Invasive treatment trends in urinary calculi in a third level hospital

How to maximize the efficacy of shockwave lithotripsy

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.

Is extracorporeal shock wave lithotripsy a current treatment for urolithiasis? A systematic review

INTRODUCTION

Technological advances have prompted a change in the management of urolithiasis. Endourological techniques are gaining importance because they are highly effective treatments. The aim of this study was to answer the question of whether extracorporeal shock wave lithotripsy (ESWL) is still a competitive alternative compared with other therapeutic modalities.

ACQUISITION OF EVIDENCE

We conducted a literature search of articles published in the past 5 years. We identified 12 randomized and comparative studies and assessed the methodology and results of the study variables. We performed a narrative synthesis of the included studies. To summarise the variables, we used the mean and standard deviation for continuous variables and absolute numbers and percentages for the qualitative variables.

ANALYSIS OF THE EVIDENCE

Of the studies reviewed, 7 evaluated the various treatments for nephrolithiasis and 5 evaluated the treatments for ureteral lithiasis. At the renal level, a stone-free rate of 33.33-91.5% at 3 months was reached with ESWL, while a rate of 90.4-100% was achieved with the other endourological techniques, without finding statistically significant differences in the studies. At the ureteral level, a stone-free rate of 73.5-82.2% at 3 months was reached with ESWL, while a rate of 79-94.1% was achieved with the other endourological techniques, without finding statistically significant differences in the studies.

CONCLUSION

There is a lack of homogeneity among the published studies. ESWL is a minimally invasive treatment that with an appropriate technique and patient selection achieves high effectiveness, thus maintaining an important role at this time.

Predicting the effectiveness of extracorporeal shock wave lithotripsy on urinary tract stones. Risk groups for accurate retreatment

INTRODUCTION

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive, safe and effective treatment for urinary tract lithiasis. Its effectiveness varies depending on the location and size of the stones as well as other factors; several sessions are occasionally required. The objective is to attempt to predict its success or failure, when the influential variables are known beforehand.

MATERIAL AND METHODS

We analysed 211 patients who had had previous CT scans and were treated with ESWL between 2010 and 2014. The influential variables in requiring retreatment were studied using binary logistic regression models (univariate and multivariate analysis): maximum density, maximum diameter, area, location, disintegration and distance from the adipose panniculus. With the influential variables, a risk model was designed by assessing all possible combinations with logistic regression (version 20.0 IBM SPSS).

RESULTS

The independent influential variables on the need for retreatment are: maximum density >864HU, maximum diameter >7.5mm and pyelocaliceal location. Using these variables, the best model includes 3risk groups with a probability of requiring significantly different retreatment: group 1-low risk (0 variables) with 20.2%; group 2-intermediate risk (1-2 variables) with 49.2%; and group 3-high risk (3 variables) with 62.5%.

CONCLUSIONS

The density, maximum diameter and pyelocaliceal location of the stones are determinant factors in terms of the effectiveness of treatment with ESWL. Using these variables, which can be obtained in advance of deciding on a treatment, the designed risk model provides a precise approach in choosing the most appropriate treatment for each particular case.

Combination of extracorporeal lithotripsy and flexible ureterorenoscopy optimize renal lithiasis therapy

OBJECTIVE

Describe our initial experience in the treatment of renal lithiasis with extracorporeal lithotripsy controlled by simultaneous flexible ureterorenoscopy and combined with holmium laser lithotripsy.

MATERIAL AND METHODS

We performed this novel technique in a previously selected patient with left renal lithiasis, two in the superior calix, two in the medium calix and two in the inferior calix, the biggest of which was placed in medium calix and was 6mm long. We proceeded to an extracorporeal shock wave lithotripsy and a simultaneous flexible ureterorenoscopy for better controlling the fragmentation of the lithiasis with the use of a holmium laser. In the immediate post-operative, an ultrasound was performed and, one month later, a computerized tomography (CT) was done.

RESULTS

The complete fragmentation of all the lithiasis was obtained and a double-J catheter was placed. After the assessment of the absence of stone fragments by CT the catheter was removed. No intra-operative or post-operative complications were described.

CONCLUSIONS

The technique described is novel, safe and reproducible. The good result obtained through this combined technique increases our interest in continuing with its application and consider it as an option for the treatment of renal lithiasis in our patients.

Recent advances in understanding and managing urolithiasis

During the last few years, there has been relevant progress in both understanding and managing urolithiasis. Our knowledge of stone formation has changed; although the importance of urine biochemistry was questioned by several investigators years ago, the decisive role of cellular processes (induced by oxidative stress) and the renal papilla has only recently been generally accepted as the most important step in stone formation. For calcium oxalate urolithiasis, the formation of papillary calcifications plays a key role and is of prognostic relevance. Further research has to concentrate on these aspects of preventing urolithiasis. Stone prevention (metaphylaxis) is a major issue when considering the burden it places on healthcare systems. An effective metaphylaxis could lower the cost of stone therapy significantly. For uric acid urolithiasis, so far there is only preliminary information available showing that papillary plaques are not as important as they are in calcium oxalate urolithiasis. Concerning stone management, endourology has improved stone therapy significantly during the last few years. Morbidity decreased and success (stone-free) rates increased. Therefore, the indications for extracorporeal shockwave lithotripsy (ESWL) narrowed. ESWL, however, still has its place in stone therapy. There is not one single treatment modality that is equally effective for all situations. It is important to observe the differential indications for different stones depending on size, localization, and composition.