Comparison of the effectiveness and safety of MPL 9000 and Lithostar Modularis shockwave lithotriptors: treatment results of 263 children

In this study, we aimed to compare the treatment results of two different shock wave lithotripsy (SWL) machines used in the management of pediatric urolithiasis. Between January 1993 and October 2004, Dornier MPL 9000 (electrohydraulic) had been used, and since then Siemens Lithostar Modularis (electromagnetic) has been used. The last evaluation was done 3 months after SWL treatment in terms of the success rate, use of anesthesia and complications. A total of 263 children (171 boys and 92 girls), with an age range of 9 months–14 years (mean age 8.1 ± 3.8 years) were included in this study. Of the patients treated with the Dornier MPL 9000, 60.1% (173/104) required general anesthesia and 69 needed sedation. In contrast, for all patients treated with the Lithostar Modularis necessitated only sedo-analgesia (90 children). The hospital stay was shorter for Siemens Lithostar Modularis than those of Dornier MPL 9000 (26.2 vs. 35.5 h, P = 0.03). The success rate for the electromagnetic unit (86.5%) was almost identical that achieved with the electrohydraulic unit (85.2%) in the stones for the different location. Success rates were compared for stone burden subsets, the differences were insignificant for both lithotriptors (P > 0.05, for all). The electromagnetic unit had a significantly higher success rate for distal ureteral calculi (86.2 vs. 54.5%, P = 0.034). The efficiency quotients (EQ) for distal ureteral calculi were significantly different in favor of electromagnetic machine (56 vs. 40%). The complication rates for SWL were not significantly different for electrohydraulic and electromagnetic lithotriptors (8.7 and 6.2%, respectively). This study showed that SWL treatment was effective and safe in pediatric urolithiasis using both electrohydraulic and electromagnetic machines. Electromagnetic machine was more effective than electrohydraulic one for distal ureteral calculi. Additionally, the electromagnetic lithotriptor has significant clinical advantages over the electrohydraulic lithotriptor in terms of anesthesia requirements, hospitalization duration and fluoroscopic targeting.     

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 in children

PURPOSE: We analyzed the efficacy of extracorporeal shock wave lithotripsy in children. MATERIALS AND METHODS: Between 1987 and 2000, 15,423 patients with urinary calculi were treated at our institution, of whom 86 (0.56%) children 3 to 14 years old underwent lithotripsy using the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, New Jersey). A total of 121 calculi in 90 urinary tracts were treated requiring 149 extracorporeal shock wave lithotripsy sessions. The stones were caliceal in 62 cases, renal pelvic in 35, ureteral in 18 and staghorn in 6. Followup consisted of nephrotomogram or ultrasound 1 day and 1 to 3 months postoperatively. RESULTS: Complete removal of all stone fragments was achieved in 97.6% of the stones after 3 months. Re-treatment was necessary in 24 patients (27.9%). All patients were treated as outpatients with intravenous sedation in 54 (62.8%), general anesthesia in 13 (15.1%) and no anesthesia in 19 (22.1%). Complications were present in 8 patients (10.7%) who had colic and received medical treatment followed by uneventful recovery. CONCLUSIONS: Extracorporeal shock wave lithotripsy using the Lithostar Plus has been demonstrated to be an effective noninvasive procedure to treat radiopaque and even radiolucent or slightly opaque urinary calculi in children.     

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.     

Extracorporeal Shock Wave Lithotripsy as First Line Treatment Alternative for Urinary Tract Stones in Children: A Large Scale Retrospective Analysis

PurposeManagement of urinary tract stones in children represents a challenging problem. In this study we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (SWL) in children.Materials and MethodsDuring a 12-year period 408 urinary tract calculi in 344 children (mean age 8.7 ± 3.9 years, range 6 months to 14 years) were managed with the Lithostar Plus lithotriptor (Siemens Medical Systems, Iselin, New Jersey). There were 57 caliceal stones, 167 in the renal pelvis, 31 in the proximal ureter, 16 in the mid ureter and 121 in the distal ureter, and 16 bladder stones.ResultsAll patients were treated on an outpatient basis, with intravenous sedation being used in 138 (40.1%), general anesthesia in 132 (38.4%) and no anesthesia in 74 (21.5%). A maximum of 3,500 shocks and 18 kV per session was given. A total of 780 SWL sessions were applied (mean 1.9 sessions per stone). Overall, a stone-free rate of 79.9% and clinically insignificant residual fragments in 13.2% of cases were observed at 3-month followup with a re-treatment rate of 53.9%. Overall efficacy quotient was 50.9%. Significantly more favorable results were achieved in ureteral calculi and stones 2 cm or smaller (p <0.05). Complications were observed in 33 patients (9.6%).ConclusionsOur results indicate that SWL, with satisfactory stone-free rates and efficacy quotients in stones 2 cm or smaller can be offered as a first line treatment in children.     

Extracorporeal shock wave lithotripsy as first line treatment for urinary tract stones in children: outcome of 500 cases

Purpose

The continued evolution of stone treatment modalities, such as endourologic procedures, open surgery and shock wave lithotripsy, makes the assessment of continuous outcomes are essential. Pediatric urolithiasis are an important health problem allover the world, especially in Middle East region. We evaluate the safety, efficacy and factors affecting success rate and clearance of stones in children treated with shock wave lithotripsy.

Patient and methods

Between 2005 and 2010, a total of 500 children with stones in the upper urinary tract at different locations were treated by Extracorporeal shock wave lithotripsy (ESWL) in our department, Sohag University, Egypt. We have used the Siemn??s Lithostar Modularis machine, Germany. A total of 371 boys and 129 girls with the average age of 8.63?±?5?years, and a range from 9?months to 17?years were included in this study. Diagnosis of their urinary calculi was established either by the use of abdominal ultrasound, plain X-ray, intravenous urography, or CT scan. The stones were located in the kidney in 450 (90%) patients; 298 (66%) pelvic, 26 (5.7%) upper calices, 57 (12.6%) mid calices, and lower calices in 69 (15.3%) patients. The average of their stone sizes was 12.5?±?7.2?mm. The other 50 children their stone were located in the proximal ureteral stones in 35 patients (70%); middle third in 5 (10%) patients and in the distal ureter in 10 (20%) patients. The average ureteral stone size was 7.5?±?3.2?mm. All children were treated under general anesthesia with adequate lung and testes shielding using air foam. We treated the distal ureteral stones of young children in the supine position through greater sciatic foramen and lesser sciatic foramen as the path of shockwave instead of prone position, which is not a comfortable or natural position and could adversely affect cardiopulmonary function especially under general anesthesia. Localization was mainly done by ultrasound, and X-ray was only used to localize ureteral calculi. For follow-up, we have used abdominal ultrasound, plain X-ray, and CT scan if needed to confirm stone disintegration and clearance.

Results

The overall success rate for renal and ureteral calculi was 83.4 and 58.46%, respectively. The re-treatment rate was 4% in renal group and 28% for the ureteral group. No serious complications were recorded in our patients. Minor complications occurred in 15% of our patients; renal colic was reported in 10% of our treated patients, and repeated vomiting was reported in 5% that respond to antiemetics. In the renal group; children with history of pervious urologic surgical procedures had low success rate of stone clearance after ESWL. In the ureteral group stone burden, stone location, had a significant impact on stone clearance outcome.

Conclusion

This study showed that SWL in pediatric age group for both renal and ureteral stone is cost effective, safe with an acceptable re-treatment rate; however children with large stone burden or previous urologic surgery have low success rate.     

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.     

Local shock-wave lithotripsy of distal ureteral calculi

Since the initiation of the clinical trial utilizing a second-generation lithotripor (Lithostar, Siemens, Erlangen, FRG), 96 patients with distal ureteral calculi (i.e. calculi below the pelvic brim) underwent local shock-wave lithotripsy. Routine treatment was conducted under intravenous sedation and light analgesia only. Complete stone disintegration was achieved in 84 patients (87.5%), 11 requiring two sessions and 1 patient, three. In 7 patients ureteroscopy became necessary after unsuccessful local shock-wave treatment. In 2 of these patients a 9-french flexible ureteroscope and the Storz Q-switched neodymium-YAG laser was used for stone disintegration. In 3 cases loop extraction and in 2 cases open surgery had to be performed for definitive stone removal. All pre- and postoperative manipulations (except open surgery) were done on the Lithostar. Local shock-wave lithotripsy is a highly successful, noninvasive, time-saving and easily applicable technique. It has become our primary approach in the treatment of distal ureteral calculi.     

Optimal treatment for distal ureteral calculi: extracorporeal shockwave lithotripsy versus ureteroscopy

BACKGROUND: The optimal treatment for distal ureteral calculi remains controversial. We present data from our institution to compare the efficacy of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy with different lithotripsy modalities (URSL). METHODS: From January 1994 to September 1997, 954 distal ureteral calculi were treated at our institution using in situ SWL (Siemens Lithostar) in 524 patients and ureteroscopy (Wolf 8.0F instrument and Swiss Lithoclast) in 430 patients. Stone sizes and patient ages were similar in these two groups. RESULTS: In the SWL group, the 3-month stone-free rate was 87%, and the effectiveness quotient (EQ) was 68.7%. In the URSL group, there was a 96% stone-free rate with an EQ of 92.1%. The SWL treatment was more expensive than URSL. CONCLUSION: At our institution, ureteroscopy is more efficacious than SWL for the treatment of distal ureteral calculi. In selected patients who had stones >10 mm with evidence of impaction and severe colic pain, we strongly suggest that URSL is the best choice.     

Treatment options for ureteral calculi: endourology or extracorporeal shock wave lithotripsy

Two therapeutic methods, endourology and extracorporeal shock wave lithotripsy (ESWL), can be used in the treatment of ureteral calculi. In a retrospective analysis during a 2-year period 236 patients treated with endourological procedures and 71 who underwent ESWL with a Siemens Lithostar were analyzed as to the success rate, effectiveness quotient, complication rate and hospitalization. The mean stone size was 1.12 cm. in the endourology group and 1.03 cm. in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated endourologically and without retreatment. In the ESWL group success was obtained in 90.1%, with an 11.2% retreatment rate. The retreatment rate was higher (25.0%) for calculi in the mid ureter. The group treated endourologically had a better success rate and no retreatment was necessary. On the other hand, the group treated with ESWL had a shorter hospitalization and a lower complication rate. Followup ranged from 11 to 60 months (mean 48 months) in the endourology group and 7 to 29 months (mean 11 months) in the ESWL group. These observations showed that in situ ESWL therapy with the Siemens Lithostar device is the method of choice for upper ureteral stones. Lower ureteral calculi should be treated endoscopically. Mid ureteral stones larger than 1 cm. had better results with endoscopic procedures and those smaller than 1 cm. had better results with ESWL.     

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 shock wave lithotripsy for renal calculi in children.

Fifteen children (8 male and 7 female) with an age range of 18 months to 15 years were treated with extracorporeal shock wave lithotripsy (ESWL) using the Siemens Lithostar. Two children had a history of metabolic stone disease and 1 child had previously undergone open stone surgery. Four children were treated with a ureteric stent in place and 1 nephrostomy was inserted before treatment. All children were treated under general anaesthesia and all of the stones treated were confined to the kidney and ranged in size from 5 mm to a complete staghorn. The number of treatments ranged from 1 to 6 and generator voltage ranged from 16 to 19 kV with a maximum number of 30,000 shocks to a complete staghorn. Complications were minimal, with 3 children presenting with colic, 1 child requiring a stent and none requiring a nephrostomy after treatment. The overall stone clearance rate at 3 months was 65%. ESWL provides an effective treatment for selected calculi in children. In the short term, complications are minimal but the long-term effects on children need to be monitored.     

Shock wave monotherapy of staghorn calculi

From June 1987 to October 1988, 52 staghorn calculi were treated without anesthesia by shock wave lithotripsy with the second-generation lithotriptor, Lithostar Siemens. 36 calculi were evaluated. Multiple sessions (n = 1-6) were necessary according to the size of the stone. The mean hospital stay for complete treatment was 7 days. Double-J stenting was used in 45% of the patients with calculi of less than 40 mm and in 81% of the patients with calculi of greater than 40 mm. After 3 months, 50% of the patients with calculi of less than 40 mm were free of stones, as were 43% of the patients with calculi greater than 40 mm. After 9 months, the stone-free rate rose to 75%. At 3 months, the success rate (stone free or residual fragments of less than 4 mm) is 87.5% and rose to 92% at 9 months. Two severe complications were observed: one patient with acute infected hydronephrosis with sepsis and one with perirenal hematoma. Shock wave lithotripsy monotherapy of staghorn calculi is possible in multiple treatment sessions. Double-J stenting is mandatory in most of the cases but, even in this condition, anesthesia is not necessary.     

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.     

Extracorporeal shock wave lithotripsy of urolithiasis in patients with urinary diversion

We evaluate the efficacy of ESWL in the management of calculi in patients with urinary diversion. We treated 5 patients who suffered from urinary lithiasis after urinary diversion post cistectomy. We managed the patients with extracorporeal shock wave lithotripsy in monotherapy with a Siemens Lithostar Modularis device. Mean stone size (long axis) was 1.95 cm (range 1 to 3.5 cm). The mean shockwave number per session was 2.6 per patient. Stone free result was 100%. We conclude that ESWL technique can provide acceptable results in patients with urinary diversion and can be used as first choice treatment in these type of patients due to its minimal morbidity and excellent results, equivalent to those achieved in patients without urinary diversion.     

Urolithiasis update: clinical experience with the Swiss LithoClast

This article describes the authors' first experience using the EMS Swiss LithoClast pneumatic lithotriptor in the management of middle and distal ureteral calculi. Also presented is a review of the literature comparing different modalities of intracorporeal lithotripsy. A retrospective analysis was performed on 11 patients treated with the Swiss LithoClast using the Circon ACMI MR6 Rigid Mini-ureteroscope (7 patients with distal calculi and 4 patients with midureteral calculi). The lithotriptor successfully fragmented 91% of the calculi, independent of stone composition. Complete failure of fragmentation was only encountered in one patient, and this was secondary to the lithotriptor's inherent ballistic force causing retrograde passage of the calculus. One patient had postoperative radiographic evidence of stone fragments along the ureteral stent. There was no intraoperative morbidity or long-term complications encountered with use of the pneumatic lithotriptor. Additionally, patients' overall satisfaction was 91% with respect to the procedure itself and relief of preoperative pain. The only significant postoperative complaint was ureteral stent discomfort in one patient. The authors conclude that the EMS Swiss LithoClast pneumatic lithotriptor is a safe and effective tool in the management of middle and distal ureteral calculi. However, as noted with one patient, there is always a risk of stone push from the ballistic force of the lithotriptor.     

Extracorporeal shock wave lithotripsy monotherapy: experience with piezoelectric second generation lithotriptor in 642 patients

Extracorporeal shock wave lithotripsy monotherapy was performed in 642 patients for 1 year with an EDAP-LT01 piezoelectric lithotriptor. Of 642 patients 398 completed extracorporeal shock wave lithotripsy treatment and 244 still are undergoing multiple extracorporeal shock wave lithotripsy sessions. The 398 patients had renal (64.6 per cent) or ureteral (35.4 per cent) stones 0.6 to 4.8 cm. in diameter (mean 1.4 cm.). No general or regional anesthesia was required except in 7 children. Among 398 patients who completed extracorporeal shock wave lithotripsy the rate free of stones was 73.4 per cent and the rate of clinically insignificant residual fragments was 12.8 per cent. The success rate (rate free of calculi plus that of clinically insignificant renal fragments) ranged from 95.6 per cent for stones 0.6 to 1.0 cm. in diameter to 52.6 per cent for stones larger than 3.0 cm. (mean 86.2 per cent). The number of treatment sessions in 343 patients with successful results increased in accordance with the stone size, with an average of 1.6 sessions. Double-J* stents were placed in 7 patients and ureteral catheterization was performed in 11 as post-extracorporeal shock wave lithotripsy adjunctive measures. The steinstrasse phenomenon was noted in 14 patients, of whom only 1 required Double-J stenting. There were no significant complications. Therefore, extracorporeal shock wave lithotripsy monotherapy with the piezoelectric lithotriptor is considered to be a safe and efficient outpatient procedure for the initial treatment of urinary stones regardless of stone sizes.     

Extracorporeal shock wave lithotripsy monotherapy for bladder stones with the second generation lithotriptors

Between June 1987 and April 1989 a total of 4,500 extracorporeal shock wave lithotripsy treatments was performed in our department with the Siemens Lithostar lithotriptor. Renal (pelvic, caliceal and staghorn stones), ureteral and even bladder calculi can be treated by means of a system of fluoroscopic detection and electromagnetic shock wave generation. The treatments are performed without the use of anesthesia and on an outpatient basis. Hospitalization is indicated whenever underlying infectious stone disorders are suspected (associated urinary tract infection or infected calculi). Initial experience in the first 10 patients with bladder stones treated by electromagnetic extracorporeal shock wave lithotripsy monotherapy is reported. All stones disintegrated after 1 treatment, except in a patient with 2 bladder stones who required 2 sessions. Mean treatment duration was 53 minutes. Mean number of shock waves was 3,600 and electrical discharge averaged 20.2 kv. per shock wave. Minute fragmentation was obtained and uncomplicated evacuation occurred without the need for adjuvant procedures, even in the presence of prostatic hypertrophy (2 patients) or neurogenic bladder dysfunction (3). No morbidity during or after treatment was encountered in these 10 patients.     

Endoscopy vs. extracorporeal shockwave lithotripsy in the treatment of distal ureteral stones: ten years' experience.

BACKGROUND: The lower third is the location of the great majority of ureteral stones. Treatment of these stones remains controversial: in situ extracorporeal shockwave lithotripsy (SWL) vs. ureteroscopy (URS). METHODS: During the last decade, 633 distal ureteral calculi were treated at our institution using in situ SWL (Siemens Lithostar electromagnetic lithotripter) in 395 patients and URS (with 11.5F instrument and ultrasonic lithotripsy) in 228 patients. The patients' age and stone size were similar in the two groups. All SWL therapies were performed on an outpatient basis. RESULTS: The overall success rate was 99% for SWL, and the efficiency quotient (EQ) was 92.4%. The treatment was more effective for <10 mm calculi. In the URS group, there was a 92% overall success rate with an EQ at 91.2%. Compared with SWL, URS was more time consuming, at least for the initial cases; often required intravenous sedation; entailed routine placement of a ureteral stent; and more often led to hospitalization. On the other hand, stone clearance was rapid after URS, although most of the SWL patients were stone free at the end of 6 weeks. The cost was similar in the two groups. CONCLUSION: We believe that multiple factors should be considered when deciding the most appropriate approach to distal ureteral calculi. In situ SWL provides optimal first-line treatment for calculi < 10 mm, whereas URS is better reserved for stones >10 mm.     

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.