Analgesia for patients undergoing shockwave lithotripsy for urinary stones – a systematic review and meta-analysis

Abstract

Background Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain.Objectives To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones.Materials and Methods We searched the Cochrane Renal Group’s Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT’s) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals.Results Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures.Conclusion Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.

Efficacy of pethidine, ketorolac, and lidocaine gel as analgesics for pain control in shockwave lithotripsy: A single-blinded randomized controlled trial

“…Akcali et al [18] concluded that lornoxicam, an NSAID, can be safely and efficiently preferred in pain control during SWL. In a recent meta-analysis that assessed analgesia for patients undergoing SWL, no significant difference in pain scores was reported between NSAIDs or opioids [4].…”

“…Analgesics including paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids have also been found to provide sufficient pain control during SWL. Nontraditional methods such as music, acupuncture, and transcutaneous electrical nerve stimulation have also been used [4].…”

Transcutaneous Electric Nerve Stimulation (TENS) for pain relief during Extracorporeal Shock-Wave Lithotripsy (ESWL)

“…More side effects would be anticipated from using opioids than simple analgesics or NSAIDs. [14,15]. Still, there is no consensus on the standard analgesic regimen for controlling pain during ESWL.…”

Comparison of Different Analgesic Techniques for Pain Relief During Extracorporeal Shock Wave Lithotripsy: a Double-blind, Randomized Clinical Trial

“…Due to the high intensity of pain that is applied by the first generation of lithotripters, ESWL required general or spinal-epidural anesthesia, but with the use of the new generation of the lithotripters that needs low energy for lithotripsy, we can use the topical and local methods such as oral medications and infiltration of local anesthetics and intravenous administration of sedative drugs for stone breaking. Therefore, ESWL has become an outpatient procedure ( 7 , 8 ).…”

“…An alternative to this method is to use of infusion pumps such as patient-controlled analgesia (PCA) device, with administering a bolus on demand, and low dose infusion plus bolus. It has been shown that PCA is superior to the bolus-only technique ( 7 , 8 ). Also, the successful use of target-controlled infusion (TCI) device for pain management in ESWL has been reported.…”