title: Emergent versus delayed lithotripsy for obstructing ureteral stones: a cumulative analysis of comparative studies.
abstract: OBJECTIVE
  To analyze the current evidence on the use of ureteroscopy (URS) and extracorporeal shock wave lithotripsy (ESWL) for the management of obstructing ureteral stones in emergent setting.
  
  
  METHODS
  A systematic literature review was performed up to June 2016 using Pubmed and Ovid databases to identify pertinent studies. The PRISMA criteria were followed for article selection. Separate searches were done using a combinations of several search terms: "laser lithotripsy", "ureteroscopy", "extracorporeal shock wave lithotripsy", "ESWL", "rapid", "immediate", "early", "delayed", "late", "ureteral stones", "kidney stones", "renal stones". Only titles related to emergent/rapid/immediate/early (as viably defined in each study) versus delayed/late treatment of ureteral stones with either URS and/or ESWL were considered for screening. Demographics and operative outcomes were compared between emergent and delayed lithotripsy. RevMan review manager software was used to perform data analysis.
  
  
  RESULTS
  Four studies comparing emergent (n = 526) versus delayed (n = 987) URS and six studies comparing emergent (n = 356) versus delayed (n = 355) SWL were included in the analysis. Emergent URS did not show any significant difference in terms of stone-free rate (91.2 versus 90.9%; OR 1.04; CI 0.71, 1.52; p = 0.84), complication rate (8.7% for emergent versus 11.5% for delayed; OR 0.94; CI 0.65, 1.36; p = 0.74) and need for auxiliary procedures (OR 0.85; CI 0.42, 1.7; p = 0.85) when compared to delayed URS. Emergent ESWL was associated with a higher likelihood of stone free status (OR 2.2; CI 1.55, 3.17; p < 0.001) and a lower likelihood of need for auxiliary maneuvers (OR 0.49; CI 0.33, 0.72; p < 0.001) than the delayed procedure. No differences in complication rates were noticed between the emergent and delayed ESWL (p = 0.37).
  
  
  CONCLUSIONS
  Emergent lithotripsy, either ureteroscopic or extracorporeal, can be offered as an effective and safe treatment for patients with symptomatic ureteral stone. If amenable to ESWL, based on stone and patient characteristics, an emergent approach should be strongly considered. Ureteroscopy in the emergent setting is mostly reserved for distally located stones. The implementation of these therapeutic approaches is likely to be dictated by their availability.
authors.affiliation: Urology Unit, Second University of Naples, Naples, Italy.
authors.forename: Davide
authors.initials: D
authors.lastname: Arcaniolo
authors.affiliation: Urology Unit, Second University of Naples, Naples, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: De Sio
authors.affiliation: Department of Urology, SLK-Kliniken Heilbronn, Heilbronn, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Rassweiler
authors.affiliation: University Hospitals Urology Institute, Case Western Reserve University, 27100 Chardon Rd, Richmond Heights, OH, 44143, USA.
authors.forename: Jilian
authors.initials: J
authors.lastname: Nicholas
authors.affiliation: Life and Health Sciences Research Institute, University of Minho, Braga, Portugal.
authors.forename: Estevão
authors.initials: E
authors.lastname: Lima
authors.affiliation: Department of Urology, University of Foggia, Foggia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Carrieri
authors.affiliation: Department of Urology, University of Patras, Patras, Greece.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Liatsikos
authors.affiliation: Department of Urology, Federico II University, Naples, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mirone
authors.affiliation: Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, USA.
authors.forename: Manoj
authors.initials: M
authors.lastname: Monga
authors.affiliation: Urology Unit, Second University of Naples, Naples, Italy. ricautor@gmail.com.|University Hospitals Urology Institute, Case Western Reserve University, 27100 Chardon Rd, Richmond Heights, OH, 44143, USA. ricautor@gmail.com.
authors.forename: Riccardo
authors.identifier: http://orcid.org/0000-0001-7045-7725
authors.initials: R
authors.lastname: Autorino
mesh_terms: D000328:Adult; D004630:Emergencies; D005260:Female; D006801:Humans; D008096:Lithotripsy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D016896:Treatment Outcome; D014514:Ureteral Calculi / Q000150:complications / Q000628:therapy*; D014517:Ureteral Obstruction / Q000209:etiology / Q000628:therapy*; D018666:Ureteroscopy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data
keywords: Emergency; Shock wave lithotripsy; Ureteral stone; Ureteroscopy