Small caliceal stones: is extracorporeal shock wave lithotripsy justified?

Of 446 patients treated by extracorporeal shock wave lithotripsy 22 had small nonobstructive caliceal stones associated with lumbar or flank pain. Size (less than 1 cm.) and location of the stone did not explain the severity of the symptoms, nor would they have been an indication for open or percutaneous stone removal. Followup consisted of a sonogram and a film of the kidneys, ureters and bladder on postoperative day 1, a film of the kidneys, ureters and bladder 2 weeks after treatment, and a film of the kidneys, ureters and bladder and/or excretory urography after 3 months for patients with residual stone fragments. All patients were interviewed 3 to 15 months after treatment to ascertain the resolution or persistence of the symptoms. After extracorporeal shock wave lithotripsy, 3 of 22 patients had persistent stone fragments for more than 3 months: 2 reported no change and 1 had marked improvement of the symptoms. Of the remaining 19 patients 15 (79 per cent) had complete resolution of the pain and 4 (21 per cent) had significant symptomatic improvement. Thus, 20 of 22 patients (91 per cent) achieved complete or significant relief of pain. The only complication was a perirenal hematoma that resolved spontaneously. These results indicate that small, nonobstructive caliceal stones can be responsible for persistent, severe flank pain. Extracorporeal shock wave lithotripsy is an effective, noninvasive treatment for caliceal stones and it can be justified as therapeutic treatment when the correlation between a small caliceal stone and persistent flank pain is indeterminable.     

Adjunct controlled inversion therapy following extracorporeal shock wave lithotripsy for lower pole caliceal stones

The lower calix is responsible for a significant number of kidneys with residual stone fragments after extracorporeal shock wave lithotripsy (ESWL*). To compare the effectiveness of controlled inversion therapy as an adjunctive method to the elimination of calculous fragments, 42 patients who had undergone treatment for lower caliceal stones with a Siemens Lithostar lithotriptor were reviewed. Of the patients 25 had no adjunctive therapy and 17 underwent controlled inversion therapy. The success rate, effectiveness quotient and complication rate were analyzed. Followup consisted of ultrasound and a nephrotomogram 1 day and 1 to 3 months postoperatively. Complete removal of all stone fragments was achieved in 84% of the patients without an adjunctive maneuver and in 64.7% of those treated with controlled inversion therapy. The effectiveness quotient was 72.4% and 35.5%, respectively. The group treated without adjunctive therapy had fewer retreatment sessions and a lower complication rate. There were no complications related to the controlled inversion therapy and patient acceptance was generally enthusiastic. We conclude that controlled inversion therapy did not improve the results of ESWL for lower pole caliceal calculi.     

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.     

Management of ureteral stones by extracorporeal shock wave lithotripsy. 3 years of experience

From April 1985 to March 1987 181 patients with ureteral stones were treated by means of extracorporeal shock wave lithotripsy (ESWL). Management for proximal calculi changed from in situ ESWL treatment (group n = 27) or placement of a ureteral catheter below calculi (group II, n = 30) to retrograde stone manipulation into renal pelvis (group IV, n = 52) or ESWL treatment under intraoperative irrigation of saline in cases where repositioning failed (group III, n = 50). The best stone-free rate for upper ureteral stones was obtained in group IV with 96% after 6 weeks, presenting also the shortest hospital stay (4.2 days) and lowest quota of postoperative auxiliary procedures (2%). Stones, not being dislodged into renal pelvis (49%), could be treated successfully in 86% by irrigation with saline during ESWL (group III). The stone-free rate decreased in patients with in situ treatment (group I: 67%) or ureteral catheter placement (group II: 83%). Treatment of these stones increased the need of postoperative ancillary procedures to approximately 30%. For distal ureteral stones ESWL and preoperative Zeiss placement achieved a stone-free rate of 95%.     

Bacteriuria following extracorporeal shock wave lithotripsy of infection stones

Extracorporeal shock wave lithotripsy effectively pulverizes infected (struvite) renal calculi. However, after treatment minute residual fragments that may harbor bacteria and cause persistent bacteriuria remain in the renal collecting system for months. We investigated prospectively the incidence of persistent Proteus mirabilis bacteriuria after extracorporeal shock wave lithotripsy among 15 consecutive women with Proteus mirabilis urinary tract infections and struvite calculi. All patients received parenteral gentamicin for 3 to 8 days (mean 4.7 days) immediately before and after extracorporeal shock wave lithotripsy. Oral antimicrobials then were administered for 14 to 34 days (mean 25 days). Ten patients have maintained a sterile urine or experienced urinary reinfection by other organisms during 8 to 19 months (mean 13 months) of subsequent bacteriological surveillance. Of these 10 patients 9 had residual fragments. Five patients had Proteus mirabilis bacteriuria after 1 to 7 months of surveillance, including 3 with residual fragments. The mean stone size, methods and duration of renal drainage procedures, and duration of antimicrobial therapy were similar for the 2 patient groups. Proteus mirabilis was isolated from the cultures of only 3 of 11 retrievable stone fragments. In contrast to intact infected renal calculi, residual stone fragments after extracorporeal shock wave lithotripsy often are susceptible to sterilization with antimicrobials.     

Elective treatment of ureteral stones with extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy was used as an elective treatment in 128 ureteral stones. Of the 108 with adequate follow-up, 88% were successfully disintegrated. Ureteral catheters proved to be particularly useful for more precise stone localization and as a mechanical means to push the calculi inside the renal cavities or to create a fluid interface around them, in order to increase the efficiency of the shock waves. When ureteral catheters were used a success rate of 95.5% was observed, as opposed to 82.8% when stents were not used (p less than 0.05).     

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.     

Treatment of urethral stones by retrograde manipulation and extracorporeal shock wave lithotripsy

Objective To assess the effect of retrograde manipulation and extracorporeal shock wave lithotripsy (ESWL) as a monotherapy for urethral stones that are not associated with urethral strictures. Patients and methods Between August 1993 and January 1995, 34 male patients (mean age 38.7 years, range 7–55) presented with urethral stones. No patient had a suggested or past history of urethral stricture. Lidocaine jelly (2%) was instilled and retained inside the urethra for 5 min. A 16 F urethral catheter was advanced gently to push the stone back to the urinary bladder. Twenty patients had ESWL of their stones in the bladder, using a Storz Modulith SL20, in the prone position. Tilting the patient about 15° towards the side with the stone minimized movement of the stone during fragmentation. In-line co-axial echography (3.5 MHz) and intermittent pulsed fluoroscopy were used to monitor stone fragmentation. In situ fragmentation of posterior urethral stones was not possible because localization was difficult and the treatment was painful. Thirteen patients had cysto-urethroscopy and mechanical cystolitholapaxy under general anaesthesia. Results Stones impacted in the posterior urethra in 31 (91%) patients and in the anterior urethra in three (9%) patients. Stones ranged in size from 7 to 25 mm. One patient expelled an anterior urethral stone after the instillation of 2% lidocaine jelly. The urethral stones were pushed back to the bladder without complication in the remaining 33 patients. All 20 patients except one had their stones fragmented by ESWL in one session. The mean number of shock waves was 3600 ± 1480 (range 1200–6000) and the generator voltage ranged between 5 kV (560 bar) to 8 kV (940 bar). No patient in the ESWL group required anaesthesia or analgesia. Thirteen patients had successful mechanical cystolitholapaxy with no complications. Conclusion Both endoscopic lithotripsy and ESWL of urethral stones are safe and effective. However, transurethral lithotripsy requires general anaesthesia and carries a risk of bladder and urethral trauma. This study demonstrated that, in the absence of urethral stricture, urethral stones can be pushed back safely to the urinary bladder and fragmented effectively by ESWL. The success of the treatment depends on adequate anaesthesia of the urethra before inserting the urethral catheter. We propose that this new technique should be considered before resorting to endoscopic or surgical management of urethral stones, particularly in children.     

Continuous alfentanil infusion for extracorporeal shock wave lithotripsy of gallbladder stones

Extracorporeal shock wave lithotripsy has recently been introduced in clinical trials for the treatment of cholelithiasis. General anesthesia, epidural anesthesia, and intravenous opiates have been used in the anesthetic management of patients undergoing this procedure. This report details our anesthetic management, which was used in 23 patients who underwent 27 procedures, and presents three illustrative cases. A continuous infusion of alfentanil and a 0.625-2.5-mg dose of droperidol were administered to the patients who were easily arousable during the procedure, and were able to cooperate with positioning change requests. Our patients did not develop apnea, hemodynamically significant bradycardia, or chest wall rigidity. One patient became nauseated, and one patient experienced a hypotensive episode that was unheralded by a change in respiratory rate, heart rate, or oxygen saturation. The patients were comfortable throughout the procedure, alert upon arrival to the postanesthesia care unit, and satisfied with this technique. A continuous infusion of alfentanil can be successfully used for the management of patients undergoing biliary lithotripsy.     

Efficacy of extracorporeal shock wave lithotripsy for ureteric stones in children

Objectives: Management of ureteral stones in children represents a challenging problem. In this study, we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (ESWL) in 192 children with ureteric stones. Methods: Between 1990 and 2003, 192 children (≤ 14 years old) with ureteric calculi were treated with the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, NJ). There were 39 stones in the proximal ureter, 19 in the mid-ureter and 134 in the distal ureter. Results: Mean patient age was 7.3±4.1 years (6 months–14 years). There were 122 boys (64.2%) and 70 girls (35.8%). All procedures were performed on an outpatient basis with intravenous sedation in 73 cases (38.1%), general anesthesia in 68 cases (35.7%) and no anesthesia in 51 cases (26.2%). A maximum of 3500 shocks and 18 kV per session were used. A 94% success rate was achieved in proximal (n: 39) and mid-ureteral stones (n: 19). Stone free rates for distal ureteral calculi were 90.6% for stones less than 1 cm in diameter (n: 94) and 91.7% for stones between 1 and 2 cm (n: 26). Overall re-treatment and efficacy quotient rates for proximal ureteral stones were 45.1% and 68.9%, 62.5% and 61.5% for mid-ureteral calculi, and 49.6% and 60.0% for distal ureteral stones. Conclusion: Our results indicate that ESWL with highly satisfactory stone free rates ranging between 90 and 100% and negligible complications can be considered as a first line treatment for ureteric stones in the pediatric age group.     

Extracorporeal shock wave lithotripsy of caliceal diverticula calculi

We reviewed 10 patients with calculi in caliceal diverticula to determine whether they could be treated successfully by extracorporeal shock wave lithotripsy. Of the patients 7 required 1 and 3 required 2 treatment attempts to fragment the calculi completely. After a minimum followup of 3 months (mean 5.9 months) 2 patients (20 per cent) had passed successfully all of the stone fragments, while 3 (30 per cent) had passed more than half and 5 (50 per cent) had passed less than half of the fragments. Of the 8 patients with residual fragments only 3 had persistent symptoms indicating that symptom relief is not dependent on complete stone removal. The possibility of producing a satisfactory result (70 per cent free of symptoms) and the low morbidity of extracorporeal shock wave lithotripsy suggest that this treatment may be appropriate for calculi in caliceal diverticula.     

Treatment of painful caliceal stones

Nonmobile caliceal stones cause pain more often than previously appreciated. The character and intensity of the pain differs from typical renal colic. Twenty-six patients with caliceal stones and pain underwent attempted treatment for pain control via stone removal or disintegration: 15 were treated with percutaneous stone extraction (PSE), 10 with extracorporeal shock-wave lithotripsy (ESWL), and 1 required open surgery after failing PSE. One patient had persistent pain after ESWL and subsequently underwent PSE; 25 of 26 patients had complete relief of pain. Morbidity was minimal. Patients with painful caliceal stones should be offered ESWL, followed by PSE if pain persists.     

The impact of radiological anatomy in clearance of lower caliceal stones after shock wave lithotripsy

The goal of this study was to determine the factors affecting stone clearance after extracorporeal shock wave lithotripsy (ESWL) for lower caliceal stones. Lower pole stone clearance was investigated in 128 (80 males, 48 females) patients treated with ESWL during 1998–2003 in our clinic. Renal anatomy was determined on standard intravenous urogram. The lower infundibulopelvic angle (LIPA) was measured as the angle between the vertical pelvis axis and the vertical axis of lower infundibulum (Sampaio’s method). The mean age of the patients was 42.8 ± 12.4 (19–77) years. The mean stone diameter and burden were found to be 1.28 ± 0.58 (0.5–3.5) cm and 1.2 ± 1 (0–7) cm² respectively. The stone-free rate was 62.5% and ESWL was unsuccessful in 16 (12.5%) patients. Thirty-two (25%) patients had residual fragments ≤4 mm retained in lower calices after lithotripsy. The stone clearance was found to be unrelated to stone burden and diameter (P = 0.17 and P = 0.14, respectively). However, there was a significant difference between mean lower pole infundibulum length (P = 0.001), infundibulum width (P = 0.001) and LIPA (P = 0.0001) between stone-free patients and patients with residual fragments. Multivariate logistic regression analysis accepting stone-free as the favourable result also confirmed that LIPA, lower pole infundibulum length and width were factors that significantly affected the outcome. Lower pole anatomy has a significant influence on clearance of fragments after ESWL.     

Noninvasive management of obstructing ureteral stones using electromagnetic extracorporeal shock wave lithotripsy

Background Extracorporeal shock wave lithotripsy (ESWL) represents noninvasive management of urolithiasis. Since the first HM3 model, technological progress has improved the efficacy and safety of this treatment. The current study aimed to evaluate the role of ESWL as a first-line emergency therapy of renal colic due to ureteral stone with impaired renal function. Methods This prospective study enrolled all the patients admitted from the emergency room with acute renal colic meeting the following criteria: serum creatinine level ranging from 1.5 to 2.5 mg/dl, hydronephrosis, ureteral stones 6 to 15 mm in size, body mass index less than 30, normal renal function at baseline, and no evidence of urinary tract infection. The patients were submitted to a single-session emergency treatment using Dornier Litothripter S. Follow-up assessment, performed at 24 and 72 h, included radiologic and ultrasound examinations with renal function serum assessment. The end points were a decrease in creatinine level and a stone-free condition. Results A total of 40 patients were eligible for the study. The mean creatinine level at admission was 1.93 ± 0.26 mg/dl. After the treatment, renal function recovery occurred for 34 subjects (85%), with a significant global decrease in creatinine levels (p = 0.00). The global stone-free rate 72 h after SWL was 67.5% (27/40). The patients with residual fragments were managed using re-SWL (n = 7) and endoscopic technique (n = 6). Conclusions Emergency SWL represents an effective tool in the treatment of ureteral stones with hydronephrosis and slight renal impairment. Although complete stone clearance after one treatment still remains a difficult target, the actual role of SWL in the management of acute obstruction is to obtain ureteral canalization and renal function recovery. An erratum to this article can be found at     

Clinical study of extracorporeal shock wave lithotripsy for stones in solitary kidney

Extracorporeal shock wave lithotripsy (ESWL) treatment was performed on 17 patients with a solitary or sole functioning kidney from August 1986 to April 1988. Some patients with renal stone had a double pig tail catheter to protect the stone street and those with ureteral stones had a ureteral balloon occlusion catheter to raise the efficiency of fragmentation placed prior to ESWL as much as possible. Combined manipulation with such an instrument as nephrostomy tube to wash out residual stone fragments or endoscopic operation were performed. Despite of these devices, ESWL treatments for staghorn calculi and cystine stones were troublesome in solitary kidneys. After follow up ranged from 9 to 602 days (mean 87.6 days), 10 patients (58.8%) were stone free. ESWL treatment is safe and effective for solitary kidneys. We recommended premedication and pretreatment by ureteral stenting in patients with a solitary kidney.     

Long-term follow-up after extracorporeal shock wave lithotripsy of large kidney stones.

In 76 patients (53 women and 23 men) aged 24-92 years, extracorporeal shock wave lithotripsy (ESWL) was performed between June 1986 and December 1988 as monotherapy for large kidney stones (diameter > 2.5 cm). There were 41 complete and 24 partial staghorn calculi. The patients were treated with the Dornier HM3 lithotripter under sedoanalgesia. Of the 60 patients with large stones whose last ESWL treatment had been at least 24 months earlier, only 15 ultimately came for this long-term control check-up. Reports on 15 other patients were received from their doctors stating that the patients were doing well, not having new stone episodes. These subjects had to be excluded from final evaluation since they did not fulfill all requirements. Thirty patients had either moved out of the area or were from distant locations and therefore unable to appear. Creatinine was normal and urinalyses negative in these 15 patients; 12/15 were stone-free. The ones who were not had small remnants in the lower pole calices which did no harm at all. One patient already had elevated pretreatment blood pressure; 6/14 with normal blood pressure before ESWL showed elevated values 30 or more months after the last ESWL. Radioisotope examinations with separate clearance tests demonstrated no real evidence of loss of kidney function on the treated in comparison with the untreated side. Sonographic findings on the longitudinal and transverse diameter of the treated and untreated kidneys with regard to the total number of shock waves did not show marked differences as they all remained below the 9% limit.     

Emergency extracorporeal shock wave lithotripsy (ESWL) for obstructing ureteral stones

OBJECTIVE: To evaluate emergency treatment of obstructing ureteral stones by in situ extracorporeal shock wave lithotripsy (ESWL) during acute renal colic. PATIENTS AND METHODS: From January 1994 to February 2000, 200 patients (mean age: 42 years) were treated by ESWL (EDAP LT-02) for obstructing ureteral stones causing acute renal colic refractory to medical treatment or recurring within 24hours of such treatment. Stones were visualised by fluoroscopic imaging and/or ultrasound. Follow-up included radiological and/or ultrasound examinations and lasted three months. RESULTS: Mean stone size was 7mm (3-20mm). At three months, 164/200 (82%) patients were stone-free. This rate ranged from 79% to 83% according to the location of the stone, and from 75% to 86% according to the size of the stone. These differences in rate were not significant. Two or three ESWL sessions were required in 79 patients. ESWL was well tolerated in 90% of patients. The only complication was a case of pyelonephritis requiring the placement of a JJ stent, administration of antibiotics, and distant ureteroscopy. The 36 patients, in whom ESWL failed, underwent ureteroscopy (n=23) or lithotripsy with a Dornier machine (n=13). CONCLUSION: Non-deferred ESWL for acute renal colic secondary to obstructing ureteral stones has a satisfactory success rate and very low morbidity.