Comparison of Intravenous Sedation Versus General Anesthesia on the Efficacy of the Doli 50 Lithotriptor

2022 Recommendations of the AFU Lithiasis Committee: Extracorporeal shock wave lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive technique for the fragmentation of urinary tract stones using shock waves under fluoroscopic and/or ultrasound guidance. ESWL results depend on the indication (stone size/composition, clinical context) and also on how it is performed. The stone structure, nature and density (Hounsfield units; evaluated by CT without contrast agent) influence the fragmentation achieved by ESWL. The upper size limit of kidney stones has been lowered to 15mm (1.68cm3) due to the increased risk of steinstrasse with larger sizes and the potential need of anesthesia and ureteral stenting. Conversely, the development of endourological technologies allows a finer stone fragmentation and/or better elimination, thus reducing the risk of steinstrasse and decreasing the potential number of sessions or additional interventions. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) 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 2022]) and their adaptability to the French context.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

The effect of music on state anxiety in patients undergoing extracorporeal shockwave lithotripsy

AIM

Extracorporeal shockwave lithotripsy is a commonly used method to break down kidney stones in urology clinics. This study aims to investigate whether or not listening to music is effective against state anxiety in patients undergoing kidney stone treatment with this method.

METHODS

A total of 80 patients (50 males, 30 females) undergoing extracorporeal shockwave lithotripsy for the first time at our clinic were included in the study. The first group (24 patients) listened to instrumental classical music through headphones 20 minutes before the procedure, while the second group (28 patients) listened to instrumental classical music during the procedure. The third group (28 patients) was the control group and consisted of patients who did not listen to music before or during the procedure. Patients were administered a state-trait anxiety inventory test to measure state anxiety after the process, and their results were compared.

RESULTS

While there was a significant difference in state-trait anxiety inventory scores between patients who listened to music before/during the procedure and the control group, there was no significant difference between patients who listened to music before and those who listened to music during the procedure. Assessment of randomisation showed groups achieved homogeneity.

CONCLUSION

Among the groups homogeneously distributed according to age and gender, significantly lower anxiety scores of groups that listened to music compared with the control group have provided supporting data to be open-minded and exploratory about increasing patient tolerability and comfort during these potentially pain-inducing procedures.

Is extracorporeal shockwave lithotripsy (SWL) still suitable for >1.5 cm intrarenal stones? Data analysis of 1902 SWLs

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.

Efficacy of pethidine, ketorolac, and lidocaine gel as analgesics for pain control in shockwave lithotripsy: A single-blinded randomized controlled trial

Purpose

To compare the safety and efficacy of xylocaine gel and ketorolac as opioid-sparing analgesia compared with pethidine for shock wave lithotripsy (SWL) pain.

Materials and Methods

A single-blinded randomized controlled trial (RCT) was performed in 132 patients with renal and upper ureteral stones amenable to treatment with SWL. The first patient group received intravenous (IV) pethidine and placebo gel; the second group received IV ketorolac plus placebo gel; the third group received lidocaine gel locally plus normal saline IV. Stone disintegration was classified as none (no change from basal by kidney, ureter, bladder X-ray or ultrasound [US] imaging), partial (fragmented and >4-mm residual fragments), and complete (≤4-mm residual fragments). Stone disintegration was assessed by kidney-ureter-bladder X-ray and US imaging. Pain was evaluated by use of the Numeric Pain Rating Scale (NPRS).

Results

The NPRS scores were highest in the xylocaine group at 10, 20, and 30 minutes (p=0.0001) with no significant difference between the ketorolac and pethidine groups, except at 10 minutes (p=0.03) and a near significant difference at 30 minutes (p=0.054) in favor of ketorolac. Results for stone disintegration (none, partial, and complete, respectively) were as follows: 25 (50.0%), 23 (46.0%), and 2 (4.0%) for pethidine; 19 (35.8%), 23 (43.4%), and 11 (20.8%) for ketorolac; and 26 (89.7%), 3 (10.3%), and 0 (0.0%) for lidocaine (p=0.008).

Conclusions

Ketorolac is a safe and more effective alternative to morphine derivatives for SWL analgesia. Lidocaine gel should not be used as mono-analgesia for SWL.

Extracorporeal shock wave lithotripsy under intravenous sedation for treatment of urolithiasis

BACKGROUND

In contrast to treatment with oral or intramuscular analgesics, extracorporeal shock wave lithotripsy (E.S.W.L.) can be performed with patients under sedation too. Besides the advantage of increased shock energy, patients tend to have more constant breathing excursions and are more idle during treatment, potentially increasing the stone-free ratio (S.F.R.) after treatment.

METHODS

This study presents the results of 310 patients who underwent 400 E.S.W.L. procedures under sedation, with a stationary lithotripter.

RESULTS

After one procedure, the S.F.R. was 54.8% (170/310). A second treatment was successful in 42.1% (32/76), a third treatment in 21.4% (3/14). Therefore, 66.1% (205/310) of patients eventually became stone-free. Kidney stones were successfully treated in 65.4% (161/246), ureteral stones in 68.8% (44/64) of cases. Patients with stones ≤15 mm were successfully treated in 67.4% (194/288), patients with stones >15 mm in 50% (11/22) of cases. Considering each procedure individually, 45.3% (181/400) of procedures were successful after 3 weeks. Extending follow-up to 3 months is important, since 26.7% of stones (24/90) eventually still disappeared, increasing S.F.R. to 51.3% after one procedure. Complications occurred after 5.5% E.S.W.L.-procedures.

CONCLUSIONS

E.S.W.L. is a well-tolerated, non-invasive procedure that produces reasonable stone clearance of both upper and lower urinary tract calculi. Performing the procedure whilst patients are intravenously sedated results in an acceptable S.F.R. Strong selection based on unfavourable factors could increase the chance on successful treatment and spare patients a pointless procedure. However, considering E.S.W.L.'s elegant nature, sometimes a more tolerant approach seems justifiable.

Extracorporeal shock wave lithotripsy in the treatment of renal and ureteral stones

The use of certain technical principles and the selection of favorable cases can optimize the results of extracorporeal shock wave lithotripsy (ESWL). The aim of this study is to review how ESWL works, its indications and contraindications, predictive factors for success, and its complications. A search was conducted on the Pubmed® database between January 1984 and October 2013 using "shock wave lithotripsy" and "stone" as key-words. Only articles with a high level of evidence, in English, and conducted in humans, such as clinical trials or review/meta-analysis, were included. To optimize the search for the ESWL results, several technical factors including type of lithotripsy device, energy and frequency of pulses, coupling of the patient to the lithotriptor, location of the calculus, and type of anesthesia should be taken into consideration. Other factors related to the patient, stone size and density, skin to stone distance, anatomy of the excretory path, and kidney anomalies are also important. Antibiotic prophylaxis is not necessary, and routine double J stent placement before the procedure is not routinely recommended. Alpha-blockers, particularly tamsulosin, are useful for stones >10mm. Minor complications may occur following ESWL, which generally respond well to clinical interventions. The relationship between ESWL and hypertension/diabetes is not well established.

How to improve results with extracorporeal shock wave lithotripsy

OBJECTIVE

Shock wave lithotripsy (SWL) has greatly revolutionized the treatment of patients suffering from stone disease. There are a number of patient- and device-specific factors that can affect treatment outcome. Herein, we review practices that can increase the likelihood of SWL treatment success.

METHODS

A systematic literature review was performed to identify studies of SWL treatment parameters.

RESULTS

Among the factors affecting the outcome of SWL were patient selection criteria, such as stone burden, stone location, and anatomic features. Additionally, technical aspects of the SWL procedure also can affect outcome; these factors include the acoustic output of the lithotripter, the coupling of the lithotripter to the patient, and the power, total number, and rate of shock wave delivery.

CONCLUSIONS

The outcome of SWL can be optimized with close attention to patient selection criteria as well as the manner in which the treatment is performed.

Shock wave technology and application: an update

CONTEXT

The introduction of new lithotripters has increased problems associated with shock wave application. Recent studies concerning mechanisms of stone disintegration, shock wave focusing, coupling, and application have appeared that may address some of these problems.

OBJECTIVE

To present a consensus with respect to the physics and techniques used by urologists, physicists, and representatives of European lithotripter companies.

EVIDENCE ACQUISITION

We reviewed recent literature (PubMed, Embase, Medline) that focused on the physics of shock waves, theories of stone disintegration, and studies on optimising shock wave application. In addition, we used relevant information from a consensus meeting of the German Society of Shock Wave Lithotripsy.

EVIDENCE SYNTHESIS

Besides established mechanisms describing initial fragmentation (tear and shear forces, spallation, cavitation, quasi-static squeezing), the model of dynamic squeezing offers new insight in stone comminution. Manufacturers have modified sources to either enlarge the focal zone or offer different focal sizes. The efficacy of extracorporeal shock wave lithotripsy (ESWL) can be increased by lowering the pulse rate to 60-80 shock waves/min and by ramping the shock wave energy. With the water cushion, the quality of coupling has become a critical factor that depends on the amount, viscosity, and temperature of the gel. Fluoroscopy time can be reduced by automated localisation or the use of optical and acoustic tracking systems. There is a trend towards larger focal zones and lower shock wave pressures.

CONCLUSIONS

New theories for stone disintegration favour the use of shock wave sources with larger focal zones. Use of slower pulse rates, ramping strategies, and adequate coupling of the shock wave head can significantly increase the efficacy and safety of ESWL.

Impact of type of anesthesia on efficacy of medstone STS lithotripter

PURPOSE

To evaluate the impact of the type of anesthesia on treatment efficacy, using a comparison of general anesthesia (GEN) and monitored anesthesia care with intravenous sedation (MAC), for patients undergoing extracorporeal shockwave lithotripsy (SWL) on the Medstone STS lithotripter.

PATIENTS AND METHODS

A case-control study was conducted of 660 patients treated from 1986 to 2002. General anesthesia and MAC were utilized in 330 procedures each. Case matching was performed for stone size, stone location, and body mass index. All lithotripter units were staffed by a rotating schedule of the same 10 SWL-certified radiologic technicians. Patient characteristics, treatment parameters, complications, repeat procedures, and secondary procedures were recorded. Stone-free success rates (no residual fragments) were reported by the treating physician on the basis of plain radiographs. Chi-square analysis was used to compare patients in the two groups.

RESULTS

The overall stone-free rate was better with GEN (67%) than MAC (55%; P = 0.04). Stone-free rates were not affected for stones <or=10 mm (GEN 69%, MAC 63%; P = 0.42). The type of anesthetic impacted stone-free rates in the upper calix (GEN 75%, MAC27%; P = 0.05).

CONCLUSIONS

This study helps define that population that may benefit most from the use of GEN: those with stones >10 mm or in an upper calix. General anesthesia may decrease excursion of the calculus out of the focal area secondary to breathing or patient movement.

Shock wave lithotripsy correlates with stone density on preoperative computerized tomography

PURPOSE

We reviewed our experience with the Dornier Doli S lithotriptor to address 2 questions. 1) What is the stone-free rate? 2) Can a stone-free outcome be predicted by preoperative computerized tomography?

MATERIALS AND METHODS

The records of 76 consecutive patients undergoing shock wave lithotripsy for solitary urinary calculi 5 to 20 mm in diameter were studied retrospectively. Pretreatment noncontrast computerized tomography was reviewed to determine Hounsfield density. The shock wave lithotripsy outcome was determined at 12 weeks on imaging and categorized as 1) stone free, 2) any residual fragments or 3) stone unchanged.

RESULTS

Of the patients 28 (37%) were stone free, 11 (14%) had residual fragments and 37 (49%) had stones that remained unchanged on computerized tomography after a single treatment with shock wave lithotripsy using a Dornier Doli S. Stones of patients rendered stone free had a lower median density compared to stones in patients with residual fragments and unchanged stones (684 vs 1,034 and 920 HU, respectively, p = 0.04). The stone-free rate for stones less than 1,000 HU was 46% vs 17% for stones 1,000 HU or greater (p = 0.01).

CONCLUSIONS

The combined stone-free and fragmentation rate was 51%, lower than in other published reports. In patients with calculi greater than 1,000 HU shock wave lithotripsy achieved a stone-free rate of only 17%. Patients should be informed of the likelihood of treatment failure or need for auxiliary procedures if the Doli S lithotriptor is used, particularly for stones greater than 1,000 HU.

Comparison of Two Ventilation Techniques During General Anesthesia for Extracorporeal Shock Wave Lithotripsy: High-Frequency Jet Ventilation Versus Spontaneous Ventilation with a Laryngeal Mask Airway

OBJECTIVES

To compare high-frequency jet ventilation (HFJV) with spontaneous ventilation (SV) in general anesthesia for extracorporeal shock wave lithotripsy (ESWL).

METHODS

We conducted a retrospective review of 91 consecutive patients undergoing either HFJV with a Ben Jet airway or SV with a laryngeal mask airway, comparing the total number of shocks for stone ablation and the time in the post-anesthetic care unit between groups. Stone ablation rates on postoperative x-rays were compared.

RESULTS

The HFJV group needed significantly fewer shocks for stone ablation (median, 2000 versus 3000, P = 0.0001), and there was no difference in post-anesthetic care unit time. No patient in either group had significant clinical signs of ESWL-related tissue trauma. There was no difference in stone ablation rates on follow-up x-ray (HFJV 77% versus SV 74%).

CONCLUSIONS

This study supports the use of HFJV as a ventilation mode for ESWL when general anesthesia is chosen. Similar stone fragmentation rates can be achieved with fewer shocks, which may have beneficial effects, such as less pain and nausea, requiring further study.

Characteristics and treatment outcome of patients requiring additional intravenous analgesia during extracorporeal shockwave lithotripsy with Dornier Compact Delta Lithotriptor

OBJECTIVE

To investigate the effect of additional intravenous analgesia (besides oral analgesic premedication) on the treatment outcome in patients receiving extracorporeal shock wave lithotripsy (SWL) with Dornier Compact- Delta lithotriptor.

METHODOLOGY

Five hundred and twenty adults receiving SWL for solitary urinary stone of size </=10 mm were retrospectively reviewed. They received the same analgesic protocol--oral diclofenac 50 mg as premedication and additional intravenous bolus alfentanil if they experienced discomfort during ESWL. After reviewing the analgesic usage, they were divided into two groups, Group-A--received oral analgesic alone and Group-B--received both oral and additional intravenous analgesia during ESWL. Treatment outcome of the two groups was then compared.

RESULTS

There were 306 patients in Group-A and 214 patients in Group-B. The stone-free rates at 3-month for Group-A and -B were 38.2% and 44.9% respectively (P = 0.100). The re-treatment/auxiliary procedure rates for the Group-A and Group-B were 40.8%/12.7%, and 35.0%/18.2% respectively. The additional use of intravenous analgesia improved the effectiveness quotient by 17.7% [from 0.249 (Group-A) to 0.293(Group-B)].

CONCLUSIONS

The additional use of intravenous analgesia during SWL with Dornier Compact Delta lithotriptor resulted in improvement of effectiveness quotient.

Effect of modification of shock-wave delivery on stone fragmentation

PURPOSE OF REVIEW

Shock-wave lithotripsy has been the mainstay of urinary-stone treatment over the past 20 years, with three generations of lithotripters now in the market place. Little improvement, however, has been made in the overall efficiency, since the original Dornier HM3 lithotripter. Over the past 5 years much progress has been made in the basic research of shock-wave lithotripsy, with better understanding of the mechanisms involved in stone fragmentation. This progress has led to new modifications in the way shock-wave pulse is generated and delivered.

RECENT FINDINGS

Clinical studies, reflecting improved understanding of basic mechanisms of stone comminution, are being published. Two recent prospective clinical trials have shown the higher efficiency of slow-rate compared with fast-rate shock-wave lithotripsy. A very practical solution requiring no hardware upgrade albeit at longer procedure times. Other promising developments include the use of twin-head technology, with either simultaneous or sequential shock waves. In addition, chemolytic pretreatment and dose-escalation techniques have shown early encouraging results. This review provides an update of the latest shock-wave technology and delivery strategies.

SUMMARY

Long-term studies, to document anticipated improved safety with slow shock-wave rate, are needed. Future in-vivo and clinical studies of twin-head technology and dose-escalation strategy of shock-wave lithotripsy may initiate new lithotripter designs that will lead to improved stone-free rates, while simultaneously reducing associated renal trauma.

[Extra corporeal shock wave lithotripsy (ESWL) procedure in urology]

Since 1980, extra corporeal shock wave lithotripsy (ESWL) has become the first line treatment for most stones in adults and children. The indications are based on criteria depending on localization, chemical composition and size of the renal and ureteral calculi. Since the DORNIER HM 3 which remains the gold standard of first generation lithotripters, many devices of second and third generation have been built (electro hydrolic, piezo electric and electromagnetic) with fluoroscopic and ultrasound localization systems. SWL may now be performed on an out-patient basis without anaesthesia or under neuroleptic analgesia. Indications and evaluation criteria on 3 months plain abdominal X-ray are better defined since 1996. Nevertheless, comparison of reported results remains difficult due to the multiplicity of lithotripter types and the lack of consensus on efficacy criteria. Today, the third generation of mobile electromagnetic lithotripters give an average of 80% stone free rate of patients with kidney and ureteral calculi whatever the localization and size.

Is stone radiodensity a useful parameter for predicting outcome of extracorporeal shockwave lithotripsy for stones < 2 cm?

PURPOSE

Several factors determine the success of extracorporeal shockwave lithotripsy (SWL) for kidney stones: stone size, stone location within the collecting system, stone type, and the SWL machine used. It has been suggested that stone radiodensity, as determined either by plain radiography or computed tomography attenuation values, may be an independent predictor of SWL success. We examined the outcome of SWL for solitary stones less than or equal to 2 cm located within the renal pelvis, based on their radiodensity.

MATERIAL AND METHODS

211 patients with solitary renal pelvic stones measuring less than or equal to 2 cm were treated on a Dornier Doli 50 lithotriptor under general anesthesia. The radiodensity of the stone was determined to be either less than, equal to, or greater than the radiodensity of the ipsilateral 12th rib. Stone-free rates (SFR) were determined at 3 months by kidney, ureters and bladder (KUB) plain X-rays. Patients requiring re-treatment or auxiliary procedures were considered failures of SWL.

RESULTS

Follow-up SFR information was available in all 211 patients. Stone composition was available in 158 (75%) treated patients, but no correlation was found between stone radiodensity and stone composition. For stones < or = 10 mm within the renal pelvis, the SFRs were similar (71 to 74% regardless of stone radiodensity). For stones between 11 and 20 mm, the SFR was 60% if the stone had a radiodensity > 12th rib compared to a SFR of 71% if the stone radiodensity was < or = 12th rib. However, these differences in SFRs were not statistically significant.

CONCLUSIONS

On the Doli machine, stone radiodensity alone does not predict lithotripsy treatment outcome for stones < or = 1 cm within the renal pelvis. This parameter is probably only useful as the stone size becomes larger than 1 cm, and should be used in conjunction with other stone parameters to select appropriate therapy.