Extracorporeal Shock Wave Lithotripsy in von Willebrand's Disease

A renal calculus in a patient with von Willebrand's disease was successfully fragmented by extracorporeal shock wave lithotripsy (ESWL) with the administration of Haemate® P. No serious bleeding was observed after ESWL. With supplementation of the missing von Willebrand's factor, ESWL may be applied to patients with this bleeding diathesis.     

体外冲击波碎石术治疗肾感染石

作者采用体外冲击波碎石术连续性治疗72例肾感染石,观察其疗效。部分性鹿角结石69例,完全性鹿角结石3例.总共93枚,直径1.4～4.7cm,平均2.2 cm。在16例结石体积较大的患者中,术前15例放置双J管,1例放置Dormia支架、单次治愈者63.89％(46例),2次者19.44％(14例),3次者9.72％(7例),4次者2.78％(2例),5次者2.78％(2例),失败者1.39％(1例)。术后因尿路感染发热者9例,均用抗生素治愈。作者认为,采用体外冲击波治疗肾感染石是一种安全有效的方法。并侧重探讨了碎石过程中的定位技术和冲击方法以及有关尿路感染的预防和治疗。     

Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Calculi

Purpose

A review was done to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL^†) in the treatment of impacted pancreatic duct calculi.

Materials and Methods

A total of 19 patients, who were potential candidates for radical pancreatic surgery after unsuccessful endoscopic retrograde cholangiopancreatography, sphincterotomy and attempted stone extraction from the pancreatic ducts, underwent ESWL of the calculi. Followup ranged from 6 months to 6 years.

Results

Of the 19 patients 14 avoided a major operation and 6 have remained pain-free for the long term. Two patients died of causes not related to ESWL or endoscopic retrograde cholangiopancreatography. Five patients eventually underwent a Whipple or Puestow procedure for relief of symptoms or persistent obstruction. Complications were minimal.

Conclusions

ESWL is a valuable adjunct in patients with impacted pancreatic duct calculi unretrievable by primary endoscopic retrograde cholangiopancreatography.     

Long-Term Stone Recurrence Rate After Extracorporeal Shock Wave Lithotripsy

Purpose

We followed patients who were stone-free after extracorporeal shock wave lithotripsy (ESWL^*) to investigate the factors that contributed to recurrent calculi.

Materials and Methods

For longer than 5 years 903 patients without residual fragments 3 months after ESWL were enrolled in this study. Plain abdominal films and/or excretory urograms were evaluated every 6 months for recurrent stones on the side of ESWL. Patients who presented with colic pain or other complaints and who were suspected of having recurrent stones were also examined. Stone recurrence rates were calculated with the Kaplan-Meier method. We assessed the influence of patient age; size, location, composition and configuration of the original stones, and pyuria after ESWL on stone recurrence.

Results

Mean followup was 25 months and stones recurred in 183 of 903 renal units (20.3 percent). Kaplan-Meier recurrence rates were 6.7, 28.0 and 41.8 percent after 1, 3 and 5 years, respectively. There was a significant correlation between stone recurrence and multiple stones on one hand, and pyuria after ESWL on the other hand. Stones recurred most frequently in the lower calix. Recurrent stones were passed without intervention in 33 cases, while ESWL was repeated in 53.

Conclusions

These data demonstrate the importance of long-term followup and the search for an effective prophylactic therapy to prevent recurrence.     

Renal Vascular Doppler Resistance after Extracorporeal Shock Wave Lithotripsy

Objectives: Extracorporeal shock wave lithotripsy (ESWL) is mainly an alternative for other therapeutic methods such as surgery and endourology to treat urinary tract calculus. Although it is safe and effective, it has undesirable effects on renal function. Diagnostic techniques such as color Doppler ultrasonography create a new attitude toward renal function. The aim of this study was to evaluate renal vascular resistance change before and after extracorporeal shock wave lithotripsy. Methods: During the present study, vascular resistive index (RI) of renal intralobar artery was measured before, 30 min, and 1 week after ESWL using Doppler ultrasonography. Results: Thirty minutes after ESWL, RI was significantly increased from primary value of 0.62 ± 0.05 to 0.66 ± 0.06 (p = 0.0001). There was no correlation between increase of RI and patients’ age. Following up the patients revealed that mean RI did not return to pretreatment level after 1 week (p < 0.05). The RI level in the old patients (3 patients who were 60 years or older) was higher than that of the younger ones (19 patients who were younger than 60 years) after 1 week (0.76 ± 0.05 vs. 0.64 ± 0.06). There was no meaningful relationship between ESWL voltage or number of shocks and RI variation before and after ESWL. Conclusion: Following ESWL, patients are at risk of renal tissue damage due to increase of primary RI level. Measuring RI variations using ultrasound techniques after ESWL may provide helpful information to clinical detection of renal tissue damage.     

输尿管镜碎石术联合体外冲击波碎石治疗较大肾盂结石疗效分析

目的：本研究旨在比较输尿管镜钬激光碎石术或气压弹道碎石术合并体外冲击波碎石术（ESWL）与单一使用ESWL两种方法处理较大肾盂结石（2～3cm）的手术效果和并发症。方法：治疗肾盂结石为2～3cm的总共42例患者。被随机分为两组,其中1组为18例,2组为24例。对l组患者首先行钬激光或气压弹道碎石治疗,并于术后置双J管,于2～4周后行ESWL。2组患者,置双J管后行ESWL。3个月后评估两组间结石清除率、并发症和总治疗费用。结果：1组患者中,6例患者（33．3％）行输尿管镜碎石术后,结石被完全击碎,无需继续ESWL处理;7例患者（38．8％）输尿管镜碎石术后需一期ESWL,2例患者（12．5％）术后需二期ESWL,结石才能被完全清除。2组患者一期ESWL成功处理结石为5例（20．8％）,二期ESWL成功处理结石为7例（29．1％）。两组结石清除率,1组明显高于2组（83．3％与50．0％,P〈O．05）。l组输尿管镜手术时间平均为27min,2组输尿管镜置输尿管导管平均用时15min。两组间均未出现严重并发症。两组平均治疗费用分别为3200元和2800元。结论：输尿管镜碎石术联合ESWL治疗肾盂较大结石是一种合理而且有效的治疗方法。     

Renocutaneous Fistulae: A Rare Complication of Extracorporeal Shock Wave Lithotripsy

We report the case of a 67 years old woman who presented with a renocutaneous fistula as a complication of extracorporeal shock wave lithotripsy.     

Role of Extracorporeal Shock Wave Lithotripsy in Management of Upper Ureteric Stones

Introduction

The treatment options for upper ureteric stones range from open surgeries to minimally invasive and non invasive techniques. Presently the two most frequently used options for upper ureteric calculi that require intervention are extracorporeal shock wave lithotripsy (ESWL) and ureterorenoscopy (URS) with contact lithotripsy applied by attaining endoscopic access to the calculi.

Extracorporeal Shock Wave Lithotripsy of Renal Pelvis Stones with PCK Stonelith Lithotripter

Shock wave lithotripsy (SWL) has made a revolution in the treatment of urolithiasis. It is a safe procedure with a lower morbidity than open surgery or percutaneous nefrolithotomy (PCN) [Brannen GE, Bush WH, Correa RJ et al., J Urol 1985; 133: 6 and Lingeman JE, Newman D, Mertz JHO et al., J UROL 1986; 135: 1134]. In this article, we analyze our results of SWL with PCK Stonelith-V5 Lithotripter for the renal pelvis localized stones. About 97 patients with radiopaque stone localized in the renal pelvis were treated with PCK lithotripter from January 2001 to March 2003. The study group was divided into two groups according to their stone size. The stone size was ≤ 10 mm in the first group and 11–20 mm in the second group. 56(57) patients were male and 41 (43) were female. Age range was 7–68 (mean 44) years. The overall success rates of SWL for the treatment of renal pelvic stones in our study group was 35 and 62.2 for stones 10 mm or less and 11–20 mm, respectively. Since the focal zone is 7.7 × 30 mm, the stones can easily get out of the focal zone area with respiration and as a result, the success rate is decreased. So, general anesthesia can be preferred for the treatment of stones ≤10 mm with the PCK Stonelith Lithotripter.     

Extracorporeal Shock Wave Lithotripsy in L-shaped Kidneys: Report of Two Cases

The L-shaped or tandem kidney is a type of crossed ectopia with fusion in which the crossed kidney assumes a transverse position during its attachment to the inferior pole of the other kidney. Calculus formation is a well-known sequel of congenital abnormalities of the urinary tract and we like to present two patients harbouring calculi in L-shaped kidneys treated by extracorporeal shock wave lithotripsy (ESWL). The first patient had a calculus in renal pelvis of the transverse kidney. The second case had multiple calculi in renal pelvis and calices of the vertically positioned kidney. After three sessions, first patient was stone free, whereas no fragmentation in the second case. As a conclusion, ESWL might be an option for L-shaped kidneys.     

Clinical Implications of Clinically Insignificant Stone Fragments After Extracorporeal Shock Wave Lithotripsy

Purpose

We determined the natural history and clinical significance of small, asymptomatic, noninfection related stone fragments after extracorporeal shock wave lithotripsy (ESWL*).

Materials and Methods

We prospectively followed 160 patients with 4 mm. or less asymptomatic calcium oxalate/phosphate stone fragments after ESWL for 1.6 to 88.8 months (mean 23) to stone-free status, censorship or intervention. Kaplan-Meier estimates of probability to anatomical stone-free, decreased or stable status were determined as well as the probability of symptomatic episodes or required urological intervention.

Results

Stone-free status or a decreased, stable or increased amount of residual stone occurred in 38 (23.8 percent), 26 (16.3 percent), 67 (41.9 percent) and 29 (18.1 percent) of the 160 patients, respectively. At 5 years after ESWL the probability of a stone-free, stone-free or decreased status, or stone-free, decreased or stable status was 0.36, 0.53, and 0.80, respectively. A total of 91 patients (56.9 percent) remained asymptomatic while 69 (43.1 percent) had a symptomatic episode or required intervention 1.6 to 85.4 months (mean 26) after ESWL (probability estimated at 0.71 at 5 years).

Conclusions

While patients with small noninfection related stone fragments after ESWL may be followed expectantly, a significant number will require intervention or have symptomatic episodes within 2 years. The term clinically insignificant applied to any residual stone after ESWL is likely a misnomer.     

Dissolution of Residual Microfragments with Citrate Therapy after Extracorporeal Shock Wave Lithotripsy

Residual microfragments after ESWL were studied for their presence and for possibility of dissolution with citrate therapy. Among 123 patients with renal stones who became stone–free following ESWL, a computed tomogram (CT) identified remaining microfragments within the treated kidney in 31.7% of the patients, even though stone fragments were not detectable on ordinary x–ray (KUU). The experiments, in which calcium oxalate stone fragments collected after ESWL were incubated in buffer solutions with citrate 0 to 4 mmol/L, showed that citrate dissolved the stone fragments. Using human urine as a solution, the dissolving effect was greater in spot urines after alkali citrate administration than in control urines. Eighteen patients with microfragments underwent a follow–up CT 3 months later. The results showed that the microfragments had disappeared in 6 of 11 (54.5%) patients who had been taking alkali citrate, whereas microfragments remained unchanged in all 5 patients without medication. Our results suggest that citrate therapy would be advisable as a prophylaxis for stone recurrence especially after ESWL treatment.     

Effects of Extracorporeal Shock Wave Lithotripsy on Plasma Concentrations of Endothelin and Renin in Humans

Purpose

There is ongoing controversy regarding blood pressure changes after extracorporeal shock wave lithotripsy (ESWL*). Experimental data suggest a role for renin but only few data are relevant to humans. It has been shown that renin secretion is stimulated by endothelin, a recently discovered peptide with strong vasoconstrictive properties and stimulating effects on renin secretion. Endothelin is relevant in the development of hypertension and acute renal failure.*Dornier Medical Systems, Inc., Marietta, Georgia.

Materials and Methods

In a prospective study of 48 normotensive patients undergoing ESWL for renal stones the influence of high energy shock waves on plasma endothelin and active renin was analyzed. These substances are secreted by renal cells in response to hemodynamic alterations, and inflammatory and traumatic processes. Peripheral blood samples were analyzed for active renin and endothelin before, and immediately, 1, 3 and 5 days after ESWL. Blood pressure was measured before, and 1, 3 and 5 days after ESWL.

Results

Only a slight and transient increase was noted in active renin, which was in the same range as that found after mental stress. Endothelin and blood pressure were not significantly influenced by ESWL. There was no correlation between endothelin and active renin. Thus, the increase in active renin was not mediated by endothelin.

Conclusions

The transient increase in active renin cannot be attributed to the development of hypertension. The lack of influence of ESWL on endothelin indicates that ESWL, at least in the routine clinical setting, does not cause severe renal trauma.