Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel

Context:
Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review on their treatment.

Objective:
To assess the efficacy (primary outcome: stone-free rate; SFR) and morbidity of BS treatments.

Evidence Acquisition:
This systematic review was conducted in accordance with the EAU Guidelines Office. Database searches (1970-2019) were screened, abstracted and assessed for risk of bias for comparative RCTs and non-randomized studies (NRS) with ³10 patients per group. Quality of evidence (QoE) was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Evidence Synthesis:
2742 abstracts and 59 full-texts were assessed: 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL) (RR 0.88, p=0.03; low QoE). Four RCTs compared TUCL vs. percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference; MD; 0.82days, p<0.00001) and procedure duration (MD 9.83minutes, p<0.00001) favored TUCL (moderate QoE).

Four NRS comparing open cystolithotomy (CL) vs. TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favored endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope vs. cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favored using a nephroscope (MD 22.74 minutes, p<0.00001; moderate QoE).

In children, one NRS showed lower SFR following SWL than TUCL or CL. Two NRS comparing CL vs. TUCL/PCCL found similar SFRs; catheterization time and hospital stay favored endoscopic treatments. One RCT comparing laser vs. pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases, QoE was very low.

Conclusion
Current available evidence indicates TUCL is the intervention of choice for BS in adults and children, where feasible. Further high quality research on the topic is required.