Which is the best treatment of pediatric upper urinary tract stones among extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy and retrograde intrarenal surgery: a systematic review

BACKGROUND: Although the indications of minimally invasive treatments for pediatric urolithiasis are similar to those in adults, it is still crucial to make the right treatment decision due to the special considerations of children. This review aims to evaluate the efficacy and safety of extracorporeal shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and retrograde intrarenal surgery (RIRS) in the management of pediatric upper urinary tract stones. METHODS: EMBASE, PubMed, and the Cochrane Library were searched from their first available date to March 2018. The studies that meet the inclusive criteria were included. The efficacy and safety of the treatments were assessed by means of meta-analysis of the stone free rate (SFR), complication rate, effectiveness quotient (EQ) and secondary outcome indicators. RESULTS: A total of 13 comparative studies were identified for data analysis. PCNL presented a significantly higher SFR compared with SWL. Similarly, the single-session SFR of RIRS was significantly higher than SWL. However, no significant difference was found between RIRS and SWL in the overall SFR. There was no significant difference between PCNL and RIRS in the SFR. Furthermore, no significant differences in complication rates were found among the three therapies. Compared with the other two treatments, PCNL had a longer operative time, fluoroscopy time and hospital stay. SWL had a shorter hospital stay, higher retreatment rate and auxiliary rate in comparison with the other two treatments. The present data also showed that PCNL presented a higher EQ than the other two treatments, and RIRS had a lower efficiency than SWL and PCNL. In the subgroup analysis of pediatric patients with stone ≤20 mm, the comparative results were similar to those described above, except for the higher complication rate of PCNL than SWL. CONCLUSIONS: Although SWL as an outpatient procedure provides shorter hospital stay and reduces operative time, it has a lower SFR and higher retreatment rate than the other two treatments. PCNL exhibits a higher SFR and EQ than SWL; nevertheless, it has a longer operative time and fluoroscopy time than the other two procedures. RIRS offers a similar SFR as PCNL but a lower efficiency than PCNL.