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Alić J, Heljić J, Hadžiosmanović O, Kulovac B, Lepara Z, Spahović H, Bajramović S, Aganović D. The Efficiency of Extracorporeal Shock Wave Lithotripsy (ESWL) in the Treatment of Distal Ureteral Stones: An Unjustly Forgotten Option? Cureus 2022; 14:e28671. [PMID: 36196280 PMCID: PMC9525100 DOI: 10.7759/cureus.28671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 11/05/2022] Open
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Satjakoesoemah AI, Alfarissi F, Wahyudi I, Rodjani A, Rasyid N. Factors related to the success rate of pediatric extracorporeal shock wave lithotripsy (ESWL) in Cipto Mangunkusumo Hospital: an 8-year single-center experience. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00187-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
ESWL is still considered as the first favorable therapeutic option for urinary stone disease with acceptable effectivity. However, factors associated with favorable outcome have not been widely studied in pediatrics due to the small number of urinary stone prevalence. The aim of this study is to evaluate the factors associated with the success rate of pediatric ESWL in our center according to immediate stone-free rate and 3-month stone-free rates.
Methods
This is a retrospective cohort study of children less than 18 years who had ESWL for urolithiasis from January 2008 until August 2015. Patient’s characteristics including age, gender, BMI, stone location, stone length, stone burden, stone opacity, and number of ESWL sessions were gathered from the medical record. Nutritional status was determined according to the Centers for Disease Control and Prevention BMI curve. The outcome of this study was the factors related to the success rate in pediatric ESWL.
Results
Extracorporeal shock wave lithotripsy was done for 36 patients and 39 renal units (RUs) with mean age of 13.7 ± 4.3 years old, height of 1480 ± 16.0 cm, and BMI of 20.0 ± 3. Of 36 patients included, 39 renoureteral units (RUs) and 46 ESWL sessions were recorded. The mean overall treatment was 1.2 ± 0.5 sessions with mean stone length of 11.1 ± 6.3 mm and stone burden of 116.6 ± 130.3 mm2. Within 3 months of follow-up, we recorded that the overall 3-month success rate was 100%, while the overall 3-month stone-free rate was 66.7%. Stone length (p < 0.001 and p < 0.001), stone perpendicular length (p < 0.001 and p < 0.001), and stone burden (p < 0.001 and p = 0.001) were found to be significantly associated with immediate success and 3-month stone-free status, respectively.
Conclusions
ESWL is an effective and safe modality to treat pediatric urolithiasis cases. Stone length, stone perpendicular length, and stone burden were found to be associated with immediate success and 3-month stone-free status after pediatric ESWL treatment.
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Azal Neto W, Morales E, Joseane Pachecco M, Pedro RN, Reis LO. Is extracorporeal shockwave lithotripsy (SWL) still suitable for >1.5 cm intrarenal stones? Data analysis of 1902 SWLs. Scand J Urol 2021; 55:388-393. [PMID: 34279162 DOI: 10.1080/21681805.2021.1950830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE According to the American Urological Association and European Association of Urology guidelines, shockwave lithotripsy (SWL) is the least-invasive treatment option for kidney stones smaller than 2 cm. However, it is well known that SWL stone-free rates (SFR) decline as stone size increases. We sought to evaluate whether the size limit of 1.5 cm could be a better predictor of success after a single SWL session than current recommendations. METHODS Data from an SWL-dedicated center were prospectively scrutinized according to stone locations and sizes. Information on patients' demography, lithotripsy parameters, and outcomes was evaluated by multivariate analysis among 1902 SWLs. RESULTS The overall SFR was 70.8% (1347/1902). SFRs according to stone size were <1 cm: 73.8% (825/1118), 1-1.5 cm: 70.4% (401/569) and >1.5 cm: 56.2% (121/215); and according to calculi location were lower pole (LP) 64.4% (398/618), mid pole 73.8% (339/459), upper pole 73.8% (273/370) and renal pelvis 74.1% (337/455). Multivariate analysis revealed better SFR independent better SFR in <1.5 cm (p < 0.01), and non-LP stones (p < 0.01). CONCLUSION SWL is an effective treatment modality for kidney stones. The single session reached up to 74.8% SFRs (range 70.8%-74.8%) when indicated for intrarenal non LP stones smaller than 1.5 cm. Patients with stones >1.5 cm or >1 cm located in the LP should be counseled on the lower SFRs after a single SWL session.
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Affiliation(s)
- Wilmar Azal Neto
- UroScience, University of Campinas and Pontifical Catholic University of Campinas, Campinas, Brazil
| | - Enzo Morales
- Medicine, Faculdade São Leopoldo Mandic, Campinas, Brazil
| | | | - Renato Nardi Pedro
- Endourology Section, University of Campinas and AME/SBO Lithotripsy Center - UNICAMP, Campinas, Brazil
| | - Leonardo O Reis
- UroScience, University of Campinas and Pontifical Catholic University of Campinas, Campinas, Brazil
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Azal Neto W, Reis LO, Pedro RN. Prediction of stone-free rates following extracorporeal shockwave lithotripsy in a contemporary cohort of patients with stone densities exceeding 1000 HU. Scand J Urol 2020; 54:344-348. [PMID: 32597283 DOI: 10.1080/21681805.2020.1782981] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Purpose: Nephrolithiasis is a common urologic problem, and its incidence is increasing. Shockwave Lithotripsy (SWL) has better results for patients with stones < 1000 HU. We attempted to identify SWL stone-free (SF) predictors for > 1000 HU stones.Methods: From January 2013 to September 2019, patient shared decision consecutive SWL for the treatment of a single > 1000 HU renal stone diagnosed by non-contrast computed tomography (NCCT). Endpoints: Fragmentation and SF or clinically insignificant residual fragments ≤ 4 mm at 4 weeks. Age, gender, stone side, location, size and density, number and average energy (Joules) of shocks were explored on uni- and multivariate regression analysis.Results: All sixty-one patients included were diagnosed with renal stone between 5 and 20 mm (maximum length) and underwent one SWL session only: 62.3% males, median age 48 (21-80) years, mean stone size 9.43 ± 2.9 mm (6.0-20.0), mean density 1210 ± 135 HU (1000-1558). There were 39 (63.9%) cases of SF, 16 (26.2%) of partial success and six (9.8%) of no success. Stone size was the only independent predictor of fragmentation, OR = 1.83, 95% CI = 1.32-2.55, p = 0.0003, and SF OR = 1.91, 95% CI = 1.31-2.78, p = 0.008. The best discriminatory stone size on ROC analysis was 1 cm.Conclusion: Stone size was the only significant success predictor in our cohort, with 76% SF rate for stones < 1 cm in 4 weeks follow-up, supporting that renal stones > 1000 HU may be suitable to SWL.
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Affiliation(s)
- Wilmar Azal Neto
- Department of Urology, State University of Campinas, Unicamp, Campinas, Brazil
| | - Leonardo Oliveira Reis
- Department of Urology, State University of Campinas, Unicamp, Campinas, Brazil.,Department of UroScience, Pontifical Catholic University of Campinas, PUC-Campinas, Campinas, Brazil
| | - Renato Nardi Pedro
- Department of Urology, State University of Campinas, Unicamp, Campinas, Brazil
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How can and should we optimize extracorporeal shockwave lithotripsy? Urolithiasis 2017; 46:3-17. [PMID: 29177561 PMCID: PMC5773650 DOI: 10.1007/s00240-017-1020-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 11/11/2017] [Indexed: 11/05/2022]
Abstract
It is well recognized that the popularity of extracorporeal shock wave lithotripsy (SWL), despite its non-invasive character, has decreased during recent years. This is partly explained by the technological achievements in endoscopy and urologists’ enthusiasm for such procedures. Another explanation is that many urologists have been insufficiently successful with SWL. The latter effect might to some extent be a result of the performance of the lithotripter used, but in too many cases, it is evident that the principles of how shock wave lithotripsy should be carried out are poorly applied. The purpose of this article is to emphasize some important aspects on how SWL best should be used. Based on decades of experience, it stands to reason that success with SWL does not come automatically and attention has to be paid to all details of this technique.
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Rabah DM, Mabrouki MS, Farhat KH, Seida MA, Arafa MA, Talic RF. Comparison of escalating, constant, and reduction energy output in ESWL for renal stones: multi-arm prospective randomized study. Urolithiasis 2016; 45:311-316. [PMID: 27687681 DOI: 10.1007/s00240-016-0912-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/10/2016] [Indexed: 11/29/2022]
Abstract
This study was designed to find out the optimized energy delivery strategy in Shock Wave Lithotripsy (SWL) that yield to the best stone-free rate (SFR). In this clinical trial, 150 consecutive patients were randomized into three groups: (a) Dose escalation, 1500 SW at 18 kV, followed by 1500 SW at 20 kV then 1500 SW at 22 kV. (b) Constant dose, 4500 SW at 20 kV. All patients undergo plain X-ray film of the urinary tract at day 1, 14, and 90 to assess stone-free rate (SFR) which was defined as no stones or painless fragments less than 4 mm. (c) Dose reduction, 1500 SW at 22 kV, followed by 1500 SW at 20 kV and then 1500 SW at 18 kV. The three treatment groups were comparable in terms of age, sex, stone size and distribution of the kidneys, and the need for Double J stent use. On day 90, the SFR achieved was 82, 90, and 84 % in the escalating, constant, and reduction energy groups, respectively. However, this rate was not statistically significant (x 2 = 1.38, p level = 0.28). At a slow rate of 60 shocks, there was no difference in stone-free rate between different voltages at 1, 14, and 90 days. Our randomized clinical trial showed no statistically significant difference in SFR between the three groups while using the slow SWL rate. Our trial is the first randomized trial comparing the three strategies. As such, a dose adjustment strategy while delivering SWL in slow rate was not recommended.
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Affiliation(s)
- Danny M Rabah
- Surgery Department, Cancer Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed S Mabrouki
- Surgery Department, Cancer Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Karim H Farhat
- Cancer Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | | | - Mostafa A Arafa
- Cancer Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Riyadh F Talic
- Surgery Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Has the pelvic renal stone position inside the upper loop of JJ stent any influence on the extracorporeal shock wave lithotripsy results? SPRINGERPLUS 2016; 5:1284. [PMID: 27547659 PMCID: PMC4977262 DOI: 10.1186/s40064-016-2954-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/29/2016] [Indexed: 11/10/2022]
Abstract
Background JJ stents are often encountered in patients with pelvic renal stones referred for shock wave lithotripsy, most of them being placed either for obstructive renal pelvic stones or for ureteric stones mobilized retrograde during the JJ stent insertion. The aim of the study was to determine whether the relative stone position in the upper loop of the JJ stent during extracorporeal shock wave lithotripsy (SWL) influences the efficiency of the procedure. The study was designed as a prospective cohort study on 162 patients addressing the same urological department, with single renal pelvic stone (primary or mobilized to the renal pelvis during the insertion of JJ stent), smaller than 15 mm, with JJ stent, treated by SWL using a second generation spark gap lithotripter, 18 kV, 3000 waves/session. Patients were divided in three groups according to the relative position of the stone to the upper loop of the JJ stent as appears on plain X-ray: stone-inside-loop, loop-crossing-stone and stone-outside the loop. The SWL success rate was the primary outcome of the study. p Value, Chi square and Kruskal–Wallis tests were used for statistical analysis. Results For stone-inside-loop cases, SWL efficiency was 22.7 versus 42 % for all the other cases (p = 0.002). Other factors for decreased SWL success rate were: higher stone radio-opacity, larger JJ of stent and obese patients. Study limitation is represented by the relative small study group and by the evaluation of stone density using plain X-ray instead of computer tomography. Conclusions For pelvic renal stones having the same density characteristics studied by plain X-ray, the SWL efficiency is lower in stone-inside-loop cases comparing with the other positions. The overall stone free rate for renal pelvic stones could be explained by the second generation lithotripter used for all procedures.
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Lantz AG, McKay J, Ordon M, Pace KT, Monga M, Honey RJD. Shockwave Lithotripsy Practice Pattern Variations Among and Between American and Canadian Urologists: In Support of Guidelines. J Endourol 2016; 30:918-22. [PMID: 27246189 DOI: 10.1089/end.2016.0153] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Shockwave lithotripsy (SWL) is a widely utilized form of treatment for urolithiasis. There are new evidence-based recommendations regarding pre-SWL patient work-up and the performance of SWL. The purpose of this study is to determine practice patterns for SWL and to determine if regional variation exists between Canada and the United States. MATERIALS AND METHODS A 19-question survey was prepared. Canadian urologists were surveyed through e-mail correspondence. In the United States, members of the Endourologic Society and members of two large stone management groups were surveyed. Canadian and American results were compared using the chi-square and Fisher's exact tests. RESULTS Ninety-four Canadian urologists and 187 U.S. urologists completed the survey. Practice patterns differed between countries. Intravenous sedation was more commonly used in Canada (Canada 94.7% vs United States 17.9%, p < 0.001); routine antibiotics were more commonly given in United States (Canada 2.1% vs United States 78.1%, p < 0.001); a shock rate of 2 Hz was more common in Canada (Canada 76.6% vs United States 16.2%, p < 0.00001); rate of discontinuing ASA for renal and ureteral stone treatment was higher in the United States (renal Canada 88.3% vs United States 95.7%, p < 0.02; ureteral Canada 62.4% vs 90.3%, p < 0.0001); and ureteral stents were more commonly used if treating a large stone or patients with solitary kidneys in the United States (large stones Canada 58.2% vs United States 88.8%, p = 0.0001; solitary kidney Canada 50.6% vs 66.3%, p = 0.02). CONCLUSIONS This study highlights the absence of standardization of SWL. Significant regional differences exist in practice patterns and performance of SWL between Canadian and American urologists.
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Affiliation(s)
- Andrea G Lantz
- 1 Department of Urology, Dalhousie University , Halifax, Nova Scotia, Canada
| | - Jeffrey McKay
- 1 Department of Urology, Dalhousie University , Halifax, Nova Scotia, Canada
| | - Michael Ordon
- 2 Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto , Canada
| | - Kenneth T Pace
- 2 Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto , Canada
| | - Manoj Monga
- 3 Department of Urology, Cleveland Clinic , Cleveland, Ohio
| | - R John D'A Honey
- 2 Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto , Canada
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Noureldin YA, Elkoushy MA, Andonian S. Changes in Urolithiasis Referral Patterns for Shock Wave Lithotripsy over a Decade: Was There Adherence to AUA/EAU Guidelines? Curr Urol 2015; 8:144-8. [PMID: 26889134 DOI: 10.1159/000365706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/09/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The primary objective was to assess changes in referral patterns of urolithiasis for shock wave lithotripsy (SWL) over a decade. The secondary objective was to evaluate the effect of the number of years of practice of referring physicians on these referral patterns. METHODS A retrospective review of SWL database was performed for consecutive referrals for SWL at a tertiary stone center between December 1999 and December 2013. Patient demographics and stone characteristics were assessed. The stone location at the time of referral was used as the reference. Retreatments were excluded. In addition, years of practice of the referring physicians were calculated. The 2007 AUA/EAU guidelines on urolithiasis were considered as a reference. RESULTS A total of 8,992 SWL treatments were included. After December 2007, there was a significant increase in the percentage of renal pelvic stones referred for SWL (23.0 vs. 27.1%, p < 0.001). Conversely, proximal ureteral stones significantly decreased after 2007 (24 vs. 18.2%, p < 0.001) including stones > 10 mm (5.1 vs. 2.9%, p < 0.001). Otherwise, there were no changes in the referral patterns for SWL of other stone locations before and after December 2007 (p > 0.05). Furthermore, percentage of stones referred for SWL by urologists practicing for less than 10 years significantly decreased after December 2007 (29.5 vs. 22.8%, p < 0.001). CONCLUSIONS The significant reduction in the referral of proximal ureteral stones after December 2007 corresponds to the latest AUA/EAU guidelines on management of ureteral stones.
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Affiliation(s)
- Yasser A Noureldin
- Division of Urology, McGill University Health Centre, Montreal, Québec, Canada; Department of Urology, Benha University Hospital, Benha University, Benha, Egypt
| | - Mohamed A Elkoushy
- Division of Urology, McGill University Health Centre, Montreal, Québec, Canada; Department of Urology, Suez Canal University, Ismailia, Egypt
| | - Sero Andonian
- Division of Urology, McGill University Health Centre, Montreal, Québec, Canada
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Piao S, Park J, Son H, Jeong H, Cho SY. Evaluation of renal function in patients with a main renal stone larger than 1 cm and perioperative renal functional change in minimally invasive renal stone surgery: a prospective, observational study. World J Urol 2015; 34:725-32. [PMID: 26226940 DOI: 10.1007/s00345-015-1653-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 07/21/2015] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To compare the perioperative relative renal function and determine predictors of deterioration and recovery of separate renal function in patients with renal stones >10 mm and who underwent mini-percutaneous nephrolithotomy or retrograde intra-renal surgery. PATIENTS AND METHODS A main stone >10 mm or stones growing, high-risk stone formers and extracorporeal shock-wave lithotripsy-resistant stones were prospectively included in 148 patients. Patients with bilateral renal stones and anatomical deformities were excluded. Renal function was evaluated by estimated glomerular filtration rate, 99m-technetium dimercaptosuccinic acid and 99m-technetium diethylenetriamine pentaacetate prior to intervention and at postoperative 3 months. Logistic regression analyses were performed to find predictors of functional deterioration and recovery. RESULTS The overall stone-free rate was 85.1 %. A third of patients (53/148, 35.8 %) with renal stones >10 mm showed deterioration of separate renal function. Mean renal function of operative sites showed 58.2 % (36.8 %/63.2 %) of that of contralateral sites in these patients. Abnormal separate renal function showed postoperative recovery in 31 patients (58.5 %). Three cases (5.7 %) showed deterioration of separate renal function despite no presence of remnant stones. Improvement rates of the abnormal separate renal function did not differ according to the type of surgery. The presence of hydronephrosis and three or more stones were significant predictors for renal function deterioration. Female gender and three or more stones were significantly correlated with postoperative recovery. CONCLUSIONS Mini-percutaneous nephrolithotomy or retrograde intra-renal surgery was effective and safe for renal function preservation. Patients with multiple large stones should be considered for candidates of active surgical removal.
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Affiliation(s)
- Songzhe Piao
- Department of Urology, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Urology, Yanbian University Hospital, Yanji, Jilin, China
| | - Juhyun Park
- Department of Urology, SMG-SNU Boramae Medical Center, Sindaebang 2-dong, 395, Dongjak-gu, Seoul, 156-707, Republic of Korea
| | - Hwancheol Son
- Department of Urology, SMG-SNU Boramae Medical Center, Sindaebang 2-dong, 395, Dongjak-gu, Seoul, 156-707, Republic of Korea
| | - Hyeon Jeong
- Department of Urology, SMG-SNU Boramae Medical Center, Sindaebang 2-dong, 395, Dongjak-gu, Seoul, 156-707, Republic of Korea
| | - Sung Yong Cho
- Department of Urology, SMG-SNU Boramae Medical Center, Sindaebang 2-dong, 395, Dongjak-gu, Seoul, 156-707, Republic of Korea.
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Kumar A, Kumar N, Vasudeva P, Kumar R, Jha SK, Singh H. A Single Center Experience Comparing Miniperc and Shockwave Lithotripsy for Treatment of Radiopaque 1–2 cm Lower Caliceal Renal Calculi in Children: A Prospective Randomized Study. J Endourol 2015; 29:805-9. [DOI: 10.1089/end.2015.0020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anup Kumar
- Department of Urology and Renal Transplant, VMMC and Safdarjung Hospital, New Delhi, India
| | - Niraj Kumar
- Department of Urology and Renal Transplant, VMMC and Safdarjung Hospital, New Delhi, India
| | - Pawan Vasudeva
- Department of Urology and Renal Transplant, VMMC and Safdarjung Hospital, New Delhi, India
| | - Rohit Kumar
- Department of Urology and Renal Transplant, VMMC and Safdarjung Hospital, New Delhi, India
| | - Sanjeev Kumar Jha
- Department of Urology and Renal Transplant, VMMC and Safdarjung Hospital, New Delhi, India
| | - Harbinder Singh
- Department of Urology and Renal Transplant, VMMC and Safdarjung Hospital, New Delhi, India
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Andonian S. Is shockwave lithotripsy on the verge of extinction? J Endourol 2014; 28:1156-8. [PMID: 25192466 DOI: 10.1089/end.2014.1647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Neisius A, Lipkin ME, Rassweiler JJ, Zhong P, Preminger GM, Knoll T. Shock wave lithotripsy: the new phoenix? World J Urol 2014; 33:213-21. [PMID: 25081010 DOI: 10.1007/s00345-014-1369-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 07/18/2014] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Following its introduction in 1980, shock wave lithotripsy (SWL) rapidly emerged as the first-line treatment for the majority of patients with urolithiasis. Millions of SWL therapies have since been performed worldwide, and nowadays, SWL still remains to be the least invasive therapy modality for urinary stones. During the last three decades, SWL technology has advanced in terms of shock wave generation, focusing, patient coupling and stone localization. The implementation of multifunctional lithotripters has made SWL available to urology departments worldwide. Indications for SWL have evolved as well. Although endoscopic treatment techniques have improved significantly and seem to take the lead in stone therapy in the western countries due to high stone-free rates, SWL continues to be considered as the first-line therapy for the treatment of most intra-renal stones and many ureteral stones. METHODS This paper reviews the fundamentals of SWL physics to facilitate a better understanding about how a lithotripter works and should be best utilized. RESULTS Advances in lithotripsy technology such as shock wave generation and focusing, advances in stone localization (imaging), different energy source concepts and coupling modalities are presented. Furthermore adjuncts to improve the efficacy of SWL including different treatment strategies are reviewed. CONCLUSION If urologists make use of a more comprehensive understanding of the pathophysiology and physics of shock waves, much better results could be achieved in the future. This may lead to a renaissance and encourage SWL as first-line therapy for urolithiasis in times of rapid progress in endoscopic treatment modalities.
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Affiliation(s)
- Andreas Neisius
- Department of Urology, Universitätsmedizin Mainz, Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany,
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Abid AF. Success Factors of Extracorporeal Shock Wave Lithotripsy (ESWL) for Renal & Ureteric Calculi in Adult. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/oju.2014.43005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Comparison of shock wave lithotripsy, flexible ureterorenoscopy and percutaneous nephrolithotripsy on moderate size renal pelvis stones. Urolithiasis 2013; 42:115-20. [PMID: 24162954 DOI: 10.1007/s00240-013-0615-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 10/15/2013] [Indexed: 12/17/2022]
Abstract
To compare success and complication rates of shock wave lithotripsy (SWL), flexible ureterorenoscopy (F-URS) and percutaneous nephrolithotripsy (PNL) according to modified clavien grading system of renal pelvis stones between 1 and 2 cm. The results of 149 patients were evaluated retrospectively. Patients were divided into three groups as 52 for SWL, 47 for F-URS and 50 for PNL. Complications were evaluated by modified Clavien grading system. In the first group, stone-free rates after a mean of 2, 6 sessions was 86 % (45/52). In Group 2, this ratio was 91.4 % (43/47), and in Group 3, it was 98 % (49/50). The success rate in Group 3 was significantly higher than other groups. Complication rates for Group 1, 2 and 3 were 7.6 % (4/52), 6.3 % (3/47) and 12 % (6/50), respectively. Although PNL was the most successful technique compared with other techniques, complications were also higher in this group. Even though PNL is the most successful, it should be performed for selected patient groups and indications should be carefully evaluated.
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Yang TK, Yang HJ, Lee LM, Liao CH. Body mass index and buttock circumference are independent predictors of disintegration failure in extracorporeal shock wave lithotripsy for ureteral calculi. J Formos Med Assoc 2013; 112:421-5. [PMID: 23927982 DOI: 10.1016/j.jfma.2012.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 02/03/2012] [Accepted: 02/05/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/PURPOSE Effective stone disintegration by extracorporeal shockwave lithotripsy (ESWL) may depend on patient- and stone-related factors. We investigated predictors of disintegration failure in ESWL for a solitary ureteral calculus. METHODS From July 2008 to May 2010, 203 patients who underwent ESWL for a solitary ureteral calculus were enrolled. Clinical and radiologic data were collected, and factors related to ESWL failure were analyzed. RESULTS Fifty-two patients (25.6%) showed ESWL failure, with a mean follow-up of 41 days. Forty patients (19.7%) required retreatment, including 12 who underwent repeat ESWL and 28 who underwent curative ureteroscopy. Patients with ESWL failure had significantly higher body weight, body mass index (BMI), and buttock circumference (BC) than patients for whom ESWL was successful. Univariate analysis showed that stone burden (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.06) and BC (OR, 1.06; 95% CI, 1.01-1.11) were predictors of ESWL failure, while BMI was a potential predictor with borderline significance (OR, 1.09; 95% CI, 0.99-1.20). Multivariate analysis showed that stone burden (OR, 1.04; 95% CI, 1.03-1.06) was a significant predictor for all patients. On stratifying patients according to the level of ureteral calculi, BC was found to be an independent predictor (OR, 1.35; 95% CI, 1.02-1.80) for ESWL failure for middle/lower ureteral calculi and BMI (OR, 1.47; 95% CI, 1.13-1.91) for upper ureteral calculi. CONCLUSION Stone burden is the main predictor of ESWL failure for all patients with ureteral calculi. BC and BMI are independent predictors for ESWL failure for middle/lower and upper ureteral calculi, respectively.
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Affiliation(s)
- Teng-Kai Yang
- Department of Surgery, Yonghe branch, Cardinal Tien Hospital, New Taipei City, Taiwan
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Hatipoglu NK, Sancaktutar AA, Tepeler A, Bodakci MN, Penbegul N, Atar M, Bozkurt Y, Söylemez H, Silay MS, Istanbulluoğlu MO, Akman T, Armagan A. Comparison of shockwave lithotripsy and microperc for treatment of kidney stones in children. J Endourol 2013; 27:1141-6. [PMID: 23713511 DOI: 10.1089/end.2013.0066] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We aimed to compare the outcomes of microperc and shockwave lithotripsy (SWL) for treatment of kidney stones in children. PATIENTS AND METHODS The medical records of 145 patients under the age of 15 years with opaque and single kidney stones treated with either SWL or microperc were retrospectively reviewed. Both groups were compared in terms of fluoroscopy and operative time, re-treatment, complications, success rate, and secondary and total number of procedures. RESULTS Microperc and SWL were performed on 37 and 108 pediatric patients, respectively. The mean age of the patients was 5.91±4.03 years (1-15) and 8.43±4.84 (1-15) years in the SWL and microperc groups, respectively (P=0.004). The mean stone size was 11.32±2.84 (5-20) mm in the SWL group and 14.78±5.39 (6-32) mm in the microperc group (P<0.001). In the SWL group, 31 (28.7%) patients underwent a second SWL session and 6 (5%) had a third session. Finally, 95 (88%) patients were stone free at the end of the SWL sessions. In the microperc group, the stone-free rate was 89.2% in a single session (P=0.645). The mean duration of hospitalization was 49.2±12.3 (16-64) hours in the microperc group and 8.4±2.3 (6-10) hours per one session in the SWL group (P<0.001). The fluoroscopy time was significantly longer in the microperc group compared with the SWL group (147.3±95.3 seconds vs 59.6±25.9 seconds, P<0.001). The rate of requirement for an auxiliary procedure was higher in the SWL group than in the microperc group. The overall complication rates for the microperc and SWL groups were 21.6% and 16.7%, respectively (P=0.498). CONCLUSIONS The results of our study demonstrate that microperc provides a similar stone-free rate and a lower additional treatment rate compared with SWL in the treatment of kidney stone disease in children.
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Kim TB, Lee SC, Kim KH, Jung H, Yoon SJ, Oh JK. The feasibility of shockwave lithotripsy for treating solitary, lower calyceal stones over 1 cm in size. Can Urol Assoc J 2013; 7:E156-60. [PMID: 23589749 DOI: 10.5489/cuaj.473] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Recently, few studies were reported about the treatment of large, solitary, renal calculi between shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PNL). We assess the feasibility of SWL for managing solitary, lower calyceal stones over 1 cm by comparing the results of lower pole calculi treatment between patients that underwent SWL or PNL. METHODS We retrospectively reviewed clinical data for patients who had undergone PNL or SWL due to lower calyceal stones over 1 cm. Group 1 consisted of patients who underwent SWL to treat lower pole renal calculi from 2010 to 2011. Group 2 included patients who underwent PNL to manage lower pole renal calculi from 2008 to 2009. We compared patient age, gender, stone size, comorbidities, postoperative complications, additional interventions and anatomical parameters between the two groups. RESULTS A total of 55 patients were enrolled in this study. The mean ages (±SD) of groups 1 (n = 33) and 2 (n = 22) were 55.1 (±13.0) and 50.0 (±10.6) years (p = 0.133) and mean stone sizes were 1.6 (±0.7) and 1.9 (±0.8) cm (p = 0.135), respectively. There were no significant differences in gender distribution, comorbidities or stone laterality between the two groups. No significant differences in various parameters were observed between patients with stones 1 to 2 cm and ones with stones 2 cm or larger. CONCLUSIONS Our results demonstrated that SWL is a safe, feasible treatment for solitary, lower calyceal stones over 1 cm.
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Affiliation(s)
- Tae Beom Kim
- Department of Urology, Gachon University Gil Hospital, Incheon, Korea
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Comparison of retrograde intrarenal surgery, shockwave lithotripsy, and percutaneous nephrolithotomy for treatment of medium-sized radiolucent renal stones. World J Urol 2012. [DOI: 10.1007/s00345-012-0991-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Razvi H, Fuller A, Nott L, Méndez-Probst CE, Leistner R, Foell K, Davé S, Denstedt JD. Risk Factors for Perinephric Hematoma Formation After Shockwave Lithotripsy: A Matched Case-Control Analysis. J Endourol 2012; 26:1478-82. [DOI: 10.1089/end.2012.0261] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Hassan Razvi
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Andrew Fuller
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Linda Nott
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Carlos E. Méndez-Probst
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Rasmus Leistner
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Kirsten Foell
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Sumit Davé
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - John D. Denstedt
- Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Bach C, Karaolides T, Buchholz N. Extracorporeal shock wave lithotripsy: What is new? Arab J Urol 2012; 10:289-95. [PMID: 26558039 PMCID: PMC4442960 DOI: 10.1016/j.aju.2012.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/01/2012] [Accepted: 04/02/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVES Thirty years after its introduction, extracorporeal shockwave lithotripsy (ESWL) is still first-line treatment for more than half of all urinary tract stones, but machines and treatment strategies have significantly developed over time. In this review, we summarise the latest knowledge about the clinically important aspects of ESWL. METHODS We searched PubMed to identify relevant reports and the latest European Association of Urology guidelines, and standard urological textbooks were consulted. RESULTS New technical developments include: Twin-head and tandem-pulse shock-wave generators; wide-focus, low-pressure systems; optimised coupling; and automated location and acoustic tracking systems. Indications have been refined, making possible the identification of patients in whom ESWL treatment is likely to fail. By lowering the shock-wave rate, improving coupling, applying abdominal compression, power 'ramping' and postoperative medical expulsion therapy, treatment protocols have been optimised. CONCLUSIONS Promising new technical developments are under development, with the potential to increase the stone-free rate after ESWL. For optimal results, the refined indications need to be respected and optimised treatment protocols should be applied.
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Affiliation(s)
- Christian Bach
- Endourology and Stone Services, Barts and The London NHS Trust, United Kingdom
| | | | - Noor Buchholz
- Endourology and Stone Services, Barts and The London NHS Trust, United Kingdom
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22
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Survey of Endourology Howard N. Winfield, M.D., Section Editor. J Endourol 2012. [DOI: 10.1089/end.2012.1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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23
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Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective. ACTA ACUST UNITED AC 2012; 40:433-46. [DOI: 10.1007/s00240-012-0485-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 05/22/2012] [Indexed: 01/20/2023]
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Connors BA, McAteer JA, Evan AP, Blomgren PM, Handa RK, Johnson CD, Gao S, Pishchalnikov YA, Lingeman JE. Evaluation of shock wave lithotripsy injury in the pig using a narrow focal zone lithotriptor. BJU Int 2012; 110:1376-85. [PMID: 22519983 DOI: 10.1111/j.1464-410x.2012.11160.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Of all the SW lithotriptors manufactured to date, more research studies have been conducted on and more is known about the injury (both description of injury and how to manipulate injury size) produced by the Dornier HM-3 than any other machine. From this information have come suggestions for treatment protocols to reduce shock wave (SW)-induced injury for use in stone clinics. By contrast, much less is known about the injury produced by narrow-focus and high-pressure lithotriptors like the Storz Modulith SLX. In fact, a careful study looking at the morphology of the injury produced by the SLX itself is lacking, as is any study exploring ways to reduce renal injury by manipulating SW delivery variables of this lithotriptor. The present study quantitates the lesion size and describes the morphology of the injury produced by the SLX. In addition, we report that reducing the SW delivery rate, a manoeuvre known to lower injury in the HM-3, does not reduce lesion size in the SLX. OBJECTIVE • To assess renal injury in a pig model after treatment with a clinical dose of shock waves using a narrow focal zone (≈3 mm) lithotriptor (Modulith SLX, Karl Storz Lithotripsy). MATERIALS AND METHODS • The left kidney of anaesthetized female pigs were treated with 2000 or 4000 shock waves (SWs) at 120 SWs/min, or 2000 SWs at 60 SWs/min using the Storz SLX. • Measures of renal function (glomerular filtration rate and renal plasma flow) were collected before and 1 h after shock wave lithotripsy (SWL) and the kidneys were harvested for histological analysis and morphometric quantitation of haemorrhage in the renal parenchyma with lesion size expressed as a percentage of functional renal volume (FRV). • A fibre-optic probe hydrophone was used to determine acoustic output and map the focal width of the lithotriptor. • Data for the SLX were compared with data from a previously published study in which pigs of the same age (7-8 weeks) were treated (2000 SWs at 120 or 60 SWs/min) using an unmodified Dornier HM3 lithotriptor. RESULTS • Treatment with the SLX produced a highly focused lesion running from cortex to medulla and often spanning the full thickness of the kidney. Unlike the diffuse interstitial haemorrhage observed with the HM3, the SLX lesion bore a blood-filled core of near-complete tissue disruption devoid of histologically recognizable kidney structure. • Despite the intensity of tissue destruction at the core of the lesion, measures of lesion size based on macroscopic determination of haemorrhage in the parenchyma were not significantly different from kidneys treated using the HM3 (2000 SWs, 120 SWs/min: SLX, 1.86 ± 0.52% FRV; HM3, 3.93 ± 1.29% FRV). • Doubling the SW dose of the SLX from 2000 to 4000 SWs did not significantly increase lesion size. In addition, slowing the firing rate of the SLX to 60 SWs/min did not reduce the size of the lesion (2.16 ± 0.96% FRV) compared with treatment at 120 SWs/min, as was the case with the HM3 (0.42 ± 0.23% FRV vs 3.93 ± 1.29% FRV). • Renal function fell significantly below baseline in all treated groups but was similar for both lithotriptors. • Focal width of the SLX (≈2.6 mm) was about one-third that of the HM3 (≈8 mm) while peak pressures were higher (SLX at power level 9: P+≈90 MPa, P-≈-12 MPa; HM3 at 24 kV: P+≈46 MPa, P-≈-8 MPa). CONCLUSIONS • The lesion produced by the SLX (narrow focal width, high acoustic pressure) was a more focused, more intense form of tissue damage than occurs with the HM3. • Slowing the SW rate to 60 SWs/min, a strategy shown to be effective in reducing injury with the HM3, was not protective with the SLX. • These findings suggest that the focal width and acoustic output of a lithotriptor affect the renal response to SWL.
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Affiliation(s)
- Bret A Connors
- Departments of Anatomy and Cell Biology, Indiana University School of Medicine Methodist Hospital Institute for Kidney Stone Disease, Indianapolis, IN 46202, USA.
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Ouzaid I, Al-qahtani S, Dominique S, Hupertan V, Fernandez P, Hermieu JF, Delmas V, Ravery V. A 970 Hounsfield units (HU) threshold of kidney stone density on non-contrast computed tomography (NCCT) improves patients' selection for extracorporeal shockwave lithotripsy (ESWL): evidence from a prospective study. BJU Int 2012; 110:E438-42. [PMID: 22372937 DOI: 10.1111/j.1464-410x.2012.10964.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Stone density on non-contrast computed tomography (NCCT) is reported to be a prognosis factor for extracorporeal shockwave lithotripsy (ESWL). In this prospective study, we determined that a 970 HU threshold of stone density is a very specific and sensitive threshold beyond which the likelihood to be rendered stone free is poor. Thus, NCCT evaluation of stone density before ESWL may useful to identify which patients should be offered alternative treatment to optimise their outcome. OBJECTIVE • To evaluate the usefulness of measuring urinary calculi attenuation values by non-contrast computed tomography (NCCT) for predicting the outcome of treatment by extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS • We prospectively evaluated 50 patients with urinary calculi of 5-22 mm undergoing ESWL. • All patients had NCCT at 120 kV and 100 mA on a spiral CT scanner. Patient age, sex, body mass index, stone laterality, stone size, stone attenuation values (Hounsfield units [HU]), stone location, and presence of JJ stent were studied as potential predictors. • The outcome was evaluated 4 weeks after the ESWL session by NCCT. • ESWL success was defined as patients being stone-free (SF) or with remaining stone fragments of <4 mm, which were considered as clinically insignificant residual fragments (CIRF). RESULTS • Our survey concluded that 26 patients (52%) were SF, 12 (24%) had CIRF and 12 (24%) had residual fragment on NCCT after a one ESWL treatment. • Stones of patients who became SF or had CIRF had a lower density compared with stones in patients with residual fragments [mean (sd) 715 (260) vs 1196 (171) HU, P < 0.001]. • The Youden Index showed that a stone density of 970 HU represented the most sensitive (100%) and specific (81%) point on the receiver-operating characteristic curve. • The stone-free rate for stones of <970 HU was 96% vs 38% for stones of ≥ 970 HU (P < 0.001). A linear relationship between the calculus density and the success rate of ESWL was identified. CONCLUSION • The use of NCCT to determine the attenuation values of urinary calculi before ESWL helps to predict treatment outcome, and, consequently, could be helpful in planning alternative treatment for patients with a likelihood of a poor outcome from ESWL.
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Affiliation(s)
- Idir Ouzaid
- Department of Urology, Bichat Claude Bernard Hospital, Paris Diderot University Medical School, Paris, France.
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Lipkin ME, Preminger GM. Shock Wave Lithotripsy: Present Indications and Future Prospects. Urolithiasis 2012. [DOI: 10.1007/978-1-4471-4387-1_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Elkoushy MA, Morehouse DD, Anidjar M, Elhilali MM, Andonian S. Impact of radiological technologists on the outcome of shock wave lithotripsy. Urology 2011; 79:777-80. [PMID: 22055696 DOI: 10.1016/j.urology.2011.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 08/15/2011] [Accepted: 09/11/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To evaluate the correlation of radiological technologists (RTs) and the outcome of shock wave lithotripsy (SWL) in terms of fluoroscopy time, fragmentation rate, and stone-free rate. MATERIAL AND METHODS A retrospective review of a prospectively collected database of 601 SWL treatments between June 2009 and March 2010 was performed. Patients with radiolucent stones were excluded. SWL was done by 6 RTs with different levels of experience. Follow up was available for 534 treatments. Multivariate analysis was performed. RESULTS RTs (A-F) performed 144, 109, 118, 58, 57, and 48 SWL sessions, respectively. There was no statistical difference among RTs in terms of mean stone size or stone location. Compared with other RTs, RT A had a significantly lower mean fluoroscopy time of 129 seconds (95% CI 120.8-137.3) (P <.001), higher stone-free rate (75.7%; P = .035), and stone fragmentation rate after a single SWL session (82.6%; P = .004). After correcting for stone size and location, fluoroscopy time (P <.001), fragmentation rate (P = .002), and stone-free rate (P = .04) maintained their significance. When comparing the top 3 RTs performing >100 SWL sessions, RTs B and C had significantly higher fluoroscopy time compared with RT A (OR [95% CI] 1.84 [1.38-2.45]; P <.001 and 2.67 [2.00-3.57]; P <.001), respectively. After correcting for stone size and location, RT B had significantly lower fragmentation rate when compared with RT A (OR [95% CI] 0.21 [0.05-0.86], P = .03]. However, there were no significant differences among the top 3 RTs in terms of stone-free rates. CONCLUSION RTs significantly differ in fluoroscopy usage in addition to stone fragmentation and stone-free rates.
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Affiliation(s)
- Mohamed A Elkoushy
- Division of Urology, Department of Surgery, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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