Extracorporeal shock wave lithotripsy of proximal and distal ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of 105 patients with ureteral stones. There were 77 stones in the upper part of the ureter, i.e. above the pelvic brim, and 28 in the lower part, i.e. below the sacroiliac joint. Successful fragmentation was attained in 101 (96%). In 93% of the patients with stones in the upper ureter and in 100% with stones in the lower ureter the fragments were eliminated completely. In 87% of the patients with stones in the upper ureter, a ureteral catheter was introduced under local anesthesia but without fluoroscopic control. It was thereby possible to remove 30% of the stones from the ureter to the kidney. For the remaining stones, saline was infused through the catheter during ESWL. For patients with stones in the lower part of the ureter, a ureteral catheter was passed in 79% and saline infused during treatment. Whereas some form of anesthesia was used for treatment of all upper ureteral stones, 89% of the treatments for lower ureteral stones were performed without anesthesia. Auxiliary procedures after ESWL were limited to four ureteral catheter manipulations for distal stones. Four proximal stones which remained unaffected by ESWL had to be treated by open surgery (3 stones) or percutaneous surgery (1 stone). Of 82 ureteric stones treated in situ the success fragmentation rate was 95%. The average number of ESWL sessions was 1.04 for both proximal and distal ureteral stones.     

经尿道输尿管镜联合体外震波碎石治疗输尿管结石256报告

目的探讨输尿管镜联合体外震波碎石（extracorporeal shock wave lithotripsy，ESWL）治疗输尿管结石的价值。方法2005年10月-2007年6月采用输尿管镜联合ESWL治疗输尿管结石256例，中段（56例）及下段（170例）结石用输尿管镜取石，上段（30例）结石用ESWL碎石，输尿管镜取石失败或结石残留联合ESWL治疗。结果输尿管下段结石一期结石清除率98．2％（167／170），中段结石一期结石清除率89．2％（50／56），上段结石一期结石清除率73．3％（22／30）。输尿管穿孔3例，输尿管黏膜撕脱1例，结石远端输尿管扭曲进镜致使尿管穿孔改切开取石1例，输尿管镜取石失败或结石残留联合ESWL治疗二期结石清除率91．7％（11／12）。结论输尿管镜治疗输尿管下段及中段结石成功率高，输尿管镜取石失败或结石残留联合ESWL可提高二期结石清除率。     

Extracorporeal shock wave lithotripsy for ureteral calculi.

Second generation tubless lithotriptors allow for easy prone positioning of patients, resulting in increased use of extracorporeal shock wave lithotripsy (ESWL) for calculi in the ureter, especially in the mid and lower third portions. The 3-month stone-free rate with single stones using a Dornier HM3 and a Medstone STS lithotriptor in the upper ureter was 79% (316 patients) and 81% (188), respectively, while in the mid ureter it was 60% (20 patients) and 81% (32), respectively, and in the lower ureter it was 80% (5 patients) and 85% (26), respectively. The retreatment rate with single stones using the Dornier HM3 and the Medstone STS devices was 5% and 4%, respectively, in the upper ureter, 13% and 12%, respectively, in the mid ureter, and 0% and 5%, respectively, in the lower ureter. The second procedure rate after ESWL with single stones using the Dornier HM3 and the Medstone STS units was 6% and 6%, respectively, in the upper ureter, 15% and 16%, respectively, in the mid ureter, and 0% and 17%, respectively, in the lower ureter. Expectant management is still an acceptable method to treat small ureteral stones, and it is questionable whether ESWL is the appropriate treatment for lower third ureteral stones compared to equally effective and less expensive ureteroscopy.     

Extracorporeal shock wave lithotripsy in the prone position: treatment of stones in the distal ureter or anomalous kidney

A total of 15 patients underwent ESWL using the Dornier HM3 lithotriptor with the patient in the prone position. The stones were in the distal ureter over the sacroiliac joint in 10 patients, 8 of whom had undergone unsuccessful ureteroscopic manipulation. Two patients had horseshoe kidneys with stones that were too anterior to permit accurate targeting with the patient in the standard supine position. One patient had a solitary stone in a pelvic kidney and 1 had an obstructing ureteropelvic junction stone in a crossed ectopic kidney. The final patient had a reconstructed lower urinary tract with a stone at 1 of the ureterointestinal anastomoses. Excellent pulverization was achieved in all patients after only 1 prone ESWL treatment. One patient required temporary percutaneous nephrostomy after ESWL and 1 may require retrograde manipulation of fragments at the ureterovesical junction. No patient had melena, and other than temporary ileus in 1 patient who had concurrent supine ESWL of renal calculi, no gastrointestinal complications were seen. All but 1 patient were free of stones 1 month after prone ESWL. Prone ESWL prevents blockage of shock wave energy by the bony pelvis, because the shock waves enter anteriorly and exit posteriorly. ESWL with the patient in the prone position is a safe and effective treatment of calculi in the distal ureter or anomalous kidney.     

Evaluation of the results of extracorporeal shock-wave lithotripsy (ESWL) for solitary upper urinary tract stone

At Osaka City University Hospital, we performed extracorporeal shock-wave lithotripsy (ESWL) for 1277 patients in a total of 1788 sessions using Dornier kidney lithotripter Model HM III from July, 1985 to the end of December, 1988. Among the patients with a solitary stone, 911 cases were available for the follow-up study and we have compared the results among these cases in respect to the stone location and size. The results obtained were as follows: the ratio of kidney stone to ureter stone was found to be 2.2:1 in male, and 3.8:1 in female patients. This indicates that ureter stones are more frequently found in male than in female patients. In addition, we compared the size of kidney stones found in the patients including 415 male and 243 female patients. Stones larger than 20 mm were more frequently found in female than in male patients. Moreover, a stone composition study of these patients showed that the contents of both phosphate calcium and magnesium ammonium phosphate were higher in female than in male patients. ESWL performed against stones at pelvis and calyces exhibited the best results. The results obtained with the stones less than 20 mm in diameter were especially favorable with a success rate of 100% for the stones less than 10 mm and 83% for the stones 10-20 mm, in diameter, while the results with the stones larger than 20 mm in diameter were rather poor with a success rate of 31%. ESWL performed against ureter stones showed poor results with a success rate of 63% for the stones smaller than 20 mm in diameter.     

Comparison of transurethral ureteroscopy and extracorporeal shock wave lithotripsy for treatment of ureteral calculi

Ureteral calculi were treated by transurethral uretereoscopy and extracorporeal shock wave lithotripsy (ESWL), and the results were compared. Rigid transurethral ureteroscopy was performed in 50 patients, and 10 of 22 stones located in the upper ureter and 25 of 29 stones located in the lower ureter were successfully extracted. On the other hand, we treated 88 patients with upper ureteral stones by ESWL and achieved a success rate of 89.8%. We therefore conclude that for upper ureteral stones, ESWL is the more effective treatment and, for lower ureteral stones, transurethral ureteroscopy.     

Evaluation of the results of extracorporeal shock-wave lithotripsy (ESWL) for solitary upper urinary tract stone]

We performed extracorporeal shock-wave lithotripsy (ESWL) on 1,701 patients in a total of 2,438 sessions using the Dornier kidney lithotriptor Model HM III from July 1985 to the end of June 1990. Among the patients with a solitary stone, 1,200 cases were available for the follow-up study in which the results of ESWL were analyzed according to the location and size of the stone. ESWL performed against stones at pelvis and calyces gave the best results. The results obtained on stones less than 20 mm in diameter were especially favorable with a success rate of 84%. ESWL performed against ureter stones showed poor results with a success rate of 62% for the stones smaller than 20 mm in diameter. We further studied the results of ESWL performed against ureter stones by dividing the patients into three groups: the patients treated in situ, the patients with ureteral stents and the patients with D-J stents. The results for stones larger than 10 mm in diameter were significantly better in the patients with D-J stents than in the patients treated in situ or the patients with ureteral stents. Among the patients treated in situ, the results were significantly worse for impacted stones than for non-impacted stones when the stone size was 10-20 mm in diameter.     

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.     

Extracorporeal shock wave lithotripsy in the prone position for stones situated anteriorly

Stones situated anteriorly cannot be satisfactorily reached with extracorporeal shock wave lithotripsy (ESWL) in the supine position. By assuming the prone position, patients with stones in horseshoe or ectopic kidneys or in the iliac ureter can be treated by ESWL with the same success rate as patients with posterior stones. This new technique has been used in 30 patients with iliac ureteral stones, 5 patients with caliceal stones in horseshoe kidneys and 1 patient with a pyelic stone in a sacral kidney.     

Does a slower treatment rate impact the efficacy of extracorporeal shock wave lithotripsy for solitary kidney or ureteral stones?

PURPOSE: We compared the efficacy of an SR (70 to 80 shocks per minute) and an FR (120 shocks per minute) for ESWL for solitary stones less than 2 cm located in the kidney or proximal ureter. MATERIALS AND METHODS: A total of 349 patients with a solitary, radiopaque kidney or ureteral stone underwent ESWL on a DoLi(R) 50 lithotriptor. Patients were grouped based on stone size, stone location and whether SR or FR treatment was performed. Of the 349 patients 135 had a renal stone between 1and 2 cm, 137 had a renal stone less than 1 cm and 77 had a proximal ureteral stone with a surface area of between 30 and 90 mm. SFRs were determined at approximately 1 month by plain x-ray of the kidneys, ureters and bladder. RESULTS: In comparison to the FR groups SR groups required fewer shocks and had significantly lower power indexes. Of patients with renal stones between 1 and 2 cm 24 of 52 (46%) in the FR group were stone-free compared to 56 of 83 (67%) in the SR group (p <0.05). For stones with a surface area of 30 to 90 mm located in the kidney or proximal ureter there was a trend toward an improved SFR in the SR group but differences between the SR and FR groups were not statistically significant. CONCLUSIONS: For solitary renal stones between 1 and 2 cm an SR results in a better treatment outcome than an FR for ESWL. However, when stone size is less than 1 cm, SFR differences in the SR and FR treatment groups become less significant.     

Lithotripsy in the treatment of urinary lithiasis

Based on an extensive review of the literature and on our own clinical experience, this article attempts to present clear guidelines for the management of various kidney stones, particularly regarding the extracorporeal shock waves lithotripsy (ESWL) treatment nowadays. Few technical developments have changed medicine more within a short period of time than ESWL. Fifteen years after the first clinical application, ESWL has gained world-wide acceptance as first choice therapy for most forms of urolithiasis. Ninety-eight per cent of stones can be successfully fragmented by the application of shock-waves, but the ability of the kidney and ureter to clear the resulting fragments is far more important in terms of successful treatment outcome. Increasing experience with new ultrasound-guided lithotriptors has shown that there are some advantages: cost reduction, permanent monitoring and lack of exposure to ionising radiations. ESWL is a safe procedure for the treatment of urolithiasis; nevertheless some problems remain. In ureteric stones, ureteroscopy (rigid or flexible device) allows a rate of stone-free patients better than ESWL. For treatment of large staghorn calculi combined approach of PCNL and ESWL is preferred. For stones located at lower calyx, the stone-free rate in patients treated by ESWL fell to 50%, when unfavourable anatomy is present. The potential long-term renal damage, associated with ESWL in children, have delayed the acceptance of shock-waves into paediatric practice. Recent reports suggest that the renal damage, including the potential risk of hypertension induced by ESWL, is mild and transient. A subgroup of patients (e.g. solitary kidney, impaired renal function, children) required further attention. The fate of residual fragments is unclear. In some cases residual lithiasis tend to result in regrowth and further progression, although ESWL itself does not increase the recurrence rate of urolithiasis. Nevertheless follow-up of stone patients after ESWL is mandatory and the ultimate goal of treating stones by whatever means is to get the patient stone-free and prevent recurrence.     

Extracorporeal shock wave lithotripsy with EDAP LT-01 lithotriptor

Extracorporeal shock wave lithotripsy (ESWL) by EDAP LT-01 was used to treat 77 patients with upper urinary tract stones. A total of 218 sessions were performed for 111 stones in 52 kidney units and 41 stones in 37 upper ureter units, and 77% of the 52 kidney stone units and 62% of the 37 ureter units were completely disintegrated. The success of fragmentation of kidney stones differed with the size of the stone, 96% of the stones less than 21 mm and 63% of the 8 stones between 21 and 30 mm were successfully fragmented. The success of fragmentation of ureteral stones differed auxiliary manipulation. Eighty-one percent of the 21 ureteral stones moved into the kidney, were successfully disintegrated, but 40% of the 20 stones unmoved could be disintegrated with retrograde manipulation. Of the 62 successful units, 89% became stone free within 3 months. Complications were subcapsular renal hematoma in 3 patients and obstruction in 5 patients. The initial 25 patients were treated under epidural anesthesia and 52 patients were treated without anesthesia. The results show that the indication of ESWL with LT-01 is better for the stones smaller than 30 mm and the indication should be determined after a couple of sessions for stones greater than 30 mm. ESWL with LT-01 can be performed on an out-patient basis without anesthesia in many cases.     

The effectivity and morbidity of URS as auxiliary therapy after ESWL

We were interested in the effectivity and morbidity of URS as an auxiliary treatment in patients who underwent ESWL for ureteral (n = 71) and kidney stones (n = 31). Between 1991 and 1995, 102 URS were performed for treatment of ureteral fragments. 28 (27.5%) were located in the proximal, 24 (23.5%) in the middle and 50 (49%) in the distal ureter. In 25 cases, fragments were found as "Steinstrasse". In the same period of time, 2554 patients with ureteral stones were treated with ESWL alone, therefore the overall rate of URS was low (4%). URS alone had a stonefree success rate of 58.9%. The success rate depended on the location of the ureteral stone: proximal 25%, middle 50% and distal 82%. URS combined with ESWL showed an overall success rate of 97.9%. Finally, only 2 patients (2.1%) required an open surgery. 29.3% of the stones were treated by extraction only. The extraction of stone was the most frequent procedure to remove the fragments after ESWL. The rate of complications were 6.9%. None of the patients suffered from late complications like stricture of the ureter. The URS for the treatment of stone fragments after ESWL has been shown to be an effective and safe procedure with a low rate of complications.     

输尿管肾镜气压弹道碎石术治疗输尿管膀胱尿道结石(附152例报告)

目的：探讨输尿管肾镜气压弹道碎石术治疗输尿管、膀胱、尿道结石的疗效与安全性。方法：回顾性分析经尿道输尿管肾镜气压弹道碎石术治疗的152例尿道、膀胱、输尿管结石患者的临床资料。结果：4例男性尿道结石和20例膀胱结石均碎石成功，输尿管中下段结石109例，107例成功，2例输尿管口狭窄改用ESWL碎石成功；输尿管上段结石19例，12例原位碎石成功，2例输尿管镜插至输尿管中段上行受阻插管改ESWL碎石成功，5例部分碎石冲入或推入肾内置引流管后行ESWL碎石成功。结论：输尿管肾镜气压弹道碎石术治疗输尿管及其以下尿路结石，具有安全可靠、损伤小、术后恢复快等优点，是微创治疗的有效方法之一。对于输尿管上段结石，将该手术配合ESWL也能取得满意疗效。     

The effectivity and morbidity of URS as auxiliary therapy after ESWL I. Teil: Sicherheit und Effektivit?t der URS als auxili?re Behandlung nach ESWL

We were interested in the effectivity and morbidity of URS as an auxiliary treatment in patients who underwent ESWL for ureteral (n = 71) and kidney stones (n = 31). Between 1991 and 1995, 102 URS were performed for treatment of ureteral fragments. 28 (27.5 %) were located in the proximal, 24 (23.5 %) in the middle and 50 (49 %) in the distal ureter. In 25 cases, fragmentes were found as “Steinstrasse”. In the same period of time, 2554 patients with ureteral stones were treated with ESWL alone, therefore the overall rate of URS was low (4 %). URS alone had a stonefree success rate of 58.9 %. The success rate depended on the location of the ureteral stone: proximal 25 %, middle 50 % and distal 82 %. URS combined with ESWL showed an overall success rate of 97.9 %. Finally, only 2 patients (2,1 %) required an open surgery. 29.3 % of the stones were treated by extraction only. The extraction of stone was the most frequent procedure to remove the fragments after ESWL. The rate of complications were 6.9 %. None of the patients suffered from late complications like stricture of the ureter. The URS for the treatment of stone fragments after ESWL has been shown to be an effective and safe procedure with a low rate of complications.     

Anesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones

Stones in the proximal, mid and distal ureter in 375 consecutive patients were treated with extracorporeal shock wave lithotripsy (ESWL) in a technically unmodified Dornier HM3 lithotriptor without regional or general anesthesia. Adequate followup was available in 162 patients with proximal, 62 with mid and 146 with distal ureteral stones. The fraction of patients with stone-free ureters within 3 months after ESWL was 96, 97 and 97%, respectively. Of all patients only 13 (3.6%) had residual stones or fragments in the ureter after 3 months. The average number of ESWL sessions was 1.34 for all patients, and 1.36, 1.45 and 1.38 for those with proximal, mid and distal ureteral stones, respectively. A ureteral catheter with saline irrigation was used whenever it was possible to insert a ureteral catheter. Only 15 stones were pushed up to the kidney during catheterization and all other stones were treated in situ. There were more retreatments in patients in whom the stone had not been bypassed by a catheter at the initial ESWL session. During at least 1 treatment session 238 patients had a ureteral catheter with the tip above the stone. Approximately half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous anesthesia with an anesthetic cream containing lidocaine-prilocaine (for proximal and mid ureteral stones). Small supplements of pethidine and diazepam were given to the other patients during the ESWL session. In situ ESWL of ureteral stones as described is a convenient, efficient and attractive procedure that, applied in a consequent manner, theoretically might result in a successful outcome in up to 98% of the patients.     

In situ extracorporeal shock wave lithotripsy for obstructing ureteral stones with acute renal colic.

In situ (no instrumentation) extracorporeal shock wave lithotripsy (ESWL*) was used to treat 49 patients with obstructing ureteral stones causing acute renal colic. Ureteral obstruction was diagnosed on the delayed films of an excretory urogram and was classified as severe (dilatation above and no contrast medium seen below the stone) in 17 patients and partial (dilatation above and contrast medium seen below the stone) in 32. Upper third ureteral stones were present in 41 patients (obstruction severe in 15 and partial in 26) and lower third ureteral stones were present in 8 (obstruction severe in 2 and partial in 6). ESWL was performed within 14 days of the onset of the acute renal colic because of persistent pain with an unmodified Dornier HM3 lithotriptor in 17 patients and a Medstone STS device in 32. With single stones the stone-free rate at 3 months, the repeat ESWL rate and the secondary procedure (stone basketing) rate were 92%, 6% and 8%, respectively, with severe obstruction, and 78%, 6% and 6%, respectively, with partial obstruction. No urinary drainage procedures for sepsis were required after ESWL. Obstructing ureteral stones, which presented mainly in the upper third of the ureter, were successfully treated with in situ ESWL without the need for either bypassing the stone with a ureteral stent or for pushing the stone back into the kidney before treatment with ESWL.     

Clinical experience of in situ extracorporeal shock wave lithotripsy using ESL-500A for bilateral ureteral stones and ureteral stones in a solitary, or a functionally solitary kidney]

Extracorporeal shock wave lithotripsy (ESWL) using ESL-500A was performed for the treatment of 18 cases of bilateral ureteral stones and 3 cases of a solitary or a functionally solitary kidney with ureteral stones from September 1991 to February 2000. Sixteen cases of the former and all 3 cases of the latter were treated by in situ ESWL, and the other 2 cases of bilateral ureteral stones were treated with auxiliary procedures. No residual stones were observed in any cases except for one of bilateral ureteral stones treated by in situ ESWL. The results show that in situ ESWL using ESL-500A seems to be useful for the treatment of bilateral ureteral stones and ureteral stones in a solitary kidney, including a functionally solitary kidney. However, auxiliary treatment will be needed in cases of urinary tract infection, undetectable stones by ultrasonography, or bilateral large stones.     

Extracorporeal shock wave lithotripsy for cystine urolithiasis in children: Outcome and complications

The Siemens Lithostar Litotriptor was used to treat 6 children withcystine nephrolithiasis, previously treated by open surgery. Fivechildren had renal calculi (3 multiple caliceal, 2 pelvis) and one hadureteral calculus. Stone size ranged from 0.2–2.5 cm in diameter,and stone burden was from 0.24 to 10.81 cm³ per kidney. Fromone to 4 ESWL sessions per unit were applied, with a total of 1,800 to12,000 shock waves. The stone free rate at 3 months was 50%. Acomplete elimination was obtained with cystine stones in renal pelvisand ureter, however, up to 4 ESWL treatments failed in caliceal stones.Rather location of cystine calculi than previous surgery was associatedwith ESWL success rate. Two patients with positive urine cultures weresuccessfully treated with appropriate antibiotics before ESWL wasattempted. Perirenal hematoma was major complication demonstrated byradionuclide scintigraphy in one patient, and resolved spontaneously by3 months. In the combined treatment of cystine urolithiasis in childrenESWL, as auxillary procedure, was safe and effective in pelvis stone butfailed in caliceal stones. Medical dissolution for retained fragmentswas found effective.     

65例输尿管阴性结石的治疗

目的 总结治疗输尿管阴性结石的方法及疗效。方法采用体外冲击波碎石（ESWL）、气压弹道碎石（PL）治疗输尿管阴性结石65例。结果65例患者中，40例采用PL，结石排尽36例，2例残留，联合ESWL，结石排出，2例改手术取石；25例采用ESWL辅助输尿管插管，1次碎石成功18例，2次碎石成功4例，3例改PL治疗。结论PL及ESWL辅助输尿管插管，是治疗输尿管阴性结石有效、安全的方法。