title: Treatment of ureteral and renal stones: a systematic review and meta-analysis of randomized, controlled trials.
abstract: OBJECTIVE
  We compared the clinical outcomes of patients with ureteral or renal stones treated with ureteroscopy, shock wave lithotripsy using HM3 (Dornier®) and nonHM3 lithotripters, and percutaneous nephrolithotomy.
  
  
  METHODS
  A systematic literature search identified 6, 4 and 3 randomized, controlled trials of treatment of distal and proximal ureteral stones, and renal stones, respectively, published between 1995 and 2010. Overall stone-free, re-treatment and complication rates were calculated by meta-analytical techniques.
  
  
  RESULTS
  Based on the randomized, controlled trials evaluated the treatment of distal ureteral stones with semirigid ureteroscopy showed a 55% greater probability (pooled RR 1.55, 95% CI 1.13-2.56) of stone-free status at the initial assessment than treatment with shock wave lithotripsy. Patients treated with semirigid ureteroscopy were also less likely to require re-treatment than those treated with shock wave lithotripsy (nonHM3) (RR 0.14, 95% CI 0.08-0.23). The risk of complications was no different between the 2 modalities. Only 2 of the 4 randomized, controlled trials identified for proximal ureteral stones evaluated flexible ureteroscopy and each focused specifically on the treatment of stones 1.5 cm or greater, limiting their clinical relevance. The degree of heterogeneity among the studies evaluating renal stones was so great that it precluded any meaningful comparison.
  
  
  CONCLUSIONS
  Semirigid ureteroscopy is more efficacious than shock wave lithotripsy for distal ureteral stones. To our knowledge there are no relevant randomized, controlled trials of flexible ureteroscopy treatment of proximal ureteral calculi of a size commonly noted in the clinical setting. Collectively the comparative effectiveness of ureteroscopy and shock wave lithotripsy for proximal ureteral and renal calculi is poorly characterized with no meaningful published studies.
authors.affiliation: The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA. bmatlaga@jhmi.edu
authors.forename: Brian R
authors.initials: BR
authors.lastname: Matlaga
authors.forename: Jeroen P
authors.initials: JP
authors.lastname: Jansen
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Meckley
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Byrne
authors.forename: James E
authors.initials: JE
authors.lastname: Lingeman
mesh_terms: D006801:Humans; D007669:Kidney Calculi / Q000628:therapy*; D008096:Lithotripsy / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome; D014514:Ureteral Calculi / Q000628:therapy*; D018666:Ureteroscopy / Q000379:methods*