Interventions for treating urinary stones in children

Review question

What is the evidence for treating stones of the kidney or ureter in children?

Background

Urinary stones occur in up to 5 in 100 children in high-income countries. These rates have been noted to be increasing. To treat urinary stones in children, urologists use medications, shock wave therapy, open surgery, and small scopes that are put into the bladder or through the skin. It is not clear how well each of these treatments work and what the side effects are.

Study characteristics

We included 14 studies with a total of 978 randomised children with stones in either the kidney or ureter, which connects the kidney to the bladder. The number of children in the studies varied from 22 to 221 children. There were seven trials of different types of surgery, four trials of medications and one study that compared medication with surgery. The amount of time the trials followed participants for ranged from one week to one year.

Key results

Shock waves versus medication to dissolve stones: we are uncertain about the effect on successful removal of stones, serious complications and the need for a second procedure to treat the stones.

Shock waves given slowly versus shock waves given fast: we are uncertain about the effect of slow shock waves on successful removal of stones. We are also uncertain about the effect on serious complications and the need for other procedures.

Shock waves versus treatment using a scope through the bladder to break up the stone: we are uncertain about the effect of shock waves on successful removal of stones compared to using a scope. We are also uncertain about the effect on serious complications and the need for other procedures.

Shock waves versus treatment using a scope through the skin into the kidney: shock waves are likely less successful in the removal of stones. Shock waves appears to reduce severe adverse events but more often secondary procedures are needed to remove all the stones.

Use of a scope through the kidney with a drainage tube afterwards versus without a drainage tube: we are uncertain about the effect on successful removal of stones, serious complications or the need for more procedures.

Use of a scope through the kidney with a regular versus very small ("mini") tube through the skin: successful removal of stones are likely similar in both procedures. We did not find any data relating to serious adverse events. We are uncertain about the effect on the need for another procedure.

Alpha-blockers versus placebo with or without ibuprofen: alpha-blockers may increase successful removal of stones. We are uncertain about serious complications and the need for more procedures.

Quality of the evidence.

The quality of evidence for most outcomes was very low. This means that we are very uncertain about most of the review findings.

Authors' conclusions: 

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Read the full abstract...
Background: 

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

Objectives: 

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

Search strategy: 

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

Selection criteria: 

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

Data collection and analysis: 

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

Main results: 

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.

Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.

Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.

Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.

Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).

Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.

Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.

Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

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