Acute morphological changes in canine kidneys after exposure to extracorporeal shock waves

Summary The acute effects of extracorporeal shock waves on renal morphology were studied by light and electron microscopy in 14 dogs. One kidney received an average clinical number of exposures, the nonexposed, contralateral kidney serving as control. The original Dornier HM-3 generator was used in 3 animals, the modified version in 11. Intravascular radiographic contrast medium was administered in five animals. Damage was observed in all exposed kidneys, none in the contralateral control kidney. The effects were characterized by renal and perirenal hemorrhage and edema, parenchymal hemorrhagic foci with tissue destruction, often extending from cortex to medulla. In the nearby regions there was endothelial cell damage in arteries, veins and glomerular capillaries. Breaks in the wall of these vessels were detected with platelet plug formations and thrombi. In glomeruli, breaks of Bowman's capsule and epithelial cell damage with loss of foot processes were observed. A wide range of tubular cell damage was demonstrated, ranging from vacuolization to complete necrosis. Tubular lumina were filled with red cells, indicating renal origin of hematuria. The tissue damage was less pronounced in kidneys exposed to the modified lithotriptor than to the original. No difference in the quantity or quality of damage was detected whether radiographic contrast medium was administered or not.     

Acute changes in kidney function following extracorporeal shock wave lithotripsy for renal stones

Seventeen patients were subjected to analysis of various renal functional parameters before and after extracorporeal shock wave lithotripsy (ESWL) for renal stones. Thirteen patients were observed at 2 weeks and 3 months. Glomerular filtration rate (GFR) was not influenced by ESWL as based on unchanged serum levels of creatinine, beta 2-microglobulin and creatinine clearance. A significant increase in urinary excretion of beta 2-microglobulin, N-acetyl-beta-glucosaminidase and alkaline phosphatase, with return to pre-treatment values within 4 to 5 days, reflected transient disturbances in proximal tubular function. Urinary albumin excretion was increased 0-24 h after ESWL. No significant alterations were observed in plasma renin activity or serum aldosterone due to ESWL. Serum lactic dehydrogenase remained significantly increased for 2 weeks. In addition, significant changes in several blood and urine parameters were caused by immersion in water and intravenous infusions during treatment and were not specifically due to ESWL.     

Surgical intervention following fragmentation of gallstones by extracorporeal shock waves

Five cases of surgical intervention following extracorporeal shock wave lithotripsy (ESWL) of gallbladder and bile duct stones are reported. This represents an incidence of surgical intervention in 1% of patients with gallbladder stones and in 9% of patients with common bile duct stones who underwent ESWL during a two-and-a-half-year investigation period. There was no mortality. In 2 patients with gallbladder stones and persistent colic after ESWL, elective cholecystectomy was performed. There was no evidence of macroscopic or microscopic damage or bleeding within the wall of the gallbladder. Furthermore, no damage to the liver, common bile duct, duodenum, or stomach was noted. ESWL was applied in 34 patients with common bile duct stones in whom endoscopic sphincterotomy and stone extraction had proved ineffective. Three (9%) of these patients required surgery. In 1 patient, a Dormia basket got stuck and the basket, together with the stone, were removed by choledochotomy. In a second patient, rupture of a juxtapapillary diverticulum occurred 10 days after ESWL and 2 days after endoscopic extraction of stone fragments. At laparotomy, the retroperitoneum was drained. In a third patient with gallbladder and common bile duct stones, acute cholecystitis developed after lithotripsy of common bile duct stones. Cholecystectomy was performed and a t-tube was inserted in the bile duct. In all patients, the postoperative course was uneventful. In our experience, ESWL is a safe procedure with no mortality and an infrequent need for surgical intervention.

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Resumen Se informan 5 casos de intervención quirúrgica después de litotripsia extracorpórea por onda de choque (LEOCH) en pacientes con cálculos de la vesícula biliar y del colédoco. Esto representa una incidencia de intervención quirúrgica de 1% en los pacientes con cálculos de la vesícula y de 9% en los pacientes con cálculos del colédoco sometidos a LEOCH en el curso de los 2 1/2 años del período de investigación. No hubo mortalidad. Se realizó colecistectomía electiva en 2 pacientes con cálculos de la vesícula y cólico persistente después de LEOCH. No se halló evidencia de daño macroscópico o microscópico o de sangrado en la pared de la vesícula; tampoco se observó daño en el hígado, colédoco, duodeno, o estómago. La LEOCH fue realizada en 34 pacientes con cálculos en el colédoco en quienes la esfinterotomía endoscópica no fue exitosa para la extracción de los cálculos. Tres (9%) de estos pacientes requirieron cirugía. En un paciente quedó aprisionada una canastilla de Dormia; la canastilla junto con el cálculo fueron removidos por coledocotomía. En un segundo caso se observó ruptura de un divertículo yuxtapapilar 10 días después de LEOCH y 2 días después de la extracción endoscópica de los fragmentos de cálculos. En la laparotomía se hizo el drenaje del retroperitoneo. En un tercer paciente con cálculos de la vesícula biliar y del colédoco se desarrolló colecistitis aguda después de la litotripsia de los cálculos del colédoco. La evolución postoperatoria fue libre de complicaciones en la totalidad de los pacientes. En nuestra experiencia la LEOCH es un procedimiento seguro, libre de mortalidad, y asociado con baja necesidad de intervención quirúrgica ulterior.

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Résumé Après traitement de lithiases vésiculaires et lithiases de la voie biliare principale par lithotritie extracorporale (LEC), une intervention chirurgicale s'est avèrée nécessaire dans 5 cas. Ceux-ci représentent donc une incidence d'intervention chirurgicale de 1% des patients ayant une lithiase vésiculaire et de 9% des patients ayant une lithiase de la voie biliaire principale traités par LEC pendant une période de 2 1/2 ans. La mortalité était nulle. Chez 2 patients avec une lithiase vésiculaire et persistence de coliques hépatiques après LEC, on a effectué une cholécystectomie. Il n'y avait ni lésion macroscopique ou microscopique, ni signes d'hémorragie intramurale au niveau de la vésicule biliaire. On n'a pas mis en évidence de lésion hépatique, duodénale, gastrique ou de lésion de la voie biliaire principale. La LEC a été employée chez 34 patients avec une lithiase de la voie biliaire principale chez lesquels la sphinctérotomie et extraction lithiasique ont été un échec. Trois (9%) de ces patients ont dû être opérés. Chez un patient, et le panier de la sonde de Dormia et la lithiase se sont coincés dans la voie biliaire et ont nécessité une cholédocotomie. Un deuxième patient a présenté une rupture d'un diverticule juxtapapillaire 10 jours après la LEC, et 2 jours après l'extraction endoscopique des fragments lithiasiques restants. A la laparotomie, on a drainé l'espace rétropéritoneal. Chez un troisième patient avec des lithiases vésiculaires et cholédociennes, une cholécystite aiguë s'est déclarée après la LEC des calculs de la voie biliaire principale. On a effectué une cholécystectomie, et on a placé un drain en T dans la voie biliaire principale. L'évolution postopératoire a été sans problème chez tous les patients. Dans notre expérience, la LEC est sans danger, ne s'accompagne d'aucune mortalité, et nécessite rarement une intervention chirurgicale secondaire.

     

逐步提高冲击波能量预处理对体外冲击波碎石术肾损伤的保护作用

目的探讨逐步提高冲击波能量（GESW）预处理对体外冲击波碎石术（ESWL）肾损伤的保护作用及机制。方法制成单肾的40只雌性家兔随机等分为对照组、GESW组、ESWL组、ESWL＋GESW预处理组。GESW组肾接受300次GESW;ESWL组肾接收标准的1500次ESWL：ESWL＋GESW预处理组先按GESW组处理,然后同ESWL组处理。24h时观察肾组织超氧化物歧化酶（SOD）活性、丙二醛（MDA）含量和尿N-乙酰-β-D-氨基葡萄糖苷酶（NAG）变化,原位缺口末端标记法（TUNEL）检测凋亡细胞。结果与ESWL组比较,GESW预处理组肾组织SOD活性增高（P〈0．05）,MDA含量和细胞凋亡指数降低（P〈0．01）、尿NAG降低（P〈0．01）。与对照组比较,GESW组各项指标差异无统计学意义（P〉0．05）。结论GESW预处理可减轻ESWL所致的肾损害,与其抗氧化应激损伤、抗细胞凋亡有关。     

Acute physiological changes following heart-lung allotransplantation in dogs

The feasibility of clinical heart-lung transplantation requires a better understanding of the physiological consequences of the operation, heart-lung denervation, and the quality of graft preservation. An acute canine model was used to evaluate heart-lung function during the first 24 hours after transplantation. Measurements of cardiopulmonary dynamics were performed in 5 donor animals and compared sequentially after transplantation in the respective recipients. Orthotopic allotransplantation was performed on cardiopulmonary bypass with moderate hypothermia after perfusion of both the heart and lung with a clinical cardioplegic solution (4 degrees C; potassium chloride, 30 mEq/L; mannitol, 20 gm/L). Postoperatively, the animals were ventilated continuously and anesthetized. Hemodynamic variables were monitored, and measurements were made of arterial and venous oxygen, carbon dioxide, saturation, and pulmonary mechanics. Cardiac output and a derived measurement of lung water were determined. Pulmonary vascular resistance, arteriovenous shunt, resistance, and compliance were calculated. At the termination of the experiment, significant differences were observed between donor and recipient lung-water levels (7.7 +/- 0.9 ml/kg versus 12.0 +/- 3.1 ml/kg, respectively; p less than 0.05); 100% arterial oxygen tension (509 +/- 37 mm/Hg versus 227 +/- 114 mm/Hg, respectively; p less than 0.01); and pulmonary compliance (38 +/- 18 ml/cm H2O versus 11 +/- 4 ml/cm H2O, respectively; p less than 0.05). Arteriovenous shunt increased from 12.2 +/- 4 to 16.5 +/- 5% (p = 0.2). This model evaluates the technique currently employed clinically and will be used in the future to compare methods of heart-lung preservation with the goal of allowing distant heart-lung procurement.     

Acute changes in renal function following extracorporeal shock wave lithotripsy in patients with a solitary functioning kidney

Twelve consecutive patients with a solitary functioning kidney were treated for renal stone by extracorporeal shock wave lithotripsy (ESWL*) with the modified Dornier HM3 lithotriptor and studied for 3 days after treatment. Urinary excretion of electrolytes, N-acetyl-beta-glucosaminidase (NAG), alkaline phosphatase, kallikrein, glycosaminoglycans, albumin and beta 2-microglobulin, and clearances of creatinine, inulin and para-aminohippuric acid were determined, as were serum levels of creatinine, urea, beta 2-microglobulin and aldosterone, and plasma renin activity. Urinary flow rate, free water clearance, and urinary excretion of NAG, kallikrein and beta 2-microglobulin were significantly increased 0 to 24 hours after ESWL. The urinary excretions of alkaline phosphatase, albumin and glycosaminoglycans were unchanged. Glomerular filtration rate was significantly decreased and effective renal plasma flow was unchanged. Filtration fraction was stable. Serum lactic dehydrogenase increased significantly after ESWL and remained high through the period of observation. Serum levels of creatinine, beta 2-microglobulin and aldosterone were unaltered. A decrease in plasma renin activity immediately after treatment is explained by the water immersion and the extracellular volume expansion during treatment.     

Morphological changes in canine kindneys following extra-corporeal shock wave treatment

Summary Extracorporal shock wave lithotripsy has rapidly become established world wide as a routine method for treatment of nephro-and ureterolithiasis. Although initial studies showed no tissue damaging effect by the shock waves, we found in an animal experiment using canine kidneys, the ESWL induced damage to the renal parenchyma is more marked than originally assumed. The damage is limited to the area that was focused on, and heals relatively rapidly by connective tissue encapsulation with final cicatrisation without any further residual effects being observed until now. This parenchymal damage is probably also the cause of the macrohaematuria that is always observed during therapy. The resulting tissue damage is not extensive enough to cause demonstrable reduction of function as measured by the usual methods (serum creatinine, creatinine clearance, isotopy renography, i/v-urography). The main clinical complication is the large subcapsular haematoma which, according to present knowledge, could well result from a lesion of the larger peripheral vessels. Damage to other organs such as subserous colonic and small bowel haematomata are to be expected although they do not lead to clinical symptoms.     

Gallstone lithotripsy by extracorporeal shock waves

Extracorporeal shock-wave lithotripsy (ESWL) in combination with adjuvant litholytic therapy using chenodeoxycholic acid and ursodeoxycholic acid (7 to 8 mg/kg body weight/day of each acid) is a safe and effective, novel nonsurgical approach to gallbladder stones, provided the patients are carefully selected. Experience has shown that patients with a radiolucent solitary stone in a functioning gallbladder are the best candidates. In addition, ESWL is a worthwhile noninvasive alternative to open surgery in patients with bile duct stones in whom routine endoscopic measures have failed.     

Blood pressure changes following extracorporeal shock wave lithotripsy for urolithiasis.

Hypertension after extracorporeal shock wave lithotripsy (ESWL) has been a controversial subject. Changes in blood pressure were studied in 262 patients (mean age 47.8 years) 18.6 months after ESWL. According to World Health Organization criteria the number of patients who showed a decrease exceeded those who showed an increase in blood pressure. The patients who have been on antihypertensive therapy showed a significantly greater decrease in blood pressure than those without medication. Of 192 normotensive patients diastolic pressure increased 1.2 mm. Hg and 2 (1.0%) had hypertension 18.4 months after ESWL. Annualized increase in diastolic pressure and new onset of hypertension were calculated to be 0.78 mm. Hg and 0.65%, respectively. Significant elevation of diastolic pressure was noted in the patients who received a larger number of shock waves. Blood pressure should be carefully followed after ESWL especially in patients who have been treated by a greater number of shock waves.     

Radiation exposure to patients during extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy is rapidly becoming an accepted treatment of renal calculi. Since fluoroscopy is involved to image the stones it is important to know how much radiation the patient receives during this proCedure. Surface radiation exposure to the patient was measured in more than 300 fluoroscopic and radiographic procedures using thermoluminescent dosimeters. Initial results showed an average skin exposure of 10.1 rad per procedure for each x-ray unit, comparing favorably with exposure rates for percutaneous nephrostolithotomy and other routine radiological procedures. Factors influencing exposure levels include stone characteristics (location, size and opacity), physician experience and number of shocks required. Suggestions are given that may result in a 50 per cent reduction of radiation exposure.     

体外冲击波治疗骨不连

骨折后骨延迟愈合和不愈合的发生率为5％-10％。传统的手术固定和骨移植为较为有效的治疗方法,治愈率可达90％左右;然而手术治疗亦产生了严重的并发症,深部感染、感觉缺失等主要并发症的发生率为8．6％;浅表感染、供骨区疼痛等次要并发症的发生率为20．6％,而且部分患者仍需再次手术治疗。为此许多学者探索有效的微创技术治疗骨不连。骨的声     

Acetabular augmentation induced by extracorporeal shock waves in rabbits

We conducted this animal study to demonstrate whether exposing the acetabulum in immature rabbits to extracorporeal shock waves induces bone formation in the acetabulum. Five thousand shock waves of 100 MPa each were directed, from outside, at the acetabular roof of eight immature rabbits. At each of two time points (4 and 8 weeks) after treatment, the pelvises of four rabbits were removed and evaluated morphologically. Woven bone formation was observed on the lateral margin of the acetabular roof at 4 weeks after treatment, and the breadth of the acetabular roof in the coronal plane was significantly increased. Eight weeks after treatment, the woven bone disappeared; the breadth of the acetabular roof, however, was significantly increased. These findings demonstrated that extracorporeal shock waves induced acetabular augmentation in rabbits. We conclude that extracorporeal shock waves, perhaps, could be applied clinically for the treatment of acetabular dysplasia.     

体外冲击波治疗骨不愈的临床观察

目的观察体外冲击波治疗骨不愈的疗效及安全性。方法应用体外震波碎石机所产生的高能震波对25例骨折不愈合病人进行治疗,每月复查X线片检查,了解骨折愈合情况。震波治疗3个月后如骨折处无明显骨痂生长,则再行一次震波治疗。结果震波治疗后,骨痂出现时间为4～11周,平均9周。25例中,5例无效;20例有较明显骨痂生长,其中18例最终骨折完全愈合,骨折愈合时间为10～21周,平均14周。治疗总有效率为80%,治愈率为72%。震波治疗后未观察到肢体神经血管损伤等并发症。结论体外冲击波治疗骨不愈疗效可靠、创伤小、方法简单安全,可作为治疗骨不愈的首选方法。     

Renal loss following extracorporeal shock wave lithotripsy

A patient with life-threatening retroperitoneal hemorrhage after extracorporeal shock wave lithotripsy is presented. Despite angioinfarction of the involved renal unit, nephrectomy ultimately was required to control bleeding. The urological and hematological aspects of the management are discussed.     

Severe sepsis following extracorporeal shock wave lithotripsy

A patient with life-threatening sepsis following extracorporeal shock wave lithotripsy (ESWL*) is described. The urosepsis was complicated by meningitis and diffuse metastatic endophthalmitis necessitating enucleation of the right eye. Retinal detachment occurred in the left eye following focal endophthalmitis and the operation yielded a poor functional result. The patient was discharged from the hospital 3 months after the ESWL therapy, free of urinary stones. The etiology, treatment and prophylaxis of this serious problem are discussed.     

Two cases of anesthesia-free extracorporeal shock wave lithotripsy in stone-bearing pelvic kidneys

We report 2 cases of urolithiasis in pelvic kidneys and discuss the therapy of difficult stone locations with extracorporeal shock wave lithotripsy (ESWL) alone using new techniques of positioning (prone and upright sitting position) and the modified Dornier HM3 lithotriptor for anesthesia-free ESWL.     

Unfocused extracorporeal shock waves induce anabolic effects in osteoporotic rats

Unfocused extracorporeal shock waves (UESW) have been shown to have an anabolic effect on bone mass. Therefore we investigated the effects of UESW on bone in osteoporotic rats with and without anti‐resorptive treatment. Twenty‐week‐old rats were ovariectomized (n = 27). One group was treated with saline and another group with Alendronate (ALN) 2.4 µg/kg, 3×/week. UESW were applied 2 weeks after ovariectomy. Thousand UESW were applied to one hind leg, the contra‐lateral hind leg was not treated and served as control. With the use of in vivo micro‐CT scanning it was shown that in saline treated rats trabecular bone volume fraction (BV/TV) was higher at 2 weeks follow‐up in UESW treated legs compared to control legs. However, at 4 and 10 weeks no difference was found. In ALN treated animals UESW led to a pronounced anabolic response resulting in an increase in BV/TV at all time‐points. Furthermore, UESW resulted in increased cortical volume (CtV), higher trabecular connectivity and, more plate‐like and thicker trabeculae. Biomechanical testing showed that UESW lead to a higher maximum force before failure and higher stiffness in all treatment groups. With histology abundant areas of intramembranous bone formation along the periosteal cortex and within the bone marrow were observed. In conclusion this study shows promising results for the use of UESW in the treatment of osteoporosis, especially when this treatment is combined with an anti‐resorptive treatment. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 768–775, 2013     

Evaluation of renal damage in extracorporeal lithotripsy by shock waves

Lithotrispy by shock waves is an alternative treatment to renal lithiasis surgery. On destruction of the stone, the pressure of shock waves produces renal microdamage. According to the current knowledge of renal physiopathology, we studied the variations of lactate dehydrogenase (LDH) and N-acetylglucosaminidase (NAG) levels in blood and urine of 44 patients with renal lithiasis (pelvic or calyceal) before and after treatment. We found a significant LDH and NAG increase in blood and an LDH increase in urine after lithotripsy. There was no correlation between the number of applied waves and enzymatic increase.