Outpatient extracorporeal shock-wave lithotripsy

Extracorporeal shock-wave lithotripsy (ESWL) is a new procedure for which patient-management guidelines are still being established. We retrospectively reviewed the first 246 patients treated with ESWL at our facility. Nearly 50 per cent were treated as outpatients, and more than 70 per cent of patients admitted to the hospital were discharged on the first day after ESWL. We conclude that outpatient ESWL is feasible, but that further study is necessary to improve selection of patients for this procedure.     

Extracorporeal shock-wave lithotripsy in horseshoe kidneys

Using the Dornier HM-3 lithotriptor, 10 patients (11 renal units) with calculi in horseshoe kidneys were treated with extracorporeal shock-wave lithotripsy (ESWL) and ancillary procedures. Six renal units (55%) underwent pre-ESWL manipulation consisting of a Double J stent, ureteral catheter, or percutaneous nephrostomy. The "blast path" was employed to treat five renal units which could not be positioned at F2. Good initial stone fragmentation was obtained in eight renal units (73%). There were two episodes of post-ESWL obstruction requiring intervention; both occurred in the same patient. A total of seven post-ESWL procedures were performed on two renal units. After all procedures, eight renal units (73%) were rendered stone-free, six (55%) with ESWL alone. The average follow-up interval was twelve months (range 1-28 months). ESWL can be used effectively to treat some patients with calculi in horseshoe kidneys. The ectopic location of these renal units may make it difficult to position calculi at F2, thus necessitating treatment on the blast path or placement of the patient in prone position. Multiple ancillary procedures may be necessary.     

Experience with extracorporeal shock-wave lithotripsy (ESWL) for urinary calculi

Over a 36-month period 2800 patients were subjected to extracorporeal shock-wave lithotripsy (ESWL). A total of 5154 procedures were done. Best results were seen with renal pelvic calculi (not larger than 2.5 cm in diameter). Fragments of crushed lower calyceal calculi proved the most difficult to eliminate. As ureteral stone localization approached the bladder, the ESWL results were poorer. Post-ESWL complications were proportional to the stone mass; the higher the mass the more numerous the complications tended to be. Besides erythrocyturia and gross haematuria renal colic was the most frequent complication in almost 60% of the patients. Less prevalent were impacted ureteral stones, subcapsular haematoma and fever. At our institution, thanks to the ESWL method about 80% of the patients were spared surgery.     

Cost-effectiveness of extracorporeal shock-wave lithotripsy

A study was done comparing the charges and outcomes for extracorporeal shock-wave lithotripsy (ESWL) with those for percutaneous nephrostolithotomy (PCN), which was the treatment of choice at our hospital for stones of the upper urinary tract when ESWL was introduced. Using a retrospective cohort design, patients were matched for age, sex, physical status index (American Society of Anesthesiologists), stone size, and urinary tract obstruction. Twenty-nine pairs of PCN and ESWL patients with complete data were matched. The groups were not significantly different in the matching parameters. Seventy-two per cent of patients in each group (21/29) were stone-free after the initial hospitalization. PCN patients required more auxiliary procedures per patient than did the ESWL patients; in addition, 5 (17%) of the PCN patients had perforation of the renal pelvis and 5 (17%) required transfusions. On discharge, 48 per cent (14/29) of the PCN patients had nephrostomies compared with none of the ESWL patients. The ESWL group had a shorter mean length of stay (2.9 vs 8.7 days, p less than 0.0005) and lower charges in all categories. Total charges were significantly less for ESWL ($9,290 vs $11,796 for PCN, p less than 0.005) as were physicians' fees ($3,391 vs $5,607, p less than 0.0005), room and board charges ($825 vs $2,164, p less than 0.0005), and operating room fees ($313 vs $1,452, p less than 0.0005). We conclude that ESWL is a cost-effective means for treating stones of the kidney and upper urinary tract.     

Experience with extracorporeal shock-wave lithotripsy of upper urinary tract stones

The first 121 cases of upper urinary tract stone treated by extracorporeal shock wave lithotripsy (ESWL) at our clinic were analyzed. Three months after ESWL, 78% of the patients became stone free, and 17% of the patients had residual stone fragments which were less than 5 mm in diameter and considered passable. The success rate was therefore about 94.6%. No severe side effects were observed, although temporary elevations in serum creatinine phosphokinase, lactate dehydrogenase, glutamic-oxaloacetic transaminase, aldolase and total bilirubin occurred. These results indicated that ESWL was a safe and effective procedure for upper urinary tract stones.     

Dornier extracorporeal shock-wave lithotripsy for ureteral stones

Most investigators think that ESWL is the preferred method for treating calculi in the upper ureter--that segment proximal to the superior margin of the iliac crest. Ureteroscopic manipulation, percutaneous antegrade manipulation, and open ureterolithotomy are secondary choices. The treatment of calculi in the lower ureter--that segment between the upper border of the iliac crest and the ureterovesical junction--is somewhat controversial. Most urologists favor ureteroscopic manipulation: small stones can be extracted, while larger stones can be fragmented with ultrasonic, electrohydraulic, or even laser lithotripsy. However, manipulation in the presacral ureter is more difficult than in the juxtavesicular ureter, and all stones are not amenable to ureteroscopic management. Our experience at the University of Virginia led us to use ESWL for lower ureteral stones when ureteroscopic manipulation fails or cannot safely be accomplished or when patients refuse cystoscopy. Juxtavesicular stones are treated with a minor modification (sitting position) of standard supine ESWL, whereas presacral stones are treated with prone ESWL.     

Treatment of staghorn calculi by extracorporeal shock-wave lithotripsy in children]

To evaluate the efficacy of monotherapy with extracorporeal shock-wave lithotripsy (ESWL) for staghorn calculi in children. Material and methods: Between September 1987 and December 1998, 27 children (18 boys and 9 girls) with a mean age of 5.2 years (9 months to 147 years) were managed in our department for staghorn or pseudo-staghorn calculi. They were treated with a Lithostar Siemens-Ultra lithotriptor ith ultrasound detection. The "Puigvert method", which starts with low energy which is then gradually increased, allows satisfactory painless fragmentation, avoiding the need for general anaesthesia. RESULTS: the success rate was 70% with two sessions (37% with a single session). In one case, lithotripsy was not indicated and percutaneous nephrolithotomy was necessary. Two cystine stones ina girl (probably longstanding stones) could not be fragmented and open surgery was required. The other five systine staghorn calculi ere treated successfully. Ureteral catheterization was not required and only one double J stent was placed preventively in a girl with a solitary kidney. No major complication was detected. CONCLUSION: ESWL with the Siemens-Ultra lithotriptor is a safe and effective first-line method for the treatment of staghron calculi in children.     

Nephrolithotomy in childhood by extracorporeal shock-wave lithotripsy

Extracorporeal shock-wave lithotripsy (ESWL) performed on 19 occasions in 6--15-year-old nephrolithic children is reported. The stones were present in the calyceal ends in the renal pelvis. The possibilities of treatment and its effects were examined by urography, ultrasound, camerarenography and magnetic resonance imaging procedures. After three months 13 children are free of stones.     

Practical aspects of outpatient extracorporeal shock-wave lithotripsy

Outpatient ESWL is practical for the majority of patients undergoing treatment. However, careful preoperative evaluation and patient selection are necessary. Approximately 15 per cent of patients treated require a secondary procedure. We believe that pretreatment placement of a ureteral stent aids in the passage of stone fragments.     

Large perirenal hematoma after extracorporeal shock-wave lithotripsy

We report a case of a large perirenal hematoma following extracorporeal shock-wave lithotripsy (ESWL) that resulted in compromised renal blood flow and function and necessitated open surgical drainage. Caution is advised and close follow-up recommended in patients who have taken aspirin-containing compounds, are elderly, have hypertension, or exhibit a significant drop in hematocrit following ESWL.     

Ureteral stenting with extracorporeal shock-wave lithotripsy.

We reviewed the results of ureteral stent use with extracorporeal shock-wave lithotripsy (ESWL) in 3,096 patients with renal calculi less than 3 cm in diameter. The 2,595 patients with indwelling ureteral stents required lower total power (shocks x voltage) and less radiation and had a lower secondary procedure rate but a higher retreatment rate than the 501 patients without stents. However, the only statistically significant difference was in the average radiation dose in patients with or without stents and single stones no larger than 10 mm (16 vs. 18 rad). The hospital stay was one day or less in 98 percent of the patients in both groups. With an 80 percent follow-up rate at three months indwelling ureteral stents were associated with a higher stone-free rate in patients with a single stone but a lower stone-free rate in patients with multiple stones, compared with those treated without a stent. An indwelling ureteral stent may result in urinary frequency and bladder discomfort in some patients, and with no statistical difference in the results with or without a ureteral stent it is questionable whether or not the high use of an indwelling ureteral stent is justified in patients admitted for one day or less.     

输尿管镜气压弹道碎石术与ESWL治疗输尿管结石的疗效比较

目的:比较输尿管镜气压弹道碎石术(URSL)与ESWL治疗输尿管结石的疗效及副作用。方法:分别使用URSL与ESWL治疗输尿管结石患者各200例,治疗后应用腹部平片或B超评估其疗效,随访3个月,了解结石清除率,观察并记录治疗后并发症。结果:URSL有效率为91.5%,明显高于ESWL治疗者的总有效率73.5%(P<0.01);其中上段结石有效率87.72%,低于ESWL的93.33%(P<0.05),中下段结石有效率93%,明显高于ESWL的65%(P<0.01);其肾绞痛、恶心、呕吐、发热低于后者(P<0.05)。接受URSL的患者1.5%有输尿管穿孔。结论:URSL治疗输尿管结石的疗效优于ESWL;URSL较适合于输尿管中、下段结石的治疗,而ESWL较适合于输尿管上段结石的治疗。     

Renal pelvic pressures during extracorporeal shock-wave lithotripsy

Renal pelvic pressures were studied in 4 patients with indwelling nephrostomy tubes undergoing extracorporeal shock-wave lithotripsy (ESWL). The pressures were monitored by attaching the patients' nephrostomy tubes to an electrical pressure transducer. Three of these patients had ureteral stents placed to prevent outflow obstruction from disintegrated stone fragments. The mean pelvic pressure increased from 17.0 cm H2O at the start to 52 cm H2O at the conclusion of ESWL. Two hours post-ESWL, the pressures declined to a mean of 27.0 cm H2O. The maximum pelvic urine volume as determined by aspirating the nephrostomy tubes at the conclusion of the procedure was 6 cc. The observed rise in pelvic pressure may be explained by a sustained contraction of the pelvic smooth musculature.     

Extracorporeal shock-wave lithotripsy for stones in solitary kidney

Twelve extracorporeal shock-wave lithotripsy (ESWL) treatments were performed on 10 patients with a solitary kidney. Nine patients had a ureteral stent placed pretreatment. Nine patients were available for follow-up. Seven (78%) were stone free or had insignificant fragments at three months. Complications were seen in 4 patients, including two instances of pyelonephritis. Failures were associated with an increased stone burden. ESWL is an effective and safe treatment for upper urinary tract stones in patients with a solitary kidney. We recommend pretreatment stenting in patients with a solitary kidney.     

Side effects of extracorporeal shock-wave exposure in patients treated by extracorporeal shock-wave lithotripsy for upper urinary tract stone

The side effects of shock-wave exposure on patients treated by extracorporeal shock-wave lithotripsy were analyzed by measuring chemical substances including cell-escaped enzymes in the blood and urine. Free hemoglobin, glutamic oxaloacetic transaminase (GOT) and lactate dehydrogenase (LDH) increased as a function of shock-wave count. Total bilirubin, GOT and LDH reached a peak on the 1st postoperative day and decreased to pretreatment values by the 4th day. Creatine phosphokinase and myoglobin also significantly increased on the 1st postoperative day but returned to pretreatment levels by the 4th day. The urinary ratio of N-acetyl-beta-d-glucosaminase to creatinine significantly increased after treatment and was still high on the 4th day. These results suggest that significant hemolysis and myolysis developed owing to shock-wave exposure, and that the kidney was damaged to some extent. Therefore, these side effects must be taken into account in determining the dose and frequency of treatment.