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Elbaset MA. et al., 2019: Optimal non-invasive treatment of 1-2.5 cm radiolucent renal stones: oral dissolution therapy, shock wave lithotripsy or combined treatment-a randomized controlled trial

Elbaset MA, Hashem A, Eraky A, Badawy MA, El-Assmy A, Sheir KZ, Shokeir AA.
Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
Urology Department, Mediclin Muritz Hospital, Waren, Germany.
Radiology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.

Abstract

PURPOSE: To evaluate the efficacy of oral dissolution therapy (ODT), shock wave lithotripsy (SWL), and combined SWL and ODT for medium-sized radiolucent renal stone (RLS).METHODS: A randomized controlled trial for patients with medium-sized RLS, 1-2.5 cm, ≤ 500 Hounsfield unit (HU). The ODT patients were counseled for oral potassiumsodium-hydrogen citrate (Uralyt-U®). The 2nd group underwent SWL and the last group had combined SWL and ODT. The primary outcome, stone-free rate (SFR) at 3 months, was assessed by non-contrast computed tomography (NCCT). We defined complete response (success) if no residual fragment were detected by NCCT; partial response (failure) if there was a decrease in stone size, but presence of residual stones; no response if there was no change or increase in stone size (failure). RESULTS: 150 patients completed follow-up. The SFR at 1st month and 3rd month were, respectively; 16% and 50% in the ODT group, 10% and 46% in the SWL group, and 35% and 72% patients in combined group with (p = 0.03 and 0.003, respectively. The overall SFR for all groups was 66%. Combined treatment and initial response in first month follow-up were independent factors predicting SFR. In addition, combined treatment significantly decreased the overall stone volume (p = 0.03) and the need for additional stone management procedures after 3 months (p = 0.01). CONCLUSION: Combined ODT and SWL treatment constitutes the most rapid and effective therapeutic approach for medium-sized RLS, decreasing overall stone volume as well as the number of SWL sessions needed in comparison to SWL therapy, alone.

World J Urol. 2019 Apr 3. doi: 10.1007/s00345-019-02746-2. [Epub ahead of print]

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Комментарии 1

Peter Alken в 11.11.2019 09:11

This is an important paper because ODT is frequently neglected (because ESWL, PNL or URS get a much better reimbursement than prescribing pills and checking with sonography). In 40 cases (26,6%) persistent stones were removed by URS or PNL. In the ODT oral- dissolution -only group this were half of the patients. Four (8%) patients of the ODT group showed an increase in stone volume. Unfortunately there are no stone analyses of the removed stones which might have been non-uric-acid stones. If they would have been uric acid stones this would simply demonstrate that you have to wait and treat longer than 3 months. In my experience with ODT of uric acid staghorn stones tretead with urinary alkalinisation plus Allopurinol it took sometimes up to 6 months to completely dissolve them. The advantage of ODT-only is that the stones simply got smaller without causing any problems. In the present series colics during therapy happened in both ESWL groups but not in the ODT-only group.
The ESWL-only group does not seem to have got the same recommendation as the ODT groups: drink 2-3 lit. per day.
Costs are not evaluated but it is stated that up to 4 ESWL sessions were done.

This is an important paper because ODT is frequently neglected (because ESWL, PNL or URS get a much better reimbursement than prescribing pills and checking with sonography). In 40 cases (26,6%) persistent stones were removed by URS or PNL. In the ODT oral- dissolution -only group this were half of the patients. Four (8%) patients of the ODT group showed an increase in stone volume. Unfortunately there are no stone analyses of the removed stones which might have been non-uric-acid stones. If they would have been uric acid stones this would simply demonstrate that you have to wait and treat longer than 3 months. In my experience with ODT of uric acid staghorn stones tretead with urinary alkalinisation plus Allopurinol it took sometimes up to 6 months to completely dissolve them. The advantage of ODT-only is that the stones simply got smaller without causing any problems. In the present series colics during therapy happened in both ESWL groups but not in the ODT-only group. The ESWL-only group does not seem to have got the same recommendation as the ODT groups: drink 2-3 lit. per day. Costs are not evaluated but it is stated that up to 4 ESWL sessions were done.
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