The fate of residual fragments after extracorporeal shock wave lithotripsy monotherapy of infection stones

We reviewed 53 patients with infection stones treated by extracorporeal shock wave lithotripsy (ESWL*) monotherapy to determine the long-term rate free of stones and the stone recurrence rate as correlated with the pre-treatment stone burden and the radiological presence of sand or fragments after the procedure. Long-term followup (mean 26.6 months) was available on 33 patients representing 38 kidneys. Although only 3 kidneys were free of stones immediately after ESWL, 20 were without stones at 3 months and 18 (47%) were stone-free at followup. Of 9 kidneys with fragments of more than 5 mm. after the final treatment 7 (78%) had residual fragments at 3 months and experienced stone progression. Of 9 kidneys with sand remaining 6 (66%) and all 3 kidneys that appeared to be free of stones after ESWL were without stones at followup. The 3-month plain film of the kidneys, ureters and bladder was a reliable indicator of eventual outcome. Of 20 kidneys that were free of stones at 3 months 16 remained without stones. Of 18 kidneys with residual stone particles at 3 months 14 showed disease progression, 2 had stable disease and 2 passed residual sand. Only 1 of 17 patients who were free of stones or had stable stone disease had a positive urine culture at followup. Patients with infection stone fragments 3 months after ESWL monotherapy have a high rate of stone progression (78%) and should undergo further treatment. ESWL monotherapy of infection stones requires close patient followup to assure that all residual fragments have passed and urine remains sterile.     

Treatment of staghorn calculi. Strategies and results of the combined use of new technics

From January 1984 to June 1986, 270 patients with staghorn calculi were treated by ESWL, PCNL, or a combination of both. The indications were determined according to stone burden, distribution of stone load, architecture of the renal collecting system, radiopacity, and chemical composition of the calculi. Another group (83 patients) treated from January 1982 to October 1983 exclusively with open surgery was also examined. In a retrospective study, the treatment and follow-up data of the two groups were evaluated and compared. At discharge, 78 (29%) of the patients treated by the new techniques were free of stones, while 192 (71%) still had residual fragments in the kidney or in the ureter. Among the group treated by open surgery, 54 (65.1%) were free of stones at discharge, 17 (20.4%) still had residual fragments, and 12 (14.5%) had to undergo nephrectomy. The follow-up data (18 months n = 186) for the ESWL-PCNL-group revealed a stone-free rate of 54.8%. Residual fragments were observed in 40.3% and recurrent stone formation occurred in only 4.9%. Follow-up examination of group treated by open surgery (42 months, n = 61) revealed a stone-free rate of 72.1%, while residual stones persisted in 8.2% and recurrent stone formation occurred in 19.7%. The incidence of urinary tract infection was only 11.3% after ESWL/PCNL, as against 30% after open surgery. It is remarkable that 80% of the patients with residual fragments after ESWL-PCNL did not have any such symptoms as infection or colic.     

Effect of potassium citrate therapy on stone recurrence and residual fragments after shockwave lithotripsy in lower caliceal calcium oxalate urolithiasis: a randomized controlled trial

BACKGROUND AND PURPOSE: To evaluate the efficacy of potassium citrate treatment in preventing stone recurrences and residual fragments after shockwave lithotripsy (SWL) for lower pole calcium oxalate urolithiasis. PATIENTS AND METHODS: One hundred ten patients who underwent SWL because of lower caliceal stones and who were stone free or who had residual stone 4 weeks later were enrolled in the study. The average patient age was 41.7 years. All patients had documented simple calcium oxalate lithiasis without urinary tract infection and with normal renal morphology and function. Four weeks after SWL, patients who were stone free (N = 56) and patients who had residual stones (N = 34) were independently randomized into two subgroups that were matched for sex, age, and urinary values of citrate, calcium, and uric acid. One group was given oral potassium citrate 60 mEq per day, and the other group served as controls. RESULTS: In patients who were stone free after SWL and receiving medical treatment, the stone recurrence rate at 12 months was 0 whereas untreated patients showed a 28.5% stone recurrence rate (P < 0.05). Similarly, in the residual fragment group, the medically treated patients had a significantly greater remission rate than the untreated patients (44.5 v 12.5%; P < 0.05). CONCLUSION: Potassium citrate therapy significantly alleviated calcium oxalate stone activity after SWL for lower pole stones in patients who were stone free. An important observation was the beneficial effect of medical treatment on stone activity after SWL among patients with residual calculi.     

Comparative study of long-term stone recurrence after extracorporeal shock wave lithotripsy and open stone surgery for kidney stones

Background: Extracorporeal shock wave lithotripsy (ESWL) has become the treatment of choice for most calculi of upper urinary tract and the need for open stone surgery (OSS) have considerably reduced. However, stone recurrence is often encountered as a long-term problem requiring re-treatment.
Methods: In the present retrospective study, the recurrence rates of ESWL and OSS were compared in the treatment of kidney calculi. During the 1 year period of the present study, 43 patients were treated by OSS and 400 underwent ESWL (the Dornier MPL 9000 lithotriptor). The recurrence of stone was defined as reappearance of the stone on plain abdominal radiography during the follow-up period.
Results: Complete removal of all stone fragments was achieved in 51.2% of patients ( n = 22) treated with OSS. In the ESWL group, the stone free rate was 56.7% ( n = 237). The recurrence rate was 31.8% within a mean of 40 months (range 32–48 months) in the OSS group, whereas this figure was 13.9%, with a mean period of 46 months (range 42–48 months) in the ESWL group ( P < 0.05). The mean periods of recurrence in ESWL and OSS groups were 20 (range 6–42 months) and 11 months (range 8–44 months), respectively ( P < 0.05). However, the mean stone burdens of both groups were different (2.9 ± 0.8 vs 1.4 ± 1.1 cm). For comparable stone burdens, the recurrence rate was similar. In the ESWL group, stones in the lower calyx, multiple stones and larger stones showed a higher recurrence rate. The recurrence after OSS was also influenced by stone burden.
Conclusions: The results of the present study demonstrate that stone burden may be the primary risk factor for stone recurrence after ESWL and OSS.     

ESWL monotherapy for large-volume renal calculi: efficacy and morbidity

We assessed the efficacy and morbidity of extracorporeal shock-wave lithotripsy (ESWL) monotherapy in the treatment of 25 consecutive patients with large-volume renal calculi (surface area greater than or equal to 5.0 cm2). Eighteen of the calculi were infection (struvite) stones and 7 were sterile stones. In 21 cases internal ureteral stents were positioned before ESWL, but no patient underwent pretreatment percutaneous nephrostomy (PCN) or percutaneous nephrostolithotomy (PNL). An average of 2.1 procedures including ESWL, PCN, or ureteral interventions were required to achieve a stone-free renal collecting system and ureter, or residual stone particles less than 4 mm in diameter confined to the renal collecting system. Sixty percent of the patients required no ancillary procedures after ESWL. There were no differences in the mean duration of hospitalization, need for post-treatment ancillary procedures, time to clearance of ureteral fragments, and incidence of residual stone particles among patients with infection and sterile stones. Of 23 patients observed greater than three months (mean 10.9 mos) after ESWL, 43 percent had residual stone particles in the renal collecting system. Expansion of these particles or stone recurrence in the absence of residual particles has not been observed. We conclude that large volume renal calculi may be managed effectively and safely with ESWL monotherapy.     

Clinical experience with extracorporeal shock wave lithotripsy (ESWL) in upper urinary tract stones

We treated 100 patients of upper urinary tract stone using extracorporeal shock wave lithotripsy (ESWL), from April to October 1986. Eighty-six of the patients were treated by ESWL monotherapy, and the other cases required further treatment, such as percutaneous nephrostomy (PCN), percutaneous nephrolithotomy (PNL), and transurethral ureterolithotripsy (TUL). On the X-ray film obtained from one to three months after ESWL, 73 patients had no stones, 8 patients had sandy stones, 7 patients had small fragments less than 5 mm, 2 patients had large stones equal to or greater than 5 mm and 10 patients could not be followed up. Therefore, 97.7% of all patients were successfully treated. In conclusion, ESWL is considered to be an ideal method to treat upper urinary tract stones, and soon will become the first choice of treatment of urolithiasis together with the progress in endourological techniques.     

Cost effectiveness of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for medium-sized kidney stones. A randomised clinical trial.

To evaluate percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL) for their clinical effects, their cost effectiveness, their complication rates, and the patients' experiences, 55 consecutive patients were randomised to have one or other operation between October 1986 and October 1988. Six patients were excluded, 21 were treated with PNL and 28 with ESWL as primary treatment. Mean hospital stay and length of treatment were longer for PNL than for ESWL. Since 1 July 1987 all patients having ESWL have been treated without anaesthesia (n = 15), whereas epidural anaesthesia was used for all PNL. Slightly more of the ESWL patients experienced some pain during treatment. Minor complications or pain were more common after ESWL during the first 10 days after discharge from hospital. If patients with stone fragments of 4 mm or less were regarded as having a successful outcome, the success rates after one year were 94% for PNL and 77% for ESWL. The overall total cost was lower for ESWL than for PNL, the cost per successfully treated patient being 2172 pounds for PNL and 1810 pounds for ESWL. Medium sized kidney stones (6-30 mm, or 2-3 stones of 20 mm or less) can be efficiently and cheaply treated by both PNL and ESWL, though the cost of ESWL is lower. Even if effects other than cost (such as complications and patients' experience) are borne in mind, ESWL was superior to PNL for this group of patients.     

Prognostic Factors of Success of Extracorporeal Shock Wave Lithotripsy (ESWL) in the Treatment of Renal Stones

Objectives: To evaluate the factors that affect the success rate of extracorporeal shock wave lithotripsy (ESWL) for treatment of renal stones. Patients and methods: Between January 2000 and December 2003, 427 patients with single or multiple renal stones (<30 mm, largest diameter) underwent ESWL monotherapy using Storz SL 20 lithotriptor. The results of treatment were evaluated after 3 months of follow-up. Treatment success was defined as complete clearance of the stones or presence of clinically insignificant residual fragments <4 mm. The success rate was correlated with the characteristics of the patients, conditions of the urinary tract and stone features. Results: At 3-month follow-up, the overall success rate was 333/427 (78%). Repeat treatment was needed in 226 patients (53.1%). Post-ESWL auxiliary procedures were required in 36 patients (8.4%). Post-ESWL complications were recorded in 16 patients (3.7%). Of the 10 prognostic factors studied, 5 had a significant impact on the success rate, namely: renal morphology, congenital anomalies, stone size, stone site and number of treated stones. Other factors including age, sex, nationality, stone nature (de novo or recurrent) and ureteric stenting had no significant impact on the success rate. Conclusions: The success rate of ESWL for the treatment of renal stones could be predicted by stone size, location and number, radiological renal features and congenital renal anomalies.     

Calyceal stones: Fate of shock wave therapy with respect to stone localization

In a retrospective analysis the results of extracorporeal shock wave lithotripsy (ESWL) treatment were evaluated in patients with renal stones according to calyceal localization of treated stones. The 198 patients who underwent ESWL with the Dornier MPL 9000 were analyzed for success rate, complication rate, residual fragments, regrowth and recurrence rates. Totally 210 calyceal calculi located in different portions of the kidney have been comparatively evaluated. No major complications were noted during or after ESWL. Some minor complications such as flank pain, renal colic, haematuria were observed. Flank pain was observed during ESWL treatment especially in patients with upper calyceal stones. Although stone-free and residual fragment rates were similar in pelvic, upper and middle calyces, patients with lower calyceal and pelvicalyceal stones had high residual fragment rate and lower stone-free rate. Patients with stones in the lower calyces or pelvicalyces had high recurrence and regrowth rates (p<0.05). ESWL has been considered as the optimal treatment modality for most upper urinary tract calculi. It is especially effective in patients with pelvic, upper and middle calyceal stones. Patients with lower calyceal stones often failed to eliminate the fragments, hence had high recurrence and regrowth rates.     

Extracorporeal shock wave lithotripsy (ESWL): alternatives and adjuvant procedures

Summary Within a short time, extensive statistics on ESWL have documented its efficiency in the treatment of most renal and ureteral stones. Approximately 20% of all stone patients, however, require additional or other forms of therapy, such as URS, PNL, or surgery. Up to now, the differential indications for these procedures have not been completely established. A crucial factor for successful application of ESWL is stone volume and localization. Large stones with a central stone mass may be successfully treated by combining ESWL and PNL, while surgery is still preferred in those with a peripheral stone mass.     

Metaphylaxis of nephrolithiasis

The introduction of extracorporeal shockwave lithotripsy (ESWL), with its noninvasive removal of stones and considerable reduction in the morbidity of stone disease, has revolutionized the therapy of urolithiasis. Unfortunately the propensity for stone recurrence is not altered by removal of stones with ESWL and stone recurrence is still about 50%. Progress in medical treatment has shown how different therapies can prevent the stone recurrence, even though it is often difficult to predict which patient will go on to become a recurrent stone former. With the right evaluation, however, the cause of calculi formation can be treated in 97% of the patients. Primary prevention of urolithiasis includes general prophylaxis in a no-risk population that has never been affected by urinary tract stones, is without familial predisposition, metabolic or genetic alterations, or urinary tract abnormalities or infections and who live in a geographical area that is at risk. Secondary prevention or metaphylaxis of stone disease is aimed at the population at risk, that is patients already affected by the stone disease, with familial predisposition, with urinary tract alterations, with metabolic or genetic alterations (gout, bone or bowel diseases) and urinary infection.     

双J管在ESWL治疗巨大肾结石中的应用

目的：探讨双J管内引流在体外冲击波碎石术（ESWL）治疗巨大肾结石后防止石街发生的作用。方法：预置组73例巨大肾结石患者采用预置双J管，ESWL治疗；对照组29例均为拒绝手术和不愿置双J管而行ESWL的巨大肾结石患者。结果：预置组2例发生石街（2．7％），结石排净率为97．3％；对照组17例发生石街（58．6％），3例发生急性梗阻性肾功能衰竭，结石排净率为81．9％。两组差异有显著性意义（P＜0．05）。结论：双J管作为巨大肾结石患者ESWL治疗的辅助治疗能有效地防止石街的形成，有利于结石的排出，且操作简单，并发症少，适于推广应用。     

Clinical experience of extracorporeal shock wave lithotripsy for cystine calculi

Thirty patients (16 men and 14 women) with cystine urinary stones were treated by extracorporeal shock wave lithotripsy (Dormer HM-3) from December 1984 through October 1989. The average patient age was 35.2 years with a range of 14 to 59 years. Seventy per cent of these subjects had had previous open surgical operations for stones. The cases consisted of 7 ureteral stones and 37 renal stones, including 15 staghorn calculi. An average of 1.3 session of ESWL was carried out to treat ureteral stones. Thirty-seven renal units with renal stone required 96 sessions of lithotripsy (average 2.6 sessions per unit). Seven patients with ureteral stones required auxiliary procedures, i.e., one transurethral lithotripsy (TUL), two percutaneous nephrostomies (PNS) and one open surgery. Thirty-seven renal stones, including staghorn calculi was treated by ESWL and auxiliary treatment of 21 TUL procedures, one PNS, 16 PNL procedures and one chemical chemolysis. Successful fragmentation (residual debris less than or equal to 4 mm) was achieved in 85.7% of ureteral stones, 90.9% of renal stones and 73.3% of staghorn calculi. The stone free rates of patients with ureteral stones, renal stones and staghorn calculi were 71.4%, 50.0% and 53.5%, respectively, at 3 months after ESWL. No serious complications were seen in this series. Fever above 38.5 degrees C was the most common complications (13.5%). Ureteral perforation was encountered once in TUL procedures. Transfusion and selective arterial embolization were needed for one case treated by PNL procedures. Although cystine stone is harder to be fragmented by ESWL than other stone composition, ESWL and endourology may be effective and safe procedures for cystine stone patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

The recurrence rate of stones following ESWL

Summary With extracorporeal shockwave lithotripsy (ESWL) stone fragmentation and the potential creation of residual stones has become an integral part of the treatment strategy. Therefore true recurrence, regrowth and pseudo-recurrence determine the rate of new stone formation. In unselected series the overall recurrence rate after ESWL varies between 6% after 1 year and 20% after 4 years. The comparison between the recurrence rate after ESWL and the natural recurrence rate reveals that the results of ESWL are better than expected. Lithotripsy has no special effect on true stone recurrence, and even pseudo-recurrence is of minor clinical significance.     

Treatment of stones in caliceal diverticula: extracorporeal shock wave lithotripsy versus percutaneous nephrolitholapaxy.

Stones in caliceal diverticula may cause symptoms for which treatment is indicated. Both extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolitholapaxy (PNL) are recommended. We have evaluated the results of ESWL treatment of stone-containing caliceal diverticula and compared these with the results obtained by percutaneous surgery. In the ESWL group, 15 patients were treated with an electromagnetic lithotriptor (Siemens Lithostar). After 3 months, plain abdominal X-rays revealed that only 2 patients were both stone-free and symptom-free. Of the 13 patients with residual fragments, 7 had no symptoms. The remaining 6 were treated by a lower pole resection (n = 3), a percutaneous procedure (n = 2) and long-term administration of antibiotics (n = 1). Sixteen patients were treated percutaneously. Puncture failed in 3 and they underwent a lumbotomy. In the remaining 13 patients the stones were reached by direct puncture (n = 12) or via an adjacent calix (n = 1). After 3 months, 10 patients were stone-free and had no symptoms. Morbidity consisted of post-operative bleeding (n = 3) and high fever (n = 1). It was concluded that caution should be exercised in the treatment of stone-containing caliceal diverticula. Only in symptomatic cases is treatment indicated and ESWL is the first choice. If ESWL fails (residual stones and persistent symptoms), PNL should be performed, although it is associated with a higher morbidity rate.     

A study on the passage of the upper urinary tract stones after in situ ESWL]

Two hundred patients with upper urinary tract stones underwent in situ ESWL with Lithostar during the recent 20 months at Kanagawa Prefectural Atsugi Hospital. Actual residual stone rates were calculated based on the period from the initiation of the treatment to the stone free status, and discussed according to the location and size of the stone treated. Total 200 patients were submitted to 1.67 +/- 0.97 treatment sessions with 6742 +/- 5545 shock waves. After 3 months, 148 patients (78%) showed stone free status, and 32 patients (16%) had residual stones less than 4 mm. The actual residual stone rates were 90.5%, 66.5%, 39.1%, 26.9% and 17.9% after 1, 3, 6, 12 and 20 weeks, respectively. The residual stone rate were lower in the lower ureter, uretero-pelvic junction, upper ureter, renal parenchyma or diverticulum and renal pelvis or calyx in order. As for the size, the larger the stones the higher the residual stone rates; the therapeutic results were significantly worse in patient group of stones larger than 21 mm compared to the patient group of smaller stones (p less than 1%). The destructed stones were passed gradually up to 6th week after in situ ESWL, however, after that fragments seldom passed out. Therefore, it was concluded that decision on the additional or combination therapeutic intervention, if necessary, should be made after 6 weeks. Combination therapy with endoscopic surgery and/or others was seemingly needed for the patients with stones of more than 21 mm in size and of renal pelvis and renal calyx to improve the rates of stone free.     

Clinical experience with extracorporeal shock wave lithotripsy MFL-5000 for urinary stone

A Dornier MFL 5000, a new generation extracorporeal shock wave lithotripter, was installed in our hospital and the first Japanese clinical experience has been collected between July and November in 1989. We report our experience with the first 35 patients with 45 stones who were treated in 42 treatments using ESWL. We followed up 3 weeks. No invasive anesthesia was performed except 2 cases of epidural anesthesia. A double J catheter was installed in 2 patients, a ureteral catheter in 4 patients, and PNL was performed in 2 patients before ESWL. We did not use a PNL or a TUL in the postoperative treatment. In the 3 week followed up period, 29 patients (82.9%) were completely free from stone fragments. No serious complications were observed after ESWL. We conclude that the DORNIER MFL 5000 is effective for renal and ureteral stones without serious complications.     

Long-term results of percutaneous nephrolithotomy for treatment of staghorn stones

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Short‐term results; as stone‐free and complication rates; of percutaneous nephrolithotomy for treatment of staghorn stones. Long‐term results of PNL; as recurrence rate and differential renal functional changes for treatment of staghorn stones with focus.

OBJECTIVE

? To study long‐term results of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones.

PATIENTS AND METHODS

? The records of patients who underwent PNL for staghorn stones between January 1998 and January 2008 were retrospectively reviewed. ? Patients who completed follow‐up for one year or more were included. Follow‐up with KUB and renal ultrasonography were performed every 3–6 months. ? Renal radioisotopic scan was performed for patients who had already undergone this study before doing PNL.

RESULTS

? The study included 122 patients (69 male and 53 female) with mean age 47.6 ± 14.5 years (5–74). They underwent 126 PNL. ? Perioperative complications were encountered in 28 procedures (22%). The mean period of follow‐up was 3.5 ± 2.3 years (1–11.3). Among 71 stone‐free kidneys, 18 (25%) developed stone recurrence. Of 55 kidneys with residuals at the start of follow‐up, 36 (65%) showed growth of these residuals. ? Preoperative and postoperative renograms were performed for 71 patients. ? At the last follow‐up, differential GFR was stable in 53 (74.5%), improved in 12 (17%) and deteriorated in 6 (8.5%). Among patients with deteriorated renal function, 3 had undergone embolization to control severe bleeding, one developed secondary UPJO, and one had recurrent stone obstructing the kidney.

CONCLUSION

? Long‐term functional results of PNL for staghorn stones are satisfactory as 91.5% of kidneys showed stable or improved GFR. Long‐term follow‐up is mandatory especially for patients with residual stones.     

Study of factors requiring more than two ESWL treatments]

Nine hundred and fifty cases with renal and ureteral stones were treated by extracorporeal shock wave lithotripsy (ESWL) with Siements Lithostar unit from September, 1988 to October, 1990 at Kinki University Hospital. ESWL treatments were performed twice or more on 110 cases (DIFFICULTY GROUP). Ninety-seven cases who were cured by only one ESWL treatment were selected randomly as the control group. The two groups were retrospectively compared to study the factors requiring more than two times of ESWL treatments. There was a significant difference in the time of spontaneous stone discharge before ESWL treatment, the degree of hydronephrosis and the incidence of staghorn calculi as well as middle-lower ureteral calculi between the two groups. There was not a significant difference but a tendency to a longer period of stone existing at the same position and a higher percentage of past history of percutaneous nephrolithotropsy (PNL) in DIFFICULTY GROUP. Because ESWL monotherapy is considered to have limitations, auxiliary procedures or other treatments such as PNL and transurethral lithotripsy are recommended for patients in who in the stones were poorly disintegrated by the first ESWL treatment.     

倒立排石床与常规排石疗法治疗肾下盏结石的疗效对比

目的：观察自行设计的倒立排石床与常规排石法治疗肾下盏结石的疗效差异。方法：选取符合治疗标准的患者160例,包括原位肾下盏结石50例和ESWL后残留肾下盏结石110例。随机分为两组（各80例）分别接受倒立排石床和常规排石疗法的治疗,最长治疗时间为30d,观察结石排出肾下盏的排净率和排净时间。结果：倒立排石床治疗组80例中,56例ESWL后肾下盏残留结石全部排净,排净时间3－6d;24例原位下盏结石有12例排净,排净时间16－21d,12例治疗30d未能排出。常规排石治疗组80例中,54例ESWL肾下盏残留结石有28例排净,排净时间18－30d,26例治疗30d未能排净;26例原位肾盏结石有3例排净,排净时间16－30d,23例治疗30d未能排出。两组ESWL后肾下盏残留结石的排净率和排净时间差异均有显著性意义（P＜0．01）;原位肾下盏结石排净率差异有极显著性意义（P＜0．01）,排净时间差异无显著性意义（P＞0．05）。结论：倒立排石床将倒立疗法器械化,能显著提高ESWL后残留肾下盏结石的排净率,缩短排净时间,从而减少ESWL后结石复发率,亦能提高原位肾下盏小结石的排净率。