影响体外冲击波碎石术疗效的因素分析

目的　探讨影响体外冲击波碎石术(ESWL)疗效的因素。　方法　回顾ESWL治疗尿路结石患者234例的临床资料。分析患者性别、年龄、病程、结石大小、位置、X线形态及合并肾积水情况等因素与治疗成功率的关系。ESWL术后3个月接受KUB、IVU和B超检查,剩余结石<2mm为碎石成功, >2mm为治疗不成功。　结果　234例碎石成功率78. 6% (184 /234)。男性组和女性组治疗成功率分别为80. 3% (122 /152)和75. 6% (62 /82),P>0. 05。治疗不成功组与成功组病程分别为(1262. 6±1742. 1)d、(722. 9±1364. 6)d,P>0. 05;结石直径分别为(1. 1±0. 6)cm、(1. 0±0. 4)cm,P>0. 05;年龄分别为(58. 8±13. 6)岁、(42. 8±12. 2)岁,P<0. 05。肾盂结石(22. 7%, 10 /44)与肾盏结石(40. 0%, 8 /20),肾盂结石与输尿管结石( 18. 8%, 32 /170 ),输尿管上段结石( 15. 8%, 18 /114)与下段结石(25. 0%, 14 /56)间不成功率比较,差异无统计学意义(P>0. 05)。均匀高密度结石(20. 0%, 6 /30)与杂色结石(21. 6%, 44 /204)不成功率两组比较差异无统计学意义(P>0. 05)。结石直径0. 3~1. 0cm者(1. 9%, 2 /108), 1. 0 ~2. 0cm者(29. 8%, 28 /94), >2. 0cm者(62. 5%, 20 /32)不成功率3组两两比较P<0. 05。结石大小与治疗剂量呈正相关(r=0.28,P=0. 006)。     

The clinical efficacy of outpatient extracorporeal shock wave lithotripsy

From March 1989 through December 1989, 123 patients, 9 to 78 years old, were treated by extracorporeal shock wave lithotripsy (ESWL) with the Wolf Piezolith device. Outpatient treatment was performed routinely. Anesthesia was not required in all of the patients. No analgesia or sedation was given routinely. When pyuria had been found before treatment, a course of prophylactic oral antibiotics was given. Treatment consisted of 2000 to 6000 shocks in adults. The need for re-treatment was decided on the basis of the follow up X-rays. Fragmentation into particles 5 mm in size or less occurred in 144 of the 149 renoureteral units (96.6%). Unfragmented stones were treated successfully by the combination therapy of ESWL and fiberoptic transurethral nephroureterolithotripsy (f-TUL). Of 144 renoureteral units, 3-month follow-up data are available for 96. Among the 96 units, the rate of being free of stones was 67 per cent for renal stones and 96 per cent for ureteral stones treated in situ. The over-all rate of being free of stones was 80.2 per cent. There were no significant complications. Ultrasound imaging has proved to be as effective as X-ray imaging. Outpatient ESWL with the Wolf Piezolith device is considered to be safe and efficient for the initial treatment of urinary stones. On the other hand, ESWL monotherapy is not sufficient for the treatment of complete staghorn calculi or long-term impacted ureteral calculi. We think that the combination use of ESWL and f-TUL is the most effective procedure for treatment of complicated stones.     

Analgesia for shock wave lithotripsy

PURPOSE: We evaluated the effectiveness of and patient preference for analgesia used during shock wave lithotripsy by comparing diclofenac alone with a combination of diclofenac and patient controlled analgesia, that is alfentanil. MATERIALS AND METHODS: A total of 64 patients were treated using a Lithotriptor S (Dornier Medical Systems, Marietta, Georgia) and randomized to receive diclofenac alone or combined with an alfentanil patient controlled analgesia pump. If treated twice, they crossed over to the alternative form of analgesia. A record was maintained of the site and size of the stone, maximum power achieved, number of shocks, amount of alfentanil used and need for additional analgesia. After treatment patients scored on a visual analog scale the maximum level of pain and satisfaction with analgesia. RESULTS: There was no difference in the mean size of the stone treated (8.6 and 7.5 mm.), energy level (71% and 71% or approximately 17 kV.) or number of shocks (3,000 and 2,900, respectively) in the groups. Only 2 patients in the diclofenac group required additional analgesia and there were no significant side effects from either treatment. The mean pain scores were not significantly different in the diclofenac and patient controlled analgesia groups (3.54 and 2.93, respectively, (p = 0.34), although those on patient controlled analgesia were more satisfied (7.72 versus 9.14, p = 0.04). Of the 38 patients who presented twice 58% preferred diclofenac alone. CONCLUSIONS: This study suggests that there is no significant difference in the level of pain experienced with diclofenac alone or when combined with an alfentanil patient controlled analgesia pump during shock wave lithotripsy. However, patients are more satisfied with treatment when a patient controlled analgesia pump is available.     

Anaesthesia for extracorporeal shock wave lithotripsy

The anaesthetic considerations of patients presenting for extracorporeal shock wave lithotripsy are described. Regional anaesthesia with sedation may be preferable to general anaesthesia for patients undergoing this form of therapy. If regional anaesthesia is contra-indicated, general anaesthesia using controlled ventilation with muscle relaxation, supplemented with a narcotic and a low concentration of volatile anaesthetic has been found to be a suitable alternative. The additional epidural preparation time has to be balanced against the benefits of easier patient transfer, especially during multi-stage procedures, and better postoperative analgesia. The epidural catheter can be left in situ in patients who require multiple treatments or who may experience severe ureteric pain as the resulting 'sand mass' is passed. Epidural space localisation using a 'loss of resistance to saline' technique is recommended, in order to avoid the possible risk of damage to the spinal cord and emerging nerves (due to the presence of an air-water interface). Patients with cardiac insufficiency need special consideration, in view of the effects of immersion on right and left heart filling pressures.     

Extracorporeal shock wave lithotripsy

Urolithiasis represents the symptomatic manifestation of various metabolic disturbances which persist after elimination of the immediate problem, i.e., urinary stones, and may lead to the development of recurrent stones. Invasive surgical removal of recurrent stones is sometimes associated with considerable problems. Against this backdrop it is not surprising that after development (1974-1980) and clinical testing (1980-1982) at the Department of Urology of the Ludwig Maximilian University in Munich, a meanwhile clinically proven method of totally noninvasive extracorporeal lithotripsy (ESWL) has disseminated within a relatively short time (from October 1983), first in West Germany (April 1986: 20 ESWL centers) and later all over the world (April 1986: 133 ESWL centers). With the advent of ESWL and semiinvasive techniques of stone extraction (percutaneous lithotripsy, ureterorenoscopy) a transformation of the therapeutic strategy for urolithiasis has been ushered in.     

Extracorporeal shock wave lithotripsy for upper urinary tract stones using piezoelectric shock wave lithotripsy]

Between August 1999 and July 2000, 123 cases of renal stones and 52 cases of ureteral stones in 116 males and 59 females were treated with the New Piezolith 2500. The average number of sessions required for renal and ureteral stones was 2.50 and 1.48, respectively. At 3 months postoperatively, stone-free rates for renal and ureteral stones were 64.2% and 72.7%, respectively. Assessing residual stones less than 4 mm in diameter as an effective treatment outcome, the efficacy rates for renal and ureteral stones were 94.3% and 86.4%, respectively. Side effects were encountered in 5 cases (2.9%) of high fever and one case (0.57%) of renal subcapsular hematoma. New Piezolith 2500 is effective and safe for the treatment of upper urinary stones.     

Laser-induced shock wave lithotripsy

Summary With a high intensity Q-switched Nd-YAG laser shock waves can be generated in a liquid close to the calculus. Up to 80 mJ single pulse energy with 8 nsec pulse duration can be transmitted through flexible quartz fibers. Energy conversion and enhancement can be accomplished at the fiber tip with optical focussing of the light at the quartz tip, with irrigation solutions and with high pulse energies. Iron-III-dextran solutions (1 mg Fe³⁺/1) and magnesium chloride (50 mmol/l) increased the pressure in the laser induced breakdown up to ten times (8,000–10,000 bar). Smaller stone particles and higher efficacy in stone fragmentation could be achieved.     

Biliary extracorporeal shock wave lithotripsy: the efficacy and safety of concomitant catheter cholecystostomy during biliary lithotripsy

The major limitations of biliary extracorporeal shock wave lithotripsy (ESWL) relate to adequate stone fragmentation and clearance of the stone fragments. We hypothesized the removal of small fragments with concomitant catheter cholecystostomy during ESWL would improve its efficacy. ESWL with aspiration or flushing through three different cholecystostomy catheters was performed on pigs with surgically implanted gallstones. Twenty-two percent and 46% of the pre-ESWL stone weight were aspirated through the 10 and 12 French catheters respectively. The clearance, size, and visualization of fragments was not significantly different between any of the groups. No significant post-mortem tissue or catheter damage was found. Catheter aspiration is a safe and effective method of removing gallstone fragments during biliary ESWL, but it does not improve stone fragmentation, stone clearance, or visualization of other fragments.     

Effect of air bubbles in the coupling medium on efficacy of extracorporeal shock wave lithotripsy

OBJECTIVES: Replacement of the water bath by a water cushion in newer lithotriptors introduces an acoustic interface and an ideal coupling agent is required to prevent energy loss at this interface. We aim to study the effect of bubbles in the coupling media on efficacy of extracorporeal shock wave lithotripsy (ESWL) by an in vitro experiment. METHODS: Using a standardised in vitro model 40 artificial stones were randomly treated on Modulith SLK lithotriptor using either conventional ultrasound gel (high bubble content) before and after displacing visible bubbles, a thin ultrasound gel (Therasonic) or silicon oil (both with negligible bubbles). Percentage area covered by bubbles in each case and the diameters and depth of crater created in each stone were measured by two blinded observers to determine the correlation between the bubble contents and disintegration efficacy. In vivo effect of two ultrasound gels was compared in terms of pain scores and stone fragmentation rates in ten patients treated with both gels. RESULTS: Volume of the craters was significantly greater with the Therasonic gel (102.4+/-33.4 mm3) or silicon oil (98.8+/-9.8 mm3) than the conventional ultrasound gel (49.2+/-32.6 mm3). But it was greatest (p<0.001) with ultrasound gel without bubbles (163.5+/-22.6 mm3). Depth and volume of the stone crater increased significantly with decreasing bubble contents of gel (p<0.001). Compared to standard ultrasound gel, patients treated with Therasonic gel reported significantly higher pain scores (median 3.5 vs. 8.0; p<0.001). CONCLUSIONS: Efficacy of ESWL is significantly correlated to air bubbles within the coupling gel and can be improved significantly by eliminating the bubbles from the coupling medium.     

Improved acoustic coupling for shock wave lithotripsy

Previous in vitro studies of acoustic coupling in shock wave lithotripsy (SWL) have shown that air pockets trapped at the surface of the treatment head significantly reduce transmission of shock wave (SW) energy to the focal zone of the lithotripter, reducing the effectiveness of stone breakage. Since there are no reliable means to monitor the quality of coupling during SWL, we looked for a practical protocol to improve how coupling is achieved. In vitro studies were performed using a Dornier DoLi-50 lithotripter. LithoClear^TM gel was used to couple the treatment head to the acoustic window of a clear acrylic test tank. Numerous methods of applying gel were tested including common sense variations of routine protocols typically used with patients. For each method the coverage of air pockets (% defects) was determined using digital imaging. Different coupling regimes were tested for effect on the breakage of gypsum model stones. The quality of acoustic coupling was affected by how the gel was handled—how it was dispensed and applied, and whether the gel was applied only to the treatment head or to both the lithotripter water cushion and the test tank (surrogate patient). Dispensing gel from a squeeze bottle for application by hand created significantly more defects than when a large volume (∼250 ml) of gel from the stock jug was applied as a mound to just the treatment head (26.5 ± 2.7 vs. 1.2 ± 0.5% defects, P < 0.001). The efficiency of stone breakage was better when gel was applied from the stock jug compared to application by hand (P < 0.006). Poor coupling was substantially improved by using the inflation feature of the water cushion to collapse air pockets, but this strategy was not a substitute for establishing good coupling at the outset. The quality of coupling in shock wave lithotripsy can be improved by minimizing the handling of the coupling medium. Hand application of coupling gel is clearly not the best way to prepare for lithotripsy. Better results can be obtained by delivering lithotripsy gel as a bolus to the treatment head alone, and allowing it to spread upon contact between the treatment head and the skin. These in vitro tests also suggest that the inflation feature of the lithotripter may be useful in reducing defects in coupling.     

体外震波碎石治疗肾结石

本院于１９９７年８月至２００１年８月，用德国DonrnierCompacts碎石机治疗肾结石８０２例，取得满意的疗效。现报告如下。资料与方法１．对象：８０２例肾结石门诊病人，男５４７例，女２５５例；年龄１９～６７岁（平均４３．４岁）；其中单侧５７３例，双侧２２９例。２．方法：所有病人在碎石前均进行KUB＋IVP检查，部分病人还作尿培养＋药敏，肾脏B超或CT等。病人在碎石治疗后３天行KUB或B超检查，若结石散开不够完全，则再次ESWL。按照结石的大小，将所有病人分为３组：Ⅰ组：直径≤０．８cm，１９６例；Ⅱ组：０．９～１．…     

Extracorporeal shock wave lithotripsy for biliary stones

Extracorporeal shock wave lithotripsy is a noninvasive technique for treatment of patients with gallbladder and bile duct stones. Selected patients with gallbladder stones can be treated on an outpatient basis without general anesthesia and may return to full activity within 1 or 2 days. Stone-free rates of 40% to 60% at 6 months have been achieved in most reported series with minimal morbidity. Bile duct stone lithotripsy has achieved stone clearance in 80% of patients in whom conventional methods were unsuccessful and therefore constitutes a valuable second-line treatment for these patients.     

Extracorporeal shock wave lithotripsy for choledocholithiasis]

By the advent of extracorporeal shock wave lithotripsy (ESWL), the plan to manage choledocholithiasis has changed greatly. As a non-operative treatment, endoscopic sphincterotomy (EST) is intensively performed, but ESWL is much safer than EST in invasiveness and complications. Without EST, 5 Fr endoscopic naso-biliary drainage (ENBD) and percutaneous transhepatic biliary drainage (PTBD) aiming at preservation of the function of the papilla Vater were inserted to make drainage first for the patients with choledocholithiasis with obstructive jaundice who visited our hospital. After the cholangitis subsided, ESWL was performed under the direct cholangiography through ENBD and PTBD and excellent results were obtained which are herein reported. ENBD has been performed on 98 cases of choledocholithiasis over the past 4 years. ESWL has been performed on 42 cases (ENBD 36 cases and PTBD 6 cases). Choledocholithiasis completely disappeared in 31 cases (73.8%). For unsuccessful cases, EST, percutaneous transhepatic cholangioscopy (PTCS), or laparotomy was performed.