Extracorporeal shock wave lithotripsy in the management of pediatric urolithiasis

The main objective of this paper was to evaluate the efficacy and safety of the management of pediatric urolithiasis by extracorporeal shock wave lithotripsy (ESWL). Between November 1988 and July 2000, 165 renal stones, 53 ureteral stones, and 5 bladder stones were treated in 126 pediatric patients using Siemens Lithostar lithotriptor. The ESWL treatments ranging from 1 to 7 were needed per patient (mean: 2.1). One ESWL session was performed for 49.6% of stones, two for 24.6%, three for 13.0 %, four for 5.6% and > 4 for 8.2%. The success rate for renal stone units (asymptomatic fragments less than 4 mm) was 88.2%, stone-free rate was 49.0%. The stone-free rate for ureteral stone units was 87.5%, but was 75% for bladder stones. The overall results of ESWL treatment in 126 children was satisfactory: the success rate was 90.5%, stone-free rate was 51.6%, residual fragments > 4 mm were 9.5%. General anesthesia was required in 65 children (136 treatments) under the age of 10, and only in 18 children (40 treatments) in the age 11–14. Auxiliary procedures, such as double J stent and percutaneous nephrostomy (PCN) were used in 19 and 7 patients, respectively. Perirenal hematoma in one patient and hematomas in enteric wall in another one patient were the only major complications managed conservatively without consequences. Low energy lithotripsy with the Siemens Lithostar in our series of pediatric patients was safe and relatively effective.     

Second generation shock wave lithotripsy: experience with the Siemens Lithostar

In 1980, extracorporeal shock wave lithotripsy (ESWL) was incorporated as a nonsurgical method of stone removal in the cases of nephrolithiasis and rapidly found worldwide acceptance. Several devices commonly designated "second generation" lithotripters vs "first generation" Dornier HM3 are now under experimental or clinical trial. We report our clinical experience of ESWL using a Siemens Lithostar and compared it with that obtained using a Dornier HM3. One hundred patients were treated during the period of April through October, 1986 using an HM3, and 100 other patients were treated using a Lithostar from April to August, 1988. More cases were treated with a Lithostar than with a HM3. Nearly 10% of all patients treated by ESWL required additional therapeutic approaches (excepted ureteral stent) either with HM3 or Lithostar. However, in the cases of ureteral stone, with the Lithostar more cases required adjuvant procedures (TUL) than HM3. Significantly more shock waves were needed with Lithostar than HM3 for complete fragmentation of the same size of renal and ureteral stones. The stone-free rate during a one month period after ESWL was nearly the same for HM3 and Lithostar (HM3: 84.3%, Lithostar: 83.5%). Lithostar is a multifunctional lithotriptor which has most of the advantages required by the lithotripter.     

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.     

Prospective randomized evaluation of emergency extracorporeal shock wave lithotripsy (ESWL) on the short-time outcome of symptomatic ureteral stones

OBJECTIVE: Here, we report the results of a randomized controlled trial (RCT) assessing the efficacy of emergency ESWL (eESWL) on the short-term outcome of symptomatic ureteral stones. MATERIAL: The trial enrolled 100 patients admitted in emergency room for renal colic caused by a ureteral radioopaque [corrected] stone. Patients were randomized to medical therapy alone or combined with eESWL. eESWL was performed within 6 hours of the onset of renal colic without specific analgesia on a Lithostar lithotripter (Siemens Medical, Munich, Germany). The primary endpoints were the proportion of patients stone free rate after 48 hours (SF-48) and the cumulative proportion of patients discharged from the hospital after 48 and 72 hours. RESULTS: Ureteral stone's location was proximal and distal in respectively 46% and 54% of the patients; stone's mean size was 5.5 mm (range 2-10 mm). Median hospital stay was 3 days, ranging from 1 to 14 days. SF-48 in the control group varied from 76% for distal stones <5 mm to 28.6% for proximal stones >5 mm, averaging at 61%. On average, eESWL increased SF-48 by 13% (p: 0.126), the gain strictly depending on stone size and location. SF-48 increase ranged from 40% for proximal stones >5 mm to 1.8% for distal stone <5 mm. On average, eESWL increased the median duration of hospital stay by one day. This mean negative impact results from ESWL increasing significantly the duration of hospital stay in case of distal stone, while slightly shortened it for stones located proximally. CONCLUSION: This study demonstrated for the first time that rapidly performed ESWL is a valuable therapeutic option to improve elimination of ureteral stones and shorten duration of hospital stay, proven that the stone is located proximally to the iliac vessels.     

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.     

In situ extracorporeal shock wave lithotripsy with Booster technique in the treatment of ureteral stones

Summary After treatment of more than 3000 kidney and ureteral stones with the Siemens Lithostar Multiline the results of the first 1400 ureteral stone treatments using the “Booster technique” and 3-month follow-up findings are reported. There was a disintegration rate of 98 % directly after treatment; 1 week after “Booster technique” treatment 96 % of the patients were free of stones and without any symptoms. The 3-month follow-up showed a stone-free rate of 97 %. Only in 13 % of the cases auxiliary procedures were neccessary, 7 % of them before extracorporeal shock wave lithotripsy (ESWL) and 6 % after ESWL. 43 % of the treatments were performed without any premedication, anaesthesia or sedoanalgesia. Our data even prove that in situ ESWL is a safe and effective method for the treatment of ureteral stones. In comparison to endoscopic procedures, it is superior in regard to invasivity, side effects, complications and neccessity of analgesia, while being just as efficient. Therefore it is recommended as first choice method in the treatment of ureteral stones.      

Extracorporeal shock-wave lithotripsy with Lithostar lithotriptor.

Initial experience of extracorporeal shock-wave lithotripsy (ESWL) using the Lithostar lithotriptor is reported; 193 patients underwent 248 treatments for 210 stones. A total of 139 renal calculi (126 patients) and 71 ureteral stones (67 patients) were analyzed. Treatments were performed without anesthesia in 65 calculi (27.6%), with intravenous sedation in 91 (42.5%), and under epidural anesthesia in 34 calculi (29.9%). A three-month follow-up showed a success rate of 88.0 percent for renal calculi and 95.5 percent for ureteral calculi treated in situ. Renal stone fragmentation was achieved with a mean of 4,890 shocks at 17.4 kV and ureteral calculi were fragmented with a mean number of 4,798 shocks at a mean of 18.3 kV. Auxiliary procedures after ESWL were required in 2 patients with renal stones and in 1 with ureteral calculi. A comparison between stone size and number of shock waves required to achieve stone fragmentation revealed a linear relationship. Hospitalization was not necessary in 84.4 percent of renal calculi and 89.6 percent of ureteral calculi. Retreatments were necessary in 22 (15.8%) of the renal calculi (18 had 2 sessions, 3 had 3 sessions, and 1 had 4 sessions). Of the ureteral calculi, 8 (11.3%) underwent retreatment (6 had 2 sessions, 1 had 3 sessions, and 1 had 4 sessions). The low morbidity with a large number of patients treated on an outpatient basis, minimizing the need for anesthesia, demonstrated a favorable initial successful experience with the Lithostar.     

Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study.

146 patients whose ureteral stones did not pass spontaneously participated in a prospective study on optimal management. Patients were offered two treatment options: extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS). The stone was treated with the technique preferred by the patient. In case of treatment failure after first-line therapy, patients again could decide on how to proceed. Stone analysis could be obtained from 72.6% patients. ESWL was the primary treatment in 66.4% patients. In 2 patients, ESWL was the secondary treatment after failed URS. URS was the first-line therapy in 33.6% patients. In 29 patients URS was done after failed ESWL. For analgesia, sedoanalgesia or spinal anesthesia were used. Analgesia was required in 74.2% ESWL and 100% URS sessions. Following ESWL, 70.1% patients became stone free. In 29.9% ESWL failed. Distal stones had a higher failure rate than proximal or mid-ureteral calculi. Distal stones treated without success were significantly larger than those treated successfully. Failures were switched to URS. Stone analysis could be obtained in 26 patients with failed ESWL: 23/26 consisted of pure whewellite or mixed whewellite stones. Clinically relevant complications were not observed. After URS, 94.9% of the patients became stone free. In distal stones, the stone-free rate was 97.5%. There was only 1 relevant complication: a proximal ureteral lesion requiring surgical repair. Our study demonstrates that URS is a safe and highly effective treatment option for ureteral stones. In patients with distal ureteral stones, it should be offered as a first-line treatment. When whewellite is expected as the stone mineral, URS is the treatment of choice.     

Rapid extracorporeal shock wave lithotripsy for proximal ureteral calculi in colic versus noncolic patients

OBJECTIVES: In delayed extracorporeal shock wave lithotripsy (ESWL) treatment, increasing stone impaction is associated with delayed stone clearance. Whether colic patients treated by rapid ESWL have the same time to stone clearance as noncolic patients, which supports the thesis that stones in both groups are nonimpacted, has not been investigated yet, and was the objective of this study. METHODS: A total of 82 patients were prospectively enrolled and treated with piezoelectric ESWL for a solitary proximal ureteral stone. Of these, 56 patients experienced at least one colic episode compared with 26 noncolic patients. Hydronephrosis has been assessed with the use of ultrasound and intravenous urography (IVU). Time to stone clearance after the first ESWL and stone-free rates after a follow-up period of 3 mo were recorded. RESULTS: In colic and noncolic patients, mean stone size was 7.8mm (p=0.7). Ultrasound-detected hydronephrosis was present in 88% versus 39% (p<0.0001), whereas IVU-detected hydronephrosis was present in 60% versus 7.7% (p=0.0001). Mean number of impulses applied was 8000+/-4000 versus 6700+/-3400 (p=0.1). Mean time to stone clearance was 9.5+/-12.1 d versus 4.6+/-3.8 d (p=0.1). Colic and noncolic patients were considered as treatment success in 83% and 81% after 3 mo of follow-up (p=0.9). CONCLUSIONS: Treatment outcome and time to stone clearance after rapid ESWL in colic patients compared with noncolic patients is comparable and independent of concomitant hydronephrosis. This finding suggests an absence of significant impaction in proximal ureteral stones treated within 24h after a first colic episode, enforcing the concept of performing rapid ESWL in patients harbouring proximal ureteral stones.     

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%.     

Significance of age on prognosis in patients treated by extracorporeal shock wave lithotripsy

PURPOSE: To investigate the effect of patient age on the stone-free rate (SFR) in patients with urinary stones treated by extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHOD: 138 patients with renal calculi and 463 patients with ureteral calculi were treated using the Siemens Lithostar Multiline. Multiple logistic regression was used to investigate the effect of age and other possible predicting factors, i.e., gender, location, size, side, grade of hydronephrosis, symptom at onset and history of urolithiasis, on the SFR at 3 months after treatment. RESULTS: The overall SFR was 77.2%. The SFRs of aged< = 39, 40-49, 50-59, 60-69 and 70 = < years were 87.4%, 84.4%, 75.0%, 71.1% and 66.3%, respectively. The elder patients complained less frequency of pain at onset and showed more frequency of hydronephrosis. Multiple logistic regression analysis revealed that patient age (younger) as well as stone location (middle and distal ureter), size (small), hydronephrosis (mild or less) and symptom (painful) at onset were a independent (better) prognostic factors determining stone clearance after ESWL of upper urinary tract stones. CONCLUSION: The SFR of elder patients showed lower than that of younger ones, however, the former less needed analgesia for ESWL session than the latter. ESWL is convenient, relatively useful for elder patients.     

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     

Management of painful caliceal stones by extracorporeal shock wave lithotripsy

One hundred and seven patients with caliceal stones causing flank pain were treated by extracorporeal shock wave lithotripsy (ESWL), followed up and reviewed. The total stone-free rate 3 months after ESWL was 38.8%. The total pain-free rate was 50.5%. The pain-free rate was 85% in the stone-free group and 29% in the group with residual stones. No significant differences between the stone-free rate and the duration of pain or age was noted. Patients with abnormal intravenous pyelography (IVP) had a lower stone-free rate than patients with normal IVP (16 vs. 45%, p less than 0.05). The complications included: 6 cases of stone street formation with spontaneous passage; 1 case of stone street formation needing percutaneous nephrolithotomy for drainage; 1 perirenal hematoma; 9 cases of severe colic pain following ESWL; 3 cases of fever following ESWL, and 4 cases of hydronephrosis due to a stone in the ureterovesicle junction. These results show that ESWL is an effective, noninvasive treatment for painful caliceal stones.     

Electromagnetic extracorporeal shock wave lithotripsy in children

Extracorporeal shock wave lithotripsy (ESWL) was performed for the treatment of urinary tract calculi in 28 children. All treatments were done with the standard Siemens Lithostar device in situ: no special adaptations for adequate positioning of children are required to target the stone precisely. A total of 42 calculi in 30 renal units was treated, requiring 50 ESWL sessions. The mean energy used was 16.4 kv. and the number of shock waves averaged 3,188. Mean fluoroscopy time per session was 1.5 minutes. In 26 of 50 sessions (52%) general anesthesia was needed for the child to remain perfectly still. A complete stone-free rate was achieved in 38 of 42 calculi (90.5%): after 1 session in 30 (71.4%), after 2 sessions in 6 (13.7%) and after 3 sessions in 2 (4.8%). Five staghorn calculi were treated with ESWL monotherapy. A complete stone-free result was obtained after 3 treatments in 2 patients, while 2 had residual fragments in the lower pole (5 mm. after 6 sessions and 11 months of followup in 1, and 7 mm. after 3 sessions and 3 months of followup in 1). A cystine staghorn stone necessitated open nephrolithotomy after 3 sessions without any fragmentation. One impacted sacroiliac ureteral stone required endoscopic laser lithotripsy. Except for these 2 failures no adjuvant procedures were needed. There were no intraoperative or postoperative complications and minor skin bruising at the coupling site after 3 treatments did not require any therapy. We conclude that electromagnetic ESWL with the standard Lithostar unit is a safe and effective method to treat calculi throughout the urinary tract in children.     

Extracorporeal shockwave lithotripsy in the treatment of distal ureteral stones larger than 10 mm in diameter

Optimal treatment for distal ureteral stones remains controversial. During a period of 10 years, from December 1992 to December 2002, 103 distal ureteral stones larger than 10 mm in diameter were treated at our institution with extracorporeal shock wave lithotripsy (ESWL) using the Siemens Lithostar. Only 2 patients had a ureteral stent in place at the time of treatment. The overall stone-free rate was 98% with 1-12 session and 3-month stone-free rate was 95.1%. These data reveal that a high success rate was achieved in multisession ESWL. Therefore, ESWL is considered to be acceptable as first-line therapy for fragmentation of distal ureteral stones larger than 10 mm in diameter.     

Efficacy of expulsive therapy using nifedipine or tamsulosin,both associated with ketoprofene,after shock wave lithotripsy of ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) is currently considered one of the main treatments for ureteral stones. Some studies have reported the effectiveness of pharmacologic therapies (calcium antagonists or alpha-blockers) in facilitating ureteral stone expulsion after ESWL. We prospectively evaluated the efficacy, after ESWL, of nifedipine on upper-middle ureteral stones, and tamsulosin on lower ureteral stones, both associated to ketoprofene as anti-edema agent. From January 2003 to March 2005 we prospectively evaluated 113 patients affected by radiopaque or radiolucent ureteral stones. Average stone size was 10.16 ± 2.00 mm (range 6–14 mm). Thirty-seven stones were located in the upper ureter, 27 in the middle ureter, and 49 in the lower ureter. All patients received a single session of ESWL (mean number of shock waves: 3,500) by means of a Dornier Lithotripter S (mean energy power for each treatment: 84%). Both ultrasound and X-ray were used for stone scanning. After treatment, 63 of 113 patients were submitted to medical therapy to aid stone expulsion: nifedipine 30 mg/day for 14 days administered to 35 patients with upper-middle ureteral stones (group A1) and tamsulosin 0.4 mg/day for 14 days administered to 28 patients with stones located in the distal ureter (group A2). The remaining 50 patients were used as a control group (29 upper–middle ureteral stones—B1—and 21 lower ureteral stones—B2—), receiving only pain-relieving therapy. No significant difference in stone size between the groups defined was observed. Stone clearance was assessed 1 and 2 months after ESWL by means of KUB, ultrasound scan and/or excretory urography. A stone-free condition was defined as complete stone clearance or the presence of residual fragments smaller than 3 mm in diameter. The stone-free rates in the expulsive medical therapy group were 85.7 and 82.1% for the nifedipine (A1) and tamsulosin (A2) groups respectively; stone-free rates in the control groups were 51.7 and 57.1% (B1 and B2, respectively). Five patients (14.3%) in group A1, 5 (17.8%) in group A2, 14 (48.3%) in group B1 and 9 (42.8%) in group B2 were not stone-free after a single ESWL session and required ESWL re-treatment or an endoscopic treatment. Medical therapy following ESWL to facilitate ureteral stone expulsion results in increased 1- and 2-month stone-free rates and in a lower percentage of those needing re-treatment. The efficacy of nifedipine for the upper-mid ureteral tract associated with ketoprofene makes expulsive medical therapy suitable for improving overall outcomes of ESWL treatment for ureteral stones.     

In situ extracorporeal shock wave lithotripsy for primary ureteric calculi

Objective. To determine the efficacy of the Lithostar lithotriptor for the in situ treatment of primary ureteric stones.Methods. We reviewed, retrospectively, our experience with 283 patients with primary ureteric stones treated with extracorporeal shock wave lithotripsy (ESWL) using the Lithostar lithotriptor. No attempts were made to manipulate the stones. The majority of the patients were treated using only intravenous analgesia. Auxiliary measures were used in 84 patients (29.6%). There were 112 patients (39.6%) with upper, 53 (18.7%) with middle, and 118 (41.7%) with lower ureteric stones.Results. A single ESWL session was needed for 200 patients (70.6%), two for 49 patients (17.3%), and more than two sessions for 34 patients (12%). Of the 248 patients who had adequate follow-up, 220 (88.7%) were stone free, 14 (5.65%) had some residual stone, while 14 (5.65%) patients failed to respond to the treatment. Patients' gender and body weight influenced the treatment and the clearance rate numerically without any statistical significance. The stone site was the most significant factor influencing the final result. Stones larger than 10 mm and the presence of hydronephrosis adversely affected the treatment.Conclusions. In situ ESWL of ureteral stones with the Lithostar device is a convenient and efficient method of treating calculi within the whole length of the ureter without the need for any manipulation.     

Efficacy of in situ extracorporeal shock wave lithotripsy for upper ureteral calculi

In contrast to the majority of renal calculi, in situ extracorporeal shock wave lithotripsy (ESWL) for upper ureteral stones is still controversial. Some centers recommend retrograde mobilization of the calculus into the renal pelvis prior to ESWL as a routine procedure (UC + ESWL). To evaluate the efficiency of in situ ESWL for upper ureteric stones, we initiated a prospective clinical trial. From July 1985 to January 1986, 122 patients presented with upper ureteral calculi, necessitating a total of 146 different procedures: 88 in situ ESWL; 31 UC + ESWL; 15 antegrade ureteroscopies (URS); 6 retrograde URS; 2 open surgery (ureterolithotomy, nephrectomy), and 4 patients were managed conservatively. Of all 99 patients treated at the lithotripter, 80 patients received in situ ESWL (no emergency case, no location problems): in 60 patients (75%) the stone could be disintegrated in one session; 8 patients (10%) required a second ESWL session due to partial fragmentation. Retrograde mobilization using a ureteral catheter or URS was necessary in 9 patients due to failure of in situ ESWL (11%) and, in only 3 patients, we had to remove the stone by antegrade URS (4%). In conclusion, 96% of all upper ureteric stones suitable for primary ESWL could be treated by a noninvasive (in situ ESWL) or minimally invasive (UC + ESWL) procedure. Therefore we recommend in situ ESWL for these calculi. Primary retrograde mobilization is only indicated in case of location problems (stone close to the spine, obesity, skeleton deformation) or emergency cases (colic, hydronephrosis). Antegrade URS should be performed if retrograde mobilization fails or in emergency cases (acute pyelonephritis, following percutaneous nephrostomy, after clinical stabilization). The rate of open surgery is below 2%.     

Immediate in situ ESWL as monotherapy in acute obstructive urolithiasis: useful or not?

Thirty-two patients with acute obstructive urolithiasis were treated without intervention (stent, nephrostomy tube) within 72 hours after onset of symptoms by extracorporeal shock wave lithotripsy (ESWL). Relief of obstruction, proven sonographically, was obtained within 48 hours in 78.6% of the patients and 90.6% were stone-free 6 weeks after treatment. Best results were obtained for proximal ureteral stones while the influence of stone volume did not appear to be significant. Whereas our stone-free results for treatment of calculi smaller than 5 mm (92.3%) can be criticized because without treatment these stones may pass spontaneously, a high success rate for larger stones (89.4%) was also noted. These results for in situ ESWL compare favorably to those of ESWL with stent bypass and suggest that ESWL monotherapy should be considered as a noninvasive first line therapy when treating acute obstructive urolithiasis.     

Monotherapy with extracorporeal shock wave lithotripsy for renal and ureteral stones]

We performed extracorporeal shock wave lithotripsy (ESWL) as a monotherapy using the Medstone STS lithotripter on 288 patients with renal and ureteral stones between June, 1989 and June, 1991. We compared our results with previous reports on ESWL as used in combination therapy. Our cases consisted of 121 patients with renal stones and 167 patients with ureteral stones. A total of 437 sessions of lithotripsy were performed on 288 patients, for an average of 1.52 sessions of lithotripsy per patient. The percentage of stones measuring less than 4.0 mm in diameter that were fragmented was 94.3% for renal stones and 87.6% for ureteral stones. The stone-free rates 3 months after ESWL were 60.3% and 90.4%, respectively. Our results of the monotherapy with ESWL did not differ from those reported on ESWL as used in combination therapy, in terms of the rate of stone destruction and stone-free rates. We studied the other reports carefully and determined that ESWL monotherapy could have been performed in most those cases. We concluded that ESWL monotherapy is an excellent therapeutic method in the light of fewer complications and side effects compared with those from combination therapy, and the fact that the rate of recurrence for renal and ureteral stones is high makes ESWL monotherapy very useful because the procedure can be repeated.