The acute and long-term adverse effects of shock wave lithotripsy

Stone decision engine accurately predicts stone removal and treatment complications for shock wave lithotripsy and laser ureterorenoscopy patients

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.

Efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy: a meta-analysis of randomized controlled studies

Background

This meta-analysis aimed at investigating the efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy (ESWL).

Methods

Randomized controlled trials comparing the efficacy of acupuncture with conventional treatments were retrieved from major electronic databases (e.g., MEDLINE, EMBASE, and Cochrane Library) until August 28, 2022. The primary outcome was the response rate (i.e., rate of pain relief), while secondary outcomes included stone-free rate, satisfaction rate, duration of ESWL, peri-/post-procedural pain score, and risk of adverse events.

Results

Thirteen eligible studies involving 1,220 participants published between 1993 and 2022 were analyzed. Pooled results indicated that acupuncture had a better response rate compared to conventional treatments (RR = 1.17, 95% CI: 1.06-1.3, p = 0.003, seven trials, n = 832). Despite no difference in ESWL duration (MD = 0.02 min, 95% CI: -1.53 to 1.57, p = 0.98, three trials, n = 141), stone-free rate (RR = 1.11, 95% CI: 1-1.25, p = 0.06, six trials, n = 498), and satisfaction rate (RR = 1.51, 95% CI: 0.92-2.47, p = 0.1, three trials, n = 334) between the two groups, the acupuncture group had a lower risk of adverse events (RR = 0.51, 95% CI: 0.33-0.79, p = 0.003, five trials, n = 327), peri- (MD = -1.91 points, 94% CI: -3.53 to -0.28, p = 0.02, four trials, n = 258 patient) and post-procedural (MD = -1.07, 95% CI: -1.77 to -0.36, p = 0.003, four trials, n = 335) pain score.

Conclusion

The results of this meta-analysis showed that the use of acupuncture in patients receiving ESWL was associated with a higher pain relief rate and a lower risk of adverse events, suggesting feasibility of its use in this clinical setting.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022356327.

Studies on phytochemical, mineral content, in vitro anti-urolithiatic and anti-diabetic activities of horse gram flour extracts and its biosynthesized Ag nanoparticles

The current study aims to examine the use of horse gram flour and its extracts as a low-cost source of mineral content with anti-urolithiatic, anti-diabetic properties and to compare the biological activities with its biosynthesized AgNPs. The secondary metabolites and the macro and micronutrients present in the selected herbal product, reinforces the utility of the horse gram as a promising herbal. Present investigation reveals that the biomass chosen for the study as a cheap natural source with valuable mineral content of calcium (43.06 mg/L), followed by potassium (13.78 mg/L) and sodium (6.94 mg/L). The grain's water extracts found to contain carbohydrate as dominating component with the value of (65.10 ± 0.95 mg g^-1 equivalent). Whereas both water and ethanol extract contain TPC (phenol) viz; 60.13 ± 2.45 mg g^-1, 68.24 ± 1.33 mg g^-1, TTC (terpenoids)53.21 ± 1.4 mg g^-1,51.27 ± 2.65 mg g^-1, followed by TSC (sterol)as 45.58 ± 1.7 mg g^-1, 57.27 ± 1.65 mg g^-1 in moderate amounts respectively. The aqueous extract of Horse gram was used for the synthesis the AgNPs through a straightforward green approach and characterized by FESEM, TEM, zeta potential, X-ray diffraction, UV spectroscopy and particle size measurement. These studies demonstrate the production of AgNPs with an average particle size of 30 nm-60 nm. Investigation on anti-urolithiatic property with aqueous extract, (HGW), ethanol extract (HGE) and its biosynthesized Ag nanoparticles (HG-Ag) reveal that, among the three samples chosen, the biosynthesized Ag nanoparticles possess the best inhibiting activity. The disintegration of crystals in gel medium further validated the extracts and Ag nanoparticles crystal growth inhibitory activity, at concentrations of 2% for extracts and 200 μg/ml for AgNPs. Further, it is also found that the HG-Ag nanoparticle exhibit good anti-diabetic activity (75.36%) than the other two extracts (HGW Extract-67.18% & HGE Extract-44.29%). Thus, the seed flour extracts and its AgNps demonstrated to be a promising natural herbal product with potential mineral content, antidiabetic and anti-urolithiatic activities which could be a used as a value-added product in the dietary formulations.

A Novel Approach to Calcium Destruction in Coronary and Peripheral Blood Vessels: Intravascular Lithotripsy

Lithotripsy has been used for decades in the treatment of kidney stones and gallstones, in which ultrasound shock waves generated outside of the body are used to physically break up hardened masses. In the past decade, intravascular lithotripsy (IVL), a technology developed by Shockwave Medical Inc. (Santa Clara, CA), has emerged as a novel therapy for the treatment of vascular calcification. In the coronary blood vessels, IVL modifies arterial calcium and enables percutaneous coronary interventions to be performed in a safe and consistent manner, and in the peripheral blood vessels, IVL can be used as a standalone therapy in the treatment of calcified plaque in patients with peripheral artery disease (PAD). Due to the success of the Disrupt CAD and Disrupt PAD clinical trials, IVL is now FDA-approved in the United States for use in both patients with coronary artery disease (CAD) and PAD. The widespread adoption of IVL for PAD is likely to mirror the swift uptake seen in CAD. Although questions remain regarding IVL's high cost and performance compared directly to other technologies such as atherectomy, its ease of use, speed, and safety makes its future extremely promising for the treatment of complex, heavily calcified lesions in both peripheral and coronary vessels. Despite this, more studies are certainly needed to determine in what clinical scenarios IVL should be considered as opposed to atherectomy and if there are types of calcified lesions where IVL is best utilized (ie, concentric vs eccentric).

Effects of stone density on alteration in renal resistive index after extracorporeal shock wave lithotripsy for non-obstructed kidney stones

Aim The doppler-based renal resistive index is a recently proposed technique for measuring changes in renal perfusion and predicting acute kidney damage. The purpose of this study was to look at the influence of stone density on the renal resistive index (RI) after extracorporeal shock wave lithotripsy (ESWL) in patients with non-obstructed kidney stones. Material and Method Between May 2020 and July 2021, 48 consecutive patients with unilateral renal calculi of  20 mm were treated with ESWL monotherapy. The patients' non-contrast computed tomography (NCCT) images were processed and grouped into two groups using Hounsfield units (HU) (Group 1, n=27,  1000 HU; Group 2, n=21,  1000 HU). The same radiologist performed Doppler ultrasonography on all cases before, one hour, and one week following ESWL. Measurement of the RI taken in the remote region (at least 20 mm from the stones). Patient age, gender, BMI, stone laterality, stone size, and stone position were investigated as potential predictors. Results The average stone size for Group 1 was 11.7 ± 3.3 mm and 12.1 ± 2.8 mm for Group 2. The mean RI values before ESWL for Group 1 and Group 2 were 0.54 and 0.53, respectively. On comparing the pre-treatment data with the 1 hour after SWL, a statistically significant increase was recorded in the RI value for both groups. However, there was no significant difference in RI values between groups 1 and 2 1 hour and 1 week following lithotripsy therapy. After one week, the mean RI returned to pretreatment levels, according to a follow-up doppler investigation. There was no association between stone density and RI (p > 0.05). Conclusion Stone density is a significant independent predictor of ESWL outcome; however, high stone densities detected with NCCT were not associated with a significant change in RI. Post-ESWL therapy alterations are present and reversible one week after the treatment.

Nanogels as Novel Nanocarrier Systems for Efficient Delivery of CNS Therapeutics

Nanogels have come out as a great potential drug delivery platform due to its prominently high colloidal stability, high drug loading, core-shell structure, good permeation property and can be responsive to environmental stimuli. Such nanoscopic drug carriers have more excellent abilities over conventional nanomaterials for permeating to brain parenchyma in vitro and in vivo. Nanogel-based system can be nanoengineered to bypass physiological barriers via non-invasive treatment, rendering it a most suitable platform for the management of neurological conditions such as neurodegenerative disorders, brain tumors, epilepsy and ischemic stroke, etc. Therapeutics of central nervous system (CNS) diseases have shown marked limited site-specific delivery of CNS by the poor access of various drugs into the brain, due to the presences of the blood-brain barrier (BBB) and blood-cerebrospinal fluid barrier (BCSFB). Hence, the availability of therapeutics delivery strategies is considered as one of the most major challenges facing the treatment of CNS diseases. The primary objective of this review is to elaborate the newer advances of nanogel for CNS drugs delivery, discuss the early preclinical success in the field of nanogel technology and highlight different insights on its potential neurotoxicity.

Safety and efficacy of retrograde intrarenal surgery in primary and residual renal calculi in children

BACKGROUND

Minimal invasive approach is the current standard of care in the management of pediatric renal calculi. Current guidelines are clear with extra corporal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) for stone size less than and greater than 20 mm respectively. Although retrograde intrarenal surgery (RIRS) is well established in adults but literature on its role, safety and efficacy in children is sparsely available.

OBJECTIVE

To share our experience of RIRS and its outcome in a pediatric population in both primary and residual calculi of size less than 20 mm.

MATERIALS AND METHODS

We retrospectively analysed data of children who underwent RIRS for either primary or residual renal calculi from January 2017 to January 2021. Children less than 5 years underwent passive ureteric dilatation with stenting preoperatively. A7.5 Fr flexible ureteroscope with an access sheath was used in all cases while performing RIRS. All the patients had a stent left in situ at the end of the procedure. Data including stone burden, number of sittings, operative time, stone-free rate (SFR) and grade of post procedural complications were analysed with appropriate statistical methods.

RESULTS

A total of 20 patients were included in this study. The median age at presentation was 9 years ranging from 9 months to 18 years. Eight patients (40%) presented with primary renal calculi and underwent RIRS directly while the rest of the 12 (60%) had residual calculi following other procedures like SWL, PCNL before undergoing RIRS. Seven patients (35%) had congenital renal anomalies. The mean stone size and operating time (OR) was 12.6 ± 3.2 mm 84.5 ± 7.2 min respectively. The post-procedural complications were seen in 4 (20%) patients in the form of Grade-1 modified Clavein classification in 3 and Grade 2 in 1 patient. The 100% stone-free rate was achieved in 80% of the cases after first attempt.

DISCUSSION

In the present series, RIRS was effective in both the types of stones (primary and residual) less than 20 mm in size, showing 100% stone free rate with maximum of two attempts. Choosing age based optimised passive ureteric dilation led to injury free access for RIRS. Overall complications remained with in low grades and are comparable to current literature. Limitations of the study include small cohort, retrospective study and the need of three anaesthesia procedures in children under 5 years of age.

CONCLUSION

RIRS is safe and effective in children with a renal stone(s) less than 20 mm and it has a high success rate in term of achieving stone free status in both primary and residual calculi.

Insights into the cytoprotective potential of Bergenia ligulata against oxalate-induced oxidative stress and epithelial-mesenchymal transition (EMT) via TGFβ1/p38MAPK pathway in human renal epithelial cells

Oxalate exposure to human renal epithelial cells triggers a vicious cycle of oxidative stress leading to cellular injury and deposition of calcium oxalate crystals on the injured cells. This results in further oxidative damage causing inflammation and loss of cell-cell adhesion factors, ultimately leading to irreparable kidney damage. However, these events can be attenuated or prevented by plants rich in antioxidants used in the traditional system of medicine for treatment of kidney stones. To delineate the mechanism by which Bergenia ligulata extract exerts its cytoprotective role in oxalate-induced injury we designed this study. Our results revealed that oxalate-injured HK2 cells cotreated with ethanolic extract of Bergenia ligulata displayed increased viability, reduced oxidative stress due to lowered production of intracellular reactive oxygen species (ROS) and decreased apoptosis. We also observed lowered markers of inflammation, along with increased expression of epithelial marker E-cadherin and decreased expression of mesenchymal markers Vimentin, F-actin, Transforming growth factor beta 1 (TGF-β1) and EMT-related proteins in renal tubular epithelial cells through immunocytochemistry, real-time PCR and western blotting. Our findings collectively suggest that by reducing oxidative stress, modulating crystal structure and preventing crystal-cell adhesion, B. ligulata inhibits the EMT pathway by downregulating the various mediators and thereby exerts its cytoprotective effect.

Emergent players in renovascular disease

Renovascular disease (RVD) remains a common etiology of secondary hypertension. Recent clinical trials revealed unsatisfactory therapeutic outcomes of renal revascularization, leading to extensive investigation to unravel key pathophysiological mechanisms underlying irreversible functional loss and structural damage in the chronically ischemic kidney. Research studies identified complex interactions among various players, including inflammation, fibrosis, mitochondrial injury, cellular senescence, and microvascular remodeling. This interplay resulted in a shift of our understanding of RVD from a mere hemodynamic disorder to a pro-inflammatory and pro-fibrotic pathology strongly influenced by systemic diseases like metabolic syndrome (MetS), hypertension, diabetes mellitus, and hyperlipidemia. Novel diagnostic approaches have been tested for early detection and follow-up of RVD progression, using new imaging techniques and biochemical markers of renal injury and dysfunction. Therapies targeting some of the pathological pathways governing the development of RVD have shown promising results in animal models, and a few have moved from bench to clinical research. This review summarizes evolving understanding in chronic ischemic kidney injury.

Tissue neutrophil elastase contributes to extracorporeal shock wave lithotripsy-induced kidney damage and the neutrophil elastase inhibitor, sivelestat, attenuates kidney damage with gratifying immunohistopathological and biochemical findings: an experimental study

Although the efficacy of extracorporeal shock wave lithotripsy (ESWL) has been well established within the literature, debate continues on the safety of the procedure while focusing on cellular injury and its long-term consequences. Here, we describe the role of neutrophil elastase (NE) in ESWL-related rat kidney damage and investigate the protective effects of sivelestat, an inhibitor of NE, during the early and late phases. Four groups including control, ESWL alone, ESWL with sivelestat 50 mg/kg and ESWL with treatment of 100 mg/kg, each consisting of ten rats were created. Biochemical parameters of kidney function and damage and immunohistopathological findings were compared in the early (72 h after ESWL) and late (1 week after ESWL) periods between the groups. During the early period, serum and urine creatinine levels and urine kidney injury molecule-1 (KIM-1) levels and the KIM-1/creatinine ratio increased in rats treated with ESWL compared to the control group. Furthermore, increased tissue inflammation, ductal dilatation and hemorrhage, and glomerular, tubular, and interstitial damage with increased NE staining were also detected in the ESWL treatment group. During the late phase, although urine KIM-1 levels remained stable at high levels, other parameters showed significant improvements. On the other hand, the administration of sivelestat 50 mg/kg decreased serum creatinine and urine KIM-1 and KIM-1/creatinine levels significantly in rats treated with ESWL, during the early and late periods. Significant decreases in tissue inflammation, tubular, and interstitial tissue damage were also observed during the early period. In conclusion, ESWL-related kidney tissue damage occurs primarily during the early period, and NE is involved in this process. On the other hand, the NE inhibitor sivelestat attenuated this ESWL-induced kidney damage.

Urinary neutrophil gelatinase-associated lipocalin level as a biomarker of acute kidney injury following extracorporeal shock wave lithotripsy

Introduction

Although extracorporeal shock wave lithotripsy (ESWL) is minimally invasive and highly efficient for the management of kidney stones, adverse effects have been described. Available indicators of renal function exhibit insufficient sensitivity in acute renal injury (AKI). We aimed to evaluate the severity of the kidney tissue response to ESWL injury by measuring the urinary neutrophil gelatinase-associated lipocalin (uNGAL), which can indicate AKI in its early phase.

Material and methods

The prospective, controlled study included 62 patients with nephrolithiasis undergoing single ESWL treatment. uNGAL level was measured before the procedure, and 6 h and 12 h after.

Results

The median uNGAL level increased by 126.0%, 6 h after ESWL (p <0.001). The growth rate continued and 12 h after was higher by 583.7%, compared to the pre-treatment level (p <0.001). The median value of estimated glomerular filtration rate (eGFR) dropped by 15.3% 12 h after the treatment (p <0.001). It increased by 5.0% in the period 7 days to 3 months after (p <0.001) and after 3 months it was lower by 10.1% compared to pre-ESWL values (p <0.001). uNGAL level after 12 h was significantly negatively associated with eGFR, 12 h, 7 days and 3 months after the ESWL. The sensitivity of uNGAL 12 h after ESWL was 60.6%; its specificity was 75.0%, with a positive predictive value of 74.0% and negative predictive value of 61.7%.

Conclusions

uNGAL appears to be a useful biomarker for the assessment and prediction of AKI. It was noticed that uNGAL had the highest predictive value 12 h after the ESWL treatment.

Factors Affecting Tissue Cavitation during Burst Wave Lithotripsy

Burst wave lithotripsy (BWL) is a technology under clinical investigation for non-invasive fragmentation of urinary stones. Under certain ranges of ultrasound exposure parameters, this technology can cause cavitation in tissue leading to renal injury. This study sought to measure the focal pressure amplitude needed to cause cavitation in vivo and determine its consistency in native tissue, in an implanted stone model and under different exposure parameters. The kidneys of eight pigs were exposed to transcutaneous BWL ultrasound pulses. In each kidney, two locations were targeted: the renal sinus and the kidney parenchyma. Each was exposed for 5 min at a set pressure level and parameters, and cavitation was detected using an active cavitation imaging method based on power Doppler ultrasound. The threshold was determined by incrementing the pressure amplitude up or down after each 5-min interval until cavitation occurred/subsided. The pressure thresholds were remeasured postsurgery, targeting an implanted stone or collecting space (in sham). The presence of a stone or sham surgery did not significantly impact the threshold for tissue cavitation. Targeting parenchyma instead of kidney collecting space and lowering the ultrasound pulse repetition frequency both resulted in an increased pressure threshold for cavitation.

Principles of Intravascular Lithotripsy for Calcific Plaque Modification

A significant proportion of lesions treated with transcatheter interventions in the coronary and peripheral vascular beds exhibit moderate to severe calcific plaques known to portend lower procedural success rates, increased peri-procedural adverse events, and unfavorable clinical outcomes compared with noncalcific plaques. Adapted from lithotripsy technology used for treatment of ureterorenal calculi, intravascular lithotripsy (IVL) is a novel technique for the treatment of severely calcific plaque lesions that uses acoustic shockwaves in a balloon-based delivery system. Shockwaves induce calcium fractures, which facilitate stent expansion and luminal gain. In this review, the authors summarize the physics, preclinical and clinical data on IVL use in the coronary and peripheral vasculature, and future directions of IVL in transcatheter cardiovascular therapies.

Does extracorporeal shock wave lithotripsy before retrograde intrarenal surgery complicates the surgery for upper ureter stone? The results of the RIRSearch group

AIMS

To evaluate the effect of pre-RIRS ESWL on the efficiency and safety of RIRS in the treatment of proximal ureter stones.

METHODS

The patients in the study population were divided into two groups. Group-1 was composed of patients who had undergone ESWL for proximal ureter stones before RIRS and Group-2 was composed of patients who directly underwent RIRS without any prior ESWL. The clinical and demographic properties of the patients were analysed in the RIRSearch database. The operative outcomes, peroperative complications, postoperative complications, hospitalisation time and stone-free rates were compared between the groups.

RESULTS

There were 56 patients in Group 1 and 95 patients in Group 2. The demographic and clinical properties were similar between the groups. The stone-free rates, peroperative complications and postoperative complications were also similar between the groups; however, the fluoroscopy time was significantly higher in Group 1 (P = .043). The cut-off duration of 10 weeks between ESWL and RIRS had reasonable/favourable discriminating ability, with a 51% sensitivity and 88% specificity rate for stone-free status.

CONCLUSION

Performing ESWL on the proximal ureter stones before RIRS did not change the efficacy and safety of RIRS. The time between the patient's last ESWL session and RIRS had a predictive value for stone-free status, but did not have any effect on complications.

Small bowel obstruction and strangulation secondary to an adhesive internal hernia post ESWL for right ureteral calculi: a case report and review of literature

Background

Extracorporeal shock wave lithotripsy (ESWL) is a relatively safe and convenient mode of treatment for ureteral and renal stones, despite its relative safety; ESWL is not without its complications. We present a case of a patient we managed for small bowel obstruction and strangulation due to an adhesive internal hernia after ESWL was done because of right ureteral calculi.

Case presentation

We report a case of a 59-year-old patient who presented with severe abdominal pain a few hours after ESWL because of a right upper ureteric calculus. The abdominal pain increased in severity in time and became more generalized. The patient had one episode of gross hematochezia as she was being prepped for emergency laparotomy. Intra-op, she had a strangulated internal hernia because of an omental-mesenteric adhesion.

Conclusion

This case report hopes to highlight the potential of complications like acquired IH due to adhesions in patients with a history of ureteral calculi, and also the complications that may come about post-ESWL. Patients who present with signs of persistent abdominal pain post-ESWL should be vigilantly observed. If symptoms persist, increase in intensity or there is a general deterioration of the patients’ hemodynamic status, even in light of negative MDCT findings, prompt surgical intervention is crucial for definitive diagnosis as well as management.

[Poor results and complications in the use of focused shockwaves and radial pressure waves in musculoskeletal pathology]

The application of focused shockwaves and radial pressure waves in musculoskeletal pathology has had a great development in the last decade. Although most of the publications have highlighted their safety and efficacy, poor results and complications can occur. This review analyzes the main causes of its poor results, adverse effects, and complications, emphasizing their prevention.

The role of phagocytic leukocytes following flexible ureterenoscopy, for the treatment of kidney stones: an observational, clinical pilots-study

BACKGROUND

The number of patients undergoing flexible ureterenoscopy (FURS) for the treatment of kidney stones (renal calculi) is increasing annually, and as such the development of post-operative complications, such as acute kidney injury (AKI), haematuria and infection is likely to increase. Phagocytic leukocytes are white blood cells that help fight foreign material such as bacteria and viruses, and they are intrinsically involved in the inflammatory reaction. Investigating the role of phagocytic leukocytes following FURS has not been widely researched. The main aim of the study was to evaluate the role phagocytic leukocytes (neutrophils and monocytes) function, in patients undergoing FURS for the treatment of kidney stones (renal calculi).

METHODS

Fourteen consecutive patients aged between 27 and 70 years (median 49.5 years) undergoing FURS for the treatment of kidney stones were recruited (seven males, seven females). Blood samples were collected from each patient at four time points: baseline (pre-operatively) followed by 30, 120 and 240 min post-operatively. Mononuclear (MN) and polymorphonuclear (PMN) leukocyte sub-populations were isolated by density gradient centrifugation techniques. Neutrophil and monocyte cell function was investigated by measuring the cell surface expression of CD62L (L-selectin), CD11b (Mac-1), CD99 and the intracellular production of hydrogen peroxide (H2O2), via flow cytometry.

RESULTS

Significant increases was observed in monocyte CD62L expression post FURS for the treatment of kidney stones (p ≤ 0.05); while significant decreases were observed in neutrophil CD62L. The levels of the other activation markers CD11b, CD99 and H2O2 corresponded to the increases and decreases seen in CD62L for monocytes and neutrophils respectively, though the changes were not statistically significant (p > 0.05). Limiting factors for this study were the relatively small sample size, and restriction on the recruitment time points.

CONCLUSIONS

This study demonstrates that following FURS for the treatment of kidney stones, monocytes are rapidly activated and produce potent reactive oxygen intermediates. Interestingly, the pattern of expression in neutrophils suggests that these cells are deactivated in response to the treatment. The leukocyte biomarkers assessed during this investigation may have a role in monitoring the 'normal' post-operative response, as no complications occurred in any of the patients; or may help predict potential infectious complications (e.g. urosepsis) that can occur during the post-operative period. This data, however, will need to be validated and reproduced in larger multi-centre studies.

Massive Hemoperitoneum Secondary to Splenic Laceration After Extracorporeal Shockwave Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is considered a safe technique, but not without complications, though the vast majority are minor complications. We describe a rare case of splenic injury after ESWL.

A 33-year-old male presented to the emergency department (ED) after three weeks experiencing severe intermittent left-sided flank pain that he contributed to a previous motor vehicle accident. Then computerized tomography (CT) revealed a left renal stone. ESWL was performed after three weeks. After being discharged home, he returned the same day to the ED with persistent, worsening abdominal pain, hypotension, and multiple syncopes. CT demonstrated the presence of active contrast extravasation from the spleen likely due to active bleeding. Initial resuscitation was with intravenous fluids and blood products. The following day, the embolization of the splenic artery was done. The patient was discharged home after nine days of conservative management.

After one month, he had shortness of breath due to a large left-sided pleural effusion and lung collapse managed with thoracocentesis and thoracoscopic surgery.

Subsequent follow-up reveals much improvement and successful conservative management.

Splenic injury is a rare complication of ESWL, and all of the 11 reported cases in the literature were managed with splenectomy. Our case is unique in being successfully managed conservatively.

It Comes As a Shock: Kidney Repair Using Shockwave Therapy

Chronic kidney disease is a global health care burden, yet clinically-proven treatments are limited. Low-intensity shockwave, which utilizes ≈10% of the energy levels used in clinically indicated shockwave lithotripsy, is a promising technique to ameliorate ischemia and regenerate tissues. It has been demonstrated to improve healing in tissues such as bone, muscle, myocardium, and kidney via several mechanisms, particularly through promoting neovascularization. Low-intensity shockwave stimulates mechanoreceptors located primarily in endothelial and proximal tubular cells and subsequently upregulates vascular endothelial growth factors. This, in turn, promotes angiogenesis and ameliorates renal hypoxia, inflammation, and fibrosis, and ultimately preserves renal function. Furthermore, low-intensity shockwave can stimulate release of homing factors to attract endothelial progenitor or stem cells into injured kidneys for tissue repair. These effects may be beneficial in several kidney disease models, including renal artery stenosis, diabetic kidney disease, and various chronic kidney diseases, although most studies reported to date have been performed in animal models. Because of its low energy intensity, the procedure is relatively tolerable and safe, yet, more clinical studies are needed to establish its efficacy beyond currently existing strategies. Therefore, low-intensity shockwave therapy emerges as an alternative therapeutic approach that may offer a promising noninvasive intervention for treating renal diseases. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02515461; NCT03602807; and NCT03445247.

Renal protective effect of N-acetylcysteine with stepwise ramping voltage against extracorporeal shock wave lithotripsy-induced renal injury: a prospective randomized trial

PURPOSE

To evaluate the role of combination of N-acetylcysteine with stepwise ramping voltage in renal protection against the ischemic, vascular and oxidative effects of extracorporeal shock wave lithotripsy.

PATIENTS AND METHODS

A prospective randomized trial on 164 adult patients scheduled for ESWL for single renal stones. Patients with radio-lucent stones, diabetes, hypertension, febrile UTI, and preoperative albuminuria were excluded from the study. Patients were randomized into one of four groups. Group A patients received maximal fixed voltage of ESWL. Group B patients received stepwise ramping voltage of ESWL. Group C patients received fixed maximal voltage with N-acetylcysteine (NAC) 600 mg/bid from 48 h before to 24 h after the procedure. Group D patients received gradual ramping voltage with NAC. Urinary β₂-microglobulin, 24 h albumin and N-acetyl-β-D-glucosaminidase/creatinine ratio at 1 day and 5 days post-ESWL and the stone free rate at 2 weeks were measured.

RESULTS

Group D was the only group that showed no significant difference pre and post ESWL in urinary albumin, β₂-microglobulin and N-acetyl-β-D-glucosaminidase/creatinine ratio. Post hoc analysis revealed no significant difference between group B and group C in albumin, β₂-microglobulin N-acetyl-β-D-glucosaminidase/creatinine ratio, but both of them had significantly lower levels than group A and significantly higher levels than group D. There was no statistically significant difference between all groups in the stone free rate at 2 weeks.

CONCLUSION

N-acetylcysteine protects the kidney against ESWL-induced renal injuries especially if combined with stepwise ramping voltage.

Colour-coded density-gradients stone mapping: A novel reporting system for stone density on non-contrast computed tomography and its clinical applications

Objective

To presents a novel clinically oriented system to report stone attenuation on non-contrast computed tomography (NCCT) using colour-coded density-gradients stone mapping and its clinical applications.

Patients and methods

This study was performed on 50 patients with 63 stones. All patients had a recent history of failed shockwave lithotripsy (SWL) or failed dissolution therapy by alkalinisation of urine for radiolucent stones. A multi-detector NCCT examination of the abdomen and pelvis was performed in all patients. The stones were isolated and displayed in 'Volume Rendering Technique' using four-colour encoding.

Results

Eight patients with failed dissolution therapy for radiolucent stones showed an outer layer of >500 Hounsfield units (HU) or a heterogeneous composition. A total of 42 patients with failed SWL had mean attenuations of <1000 HU on NCCT. Subsequent colour-coded stone mapping showed a dense core in all stones (>1000 HU) that failed to be clearly demonstrated by the mean HU alone.

Conclusion

The initial use of a colour-coded density-gradients stone mapping reporting system for stone density on NCCT is useful for explaining failure of SWL or failure of dissolution therapy for radiolucent stones in selected cases.Abbreviations: HU: Hounsfield units; MSD: mean stone density; NCCT: non-contrast computed tomography; PCNL: percutaneous nephrolithotomy; SWL: shockwave lithotripsy; VRT: Volume Rendering Technique.

Cerebral venous thrombosis and submandibular lithotripsy: A case report

We present the case of a 38-year-old woman with a diagnosis of cerebral venous thrombosis that developed after lithotripsy of the submandibular gland. Few cases of vessel thrombosis after lithotripsy have been reported in other organs, this is the unique cerebral case reported.

Punctures versus shocks: a comparison of renal functional and structural changes after percutaneous nephrolithotomy and shockwave lithotripsy for solitary renal stone

Objective:

To evaluate renal functional and structural changes following percutaneous nephrolithotomy and shockwave lithotripsy for solitary non-obstructing non-staghorn renal stone.

Materials and methods:

Patients with solitary unilateral non-staghorn renal stones who were planned for percutaneous nephrolithotomy (20 patients) and shockwave lithotripsy (20 patients) were prospectively evaluated for renal functional and structural changes 60 days after the procedure and complete clearance of stones. Tc99-dimercaptosuccinic acid was used to assess cortical scarring and Tc99-diethylenetriamine pentaacetic acid and Tc99-levo levo ethylecysteine were used for glomerular filtration rate calculations, respectively.

Results:

The mean stone size was 24.4 mm and 13.7 mm in the percutaneous nephrolithotomy group and the shockwave lithotripsy group, respectively. No new cortical scars developed in either of the groups on Tc99-dimercaptosuccinic acid scan. Both the treated and untreated kidneys showed an overall insignificant fall in glomerular filtration rate in both the groups. The number of patients showing significant deterioration in the individual glomerular filtration rate in both the treated and untreated renal unit was more in the shockwave lithotripsy group.

Conclusion:

Both percutaneous nephrolithotomy and shockwave lithotripsy are comparable in terms of adverse effects on renal parenchyma and renal function.

Level of evidence:

Not applicable for this multicentre audit.

Identification of Novel Human Serum Albumin (SA) Inhibitors from Scoparia Dulsis for Urolithiasis

Background::

Urolithiasis is the process of forming stones in the kidney, bladder, and/or urinary tract. It has been reported that kidney stones are the third most common disorder among urinary diseases. At present, surgical procedures and Extracorporeal Shock Wave Lithotripsy (ESWL) are commonly employed for the treatment of Urolithiasis. The major drawback of these procedures is the recurrence of stones.

Methods:

This study aimed to identify potential natural inhibitors against human Serum Albumin (SA) from the plant Scoparia Dulsis for Urolithiasis. As protein-ligand interactions play a key role in structure- based drug design, this study screened 26 compounds from Scoparia Dulsis and investigated their binding affinity against SA by using molecular docking. The three dimensional (3D) structure of SA was retrieved from Protein Data Bank (PDB) and docked with PubChem structures of 26 compounds using PyRX docking tool through Autodock Vina. Moreover, a 3D similarity search on the PubChem database was performed to find the analogs of best scored compound and docking studies were performed. Drug-likeness studies were made using Swiss ADME and Lipinski’s rule of five was performed for the compounds to evaluate their anti-urolithiatic activity.

Results:

The results showed that citrusin c (Eugenyl beta-D-glucopyranoside) exhibited best binding energy of -8.1 kcal/mol with SA followed by aphidicolin, apigenin, luteolin and scutellarein. Two compounds (PubChem CID 46186820, PubChem CID 21579141) analogous to citrusin c were selected based on the lowest binding energy.

Conclusion:

This study, therefore, reveals that these compounds could be promising candidates for further evaluation for Urolithiasis prevention or management.

Shock wave lithotripsy, for the treatment of kidney stones, results in changes to routine blood tests and novel biomarkers: a prospective clinical pilot-study

Background

The number of patients undergoing shock wave lithotripsy (SWL) for kidney stones is increasing annually, and as such the development of post-operative complications, such as haematuria and acute kidney injury (AKI) following SWL, is likely to increase. The aim of the study was to evaluate changes in routine blood and novel biomarkers following SWL, for the treatment of kidney stones.

Methods

Twelve patients undergoing SWL for solitary unilateral kidney stones were recruited. From patients (8 males and 4 females) aged between 31 and 72 years (median 43 years), venous blood samples were collected pre-operatively (baseline), at 30, 120 and 240 min post-operatively. Routine blood tests were performed using a Sysmex XE-5000, and Beckman Coulter AU5800 and AU680 analysers. NGAL, IL-18, IL-6, TNF-α, IL-10 and IL-8 concentrations were determined using commercially available ELISA kits.

Results

Significant (p ≤ 0.05) changes were observed in several blood parameters following SWL. NGAL concentration significantly increased, with values peaking at 30 min post-treatment (p = 0.033). Although IL-18 concentration increased, these changes were not significant (p = 0.116). IL-6 revealed a statistically significant rise from pre-operative up to 4 h post-operatively (p < 0.001), whilst TNF-α significantly increased, peaking at 30 min post-SWL (p = 0.05). There were no significant changes to IL-10 and IL-8 concentrations post-SWL (p > 0.05).

Conclusions

Changes to routine blood tests and specific biomarkers, in the future, may be more useful for clinicians. In turn, identification of a panel of biomarkers could provide valuable data on “normal” physiological response after lithotripsy. Ultimately, studies could be expanded to identify or predict those patients at increased risk of developing post-operative complications, such as acute kidney injury or. These studies, however, need validating involving larger cohorts.

Image Quality and Dose Comparison of Single-Energy CT (SECT) and Dual-Energy CT (DECT)

CT and its comprehensive usage have become one of the most indispensable components in medical field especially in the diagnosis of several diseases. SECT and DECT have developed CT diagnostic potentials in several means. In this review article we have discussed the basic principles of single-energy and dual-energy computed tomography and their important physical differences which can cause better diagnostic evaluation. Moreover, different organs diagnostic evaluations through single-energy and dual-energy computed tomography have been discussed. Conventional or single-energy CT (SECT) uses a single polychromatic X-ray beam (ranging from 70 to 140 kVp with a standard of 120 kVp) emitted from a single source and received by a single detector. The concept of dual-energy computed tomography (DECT) is almost as old as the CT technology itself; DECT initially required substantially higher radiation doses (nearly two times higher than those employed in single-energy CT) and presented problems associated with spatial misregistration of the two different kV image datasets between the two separate acquisitions. The basic principles of single-energy and dual-energy computed tomography and their important physical differences can cause better diagnostic evaluation. Moreover, different organs diagnostic evaluations through single-energy and dual-energy computed tomography have been discussed. According to diverse data and statistics it is controversial to definitely indicate the accurate comparison of image quality and dose amount.

The effects of shock wave lithotripsy and retrograde intrarenal surgery on renal function

Introduction: The aim of this study was to compare the early effects of shock wave lithotripsy (SWL) and retrograde intrarenal surgery (RIRS) on renal function using the cystatin C levels.Material and methods: Serum samples were taken from each of the patients preoperatively, on the first postoperative day, and on the 30th postoperative day in order to evaluate the renal damage. The cystatin C level was determined using a particle-enhanced turbid metric immunoassay with a clinical chemistry analyzer.Results: In the comparison between the preoperative and postoperative cystatin C levels on day 1, there was an increase in the SWL group (p = .001); however, the decrease in the RIRS group was statistically significant (p = .007). There were statistically significant differences in the cystatin C levels on the first postoperative day in both groups (p = .001). In the SWL group, there was a statistically significant increase between the preoperative and the 30th postoperative day cystatin C levels (p = .006), but no differences were found between these levels in the RIRS group or between the two groups (p = .255).Conclusions: RIRS may be the preferred procedure for patients who need more renal function protection when treating renal stones <2 cm.

An investigation of elastic waves producing stone fracture in burst wave lithotripsy

Burst wave lithotripsy is a method to noninvasively fragment urinary stones by short pulses of focused ultrasound. In this study, physical mechanisms of stone fracture during burst wave lithotripsy were investigated. Photoelasticity imaging was used to visualize elastic wave propagation in model stones and compare results to numerical calculations. Epoxy and glass stone models were made into rectangular, cylindrical, or irregular geometries and exposed in a degassed water bath to focused ultrasound bursts at different frequencies. A high-speed camera was used to record images of the stone during exposure through a circular polariscope backlit by a monochromatic flash source. Imaging showed the development of periodic stresses in the stone body with a pattern dependent on frequency. These patterns were identified as guided wave modes in cylinders and plates, which formed standing waves upon reflection from the distal surfaces of the stone model, producing specific locations of stress concentration in the models. Measured phase velocities compared favorably to numerically calculated modes dependent on frequency and material. Artificial stones exposed to bursts produced cracks at positions anticipated by this mechanism. These results support guided wave generation and reflection as a mechanism of stone fracture in burst wave lithotripsy.

Simultaneous Photoacoustic Imaging and Cavitation Mapping in Shockwave Lithotripsy

Kidney stone disease is a major health problem worldwide. Shockwave lithotripsy (SWL), which uses high-energy shockwave pulses to break up kidney stones, is extensively used in clinic. However, despite its noninvasiveness, SWL can produce cavitation in vivo. The rapid expansion and violent collapse of cavitation bubbles in small blood vessels may result in renal vascular injury. To better understand the mechanism of tissue injury and improve treatment safety and efficiency, it is highly desirable to concurrently detect cavitation and vascular injury during SWL. Current imaging modalities used in SWL ( e.g. , C-arm fluoroscopy and B-mode ultrasound) are not sensitive to vascular injuries. By contrast, photoacoustic imaging is a non-invasive and non-radiative imaging modality that is sensitive to blood, by using hemoglobin as the endogenous contrast. Moreover, photoacoustic imaging is also compatible with passive cavitation detection by sharing the ultrasound detection system. Here, we have integrated shockwave treatment, photoacoustic imaging, and passive cavitation detection into a single system. Our experimental results on phantoms and in vivo small animals have collectively demonstrated that the integrated system is capable of capturing shockwave-induced cavitation and the resultant vascular injury simultaneously. We expect that the integrated system, when combined with our recently developed internal-light-illumination photoacoustic imaging, will find important applications for monitoring shockwave-induced vascular injury in deep tissues during SWL.

By-products of lithotripsy: Are they related to abdominal fat and wave characteristics?

Objectives

This study aimed to evaluate the correlations between by-products of extracorporeal shock wave lithotripsy (ESWL) and some physical parameters such as abdominal fat, energy levels, and shock wave pulses.

Methods

A total of 40 patients (20 men and 20 women), aged 37.18 ± 10.64 years, with renal or ureteral stones were recruited. All patients were treated with ESWL, and their abdominal fat was measured using an Omron body fat monitor and the body mass index (BMI). Parameters such as the levels of malondialdehyde (MDA), ketones, and protein in urine were measured before and after ESWL using a Bio Doctor Analyzer. The wave characteristics of the lithotripsy procedure and the wave pulses were determined.

Results

The mean levels of urinary MDA and ketones showed statistically significant increases in post-ESWL compared with pre-ESWL values. The results showed significant elevations in MDA and ketones in both male and female patients. In addition, there was a significant correlation between MDA/ketones and energy levels and between ketones and BMI in female patients. The analysis also revealed that the shock wave pulse had an insignificant impact on the by-product parameters.

Conclusion

An energy level of ≤4 J is recommended for overweight and obese patients undergoing ESWL. In addition, measurement of the post-ESWL MDA urinary level should be performed as a routine test, especially in obese male patients.

Renal arteriovenous fistula induced by extracorporeal shock wave lithotripsy treated by retroperitoneoscopic nephrectomy

Renal arteriovenous fistula (AVF) is a rare but potentially severe and life-threatening entity. It can occur after various invasive renal interventions, including resection of a localized renal tumor, renal biopsy, percutaneous renal surgery, and even blunt injury of the kidney. The time of clinical presentation of a renal AVF is variable and may occur decades after the injury originally occurred. Here, we report a case of renal AVF induced by extracorporeal shock wave lithotripsy 11 years earlier in an asymptomatic 72-year-old woman. Given the patient's pre-existing hemodialysis dependence, retroperitoneoscopic nephrectomy was performed. On the basis of patient's clinical history, the location of the renal AVF, and the pathological diagnosis, we suggested that renal AVF was a late consequence of the injury to the intrarenal vessels induced by extracorporeal shock wave lithotripsy.

Evaluation of Renal Stone Comminution and Injury by Burst Wave Lithotripsy in a Pig Model

Introduction: Burst wave lithotripsy is an experimental technology to noninvasively fragment kidney stones with focused bursts of ultrasound (US). This study evaluated the safety and effectiveness of specific lithotripsy parameters in a porcine model of nephrolithiasis. Methods: A 6- to 7-mm human kidney stone was surgically implanted in each kidney of three pigs. A burst wave lithotripsy US transducer with an inline US imager was coupled to the flank and the lithotripter focus was aligned with the stone. Each stone was exposed to burst wave lithotripsy at 6.5 to 7 MPa focal pressure for 30 minutes under real-time image guidance. After treatment, the kidneys were removed for gross, histologic, and MRI assessment. Stone fragments were retrieved from the kidney to determine the mass comminuted to pieces <2 mm. Results: On average, 87% of the stone mass was reduced to fragments <2 mm. In three of five treatments, stones were completely comminuted to <2-mm fragments. In two of five treatments, stones were partially disintegrated, but larger fragments remained. One stone was not treated because no suitable acoustic window was identified. No injury was detected through gross, histologic, or MRI examination in the parenchymal tissue, although petechial damage and surface erosion were identified on the urothelium of the collecting system limited to the area around the stone. Conclusion: Burst wave lithotripsy can consistently produce stone fragments small enough to spontaneously pass by transcutaneous administration of US pulses. The data suggest that such exposures produce minimal injury to the kidney and urinary tract.

Response of Single Cells to Shock Waves and Numerically Optimized Waveforms for Cancer Therapy

Shock waves are used clinically for breaking kidney stones and treating musculoskeletal indications. The mechanisms by which shock waves interact with tissue are still not well understood. Here, ultra-high-speed imaging was used to visualize the deformation of individual cells embedded in a tissue-mimicking phantom when subject to shock-wave exposure from a clinical source. Three kidney epithelial cell lines were considered to represent normal healthy (human renal epithelial), cancer (CAKI-2), and virus-transformed (HK-2) cells. The experimental results showed that during the compressive phase of the shock waves, there was a small (<2%) decrease in the projected cell area, but during the tensile phase, there was a relatively large (∼10%) increase in the projected cell area. The experimental observations were captured by a numerical model with a constitutive material framework consisting of an equation of state for the volumetric response and hyper-viscoelasticity for the deviatoric response. To model the volumetric cell response, it was necessary to change from a higher bulk modulus during the compression to a lower bulk modulus during the tensile shock loading. It was discovered that cancer cells showed a smaller deformation but faster response to the shock-wave tensile phase compared to their noncancerous counterparts. Cell viability experiments, however, showed that cancer cells suffered more damage than other cell types. These data suggest that the cell response to shock waves is specific to the type of cell and waveforms that could be tailored to an application. For example, the model predicts that a shock wave with a tensile stress of 4.59 MPa would increase cell membrane permeability for cancer cells with minimal impact on normal cells.

Minimally Invasive Management of Uroliths in Cats and Dogs

Urolithiasis commonly affects cats and dogs. The American College of Veterinary Internal Medicine established guidelines for the treatment of uroliths that reflect modern techniques prioritizing minimally invasive procedures with an emphasis on prevention strategies to limit morbidity and mortality. Extracorporeal shockwave lithotripsy and endoscopic nephrolithotomy constitute some of the minimally invasive treatment modalities available for upper urinary tract uroliths. Cystoscopic-guided basket retrieval, cystoscopic-guided laser lithotripsy, and percutaneous cystolithotomy are minimally invasive options for the management of lower urinary tract uroliths. Following stone removal, prevention strategies are essential to help reduce morbidity and mortality associated with stone recurrence.

Between a Rock and an Airspace: Pneumothorax After Extracorporeal Shock Wave Lithotripsy for Renal Stones in a Patient With Cystic Fibrosis

Renal disease is a well-recognized manifestation of cystic fibrosis (CF) and people with CF are at increased risk of nephrolithiasis. Lithotripsy is the preferred treatment but has occasionally been associated with pulmonary complications. Here we report the case of a person with CF who developed a pneumothorax soon after lithotripsy and discuss the potential mechanism of injury. We hope this case highlights some of the additional considerations clinicians should take into account when managing patients with advanced pulmonary disease in CF.

3D multicellular model of shock wave-cell interaction

Understanding the interaction between shock waves and tissue is critical for advancing the use of shock waves for medical applications, such as cancer therapy. This work aims to study shock wave-cell interaction in a more realistic environment, relevant to in vitro and in vivo studies, by using 3D computational models of healthy and cancerous cells. The results indicate that for a single cell embedded in an extracellular environment, the cellular geometry does not influence significantly the membrane strain but does influence the von Mises stress. On the contrary, the presence of neighbouring cells has a strong effect on the cell response, by increasing fourfold both quantities. The membrane strain response of a cell converges with more than three neighbouring cell layers, indicating that a cluster of four layers of cells is sufficient to model the membrane strain in a large domain of tissue. However, a full 3D tissue model is needed if the stress evaluation is of main interest. A tumour mimicking multicellular spheroid model is also proposed to study mutual interaction between healthy and cancer cells and shows that cancer cells can be specifically targeted in an early stage tumour-mimicking environment.

STATEMENT OF SIGNIFICANCE

This work presents 3D computational models of shock-wave/cell interaction in a biophysically realistic environment using real cell morphology in tissue-mimicking phantoms and multicellular spheroids. Results show that cell morphology does not strongly influence the membrane strain but influences the von Mises stress. While the presence of neighbouring cells significantly increases the cell response, four cell layers are enough to capture the membrane strain change in tissue. However, a full tissue model is necessary if accurate stress analysis is needed. The work also shows that cancer cells can be specifically targeted in early stage tumour mimicking environment. This work is a step towards realistic modelling of shock-wave/cell interactions in tissues and provides insight on the use of 3D models for different scenarios.

Evaluation and physiopathology of minor transient shock wave lithotripsy - induced renal injury based on urinary biomarkers levels

Introduction

Extracorporeal shock wave lithotripsy (ESWL) is one of the most useful methods available for the treatment of urolithiasis. However, despite its significant benefits, adverse effects can occur. Oxidative stress mediated by ischemia-reperfusion might contribute to kidney injury after ESWL. Moreover, an acute kidney injury (AKI) may develop. AKI is typically diagnosed by measuring serum creatinine level, yet serum creatinine does not allow for early detection of sub-clinical AKI. The latest report has investigated multiple ways to determine ESWL - induced renal damage through the evaluation of various urine biomarkers of renal injury.

Materials and methods

The Medline and Web of Science databases were searched without a time limit in November 2017 using the terms 'ESWL' in conjunction with 'kidney failure', 'kidney damage', 'renal injury' and 'inflammation markers', 'biomarkers'. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. In this review, we described all the up-to-date reported urine markers of ESWL-induced renal damage.

Results

In recent years, several studies demonstrated evaluation of ESWL - induced renal injury based on urinary biomarkers levels and its utility in clinical practice. They have a beneficial role in the early detection of AKI, as well as in observation of a transition of this acute illness into chronic kidney disease.

Conclusions

Different markers have been evaluated in the urine before and after the ESWL treatment, but their number is still limited and results remain inconclusive. Further investigations are mandatory.

Extracorporeal shockwave therapy for intermittent claudication: Medium-term outcomes from a double-blind randomised placebo-controlled pilot trial

Objectives Peripheral arterial disease most commonly presents as intermittent claudication (IC). Early evidence has suggested that extracorporeal shockwave therapy is efficacious in the short term for the management of intermittent claudication. The objective of this pilot trial was to evaluate the medium-term efficacy of this treatment. Methods This double-blind randomised placebo-controlled pilot trial randomised patients with unilateral intermittent claudication in a 1:1 fashion to receive extracorporeal shockwave therapy or a sham treatment for three sessions per week over three weeks. Primary outcomes were maximum walking distance and intermittent claudication distance using a fixed-load treadmill test. Secondary outcomes included pre- and post-exertional ankle-brachial pressure indices, safety and quality of life assessed using generic (SF36, EQ-5D-3L) and disease-specific (vascular quality of life) measures. All outcome measures were assessed at 12 months post-treatment. Results Thirty participants were included in the study (extracorporeal shockwave therapy, n = 15; sham, n = 15), with 26 followed up and analysed at 12 months (extracorporeal shockwave therapy, n = 13; sham, n = 13). Intragroup analysis demonstrated significant improvements in maximum walking distance, intermittent claudication distance and post-exertional ankle-brachial pressure indices ( p < 0.05) in the active treatment group, with no improvements in pre-exertional ankle-brachial pressure indices. Significant improvements in quality of life were observed in 3 out of 19 domains assessed in the active group. A re-intervention rate of 26.7% was seen in both groups. Conclusions These findings suggest that extracorporeal shockwave therapy is effective in improving walking distances at 12 months. Although this study provides important pilot data, a larger study is needed to corroborate these findings and to investigate the actions of this treatment.

ISRCTN

NCT02652078.

Shear Wave Elastographic Alterations in the Kidney After Extracorporeal Shock Wave Lithotripsy

OBJECTIVES

Extracorporeal shock wave lithotripsy (ESWL) is a method used frequently for the treatment of renal stone disease. Although its safety is proven, there are still concerns about its unwanted effects on kidneys. In this prospective study, we aimed to evaluate renal tissue alterations with shear wave elastography (SWE) after ESWL. We also studied the correlation between SWE and resistive index (RI) changes.

METHODS

The study included 59 patients who underwent ESWL treatment for renal stone disease. We performed SWE and color Doppler ultrasonography to calculate SWE and RI values before, 1 hour after, and 1 week after lithotripsy treatment. A binary comparison was performed by the Bonferroni test. The correlation between SWE and RI values was evaluated by a Pearson correlation analysis.

RESULTS

The patients included 26 women (44.1%) and 33 men (55.9%). Their ages ranged from 20 to 65 years (mean ± SD, 45.0 ± 1.1 years). Stone diameters ranged from 7 to 19 mm (mean, 13.0 ± 0.5 mm). There was a significant difference in SWE values before and 1 hour after lithotripsy treatment (P = .001; P < .01). In the follow-up measurement 1 week after treatment, this difference disappeared (P > .99; P > .05). Resistive index values increased significantly 1 hour after lithotripsy treatment and returned to prelithotripsy values 1 week after treatment. In the correlation analysis, SWE and RI values were not correlated.

CONCLUSIONS

Measurements of alterations in SWE values after ESWL can provide useful information about renal tissue injury.

Tracking kidney stones in a homogeneous medium using a trilateration approach

Shock wave lithotripsy is a non-invasive procedure by which kidney stones are fragmented by thousands of shock waves. Currently, many shock waves are delivered to the body that do not impact the stone, but do result in tissue trauma. This motivates developing a monitoring system to locate kidney stones, with the goal of gating shock waves not aligned with the stone, and hence, reducing renal trauma during lithotripsy. The system consists of a circular array housing twenty-two 0.5 MHz transducers that can be mounted on a clinical lithotripter. It was deployed in a water tank and tested with two stone models made from gypsum cement and a stone model fragment. An algorithm consisting of threshold detection, automatic rejection of weak signals, and triangulation was developed to determine the location of stones. The results show that within ±15 mm of the focus of the lithotripter, the accuracy was better than 4 mm in the lateral directions and 2 mm in the axial direction. Using off-the-shelf hardware, the algorithm can calculate stone positions every 1 s allowing for real-time tracking during lithotripsy.

Management of bladder stones: the move towards non-invasive treatment

Background: Bladder stone accounts for 5% of all cases of urolithiasis. Bladder stones management has evolved over the last decades from open bladder surgery (sectio alta) to intracorporeal cystholithotripsy as well as extracorporeal shock wave lithotripsy (ESWL). ESWL presents to be a promising modality in the management of bladder calculi due to its simplicity and well tolerability. This study is thus conducted to present data on the safety and effectiveness of ESWL in the management of bladder stone patients.Methods: This is a retrospective study evaluating the medical records of 92 bladder calculi patients admitted to Cipto Mangunkusumo General Hospital (RSCM) from January 2011 to April 2015. Patient’s age, gender, type of stone and procedure being done, status of stone disintegration, length of hospital stay, and any complications that may occur are noted down and statistically analyzed using SPSS v. 20.Results: Majority of the patients underwent ESWL (49 out of 92, 53.3%). The stone free rates for ESWL, intracorporeal lithotripsy, and sectio alta are 93.9%, 97.0% and 100% respectively. One patient had to repeat ESWL. The ESWL group had the smallest stone size average compared to the intracorporeal lithotripsy and section alta group (2.5 cm±2.0 cm vs 4.8 cm±3.7 cm vs 7.4 cm±5.4 cm respectively). The ESWL sessions were conducted in the outpatient clinic, and thus no hospital stay was required.Conclusion: ESWL can be suggested as an effective non-invasive approach in the disintegration of bladder stone of ≤25 mm with a promisingly high stone-free rate (93.9%) Furthermore, ESWL can be performed on an outpatient basis with minimal complications.

Molecular dynamics simulations of heterogeneous cell membranes in response to uniaxial membrane stretches at high loading rates

The chemobiomechanical signatures of diseased cells are often distinctively different from that of healthy cells. This mainly arises from cellular structural/compositional alterations induced by disease development or therapeutic molecules. Therapeutic shock waves have the potential to mechanically destroy diseased cells and/or increase cell membrane permeability for drug delivery. However, the biomolecular mechanisms by which shock waves interact with diseased and healthy cellular components remain largely unknown. By integrating atomistic simulations with a novel multiscale numerical framework, this work provides new biomolecular mechanistic perspectives through which many mechanosensitive cellular processes could be quantitatively characterised. Here we examine the biomechanical responses of the chosen representative membrane complexes under rapid mechanical loadings pertinent to therapeutic shock wave conditions. We find that their rupture characteristics do not exhibit significant sensitivity to the applied strain rates. Furthermore, we show that the embedded rigid inclusions markedly facilitate stretch-induced membrane disruptions while mechanically stiffening the associated complexes under the applied membrane stretches. Our results suggest that the presence of rigid molecules in cellular membranes could serve as “mechanical catalysts” to promote the mechanical destructions of the associated complexes, which, in concert with other biochemical/medical considerations, should provide beneficial information for future biomechanical-mediated therapeutics.

Influence of acetylsalicylic acid and low-molecular weight heparins on the formation of renal hematoma after shock wave lithotripsy

PURPOSE

To investigate the risk of renal hematoma (RHT) after shock wave lithotripsy (SWL) among patients on acetylsalicylic acid (ASA) or low-molecular-weight heparin (LMWH).

PATIENTS AND METHODS

Retrospective analysis of 434 patients treated with SWL for nephrolithiasis and ureterolithiasis of the proximal ureter. Primary endpoint was detection of RHT by ultrasound the day after SWL. Secondary outcome variables included transfusion of erythrocyte concentrate(s), interventions, hospital readmission or death due to RHT within 30 days of SWL. Binary logistic regression analysis was used including a post hoc one-way analysis.

RESULTS

Of 434 patients, 33 (7.6%) and 67 (15.4%) patients were medicated with ASA and LMWH, respectively. RHT was detected in 20 of 434 (4.6%) patients. Of those, 3 (20%) were on ASA, 6 (35%) were on LMWH, 1 (5%) was on ASA and LMWH, and 10 (50%) had no anticoagulation. Univariate analysis showed a statistically significant higher risk for RHT among patients on ASA (p = 0.04) and LWMH (p = 0.02) with an untreated urinary tract infection (UTI) (p = 0.008) and history of cardiovascular disease (p = 0.028). On multivariate analysis, ASA medication, untreated UTI (OR 4.4, 95% CI 1.31-14.75, p = 0.016 and OR 5.79, 95% CI 1.65-20.32, p = 0.03) and a therapeutic dose of LMWH (OR 10.4, 95% CI 1.74-62.27, p = 0.01) were independent predictors for RHT.

CONCLUSIONS

Before SWL, a patient risk profile should be evaluated. If feasible, LMWH in therapeutic dosing should be avoided, and ASA should be discontinued. UTI should be treated before SWL in any case.

TRIAL REGISTRATION

http://www.clinicaltrials.gov ; Identifier NCT02875717.

A pilot study evaluating changes to haematological and biochemical tests after Flexible Ureterorenoscopy for the treatment of kidney stones

BACKGROUND

Currently there is limited research documenting the changes in blood parameters, following Flexible Ureterorenoscopy. This study aims to determine whether there are any changes in haematology and biochemistry parameters, following Flexible Ureterorenoscopy for the treatment of kidney stones.

METHODS

40 consecutive patients aged between 27-87 years (median 49 years) undergoing Flexible Ureterorenoscopy for the treatment of kidney stones were recruited (26 male, 14 female). Blood samples were collected from each patient at four time points: baseline (pre-operatively) followed by 30 minutes, 120 minutes and 240 minutes post-operatively. On these samples, routine haematological and biochemistry tests were carried out. In addition to the assessment of clinical parameters prospectively from the medical notes.

RESULTS

There was a significant decrease observed following Flexible Ureterorenoscopy in the following parameters: lymphocytes (p = 0.007), eosinophils (p = 0.001), basophils (p = 0.001), haemoglobin (p = 0.002), red blood cells (p = 0.001), platelet count (p = 0.001), fibrinogen concentration (p = 0.001), von Willebrand factor (p = 0.046), C reactive protein (p = 0.01), total protein (p = 0.001), albumin (p = 0.001), globulin (p = 0.001) and alkaline phosphatase (p = 0.001). In addition, there was a significant increase observed in the following parameters: white blood cells (p = 0.001), neutrophils (p = 0.001), activated partial thromboplastin time (p = 0.001), total bilirubin (p = 0.012), creatinine (p = 0.008), sodium (p = 0.002) and potassium (p = 0.001). Limiting factors for this study were the sample size, and restriction on the recruitment time points.

CONCLUSIONS

Significant changes were noted to occur in haematology and biochemistry parameters following Flexible Ureterorenoscopy. Some of the data presented in this study may represent the 'normal' post-operative response following FURS, as no major complications occurred, in the majority of our patients. This data on the 'normal response' will need to be validated but may ultimately aid clinicians in distinguishing patients at risk of complications, if reproduced in larger multi-centre studies.

Detection and Evaluation of Renal Injury in Burst Wave Lithotripsy Using Ultrasound and Magnetic Resonance Imaging

PURPOSE

Burst wave lithotripsy (BWL) is a transcutaneous technique with potential to safely and effectively fragment renal stones. Preclinical investigations of BWL require the assessment of potential renal injury. This study evaluates the capabilities of real-time ultrasound and MRI to detect and evaluate BWL injury that was induced in porcine kidneys.

MATERIALS AND METHODS

Ten kidneys from five female farm pigs were treated with either a 170 or 335 kHz BWL transducer using variable treatment parameters and monitored in real-time with ultrasound. Eight kidneys were perfusion fixed and scanned with a 3-Tesla MRI scanner (T1-weighted, T2-weighted, and susceptibility-weighted imaging), followed by processing via an established histomorphometric technique for injury quantification. In addition, two kidneys were separately evaluated for histologic characterization of injury quality.

RESULTS

Observed B-mode hyperechoes on ultrasound consistent with cavitation predicted the presence of BWL-induced renal injury with a sensitivity and specificity of 100% in comparison to the histomorphometric technique. Similarly, MRI detected renal injury with a sensitivity of 90% and specificity of 100% and was able to identify the scale of lesion volumes. The injuries purposefully generated with BWL were histologically similar to those formed by shock wave lithotripsy.

CONCLUSIONS

BWL-induced renal injury can be detected with a high degree of sensitivity and specificity by real-time ultrasound and post-treatment ex vivo MRI. No injury occurred in this study without cavitation detected on ultrasound. Such capabilities for injury detection and lesion volume quantification on MRI can be used for preclinical testing of BWL.

A Novel Case of Splenic Injury After Shockwave Lithotripsy

BACKGROUND

Emergency departments (EDs) are gateways for patients presenting after minor surgical procedures, particularly shockwave lithotripsy. Complications include renal and extrarenal tissue injuries, with the latter having potentially serious consequences if not detected early.

CASE REPORT

We describe a 70-year-old male presenting to the ED for syncope. The patient underwent shockwave lithotripsy (SWL) for left kidney stones 1 day prior. Upon initial evaluation, the patient had normal vital signs and a normal physical examination, without complaints of abdominal pain. Close observation and regular patient re-evaluation led to the diagnosis of life-threatening injuries that included splenic rupture. Although this is a rare complication of SWL, with only eight published cases found in the literature, the patient's initial presentation of syncope without complaints of abdominal pain presented a unique diagnostic challenge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be knowledgeable of the pre-existing conditions linked to higher rates of complications after shockwave lithotripsy and be able to identify and manage these potentially life-threatening complications.