18
continuing MET beyond this time interval. Moreover, a
shared decision making approach between patient and
clinician should be adopted in that the choice to change
from a conservative to interventional approach should
take into account social factors, such as work
obligations, travel plans, and family care issues.
56
10. Clinicians should inform patients that SWL is
the procedure with the least morbidity and
lowest complication rate, but URS has a
greater stone-free rate in a single procedure.
(Index Patients 1-6) Strong Recommendation,
Evidence Level Grade B
For the patient requiring definitive treatment of a
ureteral stone, URS and SWL are the two most
commonly used treatment modalities. (Figure 6) The
present Panel’s analysis revealed no statistically
significant differences between SWL and URS with
regard to UTI (median 4.5% versus 2.9%,
respectively), sepsis (median 1.2% versus 0.3%,
respectively), ureteral stricture (median 0% versus
0.2%, respectively), or ureteral avulsion (median 0%
versus 0.1%, respectively). However, ureteral
perforation occurred significantly more frequently
during URS than SWL (median 3.2% versus 0%,
respectively, p<0.01). The 2012 Cochrane Review
comparing SWL and URS identified 7 RCTs reporting
complication rates and found a significantly lower
complication rate for SWL compared to URS (RR 0.53,
95% CI 0.33-0.88, p=0.01).
57
Likewise, the 2007 EAU/
AUA Guideline for the Management of Ureteral Calculi
found a higher complication rate for URS compared to
SWL for stones in all locations in the ureter: 11%
versus 4%, respectively, for proximal ureteral stones;
14% versus 4%, respectively, for middle ureteral
stones; and 7% versus 1%, respectively, for distal
ureteral stones.
5
While stone-free rates are reportedly
high for both modalities, URS stone-free rates have
been shown to be superior to SWL stone-free rates in
contemporary series. The Panel’s analysis of studies
comparing URS and SWL for treatment of ureteral
calculi showed superior stone-free rates for URS over
SWL (90% for URS versus 72% for SWL, RR SWL/URS
0.294, 95% CI 0.214-0.404, p<0.001). For stones ≤10
mm in size stratified by stone location, median stone-
free rates remained superior for URS over SWL at all
locations in the ureter (85% versus 66.5%,
respectively, for proximal ureteral stones; 91% versus
75%, respectively, for middle ureteral stones; and 94%
versus 74%, respectively, for distal ureteral stones)
(Table 2). However, for stones >10 mm in size, stone-
free rates were comparable for SWL and URS (74%
versus 79%, respectively) in the proximal ureter, while
stone-free rates for stones in the mid and distal ureter
favored URS over SWL (82.5% versus 67%,
respectively, for mid ureteral stones; and 92% versus
71%, respectively, for distal ureteral stones).
Furthermore, URS is more likely than SWL to
successfully treat patients with a ≤10 mm ureteral
stone in a single procedure. According to the 2007 EAU/
AUA Guideline for the Management of Ureteral Calculi,
the mean numbers of primary URS procedures required
to treat stones in the proximal, middle and distal ureter
were 1.01, 1.00 and 1.00, respectively.
5
In contrast,
the corresponding mean numbers of primary SWL
procedures for stones in these locations were 1.34,
1.29, and 1.26, respectively. Consequently, since most
successful URS require only a single procedure and
stone-free rates are higher for URS than SWL for all
ureteral stones except proximal ureteral stones >10
mm in size, URS has an advantage over SWL with
regard to a higher success rates and need for fewer
procedures.
11. In patients with mid or distal ureteral stones
who require intervention (who were not
candidates for or who failed MET), clinicians
should recommend URS as first-line therapy.
For patients who decline URS, clinicians
should offer SWL. (Index Patients 2,3,5,6)
Strong Recommendation; Evidence Level
Grade B
The Panel’s meta-analysis demonstrated that URS is
associated with significantly higher stone-free rates in a
single procedure than SWL for patients with ureteral
stones.
8
The disparity in stone-free outcome was
particularly notable for patients with < 10 mm mid and
distal ureteral calculi (Table 2). Based on studies
comparing SWL versus URS for distal ureteral stones,
the overall success rate of SWL for distal ureteral
stones was reported to be approximately 65%
(2,260/3,488) compared to a 92% success rates for
URS (2539/2751) (p<0.001).
8
Therefore, URS should
Copyright © 2016 American Urological Association Education and Research, Inc.®
Surgical Management
of Stones
American Urological Association (AUA)
Endourological Society Guideline