Does displacement of lower pole stones during retrograde intrarenal surgery improves stone-free status?: a systematic review and meta-analysis

Purpose: Kidney stones are one of the most common urological diseases worldwide. The size and location of the stone are the most important factors in determining the most suitable treatment options. The aim of this review was to evaluate the displacement of lower pole stones. Methods: Three studies assessing the efficacy of translocating kidney stones from the lower pole of the kidney to other locations during retrograde intrarenal surgery published in the last 20 years were included. A systematic search was conducted in the PubMed, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), and Web of Science databases using the following search terms: "Lower pole," "Lithotripsy." Meta-analysis was performed using Review Manager version 5.4. Results: Stone-free rates were improved through displacement (odds ratio - OR = -0.15; 95% confidence interval-95%CI -0.24--0.05; p = 0.002; I2 = 21%), but at the cost of increased surgical duration (mean difference = -12.50; 95%CI -24.06--0.95; p = 0.03; I2 = 94%). Although this represents a potentially negative outcome, the improvement in clearance rates justifies the additional investment of time and effort. Conclusions: Displacement of lower pole kidney stones for subsequent lithotripsy brings significant benefits in terms of stone-free rate, with no difference in laser energy usage. However, it results in increased surgical time. Despite these factors, the benefits to patients undergoing the procedure are substantial.

Contemporary considerations in the management and treatment of lower pole stones

ABSTRACT The presence of lower pole stones poses a unique challenge due to the anatomical considerations involved in their management and treatment. Considerable research has been performed to determine the optimal strategy when faced with this highly relevant clinical scenario. Standard options for management include observation, shock wave lithotripsy, retrograde intrarenal surgery, or percutaneous nephrolithotomy. Indeed, each approach confers a distinct set of risks and benefits, which must be placed into the context of patient preference and expected outcomes. The current state of practice reflects a combination of lessons learned from managing calculi not only in the lower pole, but also from other locations within the kidney as well.

Eficacia de la Litotripsia Extracorpórea por Ondas de Choque en el tratamiento de litiasis renal en el Servicio de Endourología del Hospital José Carrasco Arteaga. Bienio 2015-2016 / Efficacy of Extracorporeal Shock Wave Therapy as a treatment for nephrolithiasis at the Endourology Service of Hospital Jose Carrasco Arteaga. Biennium 2015-2016.

INTRODUCCIÓN: La litiasis renal es la tercera patología urológica más frecuente, después de las infecciones y la patología prostática. Una de las opciones de tratamiento es la litotripsia extracorpórea por ondas de choque (LEOCH); se trata de una técnica mínimamente invasiva, de fácil repetición, efectiva, de baja morbilidad y bajo costo. El objetivo del presente estudio fue mostrar la eficacia de la LEOCH en el tratamiento de litiasis renal y su asociación con diferentes factores. MATERIALES Y MÉTODOS: Se realizó un estudio descriptivo, observacional, de corte transversal, con datos retrospectivos, con pacientes diagnosticados de litiasis renal, que recibieron tratamiento con LEOCH en el Servicio de Endourología del Hospital José Carrasco Arteaga, durante los años 2015 y 2016. La muestra fue de 146 pacientes. La información se obtuvo de las historias clínicas de los pacientes. Para el análisis, se empleó el programa SPSS v19.0. Los resultados se mostraron a través de frecuencias y porcentajes en tablas, se aplicó Chi cuadrado para medir la asociación entre las variables. RESULTADOS: La ubicación de los litos fue principalmente intrarenal y del lado izquierdo. El tamaño medio de los cálculos fue de 12.66 mm y la densidad media de 996.97UI. Al control tomográfico posterior a la LEOCH, en el 22.6% de los pacientes se destruyó totalmente el lito y en casi un tercio de los pacientes no se apreciaron cambios. Luego de la LEOCH, la mayoría de los pacientes recibieron tratamiento expulsivo. 97% de los pacientes no tuvieron complicaciones. CONCLUSIÓN: La efectividad de la LEOCH disminuyó con la edad, en las mujeres resultó igualmente menos eficaz, aunque las diferencias no fueron significativas. La ubicación del lito, así como su tamaño resultaron tener asociación estadísticamente significativa con la efectividad del tratamiento; los litos ureterales y pequeños se destruyeron completamente con mayor frecuencia que los renales y de gran tamaño. La densidad no mostró relación significativa con la efectividad de la LEOCH.

BACKGROUND: nephrolithiasis is the third most common urological pathology, followed by infections and prostatic pathologies. One of the treatment options is extracorporeal shock wave therapy (ESWT); it is a minimally invasive technique, easy to repeat, effective, with low morbidity and low cost. The aim of this study was to demonstrate the effectiveness of ESWT as a treatment for nephrolithiasis and its association with some factors. METHODS: We carried out a descriptive, observational, cross-sectional study with retrospective data, with patients diagnosed of nephrolithiasis and treated with ESWT at the Endourology Service of Hospital José Carrasco Arteaga, during the years 2015 and 2016. The sample was constituted of 146 patients. Data was Results are shown with frequencies and percentages in charts, Chi square was applied to measure the association between variables. RESULTS: The location of the stones was mainly intrarenal and on the left side. The mean size of the stones was 12.66 mm and the mean density was 996.97IU. After ESWT, tomographic control reported complete destruction of the stone in 22.6% of the patients and in almost a third of the patients there were no changes. After ESWL, most of the patients received expulsive treatment. 97% of the patients had no complications. CONCLUSION: The effectiveness of ESWL decreased with age, also it was less effective in women, but the association was not statistically significant. The location of the stone, and its size had statistically significant association with the effectiveness of the treatment; ureteral and small stones were completely destroyed more frequently than renal and big stones. The stone density had no association with LEOCH effectiveness.

Litiasis renal en niños / Renal lithiasis in children

Resumen Justificación y objetivo: La litiasis renal se debe a la precipitación de cristales por un desequilibrio en la orina entre sustancias promotoras y las sustancias inhibitorias. Es una patología con una prevalencia entre 2-10% en la población pediátrica, con una incidencia que ha aumentado en los últimos 25 años; razón por la cual este estudio pretende conocer la prevalencia, las manifestaciones clínicas y metabólicas de la litiasis renal en la población pediátrica del Hospital Nacional de Niños de Costa Rica. Métodos: Es un estudio retrospectivo, descriptivo y observacional, mediante la revisión de expedientes de pacientes menores a 18 años con el diagnóstico de litiasis renal, atendidos en el Hospital Nacional de Niños, en el periodo comprendido entre enero del año 2000 al 2018. Resultados: Se incluyeron un total de 106 pacientes. El 57,5% hombres, la edad promedio al diagnóstico de 6,6 ± 3,8 años; la frecuencia de casos se ha incrementado en 5,5 veces en los últimos 5 años. Factores de riesgo detectados: anormalidades del tracto urinario 22,6% y antecedentes familiares de litiasis 17,9%. El análisis metabólico mostró un gasto urinario bajo en el 74,3%, hiperfosfaturia en un 43,2%, hipomagnesuria 39,2% e hipercalciuria 37,8%. Etiologías determinadas: metabólica 54,7%, malformaciones de las vías urinarias 16% e idiopática en un 30,9%. La litotricia intracorpórea se aplicó en un 61,2%. La recidiva se observó en el 28,5% de los casos, se encontró relación entre la incidencia de recidiva con el tamaño del lito (p = 0,001) y el tratamiento quirúrgico. (p = 0,010). Conclusiones: Existe un aumento en la frecuencia de casos de litiasis pediátrica con una etiología multifactorial en el Hospital Nacional de Niños de Costa Rica.

Abstract Background and aim: Renal lithiasis is due to the precipitation of crystals due to an imbalance in the urine between promoter substances and inhibitory substances. It is a pathology with a prevalence between 2-10% in the pediatric population, with an incidence that is increasing in the last 25 years, because of that, this study pretend to know the prevalence, the clinical and metabolic, manifestation of the renal lithiasis in the pediatric population. Methods: It is a retrospective, descriptive and observational study, by reviewing records of patients under 18 years of age with a diagnosis of renal lithiasis, treated at the Hospital Nacional de Niños, in the period of 2000 to 2018. Results: A total of 106 patients were included, 57,5% men, the average age at diagnosis of 6,6+- 3,8 years, the frequency of cases has increased 5,5 times in the last 5 years. Risk factors detected: urinary trac abnormalities 22,6% and family history of nephrolithiasis 17,9%. The metabolic analysis showed a low urinary flow rate in 74,3%, hyperphosphaturia in 43,2%, hypomagnesuria 39,2% and hypercalciuria 37,8%. Etiologies determined: metabolic 54,7%, malformations of the urinary trac 16% and idiopathic in 30,9%. Intracorporeal lithotripsy was applied in 61,2%. Recurrence was observe in 28,5 % of cases, a relationship was found between the incidence of recurrence with the size of litho (p= 0.001) and surgical treatment (p= 0.01). Conclusions: There is a significant increase in the incidence of pediatric lithiasis cases with a multifactorial etiology.

Comparison of retrograde ureterorenoscopy (URS) and percutaneous anterograde ureteroscopy for removal of impacted upper ureteral stones >10mm in the elderly population

ABSTRACT Purpose: We aimed to compare the success and complication rates of the anterograde and retrograde Ureterorenoscopy (URS) for impacted upper ureteral stones in patients > 65 years of age. Materials and Methods: Data of 146 patients >65 years of age and underwent anterograde URS (n=68) in supine position or retrograde URS (n=78) for upper ureteral impacted stones>10 mm between January 2014 and September 2018 were collected prospectively. The groups were compared for success and complication rates, duration of operation, hospital stay, and ancillary procedures. Results: Anterograde and retrograde URS groups were similar for demographic and stone related characteristics. The success rate of the anterograde URS group was significantly higher than the retrograde URS group (97.1% vs. 78.2%, p=0.0007). The complication rates were similar for the two groups (p=0.86). Clavien grade I and II complications were observed in 3 patients in each group. The mean hemoglobin drop was 0.5 g/dL in the anterograde URS group and blood transfusion was not performed in any of the patients. The mean duration of operation was 41.2±12.5 minutes in the mini-PNL group and 59.6±15.1 minutes in the RIRS group and the difference was statistically significant (p=0.02). The median duration of hospitalization was 1 day for both groups. Conclusions: Performing anterograde URS in supine position provided better success rates and similar complication rates compared to retrograde URS. Based on these results anterograde URS shall be considered as one of the primary treatment options for management of impacted upper ureteral stones in the elderly population.

Adjunctive medical expulsive therapy with tamsulosin for repeated extracorporeal shock wave lithotripsy: a systematic review and meta-analysis

ABSTRACT Purpose: To evaluate the efficacy of adjunctive medical expulsive therapy (MET) with tamsulosin for the promotion of stone fragments clearance for repeated extracorporeal shock wave lithotripsy (ESWL). Materials and Methods: This meta-analysis was conducted by systematic search for randomized controlled trial (RCT) studies in PubMed/Medline, Scopus, Cochrane Library, Web of Science databases in January 2020, which compared tamsulosin with either placebo or non-placebo control for repeated ESWL. The primary endpoint was stone-free rate (SFR), the second endpoints were stone clearance time and complications. The quality assessment of included studies was performed by using the Cochrane System and Jadad score. Results: 7 RCTs were included in this meta-analysis. Tamsulosin provided higher SFR (for stones larger than 1cm, OR: 5.56, p=0.0003), except for patients with stones less than 1cm. For patients with renal stones (OR: 2.97, p=0.0005) or upper ureteral stones (OR: 3.10, p=0.004), tamsulosin can also provide a higher SFR. In addition, tamsulosin provided a shorter stone clearance time (WMD: −9.40, p=0.03) and lower pain intensity (WMD=-17.01, p <0.0001) and incidences of steinstrasse (OR: 0.37, p=0.0002). Conclusion: Adjunctive MET with tamsulosin is effective in patients with specific stone size or location that received repeated ESWL. However, no well-designed RCT that used computed tomography for the detection and assessment of residual stone fragments was found. More studies with high quality and the comparison between tamsulosin and secondary ESWL are needed in the future.

Efficacy and safety of various surgical treatments for proximal ureteral stone ≥10mm: A systematic review and network meta-analysis

ABSTRACT Purpose Various surgical options are available for large proximal ureteral stones, such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URSL), percutaneous nephrolithotomy (PCNL) and laparoscopic ureterolithotomy (LU). However, the best option remains controversial. Therefore, we conducted a network meta-analysis comparing various surgical treatments for proximal ureteral stones ≥10mm to address current research deficiencies. Materials and methods We searched PubMed, Ovid, Scopus (up to June 2019), as well as citation lists to identify eligible comparative studies. All clinical studies including patients comparing surgical treatments for proximal ureteral stones ≥10mm were included. A standard network meta-analysis was performed with Stata SE 14 (Stata Corp, College Station, TX, USA) software to generate comparative statistics. The quality was assessed with level of evidence according to the Oxford Centre for Evidence-based Medicine and risk of bias with the Cochrane Collaboration's Review Manager (RevMan) 5.3 software. Results A total of 25 studies including 2.888 patients were included in this network meta-analysis. Network meta-analyses indicated that LU and PCNL had better stone-free rates and auxiliary procedures. PCNL could result in major complications and severe bleeding. In initial stone-free rate, final stone-free rate, and auxiliary procedures results, SUCRA ranking was: LU> PCNL> URSL> ESWL. In Clavien Dindo score ≥3 complications, SUCRA ranking was: LU> ESWL> URSL> PCNL. In fever, SUCRA ranking was: ESWL> LU> URSL> PCNL. In transfusion, SUCRA ranking was: LU> URSL> ESWL> PCNL. In Cluster analysis, LU had the highest advantages and acceptable side effects. Considering the traumatic nature of PCNL, it should not be an option over URSL. ESWL had the lowest advantages. Conclusions LU have the potential to be considered as the first treatment choice of proximal ureteral stone ≥10mm.

Consenso Argentino intersociedades de Infección Urinaria 2018-2019 - Parte II / Argentine Intersociety Consensus on Urinary Infection 2018-2019 - Part II

La segunda parte del Consenso Argentino Intersociedades de Infección Urinaria incluye el análisis de situaciones especiales. En pacientes con sonda vesical se debe solicitar urocultivo solo cuando hay signo-sintomatología de infección del tracto urinario, antes de instrumentaciones de la vía urinaria o como control en pacientes post-trasplante renal. El tratamiento empírico recomendado en pacientes sin factores de riesgo es cefalosporinas de tercera generación o aminoglucósidos. Las infecciones del tracto urinario asociadas a cálculos son siempre consideradas complicadas. En caso de obstrucción con urosepsis, deberá realizarse drenaje de urgencia por vía percutánea o ureteral. En pacientes con stents o prótesis ureterales, como catéteres doble J, el tratamiento empírico deberá basarse en la epidemiología, los antibióticos previos y el estado clínico. Antes del procedimiento de litotricia extracorpórea se recomienda pesquisar la bacteriuria y, si es positiva, administrar profilaxis antibiótica según el antibiograma. Cefalosporinas de primera generación o aminoglúcosidos son opciones válidas. Se recomienda aplicar profilaxis antibiótica con cefalosporinas de primera generación o aminoglúcosidos antes de la nefrolitotomía percutánea. La biopsia prostática trans-rectal puede asociarse a complicaciones infecciosas, como infecciones del tracto urinario o prostatitis aguda, principalmente por Escherichia coli u otras enterobacterias. En pacientes sin factores de riesgo para gérmenes multirresistentes y urocultivo negativo se recomienda realizar profilaxis con amikacina o ceftriaxona endovenosas. En pacientes con urocultivo positivo, se realizará profilaxis según antibiograma, 24 horas previas a 24 horas post-procedimiento. Para el tratamiento dirigido de la prostatitis post-biopsia trans-rectal, los carbapenémicos durante 3-4 semanas son el tratamiento de elección.

The second part of the Inter-Society Argentine Consensus on Urinary Tract Infection (UTI) includes the analysis of special situations. In patients with urinary catheter, urine culture should be requested only in the presence of UTI symptomatology, before instrumentation of the urinary tract, or as a post-transplant control. The antibiotics recommended for empirical treatment in patients without risk factors are third-generation cephalosporins or aminoglycosides. UTIs associated with stones are always considered complicated. In case of obstruction with urosepsis, an emergency drainage should be performed via a percutaneous nefrostomy or ureteral stenting. In patients with stents or ureteral prostheses, such as double J catheters, empirical treatment should be based on epidemiology, prior antibiotics, and clinical status. Before the extracorporeal lithotripsy procedure, bacteriuria should be investigated and antibiotic prophylaxis should be administered in case of positive result, according to the antibiogram. First generation cephalosporins or aminoglycosides are valid alternatives. The use of antibiotic prophylaxis with first-generation cephalosporins or aminoglycosides before percutaneous nephrolithotomy is recommended. Transrectal prostatic biopsy can be associated with infectious complications, such as UTI or acute prostatitis, mainly due to Escherichia coli or other enterobacteria. In patients without risk factors for multiresistant bacteria and negative urine culture, prophylaxis with intravenous amikacin or ceftriaxone is recommended. In patients with positive urine culture, prophylaxis will be performed according to the antibiogram, from 24 hours before to 24 hours post-procedure. For the targeted treatment of post-transrectal biopsy prostatitis, carbapenems for 3-4 weeks are the treatment of choice.

Síndrome de Bouveret: Presentación de Caso Clínico / Bouveret Syndrome: Clinical Case Presentation

RESUMEN Introducción: El íleo biliar es una patología poco frecuente caracterizada por obstrucción mecánica intestinal debido a la impactación de un cálculo biliar dentro del tracto gastrointestinal, caracterizado por la tríada de Rigler, se observa en pacientes de edad avanzada con antecedentes de colelitiasis o colecistitis, por la existencia de una fístula bilioentérica. Se asocia a alta morbilidad y mortalidad. Sus síntomas y signos en su mayoría son inespecíficos y su diagnóstico se basa en un enfoque radiológico. Si bien la cirugía abierta ha sido el pilar del tratamiento, recientemente se han empleado otros enfoques, incluyendo cirugía laparoscópica y litotripsia. Caso clínico:Paciente femenino de 100 años de edad con cuadro de dolor abdominal, náusea y vómito de varios días de evolución. El diagnóstico fue realizado por tomografía computarizada. Conclusión: El íleo biliar es una entidad clínica de difícil diagnóstico. El uso de técnicas de imagen puede mejorar la precisión diagnóstica y la toma de recursos terapéuticos. Palabras claves: Obstrucción Intestinal; Cálculos Biliares; Condiciones Patológicas, Signos y Síntomas; Tomografía Computarizada por Rayos X; Litotricia; Laparoscopía

ABSTRACT Introduction: Gallstone ileus is a rare pathology characterized by mechanical intestinal obstruction due to the impaction of a gallstone inside the gastrointestinal tract, characterized by the Rigler triad, it is observed in elderly patients with a history of cholelithiasis or chole-cystitis, due to the existence of a bilioenteric fistula. It is associated with high morbidity and mortality. Its symptoms and signs are mostly nonspecific and its diagnosis is based on a radiological approach. Although open surgery has been the mainstay of treatment, other approaches have recently been used, including laparoscopic surgery and lithotripsy. Clinical case: 100 year-old female patient, with ab-dominal pain, nausea and vomiting that lasted several days of evolution. The diagnosis was made by computed tomography. Conclusion: Gallstone ileus is a clinical entity difficult to diagnose. The use of imaging techniques can improve the diagnostic accuracy and the taking of therapeutic resources. Keywords: Obstrucción Intestinal; Cálculos Biliares; Condiciones Patológicas, Signos y Síntomas; Tomografía Computarizada por Rayos X; Litotricia; Laparoscopía

Uso de la litotripsia intracoronaria en el manejo de lesiones calcificadas: reporte de dos casos / Lithoplasty for calcified coronary artery lesiones

Recently, intravascular lithoplasty (IVL) has been introduced as a novel technique for treating calcified intracoronary artery lesions. There are no reports of this intervention in Latin America. We report 2 cases in which IVL was successfully used to treat this type of coronary artery lesions.

Pancreatitis aguda como complicación infrecuente de litotricia extracorpórea por ondas de choque. Comunicación de un caso / Acute pancreatitis as an unusual complication of extracorporeal shock wave lithotripsy. A case report / Pancreatite aguda como complicação pouco frequente de litotrícia extracorpórea por ondas de choque. Comunicação de um caso

Resumen: La litotricia extracorpórea por ondas de choque para el tratamiento de la urolitiasis es un tratamiento ampliamente aceptado, pero no exento de complicaciones. La pancreatitis aguda que se desencadena inmediatamente posterior a este procedimiento es infrecuente, pero puede ser una complicación grave que amenaza la vida del paciente. La aparición aguda de dolor abdominal y vómitos en las horas posteriores al procedimiento, deben hacer al médico tratante sospechar esta complicación. Presentamos el caso de un paciente joven que luego de someterse a una sesión de litotricia para el tratamiento de una litiasis renal derecha instaló una pancreatitis aguda que requirió ingreso a terapia intensiva y que se suma a los escasos informes de casos publicados en la literatura médica.

Summary: Extracorporeal shock wave lithotripsy to treat urolithiasis is a widely aceptable treatment, although it may involve complications. Acute pancreatitis immediately after the procedures is rather unusual, but it may result in a serious life-threatening complication for patients. The appearance of severe pain and vomits a few hours after the procedure should make physicians suspicious of this complication. The study presents the case of a young patient who developed acute pancreatitis after undergoing lithotripsy to treat lithiasis in the right kidney, requiring his admission to the intensive care unit. This will add up to the scarce reports published in the medical literature.

Resumo: A litotrícia extracorpórea por ondas de choque para o tratamento da urolitíase é um tratamento amplamente aceito, mas não isento de complicações. A pancreatite aguda que se desencadeia imediatamente depois deste procedimento não é frequente, porém pode ser uma complicação grave que ameaça a vida do paciente. O surgimento súbito de dor abdominal e vómitos nas horas seguintes ao procedimento devem induzir à suspeita desta complicação. Apresentamos o caso de um paciente jovem que depois de uma sessão de litotrícia para o tratamento de uma litíase renal direita apresentou uma pancreatite aguda com posterior admissão a terapia intensiva; este caso se agrega aos poucos publicados na literatura médica.

Utilização da terapia extracorpórea por ondas de choque em acidente vascular encefálico com espasticidade: estudo piloto / Use of extracorporeal shock wave therapy in patients with spasticity related to stroke: a pilot study

Introdução: O objetivo desta pesquisa é demonstrar a redução do tônus muscular utilizando a terapia extracorpórea por ondas de choque e promover o retorno dos movimentos normais. Métodos: Foram escolhidos 10 pacientes idosos que apresentavam espasticidade, faixa etária entre 50 e 80 anos. Este estudo piloto utilizou 3 métodos: a escala de Ashworth, goniometro digital e o deslocamento do ventre muscular, antes e após as aplicações das ondas de choque. Aplicou-se uma corrente de pulso para verificar o deslocamento do ventre muscular, por meio de um laser marca LTM 165 classe 2 Stanley. O deslocamento foi medido por um sensor a laser. O equipamento de ortolitotripsia foi a Direx Integra, cuja dose/intensidade foi entre 1000 ciclos por segundo e 0,030 mJ/mm de energia em 12 gpm. Resultados: Na escala de Ashworth os resultados foram significativos (= 0,05). Na goniometria digital a abdução do ombro evoluiu em média 35° em 7 pacientes e 15° em 3 pacientes. (p > 0,05). Conclusão: Observa se que as ondas de choque não deixam os músculos hipotônicos, mas com tônus adequado. Os pacientes que obtiveram pouca melhora (15° goniometria) apresentaram micro-encurtamentos e não apresentam história de participação na fisioterapia regularmente. (AU)

Introduction: This research aims to show the reduction of muscular tonus by using extracorporeal shock wave lithotripsy in order to recover normal movements. Methods: 10 patients over 50 and under 80 years of age presenting spasticity participated in this pilot study, which used three methods: 1) the Ashworth scale, 2) the digital goniometer and 3) the dislocation of muscle tissue, before and after the shock waves. To check the dislocation of muscle tissue, a current pulse was applied, measured by a LTM 165 class 2 Laser. This approach is similar and consists of measuring the dislocation on a laser sensor basis. The Ortho-lithotripsy equipment used was a Direx Integra. The dose/intensity was 1000 cps ­ 0.030 mJ/mm². Results: We also observed a better quality of muscle contraction (Scale Ashworth p=0.05). At digital goniometry, the shoulder abduction developed 35° in 7 of the patients and 15° in 3 of them (p<0.05). Conclusion: The muscles do not become hypotonic with the shock waves treatment, (they present an adequate tonus). The patients who presented micro-shortening and did not undergo to regular physiotherapy showed a minor improvement (15° goniometry). (AU)

Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis / Litotripsia guiada por colangioscopia vs. terapias convencionais no tratamento da litíase biliar complexa: revisão sistemática e metanálise

ABSTRACT Introduction: Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. Aim: To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. Methods: Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. Results: Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). Conclusions: For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.

RESUMO Introdução: A remoção endoscópica das litíases do ducto biliar comum tem alta taxa de sucesso variando de 85% a 95%. Litíases do ducto biliar >15 mm são difíceis e frequentemente requerem litotripsia. A colangioscopia peroral permite litotripsia com taxas de sucesso semelhantes. Objetivo: Determinar a eficácia e segurança da litotripsia guiada por colangioscopia no tratamento de litíases biliares difíceis em comparação à terapias convencionais guiadas por colangiopancreatografia retrógrada endoscópica. Método: Pesquisa na Medline, Embase, Cochrane Central, Lilacs/Bireme de estudos avaliando a eficácia da colangioscopia na remoção de cálculos biliares difíceis. Duas análises foram realizadas separadamente, uma incluiu ensaios clínicos randomizados (ECR) e outros estudos observacionais. Resultados: Quarenta e seis estudos foram selecionados (3 ECR e 43 observacionais). Na análise, não houve diferença estatisticamente significativa na taxa de extração litiásica total (RD=-0,02 IC: -0,17,0,12/I²=0%), tempo médio de fluoroscopia (MD=-0,14 CI -1,60, 1,32/I²=21%) e na taxa de eventos adversos (RD=-0,06 IC: -0,14, 0,02/I²=0%).Por outro lado, o tempo médio do procedimento favoreceu terapêuticas convencionais guiadas por CPRE com significância estatística (MD=27,89 IC: 16,68, 39,10/I²=0%). Nos estudos observacionais, a taxa do tratamento completo por endoscopia foi de 88,29% (IC95: 86,9% a 90,7%), a taxa de sucesso na primeira sessão foi de 72,7% (IC95: 69,9% a 75,3%), o tempo médio do procedimento foi de 47,50±6 min por sessão e o número de procedimentos necessários para remoção total da litíase foi de 1,5±0,18. A taxa de eventos adversos foi de 8,7% (IC95: 7% a 10,9%), com 0,5% considerado como severo. Conclusão: Para litíases biliares difíceis, a litotripsia guiada por colangioscopia tem taxa de sucesso semelhante às terapêuticas convencionais guiadas CPRE em termos de sucesso terapêutico, taxa de eventos adversos e tempo de fluoroscopia. As terapêuticas convencionais guiadas por CPRE têm tempo médio de procedimento menor.