Analgesia for patients undergoing shockwave lithotripsy for urinary stones - a systematic review and meta-analysis.
BACKGROUND
Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain.


OBJECTIVE
To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones.


METHODS
We searched the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT's) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals.


RESULTS
Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures.


CONCLUSIONS
Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.
North Bristol NHS Trust, United Kingdom.
Omar M
OM
Aboumarzouk
NHS Greater Glasgow and Clyde, United Kingdom.
Rami
R
Hasan
NHS Greater Glasgow and Clyde, United Kingdom.
Ali
A
Tasleem
NHS Greater Glasgow and Clyde, United Kingdom.
Martin
M
Mariappan
Ayr University Hospital, United Kingdom.
Rachael
R
Hutton
Ayr University Hospital, United Kingdom.
John
J
Fitzpatrick
Ayr University Hospital, United Kingdom.
Laura
L
Beatty
NHS Greater Glasgow and Clyde, United Kingdom.
Gareth E
GE
Jones
NHS Greater Glasgow and Clyde, United Kingdom.
Tarik
T
Amer
D000698:Analgesia / Q000379:methods*; D000700:Analgesics / Q000008:administration & dosage* / Q000145:classification; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D006801:Humans; D008096:Lithotripsy / Q000009:adverse effects*; D010149:Postoperative Pain / Q000188:drug therapy; D014545:Urinary Calculi / Q000601:surgery*
D000700:Analgesics; D000701:Analgesics, Opioid
Calculi; Lithotripsy; Urinary Tract