Evolution of pre-treatment stenting and local anesthesia for extracorporeal shock wave lithotripsy at a single university center

Evolution of the extracorporeal shock wave lithotripsy technique involves not just second generation technology but operator innovations and experience. Retrospective analysis of the first 512 treatments at a university medical stone unit using the Dornier HM3 lithotriptor was compared to 3 intervals of 100 consecutive treatments during the next 2-year period (1985 to 1987). Patient referral and selection as well as treatment techniques and rates of endourological interventions were analyzed. Patient demographics, stone types and retreatment rates remained constant during 2,500 treatments. However, the use of local anesthesia and internal ureteral stents became increasingly common. Of the 1987 cohort 29% were treated with the patient under local anesthesia, and 23 of the 44 with a stent (52%) received internal ureteral stents. Other treatment trends identified during the study period included increasing number of large (greater than 2 cm.) and multiple stones treated; increasing use of internal and external ureteral catheters before treatment, fewer stents for small, mobile renal calculi and decreasing length of hospital stay (2.7 to 2.1 days) with increasing use of stents before lithotripsy. The increasing average number of shock waves per treatment (1,382 versus 1,580) during the study period can be attributed to the larger proportion of patients with high stone burdens and the impact of an increased number of operators with more varied criteria for endoscopy and treatment end point.

Going mobile

The high cost of ESWL and MRI have created a strong market for mobile units that can be shared by several health-care facilities. Recent modifications in the design of this technology make it convenient to use in mobile vans. Other modalities are being used in mobile vans primarily to service small hospitals.

[Extracorporeal shock wave lithotripsy: the evolution of a revolution]

Extracorporeal shockwave lithotripsy has now been in clinical use for 8 years, and it has replaced other treatment techniques for the majority of surgical calculi in the upper urinary tract. For the first time it provides a completely noninvasive method for the treatment of renal and ureteral calculi. The current range of indications means that approximately 70% of nonselected urinary stone patients can be treated by this method, while 25% of the patients with more complex stones in the upper urinary tract can receive treatment with the lithotripter combined with endourological procedures. The clinical role of this method is determined by a high success rate and minimal complications. This has led to a rapid worldwide acceptance in the urological community, and up to now more than 1.5 million patients with urinary stone disease have been treated.

The coming battle over gallstones. How will surgeons, gastroenterologists, and radiologists fare?

The standard treatment of symptomatic gallstones--initial patient evaluation, confirmation of the presence of stones by diagnostic imaging, and surgical removal of the gallbladder (cholecystectomy)--has become institutionalized in modern medical practice. In recent years alternative treatments have been developed, but none has dislodged cholecystectomy from its preeminent position. Should a new therapy, extracorporeal shock-wave biliary lithotripsy, prove to be broadly successful, it could profoundly change the future workloads of general surgeons, gastroenterologists, and radiologists, the three specialists most likely to have significant roles in providing this new treatment.