Reviews (CDSR) 2018, Issue 6. Art. No.: CD010784. DOI.10.1002/14651858.CD010784.pub2.

http://dx.doi.org/10.5489/cuaj.5787

Caption: Fig. 1. Flow chart.

Caption: Fig. 2. Summary of risk of bias assessment.
Table 1. Characteristics of included studies

Study         Population

Aghamir       <14 years old, renal stone >2.5
2012          cm or renal stone with lesser
              diameter, and extracorporeal
              Shockwave lithotripsy failure
Aldaquadossi  Group 1: 33 children - mean age
2015          7.7 years; group 2: 34 children - mean
              age 7.25 years, distal
              ureteric stone of <1 cm, and
              below the common iliac vessels
Aydogdu       2-14 years old, radiopaque
2009          lower ureteral stone 2-10 mm

Basiri        1-13 years old, distal ureteral
2010          calculi 15-56 [mm.sup.2]
De Domenici   2-17 years
2005          old, radioopaque calculi in
              distal ureter
Elderwy       0.5-13 years old, renal calculi
2014          7-24 mm <500 HU
Elgalaly      <18 years old, single unilateral
2017          radiopaque DUS, and largest
              stone diameter of [less than or equal to]10 mm
Erturhan      3-15 years old, lower
2013          ureteral stones
Fahmy         <18 years old, unilateral, single,
2017          radio-opaque distal ureteral
              stones <10 mm in size
Gamal         <15years old, with
2017          a renal stones (1-2 cm) in a
              solitary kidney
Kumar         <15 years old, single lower
2015          caliceal stone 1-2 cm
Mokhless      2-15 years old, distal ureteric
2012          calculi <12 mm
Salem         3-14 years old, renal calculi
2014          10-20 mm
Song          7-36 months old,
2015          renal stones with cumulative
              diameter <4.5 cm

Study         Intervention         Comparison

Aghamir       Tubeless             Standard
2012          percutaneous         percutaneous
              nephrolithotomy      nephrolithotomy
Aldaquadossi  Alpha-1 blocker      Ibuprofen only
2015          (tamsulosin)
              therapy in addition
              to ibuprofen
Aydogdu       Ibuprofen            Doxazosin and
2009                               ibuprofen
Basiri        Transureteral        Shock
2010          lithotripsy          wave lithotripsy
De Domenici   Ureteroscopy         Extracorporeal shock
2005          plus intracorporeal  wave lithotripsy
              lithotripsy
Elderwy       Dissolution          Standard shock
2014          therapy              wave lithotripsy
Elgalaly      Silodosin            Placebo
2017
Erturhan      Ibuprofen only       Alpha-1
2013                               blocker (doxazosin)
                                   therapy in addition to
                                   ibuprofen
Fahmy         Silodosin            Tamsuosin or
2017                               placebo
Gamal         Flexible             Shockwave
2017          ureteroscopy plus    lithotripsy
              lasertripsy
Kumar         Mini                 Shockwave
2015          percutaneous         lithotripsy
              nephrolithotomy
Mokhless      Tamsulosin and       Placebo
2012          standard             and standard
              analgesia            analgesia
Salem         Slow delivery rate   Rapid delivery rate
2014          shock                shock wave
              wave lithotripsy     lithotripsy
Song          Tubeless mini        Standard
2015          percutaneos          percutaneous
              nephrolithotomy      nephrolithotomy

Study         Outcome measured    Followup             Funding
                                                       sources

Aghamir       1. Stone clearance  24-48 hours after    Not stated
2012          2. Complications    surgery, one week
                                  and one
                                  month after surgery
Aldaquadossi  1. Stone clearance  Weekly for 4 weeks   None
2015          2. Analgesic
              requirement
Aydogdu       1. Stone clearance  19 days (mean)       Not stated
2009          2. Secondary
              procedures
Basiri        1. Stone clearance  2 weeks              Not stated
2010          2. Complications    postoperatively
              3. Secondary        with ultrasound,
              procedures          another at 3
              4. Hospital stay    months
                                  with excretory
                                  urography (more
                                  frequent if
                                  persistent stone
                                  present)
De Domenici   1. Stone clearance  6-8 months           Not stated
2005          2. Complications
              3. Secondary
              procedures
Elderwy       1. Stone clearance  Every 3-4 weeks      Not stated
2014          2. Complications    and every 3-4
              3. Secondary        months
              procedures          thereafter length
                                  of treatment:
                                  3 months
Elgalaly      1. Stone clearance  For 3 weeks          None
2017                              with weekly
                                  examinations
                                  length
                                  of treatment:
                                  3 weeks
Erturhan      1. Stone clearance  3 weeks              Authors declare
2013                              with weekly          no relevant
                                  examinations         financial
                                                       interests
Fahmy         1. Stone clearance  Stone-free rate      None
2017          2. Complications    assessed after 4
                                  weeks. Further
                                  details of followup
                                  not supplied.
Gamal         1. Stone clearance  Followup:            None
2017          2. Complications    stone-free
              3. Secondary        rate assessed after
              procedures          1 month. Further
                                  details of followup
                                  not supplied
Kumar         1. Stone clearance  3 weeks              Not stated
2015          2. Complications
              3. Secondary
              procedures
Mokhless      1. Stone clearance  4 weeks              None
2012
Salem         1. Stone clearance  2 and 4 weeks        Not stated
2014          2. Secondary
              procedures
Song          1. Stone clearance  1, 3, 6, 12 months   Not stated
2015          2. Complications    postoperatively
              3. Secondary
              procedures

Study         COI

Aghamir       Not stated
2012
Aldaquadossi  None
2015
Aydogdu       Not stated
2009
Basiri        Not stated
2010
De Domenici   Not stated
2005
Elderwy       Not stated
2014
Elgalaly      None
2017
Erturhan      Not stated
2013
Fahmy         Not declared
2017
Gamal         Not
2017          declared
Kumar         No
2015          competing
              financial
              interests
              exist
Mokhless      No conflict
2012          of interest
Salem         Not stated
2014
Song          Not stated
2015


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Author:Barreto, Lenka; Jung, Jae Hung; Abdelrahim, Ameera; Ahmed, Munir; Dawkins, Guy P.C.; Kazmierski, Mar
Publication:Canadian Urological Association Journal (CUAJ)
Article Type:Report
Date:Jun 27, 2019
Words:4992
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