Effect of high shock number on acute complication development after extracorporeal shockwave lithotripsy

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.

Can intervals in extracorporeal shock wave lithotripsy sessions affect success in the treatment of upper ureteral stones?

Introduction

Managing upper ureteral stones with shock wave lithotripsy (SWL) has been done for many years. However, no conclusive data have been found on the intervals required between repeated SWL sessions.

Aim

To identify the most optimal intervals between SWL sessions.

Material and methods

Between September 2015 and December 2016, 80 patients undergoing elective outpatient lithotripsy who required repeated SWL sessions for ureteral stones were evaluated. These patients were categorised into two groups according to different SWL session intervals. The intervals between SWL sessions (n = 40) for the first group lasted one day, whereas those for the second group (n = 40) lasted 1 week. The data recorded during SWL included visual analogue scale (VAS) scores, total number of shocks, total energy used and number of sessions. The stone clearance rates, number of urinary tract infections, complication rates and VAS scores were compared between the two groups.

Results

All patients’ clinical outcomes after SWL therapy are shown in Table I. The stone clearance rate for group 1 was 70%, whereas that for group 2 was 72.5% (p = 0.805). Additionally, the number of urinary tract infections, complications and VAS scores were similar for both groups. In group 1, 3 patients had steinstrasse, two suffered from severe renal colic, and one had a urinary tract infection. In group 2, 3 patients endured steinstrasse, and 2 patients experienced severe renal colic during the study.

Conclusions

Short-interval SWL sessions are safe and effective for treating upper ureteral stones, and such sessions do not increase complication rates.

Autophagy activation protects shock wave induced renal tubular epithelial cell apoptosis may through modulation of Akt/ GSK-3β pathway

Purpose: Extracorporeal shock wave lithotripsy (ESWL) is well documented to exert destructive effect to renal cells and its mechanism is not clear. Autophagy is one of cell basic response for stressful conditions and it is important to determine cell's fate. The aim of this study is to elucidate the role of autophagy in the process of shock wave-induced renal cells injury.

Methods: NRK-52E cell, a rat renal tubular epithelial cell, was exposed to shock wave at the voltage of 14KV. GFP-LC3 puncta was used to monitor Autophagy flux in the process of shock wave injury. Autophagic relative proteins, such as light chain 3 (LC3), beclin-1 and p62, were also examined. Cell variability and apoptosis were detected when inhibition autophagy with 3-methyladenine (3MA) or stimulating its activity with rapamycin during the process of shock wave injury. The role of Akt/ GSK-3β and its connection with autophagy in the process of shock wave injury were also investigated.

Results: Shock wave was confirmed to activate autophagy in renal cells, which was manifested in LC3-II turnover, beclin-1 induction and degradation of p62. Inhibition autophagy enhanced cell damage or apoptosis, whereas its stimulating was able to exert protection from shock wave injury. Akt/ GSK-3β, a cell-survival signaling pathway, can also be activated during the process. And its activation could be suppressed by blockade autophagy.

Conclusion: Autophagy is a self-protective response for renal cells from shock wave injury. The cyto-protection of autophagy may be connected with modulation Akt/ GSK-3β pathway.

Extracorporeal shockwave lithotripsy for upper tract urolithiasis

PURPOSE OF REVIEW

For the last three decades, extracorporeal shockwave lithotripsy (SWL) has been the mainstay of management of urolithiasis; recognized widely by patients and physicians for its noninvasive approach and good outcomes. Recent challenges by endoscopic approaches have driven ongoing research to refine indications, define outcomes and explore innovations.

RECENT FINDINGS

Utilization of SWL remains high, despite increasing utilization of endoscopic approaches. Patient selection is critical--outcomes with percutaneous nephrolithotomy and ureteroscopy after failed SWL are not as good as those obtained in patients who have not had prior SWL. A structured training in ultrasound localization and proper patient positioning can have dramatic impacts on stone-free results. Stone size, location, Hounsfield unit stone attenuation and stone volume remain important predictors of outcomes. Renal cysts may negatively impact outcomes with SWL.

SUMMARY

These recent studies highlight important considerations for patient selection, SWL technique and follow-up for patients undergoing SWL. New technologies hold promise but require further study.