Objectives To perform a systematic review and network meta-analysis comparing stone-free rates following retrograde intrarenal surgery (RIRS), extracorporeal shock wave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) treatments of renal stones. Materials and methods Clinical trials comparing RIRS, SWL, and PCNL for treatment of renal stones were identified from electronic databases. Stone-free rates for the procedures were compared by qualitative and quantitative syntheses (meta-analyses). Outcome variables are shown as risk ratios (ORs) with 95% credible intervals (CIs). Results A total of 35 studies were included in this network meta-analysis of success and stone-free rates following three different treatments of renal stones. Six studies compared PCNL versus SWL, ten studies compared PCNL versus RIRS, fourteen studies compared RIRS versus SWL, and five studies compared PCNL, SWL, and RIRS. The quality scores within subscales were relatively low-risk. Network meta-analyses indicated that stone-free rates of RIRS (OR 0.38; 95% CI 0.22–0.64) and SWL (OR 0.12; 95% CI 0.067–0.19) were lower than that of PCNL. In addition, stone-free rate of SWL was lower than that of RIRS (OR 0.31; 95% CI 0.20–0.47). Stone free rate of PCNL was also superior to RIRS in subgroup analyses including ≥ 2 cm stone (OR 4.680; 95% CI 2.873–8.106), lower pole stone (OR 1.984; 95% CI 1.043–2.849), and randomized studies (OR 2.219; 95% CI 1.348–4.009). In rank-probability test, PCNL was ranked as No. 1 and SWL was ranked as No. 3. Conclusions PCNL showed the highest success and stone-free rate in the surgical treatment of renal stones. In contrast, SWL had the lowest success and stone-free rate.

We investigated whether stone heterogeneity index (SHI), which a proxy of such variations, was defined as the standard deviation of a Hounsfield unit (HU) on non-contrast computed tomography (NCCT), can be a novel predictor for shock-wave lithotripsy (SWL) outcomes in patients with ureteral stones. Medical records were obtained from the consecutive database of 1,519 patients who underwent the first session of SWL for urinary stones between 2005 and 2013. Ultimately, 604 patients with radiopaque ureteral stones were eligible for this study. Stone related variables including stone size, mean stone density (MSD), skin-to-stone distance, and SHI were obtained on NCCT. Patients were classified into the low and high SHI groups using mean SHI and compared. One-session success rate in the high SHI group was better than in the low SHI group (74.3% vs. 63.9%, P = 0.008). Multivariate logistic regression analyses revealed that smaller stone size (OR 0.889, 95% CI: 0.841–0.937, P < 0.001), lower MSD (OR 0.995, 95% CI: 0.994–0.996, P < 0.001), and higher SHI (OR 1.011, 95% CI: 1.008–1.014, P < 0.001) were independent predictors of one-session success. The radiologic heterogeneity of urinary stones or SHI was an independent predictor for SWL success in patients with ureteral calculi and a useful clinical parameter for stone fragility.

Low quality clinical trials have a possibility to have errors in the process of deriving the results and therefore distort the study. Quality assessment of clinical trial is necessary in order to prevent any clinical application erroneous results is important. Randomized controlled trial (RCT) is a design for evaluate the effectiveness of medical procedure. This study was conducted by extracting the RCTs from the original articles published in the Journal of Korean Medical Science (JKMS) from 1986 to 2011 and conducting a qualitative analysis using three types of analysis tools: Jadad scale, van Tulder scale and Cochrane Collaboration risk of bias Tool. To compare the quality of articles of JKMS, quality analysis of the RCTs published in Yonsei Medical Journal (YMJ) and Korean Journal of Internal Medicine was also conducted. In the JKMS, YMJ and Korean Journal of Internal Medicine, the quantitative increase of RCT presented over time was observed but no qualitative improvement of RCT was observed over time. From the results of this study, it is required for the researchers to plan for and perform higher quality studies.

BackgroundThis study was carried out a network meta-analysis of evidence from randomized controlled trials (RCTs) to evaluate stent-related discomfort in patients with alfuzosin or tamsulosin versus placebo.MethodsRelevant RCTs were identified from electronic databases. The proceedings of appropriate meetings were also searched. Seven articles on the basis of RCTs were included in our meta-analysis. Using pairwise and network meta-analyses, comparisons were made by qualitative and quantitative syntheses. Evaluation was performed with the Ureteric Stent Symptoms Questionnaire to assess the urinary symptom score (USS) and body pain score (BPS).ResultsOne of the seven RCTs was at moderate risk of bias for all quality criteria; two studies had a high risk of bias. In the network meta-analysis, both alfuzosin (mean difference [MD];−4.85, 95 % confidence interval [CI];−8.53–−1.33) and tamsulosin (MD;−8.84, 95 % CI;−13.08–−4.31) showed lower scores compared with placebo; however, the difference in USS for alfuzosin versus tamsulosin was not significant (MD; 3.99, 95 % CI;−1.23–9.04). Alfuzosin (MD;−5.71, 95 % CI;−11.32–−0.52) and tamsulosin (MD;−7.77, 95 % CI;−13.68–−2.14) showed lower scores for BPS compared with placebo; however, the MD between alfuzosin and tamsulosin was not significant (MD; 2.12, 95 % CI;−4.62–8.72). In the rank-probability test, tamsulosin ranked highest for USS and BPS, and alfuzosin was second.ConclusionThe alpha-blockers significantly decreased USS and BPS in comparison with placebo. Tamsulosin might be more effective than alfuzosin.

Background:We performed a systematic review and meta-analysis comparing stone-free rates between retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL), using updated, more reliable evidence.Materials and methods:Randomized controlled trials comparing RIRS and PCNL for >2 cm stones were identified from electronic databases. Stone-free rates for the procedures were compared by qualitative and quantitative syntheses (meta-analyses). Outcome variables are shown as risk ratios (RRs) with 95% confidence intervals (CIs).Results:Eleven articles were included in this study. Most recently published studies exhibited relatively low quality during quality assessment. For the meta-analysis comparing success (stone-free) rates between PCNL and RIRS, the forest plot using the random-effects model showed an RR of 1.11 (95% CI 1.02–1.21, P < .014) favoring PCNL. After determining the among-study heterogeneity, subgroup analysis was performed of 9 studies with less heterogeneity: the stone-free rate of PCNL was superior to that of RIRS using a fixed-effect model (RR 1.07, 95% CI 1.01–1.14, P < .019) for these studies.Conclusions:RIRS can be a safe and effective procedure for selected patients with large renal stones. However, in this meta-analysis, the postoperative stone-free rate of PCNL was higher than that of RIRS in patients with >2 cm renal stones.

BackgroundThis study included a network meta-analysis of evidence from randomized controlled trials (RCTs) to assess the therapeutic outcome of transurethral resection (TUR) in patients with non-muscle-invasive bladder cancer assisted by photodynamic diagnosis (PDD) employing 5-aminolaevulinic acid (5-ALA) or hexylaminolevulinate (HAL) or by narrow band imaging (NBI).MethodsRelevant RCTs were identified from electronic databases. The proceedings of relevant congresses were also searched. Fifteen articles based on RCTs were included in the analysis, and the comparisons were made by qualitative and quantitative syntheses using pairwise and network meta-analyses.ResultsSeven of 15 RCTs were at moderate risk of bias for all quality criteria and two studies were classified as having a high risk of bias. The recurrence rate of cancers resected with 5-ALA-based PDD was lower than of those resected using HAL-based PDD (odds ratio (OR) = 0.48, 95 % confidence interval (CI) [0.26–0.95]) but was not significantly different than those resected with NBI (OR = 0.53, 95 % CI [0.26–1.09]). The recurrence rate of cancers resected using HAL-based PDD versus NBI did not significantly differ (OR = 1.11, 95 % CI [0.55–2.1]). All cancers resected using 5-ALA-based PDD, HAL-based PDD, or NBI recurred at a lower rate than those resected using white light cystoscopy (WLC). No difference in progression rate was observed between cancers resected by all methods investigated.ConclusionsThe recurrence rate of some bladder cancers can be decreased by the implementation of either PDD- and NBI-assisted TUR; in real settings, clinicians should consider replacing WLC as the standard imaging technology to guide TUR.

PurposeTo elucidate the impact of surgical varicocele repair on the pregnancy rate through new meta-analyses of randomized clinical trials that compared surgical varicocele repair and observation.Materials and MethodsThe PubMed and Embase online databases were searched for studies released before December 2012. References were manually reviewed, and two researchers independently extracted the data. To assess the quality of the studies, the Cochrane risk of bias as a quality assessment tool for randomized controlled trials was applied.ResultsSeven randomized clinical trials were included in our meta-analyses, all of which compared pregnancy outcomes between surgical varicocele repair and control. There were differences in enrollment criteria among the studies. Four studies included patients with clinical varicocele, but three studies enrolled patients with subclinical varicocele. Meanwhile, four trials enrolled patients with impaired semen quality only, but the other three trials did not. In a meta-analysis of all seven trials, a forest plot using the random-effects model showed an odds ratio (OR) of 1.90 (95% confidence interval [CI], 0.77 to 4.66; p=0.1621). However, for subanalysis of three studies that included patients with clinical varicocele and abnormal semen parameters, the fixed-effects pooled OR was significant (OR, 4.15; 95% CI, 2.31 to 7.45; p<0.001), favoring varicocelectomy.ConclusionsVaricocelectomy for male subfertility is proven effective in men with clinical varicocele and impaired semen quality. Therefore, surgical repair should be offered as the first-line treatment of clinical varicocele in subfertile men.

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