Shockwave Lithotripsy Versus Ureteroscopic Treatment as Therapeutic Interventions for Stones of the Ureter (TISU): A Multicentre Randomised Controlled Non-inferiority Trial |
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| Authors: | Ranan Dasgupta Sarah Cameron Lorna Aucott Graeme MacLennan Ruth E. Thomas Mary M. Kilonzo Thomas B.L. Lam James N’Dow John Norrie Ken Anson Neil Burgess Charles T. Clark Francis X. Keeley Sara J. MacLennan Kath Starr Sam McClinton |
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| Affiliation: | 1. Department of Urology, Imperial College Healthcare NHS Trust, London, W2 1NY, UK;2. Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK;3. Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK;4. Health Economics Research Unit, University of Aberdeen, Aberdeen, UK;5. NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK;6. Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK;7. Department of Urology, St Georges University Hospitals NHS Foundation Trust, London, UK;8. Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK;9. Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK;10. Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK;11. Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK;12. Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, UK;1. Department of Urology, Imperial College Healthcare NHS Trust, London, W2 1NY, UK;2. Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK;3. Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK;4. Health Economics Research Unit, University of Aberdeen, Aberdeen, UK;5. NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK;6. Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK;7. Department of Urology, St Georges University Hospitals NHS Foundation Trust, London, UK;8. Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK;9. Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK;10. Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK;11. Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK;12. Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, UK |
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| Abstract: | BackgroundRenal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways.ObjectiveTo report a pragmatic multicentre non-inferiority RCT comparing SWL with URS.Design, setting, and participantsThis trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention.Outcome measurements and statistical analysisThe primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned.Results and limitationsThe study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL.ConclusionsThis RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition.Patient summaryWe present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition. |
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| Keywords: | Therapeutic interventions for symptomatic ureteric stones Ureteric stones Ureteroscopy Extracorporeal shockwave lithotripsy Trial Randomised controlled trial |
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