- Email: [email protected]
Re: Percutaneous Nephrolithotomy Versus Retrograde Intrarenal Surgery: A Systematic Review and Meta-analysis
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retrospective nature of Medicare claims and diagnosis codes versus the large sample size. Randomized controlled trials monitoring other risk factors and MACE are needed to reach definitive conclusions on the benefits and safety of testosterone treatment in symptomatic hypogonadal men.
[4] Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of nonfatal myocardial infarction following testosterone therapy prescription in men. PLoS One 2014;9:e85805. [5] Morgentaler A, Feibus A, Baum N. Testosterone and cardiovascular disease—the controversy and the facts. Postgrad Med 2015;127: 159–65.
Conflicts of interest: The authors have nothing to disclose. Gert R. Dohle*, Marij Dinkelman-Smit
References
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
[1] Muraleedharan V, Jones TH. Testosterone and mortality. Clin Endocrinol 2014;814:477–87. [2] Oskui PM, French WJ, Herring MJ, Mayeda GS, Burstein S, Kloner RA.
*Corresponding author. Department of Urology, Erasmus University Medical Center, Dr. Molewaterplein 50, 3000 CA Rotterdam,
Testosterone and the cardiovascular system: a comprehensive
The Netherlands.
review of the clinical literature. J Am Heart Assoc 2013;2:e000272.
E-mail address: [email protected] (G.R. Dohle).
[3] Vigen R, O’Donnell CI, Baron AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men
http://dx.doi.org/10.1016/j.eururo.2015.06.035
with low testosterone levels. JAMA 2013;310:1829–36.
Re: Percutaneous Nephrolithotomy Versus Retrograde Intrarenal Surgery: A Systematic Review and Metaanalysis De S, Autorino R, Kim FJ, et al Eur Urol 2015;67:125–37 Experts’ summary: The authors summarized current evidence on comparisons between retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) and concluded that PCNL provides a higher stone-free rate at the expense of higher complication rates and blood loss and longer hospitalization times. Experts’ comments: The meta-analysis included only two randomized control trials of moderate quality. There were major study differences in terms of the technique and materials used, perioperative management, and the study methodology. The operative time was similar for PCNL and RIRS and represents a debatable issue, as some studies did not accurately define the operative time [1,2]. In a subgroup comparison of standard PCNL with RIRS, only one study showed a favorable operative time for RIRS. The latter study lacked accurate methodology for time measurement, and some cases involved conversion from RIRS to PCNL [1]. The use of different instruments in the case of PCNL could have had an effect on the operative time, and the use of recently introduced instruments may be related to a learning curve [3]. Other investigators compared operative times for groups with significantly smaller stone size in the case of RIRS [2]. The above issues balanced the advantage of PCNL in terms of operative time in the pooled analysis, whereas another similar meta-analysis revealed shorter operative times for PCNL [4]. Complication rates were higher for PCNL in a pooled analysis of overall complication rates. Analysis of the individual complication rates might have been more
informative. An interesting point was the lack of information on hematuria in this current meta-analysis (30% for RIRS [4]). Sepsis was twice as frequent for RIRS, in agreement with another meta-analysis, and could be attributed to the possibility of higher intrarenal pressure during RIRS [4,5]. Hospital stay length was characterized by high heterogeneity of 83–93%, which reduces the reliability of the analysis. Retreatment rates and the need for auxiliary procedures were not included in the meta-analysis, and probably represent additional points favoring PCNL [4]. Considering reintervention costs and a recent cost comparison between PCNL and RIRS, a cost advantage could be attributed to PCNL [6]. The current meta-analysis presents some aspects of the true clinical value of RIRS and PCNL. The methodology of the meta-analysis was not flawless and provides evidence worthy of critical appraisal rather than solid evidence on true clinical outcomes. Conflicts of interest: The authors have nothing to disclose.
References [1] Bryniarski P, Paradysz A, Zyczkowski M, Kupilas A, Nowakowski K, Bogacki R. A randomized controlled study to analyze the safety and efficacy of percutaneous nephrolithotripsy and retrograde intrarenal surgery in the management of renal stones more than 2 cm in diameter. J Endourol 2012;26:52–7. [2] Resorlu B, Unsal A, Ziypak T, et al. Comparison of retrograde intrarenal surgery, shockwave lithotripsy, and percutaneous nephrolithotomy for treatment of medium-sized radiolucent renal stones. World J Urol 2013;31:1581–6. [3] Sabnis RB, Ganesamoni R, Doshi A, Ganpule AP, Jagtap J, Desai MR. Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial. BJU Int 2013;112:355–61. [4] Zhang W, Zhou T, Wu T, et al. Retrograde intrarenal surgery versus percutaneous nephrolithotomy versus extracorporeal shockwave lithotripsy for treatment of lower pole renal stones: a meta-analysis and systematic review. J Endourol 2015;29:745–59.
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EUROPEAN UROLOGY 68 (2015) 736–741
[5] Rehman J, Monga M, Landman J, et al. Characterization of intra-
Panagiotis Kallidonis, Evangelos Liatsikos*
pelvic pressure during ureteropyeloscopy with ureteral access
Department of Urology, University of Patras, Patras, Greece
sheaths. Urology 2003;61:713–8. [6] Schoenthaler M, Wilhelm K, Hein S, et al. Ultra-mini PCNL versus
*Corresponding author. Department of Urology, University of Patras,
flexible ureteroscopy: a matched analysis of treatment costs
Rio Patras 26500, Greece.
(endoscopes and disposables) in patients with renal stones
E-mail address: [email protected] (E. Liatsikos).
10-20 mm. World J Urol. In press. http://dx.doi.org/10.1007/ s00345-015-1489-4
http://dx.doi.org/10.1016/j.eururo.2015.06.036
EUROPEAN UROLOGY 68 (2015) 736–741
retrospective nature of Medicare claims and diagnosis codes versus the large sample size. Randomized controlled trials monitoring other risk factors and MACE are needed to reach definitive conclusions on the benefits and safety of testosterone treatment in symptomatic hypogonadal men.
[4] Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of nonfatal myocardial infarction following testosterone therapy prescription in men. PLoS One 2014;9:e85805. [5] Morgentaler A, Feibus A, Baum N. Testosterone and cardiovascular disease—the controversy and the facts. Postgrad Med 2015;127: 159–65.
Conflicts of interest: The authors have nothing to disclose. Gert R. Dohle*, Marij Dinkelman-Smit
References
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
[1] Muraleedharan V, Jones TH. Testosterone and mortality. Clin Endocrinol 2014;814:477–87. [2] Oskui PM, French WJ, Herring MJ, Mayeda GS, Burstein S, Kloner RA.
*Corresponding author. Department of Urology, Erasmus University Medical Center, Dr. Molewaterplein 50, 3000 CA Rotterdam,
Testosterone and the cardiovascular system: a comprehensive
The Netherlands.
review of the clinical literature. J Am Heart Assoc 2013;2:e000272.
E-mail address: [email protected] (G.R. Dohle).
[3] Vigen R, O’Donnell CI, Baron AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men
http://dx.doi.org/10.1016/j.eururo.2015.06.035
with low testosterone levels. JAMA 2013;310:1829–36.
Re: Percutaneous Nephrolithotomy Versus Retrograde Intrarenal Surgery: A Systematic Review and Metaanalysis De S, Autorino R, Kim FJ, et al Eur Urol 2015;67:125–37 Experts’ summary: The authors summarized current evidence on comparisons between retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) and concluded that PCNL provides a higher stone-free rate at the expense of higher complication rates and blood loss and longer hospitalization times. Experts’ comments: The meta-analysis included only two randomized control trials of moderate quality. There were major study differences in terms of the technique and materials used, perioperative management, and the study methodology. The operative time was similar for PCNL and RIRS and represents a debatable issue, as some studies did not accurately define the operative time [1,2]. In a subgroup comparison of standard PCNL with RIRS, only one study showed a favorable operative time for RIRS. The latter study lacked accurate methodology for time measurement, and some cases involved conversion from RIRS to PCNL [1]. The use of different instruments in the case of PCNL could have had an effect on the operative time, and the use of recently introduced instruments may be related to a learning curve [3]. Other investigators compared operative times for groups with significantly smaller stone size in the case of RIRS [2]. The above issues balanced the advantage of PCNL in terms of operative time in the pooled analysis, whereas another similar meta-analysis revealed shorter operative times for PCNL [4]. Complication rates were higher for PCNL in a pooled analysis of overall complication rates. Analysis of the individual complication rates might have been more
informative. An interesting point was the lack of information on hematuria in this current meta-analysis (30% for RIRS [4]). Sepsis was twice as frequent for RIRS, in agreement with another meta-analysis, and could be attributed to the possibility of higher intrarenal pressure during RIRS [4,5]. Hospital stay length was characterized by high heterogeneity of 83–93%, which reduces the reliability of the analysis. Retreatment rates and the need for auxiliary procedures were not included in the meta-analysis, and probably represent additional points favoring PCNL [4]. Considering reintervention costs and a recent cost comparison between PCNL and RIRS, a cost advantage could be attributed to PCNL [6]. The current meta-analysis presents some aspects of the true clinical value of RIRS and PCNL. The methodology of the meta-analysis was not flawless and provides evidence worthy of critical appraisal rather than solid evidence on true clinical outcomes. Conflicts of interest: The authors have nothing to disclose.
References [1] Bryniarski P, Paradysz A, Zyczkowski M, Kupilas A, Nowakowski K, Bogacki R. A randomized controlled study to analyze the safety and efficacy of percutaneous nephrolithotripsy and retrograde intrarenal surgery in the management of renal stones more than 2 cm in diameter. J Endourol 2012;26:52–7. [2] Resorlu B, Unsal A, Ziypak T, et al. Comparison of retrograde intrarenal surgery, shockwave lithotripsy, and percutaneous nephrolithotomy for treatment of medium-sized radiolucent renal stones. World J Urol 2013;31:1581–6. [3] Sabnis RB, Ganesamoni R, Doshi A, Ganpule AP, Jagtap J, Desai MR. Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial. BJU Int 2013;112:355–61. [4] Zhang W, Zhou T, Wu T, et al. Retrograde intrarenal surgery versus percutaneous nephrolithotomy versus extracorporeal shockwave lithotripsy for treatment of lower pole renal stones: a meta-analysis and systematic review. J Endourol 2015;29:745–59.
741
EUROPEAN UROLOGY 68 (2015) 736–741
[5] Rehman J, Monga M, Landman J, et al. Characterization of intra-
Panagiotis Kallidonis, Evangelos Liatsikos*
pelvic pressure during ureteropyeloscopy with ureteral access
Department of Urology, University of Patras, Patras, Greece
sheaths. Urology 2003;61:713–8. [6] Schoenthaler M, Wilhelm K, Hein S, et al. Ultra-mini PCNL versus
*Corresponding author. Department of Urology, University of Patras,
flexible ureteroscopy: a matched analysis of treatment costs
Rio Patras 26500, Greece.
(endoscopes and disposables) in patients with renal stones
E-mail address: [email protected] (E. Liatsikos).
10-20 mm. World J Urol. In press. http://dx.doi.org/10.1007/ s00345-015-1489-4
http://dx.doi.org/10.1016/j.eururo.2015.06.036