Extracorporeal shock-wave lithotripsy of renal calculi

Extracorporeal shock-wave lithotripsy (ESWL) is a noninvasive technique that utilizes focused shock waves to fragment stones into sand-sized particles, which then pass spontaneously with urination. The clinical use of this technique was introduced in 1980 in Germany by Chaussy and associates and has replaced most open surgery and percutaneous endoscopy for stone removal. The physics of shock waves, equipment, techniques, and patient selection in ESWL are discussed. Results of treatment of renal, upper ureteral, and lower ureteral calculi are reviewed and compared. Complications of treatment, including ureteral obstruction, hemorrhage, and tissue damage, are discussed. The advent of second-generation lithotripters has widened the parameters for patient selection in the treatment of ESWL and has increased the availability of this treatment modality.     

Pediatric staghorn calculi: the role of extracorporeal shock wave lithotripsy monotherapy with special reference to ureteral stenting

PURPOSE: Treatment for staghorn calculi in children represents a unique challenge. We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) monotherapy for the management of staghorn calculi in children with special reference to ureteral stenting. MATERIALS AND METHODS: From June 1992 to January 2001 we treated 42 children 9 months to 12 years old with staghorn stones using the Piezolith 2501 (Richard Wolf GmBH, Knittlingen, Germany) lithotriptor. The initial group of 19 patients underwent ESWL without prophylactic ureteral stenting, while in the latter group of 23 a Double-J (Medical Engineering Corp., New York, New York) ureteral stent was inserted immediately before the first ESWL session. Mean patient age, stone size, number of shock waves and ESWL sessions, hospital stay, stone-free rate and major complications were compared in the 2 groups. RESULTS: Overall 33 children (79%) were stone-free after 3 months. The 2 groups were comparable in regard to patient age, stone size, number of shock waves and ESWL sessions, and stone-free rates. Major complications developed in 21% of the unstented group, whereas none were observed in stented cases. This difference was statistically significant (p = 0.035). Seven post-ESWL auxiliary procedures were required in the unstented group to manage complications. Hospital stay was significantly longer in the unstented compared with the stented group (p = 0.022). At a followup of 9 to 102 months (mean 47) stones recurred in 2 children, who were treated with further ESWL. CONCLUSIONS: ESWL monotherapy was an efficient and safe modality for the treatment of staghorn calculi in children. Stented patients had fewer major complications and a shorter hospital stay. Prophylactic ureteral stenting is advisable before ESWL for staghorn calculi in children.     

输尿管结石气压弹道碎石术与体外冲击波碎石术疗效比较

目的：比较输尿管结石气压弹道碎石术与体外冲击波碎石术的疗效。方法：回顾分析130例气压弹碎石术与1600例体外冲击波碎石术的的碎石率、结石排净率、平均结石排净时间及并发症发生率。结果：气压弹道碎石术碎石率、结石排净率均大于体外冲击波碎石术，平均结石排出时间小于体外冲击波碎石术，并发症发生率两组问无明显差异。结论：输尿管结石行气压弹道碎石术优于体外冲击波碎石术。     

Treatment of ureteral calculi with extracorporeal shock wave lithotripsy using the Lithostar device

Shock wave requirements for fragmentation and the ultimate outcome after extracorporeal shock wave lithotripsy (ESWL) with the Lithostar device were analyzed in 107 renal units with solitary ureteral calculi. In situ treatment was done in 54 stones without prior manipulation and in 15 after failure of endoscopic manipulation. A total of 25 ureteral calculi was treated after bypass with a ureteral catheter or stent and 13 after push back to the pelvicaliceal system. Shock wave requirement for fragmentation was significantly higher for calculi of 101 to 400 mm. X mm. when compared with the requirement for smaller calculi. Shock wave requirement was also significantly higher for patients with similar sized stones treated in the prone compared to the supine position. The average number of shock waves required for disintegration was not significantly different among in situ or any of the manipulation categories of similar sized stone populations. Over-all satisfactory clearance was achieved in 77.5% of the treated ureteral calculi. Clearance status was unaffected by size up to 400 mm. X mm. and the position of the patient during treatment (prone or supine). Clearance of ureteral stones treated in situ without prior manipulation (76.5%) was numerically inferior, although statistically insignificant, to that for successfully manipulated calculi (bypassed 88% and pushed back 92.3%) but it was significantly better than the outcome obtained after failed manipulation (46.2%). ESWL with the Lithostar device is a successful mode of treatment within the entire ureteral length, and a vigorous attempt at push back before lithotripsy is unnecessary.     

Experience with ultrasound-guided ESWL

The ESWL treatment of gallstones has led to the development of ultrasound-guided lithotripters. The interdisciplinary use of these new ESWL systems by urologists, general surgeons and gastroenterologists means that different requirements have to be met. As a result of this development, ultrasound in urology is gaining even more significance. While ESWL treatment of renal calculi under ultrasound guidance has quickly become a routine method, the in situ treatment of ureteral calculi is much more problematic. In our study the validity of diagnostic ultrasound for the localization of ureteral stones was investigated. In an unselected preliminary series only 30% of ureteral calculi could be located by ultrasound. The success rates were 39% for distal stones and 16% for proximal calculi. The treatment results of renal calculi are on a par with those previously obtained under fluoroscopic guidance. Once exact localization is obtained by ultrasound, disintegration rates for ureteral calculi are fully comparable to those performed under fluoroscopic guidance. However, 60% of ureteral stones can not be located by ultrasound. Therefore, retrograde manipulation and ureteroscopic stone disintegration gains more importance in interdisciplinary shock wave centers equipped with ultrasound-guided machines. A real alternative to second-generation lithotripters in the treatment of ureteral stones will thus only be obtained if an X-ray device can be added to the locating system if necessary. With this combination device the treatment of most ureteral calculi will thus be possible.     

体外冲击波碎石术与输尿管镜气压弹道碎石术治疗输尿管下段结石的疗效比较

目的　比较体外冲击波碎石术 (ESWL)与输尿管镜气压弹道碎石术 (pneumaticlithotripsy ,PL)治疗输尿管下段结石的疗效和安全性。 方法　总结ESWL和PL治疗输尿管下段结石 3 75例的临床资料 ,其中ESWL组 190例 ,PL组 185例。结果　ESWL组单次碎石成功率为 60 .5 %(115 /190 ) ,PL组为 96.2 %(178/185 ) ;ESWL组术后 4周结石排净率为 66.3 %(12 6/190 ) ,PL组为 98.3 %(175 /178)。结论　PL治疗输尿管下段结石的疗效明显优于ESWL。     

Laser lithotripsy of the difficult ureteral calculus: results in 122 patients.

We studied 122 patients with ureteral calculi who could not be treated by extracorporeal shock wave lithotripsy (ESWL) because the stones could not be localized or focused for treatment, the patient had failed prior ESWL, the stones were impacted and in situ ESWL was likely to fail or the stones were proximal to a ureteral stricture. These patients underwent laser lithotripsy using the Candela pulsed dye laser. In 107 patients (88%) the calculi were completely fragmented with the laser alone, while 10 (8%) needed another procedure (ESWL in 8 and stone fragment extraction by basket in 2), and 5 (4%) had failed laser therapy and needed some other form of treatment (ESWL in 4 and percutaneous antegrade extraction in 1). At 3 months 116 of 122 patients (95%) were stone-free. There were 2 immediate complications (ureteral perforations) and 1 late complication (ureteral stricture). Laser lithotripsy is a safe and effective method of intracorporeal fragmentation, even of the difficult ureteral calculus, and it is a useful adjunct to ESWL.     

Treatment of distal ureteral calculi with extracorporeal shock wave lithotripsy. Experience with 264 cases

Ureteroendoscopy is used by most authors to approach distal ureteral calculi. With increasing experience extracorporeal shock wave lithotripsy (ESWL) of distal ureteral calculi has gained importance. The success rate of 96% in a large series of 264 consecutive patients treated in this manner, confirmed the results of other authors. Excluding women of child-bearing age and very large calculi (over 2 cm), ESWL is a suitable treatment modality for distal ureteral calculi.     

Cumulative Renal Damage in Oogs by Repeated Treatment with Extracorporeal Shock Waves

Background: Extracorporeal shock wave Iithotripsy (ESWL) has become a routine method for the treatment of renal and ureteral calculi. Occasionally, multisequential ESWL tredtments and high energy shock waves are required to treat large calculi. The purpose of the study was to compare renal histopathologic damage caused by varying the application of shock waves.
Methods: Six groups of dogs were defined by the frequency of shocks, application time and numbers of sessions. Bilateral nephrectomies were performed immediately, 3, 7 and 60 days after the application of shock waves. Histopathologic features of the kidneys were assessed by both light and electron microscopy.
Results: Irreversible damage was observed in all exposed kidneys. After J single session of low application frequency, damage by shock waves occurred with progressive deterioration of the nephron. At any frequency rate, the damage was caused by tissue hypoxia due to rupturing of the interstitial capillaries. As the application frequency increased, capillary rupture became more severe, and consequently, morphological damage tended to be more intense. Repeated sessions at any application frequency made the damage more intense, suggesting that an accumulation of damage had occurred. Conclusions: Minimal doses of shock waves cause renal damage and repeated ESWL sessions may result in an accumulation of damage. Considering that the damage is dose-dependent, divided ESWL treatments at a low frequency rate are advisable in a clinical setting.     

Treatment of proximal ureteral calculi: holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy

PURPOSE: We compared the safety and efficacy of ureteroscopy with intracorporeal holmium:YAG laser lithotripsy and extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for proximal ureteral calculi. MATERIALS AND METHODS: A total of 67 patients underwent 81 primary procedures, including in situ ESWL with a DoLi 50 lithotriptor (Dornier Medical Systems, Inc.) or ureteroscopy combined with holmium:YAG laser lithotripsy for proximal ureteral calculi. RESULTS: Of the primary procedures 81 involved proximal ureteral calculi, including 35 done for calculi 1 cm. or greater. The initial stone-free rate in patients with calculi 1 cm. or greater was 93% for ureteroscopy combined with holmium:YAG laser lithotripsy and 50% for in situ ESWL. The efficiency quotient for treating proximal ureteral calculi 1 cm. or greater was calculated as 0.76 for ureteroscopic lithotripsy and 0.43 for ESWL. For proximal ureteral calculi less than 1 cm. the initial stone-free rate was 100% and 80% for ureteroscopic laser lithotripsy and ESWL, respectively. The efficiency quotient was calculated as 0.81 for ureteroscopic lithotripsy and 0.72 for ESWL for treating proximal ureteral calculi less than 1 cm. There were no major complications in either group and all procedures were performed on an outpatient basis. CONCLUSIONS: Our study demonstrates that ureteroscopy combined with holmium:YAG laser lithotripsy is an acceptable treatment modality for all proximal ureteral calculi and excellent results are achieved for calculi 1 cm. or larger. Although the stone-free rate was better for smaller stones with ureteroscopic laser lithotripsy, efficiency quotients were similar. Therefore, ESWL should remain first line therapy for proximal ureteral calculi less than 1 cm. because of less morbidity, and a lesser anesthesia and analgesic requirement.     

Treatment of 2019 cases with upper urinary tract calculi using a piezoelectric lithotriptor ESL-500A

PURPOSE: We evaluated the results of extracorporeal shock wave lithotripsy (ESWL) in a large number of cases with upper urinary tract calculi, and reported the strategy how to improve the efficacy and safety of ESWL. PATIENTS AND METHOD: Eight hundred fifteen patients with renal calculi and 1,204 patients with ureteral calculi were treated using a piezoelectric ultrasound-guided lithotriptor, Toshiba ESL-500A. Auxiliary measures were needed in 51 cases (2.5%) and 1,968 cases (97.5%) were treated by in situ procedures. ESWL was performed with the optimal positioning of the patient and under the continuous monitoring by ultrasound system. The visibility of stones was improved by removal of abdominal gas and administration of diuretic agent to dilate the ureter. Cases with urinary tract infection were medicated by antibiotics and the obstruction of the urinary tract was cleared away as soon as possible. RESULTS: Including the cases with residual fragments less than 4 mm, the success rates at one month after the treatment were 97.7% and 98.7% for the renal and ureteral calculi, respectively. The mean numbers of sessions were 1.49 for renal calculi and 1.16 for ureteral calculi. Multiple sessions were required in 24.2% of renal calculi and 12.0% of ureteral calculi. No serious complication has been observed except for three cases, which were sepsis after ESWL, anuria in a solitary kidney, and pyonephrosis caused by Steinstrasse with urinary infection, respectively. CONCLUSION: ESWL using ESL-500A is an efficient treatment of upper urinary tract calculi which has higher pulverization rate and fewer complications in the adequate procedure.     

ESWL与输尿管镜碎石联合处理上尿路结石

目的：探讨对部分上尿路结石采用ESWI．与输尿管镜碎石联合处理的方法。方法：对70例上尿路结石患者采用ESWI。与输尿管镜下钬激光碎石（URS）联合交替治疗。其中输尿管结石48例,。肾结石22例。结果：结石总排净率为91．4％00（64／70）,其中输尿管结石排净率为95．8％（46／48）,肾结石排净率为81．8％（18／22）。3例治疗失败,其中1例输尿管结石因输尿管狭窄无法入镜;另2例肾结石,1例因交替治疗次数过多中途停止治疗,1例因结石硬度过大ESWI,不佳,均改为PCNL术。结论：ESW[。与URS联合交替进行的疗法处理上尿路结石,避免了创伤性治疗,扩大了ESWI,治疗范围,降低了URS手术难度,缩短了URS操作时间,提高了结石排净率,患者创伤微小、恢复快、并发症少,是治疗上尿路结石,特别是部分复杂性上尿路结石较理想的方法之一。     

复杂性输尿管上段结石的微创治疗方法比较

目的:比较体外冲击波碎石(ESWL)、逆行输尿管镜碎石(URL)、微创经皮肾镜取石(MPCNL)、后腹腔镜输尿管切开取石(RLU)治疗复杂输尿管上段结石的疗效,探讨复杂性输尿管上段结石的最佳治疗方法.方法:回顾性分析、比较四种微创方法治疗复杂性输尿管上段结石患者232例的临床资料.结果:一次治疗成功率ESWL 43%,URL 71.8%,MPCNL 85.7%,RLU 96.7%.术后3个月结石清除率ESWL 81%,URL 85.9%,MPCNL96.4%,RLU 100%.效率商为ESWL 0.50,RLU 0.65,MPCNL 0.84,RLU 0.97.结论:对于复杂性输尿管上段结石的微创治疗,应根据患者临床情况及实际要求制定治疗方案.     

Comparative study of extracorporeal shock wave lithotripsy outcomes for proximal and distal ureteric stones

Objective To assess the efficacy of extracorporeal shock wave lithotripsy (ESWL) monotherapy for isolated proximal ureteral calculi and compare it to that for isolated distal calculi. Patient and methods We treated 68 patients with isolated ureteral stones using MPL 9000. Stones were located in the proximal and distal ureters in 44 and 24 patients, respectively. Patients were stratified according to stone burden and degree of obstruction. Data of all patients were prospectively collected for stone burden, stone localization, number of sessions, number of shock waves, stone-free rates (SFRs), complications, re-treatment rates and auxiliary procedures. Outcomes regarding ureteral localization were compared. Results The overall SFR was 85.3% with a 41.2% re-treatment and 17.6% auxiliary procedure rate. The mean number of shock waves applied for each stone was not different among the two ureteral locations. The SFRs were 86.3% and 79.1% for proximal and distal ureteral stones, respectively (P = 0.17). For the group with stones <100 mm2, the SFR was 85.4% and 89.5% for the proximal and distal ureter, respectively. Although the degree of obstruction did not affect SFR of the entire group (P = 0.12) and the proximal ureter group (P = 0.96), it adversely affected SFR in the distal ureter (P = 0.017). Conclusions ESWL outcomes for the ureteral calculi support the use of lithotripsy particularly for stones <100 mm2. Treatment efficacy was not significantly different among stones localized in proximal and distal ureters. Degree of obstruction did not affect the ESWL outcomes in the proximal ureter, but it adversely affected SFR in the distal ureter.     

CT值对输尿管结石ESWL疗效的预测价值

目的：了解非增强螺旋CT的结石CT值对输尿管结石ESWL疗效的预测价值。方法：对34例结石长径在0．4～1．2cm之间拟行ESWL治疗的输尿管下段单发结石患者,先进行非增强螺旋CT检查,测定结石CT值,分为CT值〈700HU组和〉700HU组,ESWI,后经复查,计算两组结石清除率,统计学分析两组间的基本特征和冲击次数、结石清除率差异。结果：与结石CT值〉700HU组相比,〈700HU组所需冲击次数少,结石清除率高。结论：非增强螺旋CT的结石CT值能预测输尿管结石ESWL后的结石清除率。CT值低者易于粉碎和排空,CT值高者结石清除率低,可考虑首选输尿管镜下碎石或开放手术取石。     

电磁式体外冲击波碎石的应用体会和输尿管镜碎石治疗输尿管结石的差别

目的比较电磁式体外冲击波碎石与输尿管镜碎石治疗输尿管结石的效果。方法选择我科室2015年7月至2017年10月就诊的150例输尿管结石患者,随机分为2组,体外冲击波组75例采用电磁式体外冲击波碎石术治疗,输尿管镜组75例采用输尿管镜碎石术治疗,对比两组临床疗效、结石大小、手术时间及并发症发生情况。结果体外冲击波组结石直径1 cm碎石成功率为95.24%,输尿管镜组结石直径1 cm为73.33%,差异具有统计学意义(P0.05),结石直径≥1 cm且2 cm和结石直径≥2 cm两组差异无统计学意义(P0.05),体外冲击波组总碎石成功率合计88.00%,输尿管镜组为72.00%,两组差异具有统计学意义(P0.05);体外冲击波组术后并发症发生率为9.33%,输尿管镜组为21.33%,差异具有统计学意义(P0.05)。结论电磁式体外冲击波碎石治疗对于1.0 cm的输尿管结石效果较好,且减少并发症发生。     

An investigation of factors associated with failure of extracorporeal shock wave lithotripsy for ureteral calculi

In this study, we attempted to determine which patients with ureteral calculi are likely to have an unsuccessful outcome for extracorporeal shock wave lithotripsy (ESWL). The records of 388 patients with ureteral calculi treated with ESWL at Ijinkai Takeda General Hospital between January 1997 and December 1998 were retrospectively reviewed. Three hundred seventeen patients had been treated with ESWL alone (single session 156, multiple sessions 161) and 71 with transurethral ureterolithotripsy (TUL) due to failure of ESWL. We compared these two groups by multivariate logistic regression analysis, which revealed that (1) middle and lower ureteral calculi, (2) stones > 8 mm, (3) moderate to severe hydronephrosis and (4) failure of the first session ESWL were factors associated with poor outcome of ESWL. Although each predictive value of these factors was relatively low (29.6-38.6%), the rate of failure of ESWL was 85.0% when patients had all four factors. We therefore recommend an early change in treatment modality to TUL for patients with ureteral calculi when all four risk factors listed above are present.     

体外冲击波碎石治疗儿童尿路结石的疗效观察(附62例报告）

目的：探讨体外冲击波碎石(ESWL)治疗儿童尿路结石的有效性和安全性。方法：采用ESWL治疗儿童尿路结石患者62例，其中肾盂肾盏结石35例，输尿管结石22例，膀胱结石4例，移植肾结石1例。结果：62例随访3个月，结石排净59例(95．2％)，结石残留2例(3．2％)，1例无效(1．6％)，改用手术治疗。结论：ESWL治疗儿童尿路结石安全、有效，是儿童尿路结石的首选治疗方法。     

Push and smash increases success rates in treatment of ureteric calculi by ESWL

During a 3-year period 105 patients underwent attempted retrograde manipulation for ureteric calculi into the renal pelvis prior to extracorporeal shock wave lithotripsy (ESWL). The success rate of this group was compared to 93 patients receiving ESWL of ureteric calculi in situ. The method of retrograde manipulation was recorded prospectively. Retrograde flushing with a 5 F Tiemann ureteral catheter was performed after coating the proximal ureter and renal pelvis with a mixture of saline and lidocaine gel. Success rate of calculi push was 91.4%. Mean number of ESWL treatments in this group of patients was 1.4, compared to 2.1 in patients with in situ treatment. Reposition of ureteric calculi prior to ESWL treatment increases successful initial treatment and can be performed easily.     

Acute pancreatitis after extracorporeal shock wave lithotripsy for a renal calculus

Extracorporeal shock wave lithotripsy (ESWL) is currently considered the standard treatment for most renal and upper ureteral calculi. The complication rates with ESWL have been reported to be low, resulting in its widespread acceptance and use. However, as the technique has become more widely available, serious complications as a result of injury to the kidney and the surrounding organs have been recognized. We report on the development of severe acute pancreatitis in a patient after ESWL for a right-sided renal calculus. The patient history and chronologic clinical course strongly suggest a causal association between the ESWL and the development of pancreatitis.