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Noble PA, Hamilton BD, Gerber G. Stone decision engine accurately predicts stone removal and treatment complications for shock wave lithotripsy and laser ureterorenoscopy patients. PLoS One 2024; 19:e0301812. [PMID: 38696418 PMCID: PMC11065282 DOI: 10.1371/journal.pone.0301812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/24/2024] [Indexed: 05/04/2024] Open
Abstract
Kidney stones form when mineral salts crystallize in the urinary tract. While most stones exit the body in the urine stream, some can block the ureteropelvic junction or ureters, leading to severe lower back pain, blood in the urine, vomiting, and painful urination. Imaging technologies, such as X-rays or ureterorenoscopy (URS), are typically used to detect kidney stones. Subsequently, these stones are fragmented into smaller pieces using shock wave lithotripsy (SWL) or laser URS. Both treatments yield subtly different patient outcomes. To predict successful stone removal and complication outcomes, Artificial Neural Network models were trained on 15,126 SWL and 2,116 URS patient records. These records include patient metrics like Body Mass Index and age, as well as treatment outcomes obtained using various medical instruments and healthcare professionals. Due to the low number of outcome failures in the data (e.g., treatment complications), Nearest Neighbor and Synthetic Minority Oversampling Technique (SMOTE) models were implemented to improve prediction accuracies. To reduce noise in the predictions, ensemble modeling was employed. The average prediction accuracies based on Confusion Matrices for SWL stone removal and treatment complications were 84.8% and 95.0%, respectively, while those for URS were 89.0% and 92.2%, respectively. The average prediction accuracies for SWL based on Area-Under-the-Curve were 74.7% and 62.9%, respectively, while those for URS were 77.2% and 78.9%, respectively. Taken together, the approach yielded moderate to high accurate predictions, regardless of treatment or outcome. These models were incorporated into a Stone Decision Engine web application (http://peteranoble.com/webapps.html) that suggests the best interventions to healthcare providers based on individual patient metrics.
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Affiliation(s)
- Peter A. Noble
- Department of Microbiology, University of Alabama Birmingham, Birmingham, AL, United States of America
| | - Blake D. Hamilton
- School of Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Glenn Gerber
- University of Chicago Medical Center, Chicago, IL, United States of America
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Popiolek M, Jendeberg J, Sundqvist P, Wagenius M, Lidén M. Finding the optimal candidate for shock wave lithotripsy: external validation and comparison of five prediction models. Urolithiasis 2023; 51:66. [PMID: 37027057 PMCID: PMC10082105 DOI: 10.1007/s00240-023-01444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
We aimed to externally validate five previously published predictive models (Ng score, Triple D score, S3HoCKwave score, Kim nomogram, Niwa nomogram) for shock wave lithotripsy (SWL) single-session outcomes in patients with a solitary stone in the upper ureter. The validation cohort included patients treated with SWL from September 2011 to December 2019 at our institution. Patient-related variables were retrospectively collected from the hospital records. Stone-related data including all measurements were retrieved from computed tomography prior to SWL. We estimated discrimination using area under the curve (AUC), calibration, and clinical net benefit based on decision curve analysis (DCA). A total of 384 patients with proximal ureter stones treated with SWL were included in the analysis. Median age was 55.5 years, and 282 (73%) of the sample were men. Median stone length was 8.0 mm. All models significantly predicted the SWL outcomes after one session. S3HoCKwave score, Niwa, and Kim nomograms had the highest accuracy in predicting outcomes, with AUC 0.716, 0.714 and 0.701, respectively. These three models outperformed both the Ng (AUC: 0.670) and Triple D (AUC: 0.667) scoring systems, approaching statistical significance (P = 0.05). Of all the models, the Niwa nomogram showed the strongest calibration and highest net benefit in DCA. To conclude, the models showed small differences in predictive power. The Niwa nomogram, however, demonstrated acceptable discrimination, the most accurate calibration, and the highest net benefit whilst having relatively simple design. Therefore, it could be useful for counselling patients with a solitary stone in the upper ureter.
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Affiliation(s)
- Marcin Popiolek
- Department of Urology, Faculty of Medicine and Health, Örebro University, 701 85, Örebro, Sweden.
| | - Johan Jendeberg
- Department of Radiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Pernilla Sundqvist
- Department of Urology, Faculty of Medicine and Health, Örebro University, 701 85, Örebro, Sweden
| | - Magnus Wagenius
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
- Department of Urology Helsingborg Hospital, Helsingborg, Sweden
| | - Mats Lidén
- Department of Radiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Garg M, Johnson H, Lee SM, Rai BP, Somani B, Philip J. Role of Hounsfield Unit in Predicting Outcomes of Shock Wave Lithotripsy for Renal Calculi: Outcomes of a Systematic Review. Curr Urol Rep 2023; 24:173-185. [PMID: 36802317 PMCID: PMC10038959 DOI: 10.1007/s11934-023-01145-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 02/23/2023]
Abstract
PURPOSE OF REVIEW Extracorporeal shock wave lithotripsy success rates depend on several stone and patient-related factors, one of which is stone density which is calculated on computed tomography scan in Hounsfield Units. Studies have shown inverse correlation between SWL success and HU; however, there remains considerable variation between studies. We performed a systematic review regarding the use of HU in SWL for renal calculi to consolidate the current evidence and address current knowledge gaps. RECENT FINDINGS Database including MEDLINE, EMBASE, and Scopus were searched from inception through August 2022. Studies in English language analysing stone density/attenuation in adult patients undergoing SWL for renal calculi were included for assessment of Shockwave lithotripsy outcomes, use of stone attenuation to predict success, use of mean and peak stone density and Hounsfield unit density, determination of optimum cut-off values, nomograms/scoring systems, and assessment of stone heterogeneity. 28 studies with a total of 4,206 patients were included in this systematic review with sample size ranging from 30 to 385 patients. Male to female ratio was 1.8, with an average age of 46.3 years. Mean overall ESWL success was 66.5%. Stone size ranged from 4 to 30 mm in diameter. Mean stone density was used by two-third of the studies to predict the appropriate cut-off for SWL success, ranging from 750 to 1000 HU. Additional factors such as peak HU and stone heterogeneity index were also evaluated with variable results. Stone heterogeneity index was considered a better indicator for success in larger stones (cut-off value of 213) and predicting SWL stone clearance in one session. Prediction scores had been attempted, with researchers looking into combining stone density with other factors such as skin to stone distance, stone volume, and differing heterogeneity indices with variable results. Numerous studies demonstrate a link between shockwave lithotripsy outcomes and stone density. Hounsfield unit < 750 has been found to be associated with shockwave lithotripsy success, with likelihood of failure strongly associated with values over 1000. Prospective standardisation of Hounsfield unit measurement and predictive algorithm for shockwave lithotripsy outcome should be considered to strengthen future evidence and help clinicians in the decision making. TRIAL REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO) database: CRD42020224647.
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Affiliation(s)
- Megha Garg
- Bristol Urological Institute, North Bristol NHS Trust, West bury-on-Trym, Bristol, BS10 5NB UK
| | - Hans Johnson
- Bristol Urological Institute, North Bristol NHS Trust, West bury-on-Trym, Bristol, BS10 5NB UK
| | - Su-min Lee
- Bristol Urological Institute, North Bristol NHS Trust, West bury-on-Trym, Bristol, BS10 5NB UK
| | | | - Bhaskar Somani
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Joe Philip
- Bristol Urological Institute, North Bristol NHS Trust, West bury-on-Trym, Bristol, BS10 5NB UK
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Yin X, Li J, Pan C, Liu G, Li Z, Bai S. Development and validation of a predictive model for stone-free failure after extracorporeal shockwave lithotripsy in patients with ureteral stone in a large prospective cohort. World J Urol 2023; 41:1431-1436. [PMID: 36912972 DOI: 10.1007/s00345-023-04358-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/09/2023] [Indexed: 03/14/2023] Open
Abstract
PURPOSE To develop and validate a nomogram for predicting stone-free failure after shock wave lithotripsy (SWL) guided by ultrasound in patients with ureteral stones. METHODS The development cohort consisted of 1698 patients who underwent SWL guided by ultrasound at our center from June 2020 through August 2021. Multivariate unconditional logistic regression analysis was used for building a predictive nomogram with regression coefficients. An independent validation cohort consisted of 712 consecutive patients from September 2020 through April 2021. The performance of the predictive model was assessed in regard to discrimination, calibration, and clinical usefulness. RESULTS Predictors of stone-free failure included distal stone location (odds ratio = 1.540, P < 0.001), larger stone size (odds ratio = 1.722, P < 0.001), higher stone density (odds ratio = 1.722, P < 0.001), larger skin to stone distance (SSD) (odds ratio = 1.058, P < 0.001), and higher grade of hydronephrosis (odds ratio = 1.755, P = 0.010). For the validation cohort, the model showed good discrimination with an area under the receiver operating characteristic curve of 0.925 (95% confidence interval, 0.898, 0.953) and good calibration (unreliability test, P = 0.412). Decision curve analysis demonstrated that the model was also clinically useful. CONCLUSIONS This study demonstrated that stone location, stone size, stone density, SSD, and hydronephrosis grade were significant predictors of stone-free failure after SWL guided by ultrasound in patients with ureteral stones. This may guide clinical practice.
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Affiliation(s)
- Xiaoming Yin
- Department of Pediatric Urology, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Jia Li
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning, People's Republic of China
| | - Chunyu Pan
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning, People's Republic of China
| | - Gang Liu
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning, People's Republic of China
| | - Zhenhua Li
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning, People's Republic of China.
| | - Song Bai
- Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning, People's Republic of China.
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Culpan M, Acar HC, Akalin K, Cakici MC, Tufekci B, Gunduz N, Dogan MB, Yildirim A, Atis G. Are the current nomograms sufficient to predict shockwave lithotripsy outcomes? Actas Urol Esp 2022; 46:473-480. [PMID: 35803872 DOI: 10.1016/j.acuroe.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/11/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND OBJECTIVES To investigate factors affecting SWL outcomes, validate three current nomograms (Kim JK, Triple D and S3HoCKwave) and compare the predictive ability of the nomograms for SWL outcomes in upper urinary tract stones. PATIENTS AND METHODS Medical records of patients with renal and proximal ureteral stones treated with SWL between March 2013 and October 2020 were retrospectively reviewed. Factors affecting SWL success were analyzed with multivariate logistic regression analysis and the three predictive scoring systems compared with the area under the curve (AUC). RESULTS A total of 580 patients were included in our study. The overall stone free rate was 61% and 144/580 patients (24.8%) were stone free after one session. In multivariate logistic regression analysis, stone location at upper calyx (OR:2.988; 95%Cl: 1.350-6.612; p = 0.007), middle calyx (OR:3.036; 95%Cl: 1.472-6.258; p = 0.003), and lower calyx (OR:2.131; 95%Cl: 1.182-3.839; p = 0.012), as well as number of stones (OR:1.663; 95%Cl: 1.140-2.425; p = 0.008), maximum diameter of stone (OR:1.156; 95%Cl: 1.098-1.217; p < 0.001) and maximum Hounsfield Unit (OR:1.001; 95%Cl: 1.001-1.002; p < 0.001) were independent risk factors of SWL failure. The AUCs of the Kim JK, Triple D and S2HoCKwave scores for predicting SWL success were 0.678, 0.548, and 0.626 respectively. CONCLUSIONS Stone location, number, maximal diameter, and maximum HU were independent predictive factors for SWL outcome in the treatment of upper urinary tract stones. Current nomograms, "Kim JK nomogram", "Triple D score" and "S3HoCKwave score" can predict treatment success after SWL, but all of them have poor discrimination according to AUC analysis.
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Affiliation(s)
- M Culpan
- Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
| | - H C Acar
- Department of Public Health, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - K Akalin
- Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - M C Cakici
- Department of Urology, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - B Tufekci
- Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - N Gunduz
- Department of Radiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - M B Dogan
- Department of Radiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - A Yildirim
- Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - G Atis
- Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
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Saad Elsayed M, Abo Ghareeb ME, Hamed H, Elmoazen M, Shorbagy AA. Evaluation of the relation between size of stone and its attenuation measured by Hounsfield units and the total laser energy required to fragment it. Scand J Urol 2022; 56:308-312. [PMID: 35929867 DOI: 10.1080/21681805.2022.2104366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Anticipating the total laser energy (TLE) of Holmium YAG laser required for ureteroscopic (URS) lithotripsy is essential to guide urologists in selecting the optimal fiber size. This study aimed at evaluating the relationship between stone size and stone attenuation measured by HU as predictors for the TLE during the procedure. METHODS We conducted an observational prospective cohort study of patients undergoing URS lithotripsy at the Urology department of Ain Shams University Hospitals from September 2018 to September 2019 with the use of a holmium YAG laser as the lithotripsy method. Patients' demographic and clinical characteristics, stone location, stone size, stone attenuation measured by HU from the non-contrast CT, TLE, and procedure time were recorded. Data were analyzed using Jamovi software (version 2.0 for macOS). RESULTS Forty patients were included in the study (22 males and 18 females) with a mean age of 57.8 years. The mean stone size was 9.8 mm3, the mean HU was 858.8 units, and the mean TLE was 3.5 KJ. Both stone size and stone attenuation measured by HU were positively correlated with TLE (r = 0.81 and 0.84, respectively; p < 0.001 for both). Further, regression analysis showed that both variables could significantly predict the TLE (ß = 0.001 and 0.71, respectively). CONCLUSIONS Both stone attenuation, as measured by HU, and stone size positively correlate with TLE required for URS lithotripsy. Therefore, both HU and stone size can predict the TLE, which will be helpful to guide the urologist in selecting the optimal fiber size for the procedure.
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Affiliation(s)
| | | | - Hany Hamed
- Department of Urology, Ain Shams University, Cairo, Egypt
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Culpan M, Acar HC, Akalin K, Cakici MC, Tufekci B, Gunduz N, Dogan MB, Yildirim A, Atis G. ¿Son suficientes los nomogramas actuales para predecir los resultados de la litotricia por ondas de choque? Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bhanot R, Jones P, Somani B. Minimally Invasive Surgery for the Treatment of Ureteric Stones - State-of-the-Art Review. Res Rep Urol 2021; 13:227-236. [PMID: 33987110 PMCID: PMC8110280 DOI: 10.2147/rru.s311010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/08/2021] [Indexed: 01/04/2023] Open
Abstract
The landscape of managing ureteric stones has evolved over the last few decades and several treatment options exist depending on the stone size, location, and other patient and stone factors. While open surgery is now rarely performed, the use of medical expulsive therapy (MET) has been controversial and perhaps only recommended for large distal ureteric stones. The mainstay treatment balances between shockwave lithotripsy (SWL) and ureteroscopy (URS), with the latter usually recommended for larger stones. While the principles of ureteric stone management have remained largely unchanged, the modern era has generated new methods and means to deliver it. Advancements have occurred in all domains of endourology to try and refine treatment and balance it with cost, patient choice and quality of life. Dissemination of technologies and demonstration of their efficacy and safety will eventually result in new recommendations among international guidelines and evolution of new gold standards.
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Affiliation(s)
- Radhika Bhanot
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Patrick Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,EAU Young Academic Urology Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Bhaskar Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK.,EAU Young Academic Urology Urolithiasis and Endourology Working Party, Arnhem, the Netherlands.,Manipal Academy of Higher Education, Manipal, India
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Jones P, Pietropaolo A, Chew BH, Somani BK. Atlas of scoring systems, grading tools and nomograms in Endourology: A comprehensive overview from The TOWER Endourological Society research group. J Endourol 2021; 35:1863-1882. [PMID: 33878937 DOI: 10.1089/end.2021.0124] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION With an increase in the prevalence of kidney stone disease (KSD), there has been a universal drive to develop reliable and user-friendly tools such as grading systems and predictive nomograms. An atlas of scoring systems, grading tools and nomograms in Endourology is provided in this paper. METHODS A comprehensive search of world literature was performed to identify nomograms, grading systems and classification tools in endourology related to KSD. Each of these were reviewed by the authors and have been evaluated in a narrative format with details on those which are externally validated and their respective citation count on google scholar. RESULTS A total of 54 endourological tools have been described in our atlas of endourological scoring systems, grading tools and nomograms. Of the tools, 23 (43%) are published in the last 3 years showing an increasing interest in this area. This includes 5 for percutaneous nephrolithotomy (PCNL), 6 for flexible ureteroscopy (fURS), 3 for semi-rigid URS (sURS), 9 for shockwave lithotripsy (SWL), 2 for stent encrustations, 3 for intra-operative appearance at the time of URS and 3 to classify intra-operative ureteric injury. There were 3 tools for renal colic assessment, one each for prediction of future stone event, stone classification and stone impaction and 2 for need of emergency intervention in ureteric stone. While 2 tools are related to stone recurrence, 6 are related to post-procedural complications. There are now 2 tools for simulation in endourology and 5 for patient reported outcome measures (PROMS). CONCLUSIONS A number of reliable and established tools exist currently in endourology. Each of these offers their own respective advantages and disadvantages. While nomograms and scoring systems can help in the decision making, these must be tailored to individual patients based on their specific clinical scenarios, expectations and informed consent.
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Affiliation(s)
- Patrick Jones
- Haukeland University Hospital, 60498, Urology, Bergen, Norway;
| | - Amelia Pietropaolo
- University Hospital Southampton NHS Foundation Trust, 7425, Urology, Southampton, Southampton , United Kingdom of Great Britain and Northern Ireland;
| | - Ben H Chew
- University of British Columbia, Urologic Sciences, Vancouver, British Columbia, Canada;
| | - Bhaskar K Somani
- University Hospital Southampton NHS Foundation Trust, 7425, Urology, Southampton, Southampton , United Kingdom of Great Britain and Northern Ireland.,University of Southampton, 7423, Southampton, Hampshire, United Kingdom of Great Britain and Northern Ireland;
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Petrides N, Ismail S, Anjum F, Sriprasad S. How to maximize the efficacy of shockwave lithotripsy. Turk J Urol 2020; 46:S19-S26. [PMID: 33135997 DOI: 10.5152/tud.2020.20441] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 11/22/2022]
Abstract
Since its introduction in the early 1980s, extracorporeal shockwave lithotripsy (ESWL) has proven to be a minimally invasive and efficient procedure for the management of renal calculi. It is currently one of the most recommended treatments for small- and medium-sized stones (<20 mm) in most guidelines internationally. The recent coronavirus disease 2019 (COVID-19) outbreak could lead to a further increase in ESWL use as it avoids a general anesthetic and its potential complications in patients with COVID-19 infection. Most publications exhibit ESWL stone-free rates (SFRs) of 70%-80%; however, this is often not the case in many centers, with multiple factors affecting the efficacy of the intervention. Various stone and patient factors have been shown to influence the ESWL success. Stone position, density and size, skin-to-stone distance, and body-mass index contribute to SFRs. Modifications in the lithotripter design and revisions in the technique have also improved the SFRs over the years, with slower shock rates, power-ramping protocols, combined real-time ultrasound, and fluoroscopy imaging technology, all enhancing the efficacy. The adjuvant use of pharmacological agents, such as alpha-blockers, potassium citrate, and the emerging microbubble technology, has also been investigated and shown promising results. Arguably, the most significant determinant of the success of ESWL in a particular unit is how the lithotripsy service is set up and monitored. Careful patient selection, dedicated personnel, and post-treatment imaging review are essential for the optimization of ESWL. Through an analysis of the published studies, this review aimed to explore the measures that contribute to an effectual lithotripsy service in depth.
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Affiliation(s)
| | - Safiyah Ismail
- Department of Urology, Darent Valley Hospital, Dartford, UK
| | - Faqar Anjum
- Department of Urology, Darent Valley Hospital, Dartford, UK
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