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Percussion, diuresis, and inversion therapy for the passage of lower pole kidney stones following shock wave lithotripsy

  1. Liang Ren Liu1,
  2. Qi Jun Li2,
  3. Qiang Wei1,*,
  4. Zhen Hua Liu1,
  5. Yong Xu1

Editorial Group: Cochrane Kidney and Transplant Group

Published Online: 8 DEC 2013

DOI: 10.1002/14651858.CD008569.pub2


How to Cite

Liu LR, Li QJ, Wei Q, Liu ZH, Xu Y. Percussion, diuresis, and inversion therapy for the passage of lower pole kidney stones following shock wave lithotripsy. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD008569. DOI: 10.1002/14651858.CD008569.pub2.

Author Information

  1. 1

    West China Hospital, Sichuan University, Department of Urology, Chengdu, Sichuan, China

  2. 2

    King's Maze London, MRC Centre for Transplantation, London, UK

*Qiang Wei, Department of Urology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China. wq933@hotmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 8 DEC 2013

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Characteristics of included studies [ordered by study ID]

Methods
  • Study design: single-blind, prospective RCT
  • Study duration: study commenced in 2001


Participants
  • Country: Singapore
  • Setting: single centre
  • Aged 18 years or over with lower pole kidney stones between 0.4 cm to 2 cm diameter at 3 months after shock wave lithotripsy treatment
  • Number: treatment group (59); control group (49)
  • Mean age; range (years): treatment group (49; 21 to 71); control group (45; 23 to 72)
  • Sex (M/F): treatment group (50/9); control group (30/19)
  • Initial stone size; range: treatment group (0.8 mm; 0.4 mm to 2 mm); control group 1.0 mm (0.4 mm to 2 mm)
  • Exclusion criteria: collecting system abnormalities; patients with ureteral stents in situ; history of cardiac, renal, or respiratory failure; history of complications from previous SWL; gastroesophageal reflux disease


InterventionsTreatment group

  • Median of four sessions of percussion, diuresis, and inversion therapy between 1 and 2 weeks after each SWL session
  • Additional percussion, diuresis, inversion therapy provided with documented radiologic residual stone fragments at 1 month or after additional SWL within the 3 month study period
  • Percussion, diuresis, and inversion therapy involved:
    • drinking 500 mL of water 30 min before therapy
    • positioning in a prone Trendelenburg position on a 45º angle
    • continuous 10 min manual mechanical percussion over the flank/session


Control group

  • SWL only


Outcomes
  • Stone-free rate
  • Stone burden reduction
  • Complications


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"Using simple randomization by computer"

Allocation concealment (selection bias)Unclear risk"Patients were randomized to a control group or SWL plus percussion, diuresis, inversion therapy group using simple randomization by computer"

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinded to the radiologist only

Blinding of outcome assessment (detection bias)
All outcomes
Low riskBlinded to the radiologist only

Incomplete outcome data (attrition bias)
All outcomes
Low riskITT analysis reported. 2.7% of randomised patients were lost to follow-up, however data for all patients were reported

Selective reporting (reporting bias)Low riskStone-free rate and the overall reduction in stone size had been reported. Study protocol was not available

Other biasLow riskSupported by a National Healthcare Group research grant (Singapore)


Methods
  • Study design: prospective, single blind, cross-over RCT
  • Study duration: January 1999 to June 2000


Participants
  • Country: Canada
  • Setting: single centre
  • All participants aged ≥ 18 years with lower pole kidney stones 4 mm or less at 3 months after SWL
  • Number: treatment group (35); control group (34)
  • Mean age ± SD (years): treatment group (52.0 ± 11.6); control group (40.6 ± 22.)
  • Sex (M/F): treatment group (23/12); control group (29/5)
  • Initial stone area ± SD: treatment group (61.7 ± 60.2 mm²); control group (70.9 ± 87.2 mm²)
  • Exclusion criteria: anatomical anomalies, such as horseshoe kidney, fragments in a caliceal diverticulum, infundibular stenosis less than 2 mm on compression film of IVP; radiolucent calculi, furosemide allergy; medical conditions that might make inversion dangerous


InterventionsTreatment group

  • Received 20 mg furosemide followed by inversion to at least 60° and 10 minutes of flank percussion with a mechanical chest percussor weekly for 3 weeks or until stone-free


Control group

  • Observation for 4 weeks. Patients were offered opportunity to cross-over to receive mechanical percussion and inversion following observation


Outcomes
  • Success: stone-free rate
  • Effectiveness: stone burden reduction rate
  • Complications


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskPatients were randomised with simple block randomisation

Allocation concealment (selection bias)Unclear riskPatients were randomised with simple block randomisation to treatment group or observation group.

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinded to the radiologist only

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"A blinded radiologist adjudicated all films to determine final stone free state"

Incomplete outcome data (attrition bias)
All outcomes
Low riskITT analysis reported, 11.5% of randomised patients were lost to follow-up, however data for all patients has been reported

Selective reporting (reporting bias)Low riskPrimary outcomes (stone free rate and stone burden reduction rate) were reported. Study protocol was available

Other biasUnclear riskSource of funding not stated

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Albanis 2009Not RCT

Arrabal-Martin 2006Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones

Azm 2002Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones

De Sio 2008Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones

Falahatkar 2008Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones

Goktas 2000Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones

Ulmann 1984Did not assess percussion, diuresis, and inversion therapy for passage of lower pole kidney stones

Zomorrodi 2008Did not assess percussion, diuresis and inversion therapy for passage of lower pole kidney stones

 
Comparison 1. Percussion, diuresis, and inversion therapy following shock wave lithotripsy versus no intervention following shock wave lithotripsy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stone-free rate1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 2 Stone burden reduction1Mean Difference (IV, Random, 95% CI)Totals not selected

 3 Complications1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 
Comparison 2. Percussion, diuresis, and inversion plus shock wave lithotripsy therapy versus shock wave lithotripsy alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Stone-free rate1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 2 Stone burden reduction1Mean Difference (IV, Random, 95% CI)Totals not selected

 3 Complications1Risk Ratio (M-H, Random, 95% CI)Totals not selected