Modified Mechanical Percussion for Upper Urinary Tract Stone Fragments After Extracorporeal Shock Wave Lithotripsy: A Prospective Multicenter Randomized Controlled Trial

Comparative analysis of renal calculi treatment via different extracorporeal shock wave lithotripsy (ESWL) pathways

OBJECTIVE

To compare the efficacy and safety of Extracorporeal Shock Wave Lithotripsy (ESWL) for treating renal calculi under different shock wave pathways.

METHODS

This study involved a prospective analysis of clinical data obtained from 264 eligible patients with renal stones treated at the Urology Department of Shanxi Bethune Hospital between January 2021 and June 2023. Among these patients, 125 underwent ESWL via the dorsal shock wave pathway (Group A), while 139 patients underwent ESWL via the ipsilateral clavicular midline shock wave pathway (Group B). Preoperatively, all patients underwent non-contrast abdominal CT (NCCT) scans to assess stone count, diameter, CT values, and Skin-to-Stone Distance (SSD). Intraoperatively, ultrasonography was utilized to remeasure SSD and monitor stone fragmentation continuously. The ESWL procedure employed a standardized intermittent stepwise energy escalation technique until treatment completion. Various metrics, including intraoperative Visual Analog Scale (VAS) pain scores, number of shocks, total shock wave energy, stone-free rate (SFR) at 4 weeks post-operation, and postoperative complication rates, were recorded and subjected to statistical analysis.

RESULTS

There were no statistically significant differences between the two groups regarding gender, age, BMI, stone count, stone diameter, stone CT values, intraoperative VAS pain scores, and postoperative complication rates (P>0.05). Preoperative SSD was significantly higher in Group B than in Group A (P<0.05), but there were no significant differences in intraoperative SSD between the groups (P>0.05). Group B showed significantly lower total shock wave energy and number of shocks compared to Group A (P<0.05). The stone-free rate (SFR) after 4 weeks did not exhibit significant differences between the groups (P>0.05). However, when the stone diameter was ≥1.3 cm, the SFR at 4 weeks post-operation in Group B was significantly higher than in Group A (P<0.05).

CONCLUSION

ESWL emerges as a safe and efficacious approach for treating renal calculi. Our findings suggest that utilizing the ipsilateral clavicular midline shock wave pathway in ESWL necessitates less shock wave energy and enhances efficiency, particularly in cases with larger stone burdens.

2022 Recommendations of the AFU Lithiasis Committee: Postural therapy

Postural therapy is a postural procedure to fight against the gravity phenomenon responsible for the non-elimination of lower calyceal stones. It allows improving or accelerating their expulsion and it increases the stone-free rate. This procedure associates forced diuresis, postural inversion, and lumbar percussion. It allows a 50% improvement and an acceleration of fragment elimination. Despite its positive impact, postural therapy remains under-used. These are the first practical recommendations on postural therapy. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they were adaptable to the French context.

Clinical application of the therapeutic ultrasound in urologic disease: Part II of the therapeutic ultrasound in urology

This article aimed to review the clinical application and evidence of the therapeutic ultrasound in detail for urological diseases such as prostate cancer, kidney tumor, erectile dysfunction, and urolithiasis. We searched for articles about high-intensity focused ultrasound (HIFU), extracorporeal shock wave therapy, ultrasound lithotripsy, and extracorporeal shockwave lithotripsy (ESWL) in the MEDLINE and Embase. HIFU may be indicated as a primary treatment for low- or intermediate-risk prostate cancer, and salvage therapy for local recurrence as a promising way to address the limitations of current standard therapies. The application of HIFU in treating kidney tumors has scarcely been reported with unsatisfactory results. Evidence indicates that low-intensity shockwave therapy improves subjective and objective erectile function in patients with erectile dysfunction. Regarding the application of ultrasound in stone management, the novel combination of ultrasound lithotripsy and other energy sources in a single probe promises to be a game-changer in efficiently disintegrating large kidney stones in percutaneous nephrolithotomy. ESWL is losing its role in managing upper urinary tract calculi worldwide. The burst-wave lithotripsy and ultrasound propulsion could be the new hope to regain its position in the lithotripsy field. According to our investigations and reviews, cavitation bubbles of the therapeutic ultrasound are actively being used in the field of urology. Although clinical evidence has been accumulated in urological diseases such as prostate cancer, kidney tumor, erectile dysfunction, and lithotripsy, further development is needed to be a game-changer in treating these diseases.

A single center study that evaluates the preclinical use of a newly developed software and moving bed system to facilitate the spontaneous excretion of residual fragments after primary stone treatment (RIRS or PCNL)

Purpose

We developed a Postural Drainage Lithotripsy System (PDLS) that uses the patient's computed tomography urography (CTU) data to reconstruct the three-dimensional figure of the renal pelvis, provides an individualized inversion and overturning angle and uses gravity to remove residual fragments (RFs). The purpose of this study was to investigate PDLS in the treatment of renal RFs.

Methods

A stone with a diameter of 4.0 mm was placed in the upper, middle, and lower calyx of the renal model. A total of 60 trials were applied to 20 renal models. The movement trajectory, passage rate, and postural drainage angle of calculi during the treatment of PDLS were observed.

Results

All of the stones in 60 trials were observed to move during treatment, and 53/60 (88%) were relocated successfully to the renal pelvis. The passage rate of the upper calyx was 14/20 (70%), that of the middle calyx was 20/20 (100%), and that of the lower calyx was 19/20 (95%).

Conclusions

PDLS can provide individualized inversion and reversal angles and remove stones from the renal model. More clinical trials are needed to verify the above view and evaluate its efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03863-7.

Use of extracorporeal physical vibration lithecbole through greater sciatic foramen for treatment of distal ureteral calculi

Introduction To evaluate the efficacy and safety of preforming extracorporeal physical vibration lithecbole(EVPL)through greater sciatic foramen(GSF)for distal ureteral calculi(DUC) treatment. Materials and methods All patients with a diagnosis of DUC (6 - 10 mm in diameter) were enrolled in this study from October 2018 to May 2020. Patients were randomly divided into three groups receiving EPVL through GSF (Group A, n = 58), or abdominal (Group B, n = 60), or combined with oral use of tamsulosin at 0.4 mg daily (Group C, n = 63). Results There was no significant difference observed in terms of demographic characteristics or size of stones among the three groups (p >0.05). Compared with the group B and C, patients of the group A displayed a significantly higher score of comfort but with significantly decreased number of renal colic attacks or analgesics required (p < 0.01). The stone-free rate also significantly increased after one and two weeks of treatment (p < 0.01), despite such a significant difference among these groups vanished after four weeks of treatment. Conclusion Extracorporeal physical vibrational lithecbole in the prone position use the greater sciatic foramen as the path is the safe and effective approach to treat the distal ureter calculi.

How to maximize the efficacy of shockwave lithotripsy

Since its introduction in the early 1980s, extracorporeal shockwave lithotripsy (ESWL) has proven to be a minimally invasive and efficient procedure for the management of renal calculi. It is currently one of the most recommended treatments for small- and medium-sized stones (<20 mm) in most guidelines internationally. The recent coronavirus disease 2019 (COVID-19) outbreak could lead to a further increase in ESWL use as it avoids a general anesthetic and its potential complications in patients with COVID-19 infection. Most publications exhibit ESWL stone-free rates (SFRs) of 70%-80%; however, this is often not the case in many centers, with multiple factors affecting the efficacy of the intervention. Various stone and patient factors have been shown to influence the ESWL success. Stone position, density and size, skin-to-stone distance, and body-mass index contribute to SFRs. Modifications in the lithotripter design and revisions in the technique have also improved the SFRs over the years, with slower shock rates, power-ramping protocols, combined real-time ultrasound, and fluoroscopy imaging technology, all enhancing the efficacy. The adjuvant use of pharmacological agents, such as alpha-blockers, potassium citrate, and the emerging microbubble technology, has also been investigated and shown promising results. Arguably, the most significant determinant of the success of ESWL in a particular unit is how the lithotripsy service is set up and monitored. Careful patient selection, dedicated personnel, and post-treatment imaging review are essential for the optimization of ESWL. Through an analysis of the published studies, this review aimed to explore the measures that contribute to an effectual lithotripsy service in depth.

Is physical therapy effective following extracorporeal shockwave lithotripsy and retrograde intrarenal surgery: a meta-analysis and systematic review

Background

Physical therapy, including percussion, inversion, vibration and combinations, was clinically performed to improve the stone free rate (SFR) following lithotripsy procedures. However, physical therapy is not widely accepted in clinical practice owing to lack of high level evidence support and a standard protocol. The present meta-analysis aimed to evaluate the efficacy and safety of physical therapy in improving SFR following extracorporeal shockwave lithotripsy (ESWL) and retrograde intrarenal surgery (RIRS).

Methods

Systematic review of literature from PubMed, Scopus, Cochrane library and Embase was performed in March 2019. The efficacy and safety of physical therapy after ESWL and RIRS were assessed by meta-analysis of SFR and complication rate.

Results

A total of 8 prospective studies with 1065 patients were enrolled. When compared to non-intervention, physical therapy provided a higher SFR (OR:3.38, 95% CI: 2.45–4.66, p < 0.0001) at all time points (week 1, week 2 and month 1), while there was no significant difference in complications such as hematuria, lumbago, dizziness and urinary tract infection (OR: 0.84; 95%CI: 0.62–1.13; p = 0.237). In subgroup analysis of different stone locations, lower calyx stone (OR: 3.51; 95%CI: 2.21–5.55; p < 0.0001), upper ureter and renal pelvic stones (OR:2.79; 95%CI:1.62–4.81; p = 0.0002) had a higher SFR after physical therapy, while there was no significant improvement in SFR in upper and middle calyx stones. In subgroup analysis of different techniques, EPVL (external physical vibration lithecbole, OR:3.47; 95%CI:2.24–5.37; p < 0.0001) and PDI (percussion, diuresis and inversion, OR:3.24; 95%CI:2.01–5.21; p < 0.0001) were both effective in improving SFR when compared to non-intervention.

Conclusions

Physical therapy is effective in improving the SFR after ESWL and RIRS, especially for lower calyx stones, upper ureter and renal pelvic stones, while without significant side effects. External physical vibration lithecbole (EPVL) might provide a relative uniformed and repeatable protocol for clinical practice of physical therapy.

Trial registration

PROSPERO 2019 CRD42019130228.

The role of extracorporeal shock wave lithotripsy in the future of stone management

PURPOSE OF REVIEW

The most relevant recent findings on the use of extracorporeal shock wave lithotripsy (ESWL) in adult population to provide an insight of its role in the current and future of stone treatment. Comparing ESWL with other modalities is not in the scope of this review.

RECENT FINDINGS

We conducted a PubMed/Embase search and reviewed recent publications that include relevant information on the development of ESWL. Low-rate shock waves improve stone breakage, ramping energy modalities improve stone fragmentation and have lower incidence of hematoma and kidney injury. Transgluteal approach is suggested to improve stone-free rates for distal ureteral stones in a single session. Proper coupling is the most important technical aspect of the treatment and coupling improvement can be achieved by optical monitorization. Triple D score is a promising tool in proper patient selection, but external validation is needed. Predictive information arising from computed tomography scans has been refined by the variant coefficient of stone density and 3D texture analysis that might improve outcomes in the future.

SUMMARY

Recent evidence suggests that modifying techniques and protocols, and better patient selection are the current trends for improving ESWL outcomes. EWSL will keep its role as the single noninvasive treatment in stone management with room for outcome improvement in the future.