Extracorporeal shock wave lithotripsy versus laser lithotripsy in the treatment of post-SWL steinstrasse: a randomized comparative study

OBJECTIVE

To compare the efficacy of Holmium laser lithotripsy with that of extracorporeal shock lithotripsy (SWL) for post-SWL ureteral steinstrasse.

MATERIALS AND METHODS

From January 2022 to July 2023, 36 patients with post-SWL ureteral steinstrasse were randomly divided into laser lithotripsy and SWL groups. Patients with pain, moderate to marked hydronephrosis, large leading stone fragments, and showing no spontaneous resolution within 3-4 weeks after medical expulsive therapy were included. Patients with sepsis were excluded. The success rate was the primary outcome. We compared the perioperative data between the groups.

RESULTS

The success rate was higher in the ureteroscopy group than in the SWL group (p = 0.034). SWL was a significantly longer operation, and the fluoroscopy time was significantly longer in the SWL group than in the URS group (p = 0.027). Auxiliary procedures were more frequently performed in the SWL group than in the URS group (p = 0.02). JJ stents were inserted in 100% of patients in the URS group. Three patients (16.7%) underwent conversion to laser ureteroscopy after the second SWL session failed. No significant difference in the incidence of postoperative complications was observed between the groups, but the incidence of postoperative LUT was high in the ureteroscopy group. The mean hospital stay was 30 h in the ureteroscopy group. SWL was performed without the need for hospital admission.

CONCLUSION

Ureteroscopic laser lithotripsy for steinstrasse was safe and effective, with a higher success rate, shorter fluoroscopy time, and shorter recovery period than SWL.

Radiation exposure of patients during endourological procedures

PURPOSE

Considering the existing gaps in the literature regarding patient radiation dose (RD) and its associated risks, a systematic review of the literature on RD was conducted, focusing on percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy (SWL), and ureteroscopy (URS).

METHODS

Two authors conducted a literature search on PubMed, Web of Science, and Google Scholar to identify studies on RD during endourological procedures. Two thousand two hundred sixty-six articles were screened. Sixty-five publications met the inclusion criteria using the PRISMA standards.

RESULTS

RD was generally highest for PCNL, reaching levels up to 33 mSv, 28,700 mGycm2, and 430.8 mGy. This was followed by SWL, with RD reaching up to 7.32 mSv, 13,082 mGycm2, and 142 mGy. URS demonstrated lower RD, reaching up to 6.07 mSv, 8920 mGycm2, and 46.99 mGy. Surgeon experience and case load were inversely associated with RD. Strategies such as optimizing fluoroscopy settings, implementing ultrasound (US), and following the ALARA (As Low As Reasonably Achievable) principle minimized RD.

CONCLUSIONS

This is the first systematic review analyzing RD, which was generally highest during PCNL, followed by SWL and URS. There is no specific RD limit for these procedures. Implementation of strategies such as optimizing fluoroscopy settings, utilizing US, and adhering to the ALARA principle proved effective in reducing RD. However, further research is needed to explore the factors influencing RD, assess their impact on patient outcomes, and establish procedure-specific reference levels for RD.

Advancements in stone classification: unveiling the beauty of urolithiasis

PURPOSE

Urolithiasis has become increasingly prevalent, leading to higher disability-adjusted life years and deaths. Various stone classification systems have been developed to enhance the understanding of lithogenesis, aid urologists in treatment decisions, and predict recurrence risk. The aim of this manuscript is to provide an overview of different stone classification criteria.

METHODS

Two authors conducted a review of literature on studies relating to the classification of urolithiasis. A narrative synthesis for analysis of the studies was used.

RESULTS

Stones can be categorized based on anatomical position, size, medical imaging features, risk of recurrence, etiology, composition, and morphoconstitutional analysis. The first three mentioned offer a straightforward approach to stone classification, directly influencing treatment recommendations. With the routine use of CT imaging before treatment, precise details like anatomical location, stone dimensions, and Hounsfield Units can be easily determined, aiding treatment planning. In contrast, classifying stones based on risk of recurrence and etiology is more complex due to dependencies on multiple variables, including stone composition and morphology. A classification system based on morphoconstitutional analysis, which combines morphological stone appearance and chemical composition, has demonstrated its value. It allows for the rapid identification of crystalline phase principles, the detection of crystalline conversion processes, the determination of etiopathogenesis, the recognition of lithogenic processes, the assessment of crystal formation speed, related recurrence rates, and guidance for selecting appropriate treatment modalities.

CONCLUSIONS

Recognizing that no single classification system can comprehensively cover all aspects, the integration of all classification approaches is essential for tailoring urolithiasis patient-specific management.

Emergency treatment of symptomatic ureteral calculi: predictors of prolonged hospital stay

PURPOSE

To assess differences in the length of hospital stay (LOS) in patients who present emergently versus electively for a symptomatic ureteral stone and to explore underlying risk factors.

METHODS

Billing data were analyzed from patients with symptomatic ureteral calculi at our department from 2010 to 2021. Statistical analysis (U test, logistic regression) was performed.

RESULTS

2274 patients (72% male, 28% female) with ureteral stones were analyzed (mean age of 52.9y). 1578 patients (69.4%) presented in an emergency setting and 696 patients (30.6%) electively. Arterial hypertension was seen in 31%, diabetes mellitus in 11% and hyperuricemia in 5% of the whole cohort. 46.5% of emergency patients were desobstructed (DJ/PCN), 35.4% underwent emergency ureteroscopy (URS), 13.4% had spontaneous passage (SP), and 4.8% underwent emergency shock wave lithotripsy (SWL). Of the electively treated patients, 58.6% underwent URS, 21.3% SWL, 18.5% DJ/PCN, and 1.6% had SP. Emergency stone treatment was associated with a significantly longer LOS when compared to primary desobstruction for patients admitted emergently. Also, LOS was significantly longer for each intervention of stone treatment in emergency patients vs. electively treated patients. Arterial hypertension was associated with a 1.8-fold increased risk of a hospital stay longer than 3 days, irrespective of hospital admission mode, whereas metabolic disorders did not influence LOS in this cohort.

CONCLUSION

For emergency patients in contrast to the electively treated patients, the type of procedure had a significant impact on the length of hospital stay. Arterial hypertension is an independent significant risk factor for prolonged hospital stay.

Extracorporeal shock wave lithotripsy for treatment of large pediatric renal pelvic stone burden more than 2 cm

BACKGROUND

The high recurrence rates in pediatric urolithiasis indicate the need for none invasive or a minimally invasive treatment such as SWL. Therefore, EAU, ESPU and AUA recommend SWL as a first line treatment for renal calculi ≤ 2, and RIRS or PCNL for renal calculi > 2 cm. SWL is superior to RIRS and PCNL as it is inexpensive, outpatient procedure, and it has a high SFR in well selected cases specially pediatrics. On the other hand, SWL therapy has a limited efficacy with a lower SFR, and high retreatment rate and/or additional interventions for treatment of larger and harder renal calculi.

OBJECTIVE

We carried out this study to evaluate the efficacy and safety of SWL for treatment of renal stones > 2 cm to extend its indications for pediatric renal calculi.

METHODS

Between January 2016 and April 2022, we reviewed the records of patients with renal calculi treated by SWL, mini-PCNL, RIRS and open surgery in our institution. Forty-nine eligible children aged 1-5 years old, presented with renal pelvic and/or calyceal calculi measuring 2-3.9 cm and underwent SWL therapy were picked up and participated in the study. The data of an additional eligible 79 children with the same age and had renal pelvic and/or calyceal calculi > 2 cm up to stag horn calculi and underwent mini-PCNL, RIRS and open renal surgery were also picked up and participated in the study. We retrieved the following preoperative data from the records of the eligible patients; age, gender, weight, length, radiological findings (stone size, side, site, number and radio-density), renal function tests, routine laboratory findings, and urine analysis. The outcomes data in the form of; operative time, fluoroscopy time, hospital stay, SFRs, retreatment rates and complication rates were also retrieved from the records of patients treated with SWL and other techniques. Also, we collected the SWL characteristics in terms of; position, number and frequency of shocks, voltage, time of the session and U/S monitoring to assess stone fragmentation. All SWL procedures were performed according to the institution's standards.

RESULTS

The mean age of patients treated with SWL was 3.23 ± 1.19 years old, the mean size of the treated calculi was 2.31 ± 0.49 and the mean length of the SSD was 8.2 ± 1.4 cm. All patients had NCCT scan and the mean radio-density of the treated calculi was 572 ± 169.08 HUs based on NCCT scans Table (1). Single- and two-session SFRs of SWL therapy were 75.5% (37/49 patients) and 93.9% (46/49 patients), respectively. The overall success rate was 95.9% (47/49 patients) after three-session of SWL. Complications experienced by 7 patients (14.3%) in the form of fever (4.1%), vomiting (4.1%), abdominal pain (4/1%), and hematuria (2%). All complications were managed in outpatient settings. Our results were obtained on the basis of preoperative NCCT scans for all patients and postoperative plain KUB films and real-time abdominal U/S. Furthermore, single-session SFRs for SWL, mini-PCNL, RIRS and open surgery were 75.5%, 82.1%, 73.7% and 90.6%, respectively. Two-session SFRs by the same technique were 93.9%, 92.8%, and 89.5% for SWL, mini-PCNL and RIRS, respectively. A lower overall complication rate and higher overall SFR were found with SWL therapy compared to other techniques, Fig. (1).

DISCUSSION

Being a non-invasive outpatient procedure with a low complication rate and good spontaneous passage of stone fragments is the main advantage of SWL. In this study, the overall SFR is 93.9% where 46 out of 49 patients were completely rendered stone free after three session of SWL with overall success rate 95.9%. Badawy et al. reported overall success rates of 83.4% for renal stones with a mean stone size of 12.5 ± 7.2 mm. In children with renal stones measuring 18.2 mm, Ramakrishnan et al. reported a 97% SFR in accordance with our results. The high overall success rate (95.9%) and SFR (93.9%) in our research were attributed to the regular use of ramping procedure, low shock wave rate, percussion diuretics inversion (PDI) approach and alpha blocker therapy in all participants and short SSD. The limitations of our study are small sample of patients and its retrospective nature.

CONCLUSION

The non-invasive nature and replicability of the SWL procedure, along with the high success and low complication rates, give us a new insight to consider its application for treating pediatric renal calculi > 2 cm over the other more invasive techniques. Short SSD, the use of ramping procedure, low shock wave rate, 2 min break, PDI approach and alpha blockers therapy help better success of SWL.

LEVEL OF EVIDENCE

IV.

Worldwide trends of practice and intervention in paediatric endourology: comparison of European versus Non-European responses

Introduction

The area of paediatric endourology is unique and is recognised to be challenging, and it requires a certain level of focused training and expertise. Our aim was to conduct a worldwide survey in order to gain an overview regarding the current practice patterns for minimally invasive treatments of paediatric upper urinary tract stone patients.

Material and methods

The survey was distributed between December 2021 and April 2022 through urology sections and societies in United Kingdom, Latin America and Asia. The survey was made up of 20 questions and it was distributed online using the free online Google Forms (TM).

Results

221 urologists answered the survey with 56 responses each from India, South America and UK and 53 responses from the rest of Europe (15 countries). In total, 163 responders (73.7%) managed paediatric stone patients in their daily practice. Of the responders, 60.2% were adult urologists and 39.8% were paediatric urologists. 12.9% adult urologists and 20.4% paediatric urologists run independent clinics while some run combined adult and paediatric clinics sometimes with the support of the nephrologists. Only 33.9% urologists offered all surgical treatments [extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)].

Conclusions

Treatment of paediatric stones can vary according to country and legislations. Based on the results of this survey, minimally invasive methods such as URS and mini PCNL seem to have become more popular. In most institutions a collaboration exists between adult and paediatric urologists, which is the key for a tailored decision making, counselling and treatment success.

The effect of bioelectric impedance analysis on the success of extracorporeal shock wave lithotripsy

Bioelectric impedance analysis (BIA) is a non-invasive method that can show the distribution of fatty and lean mass of the body. In this study, we aimed to determine the effect of BIA on extracorporeal shock wave lithotripsy (SWL) success. Our secondary aim was to determine the factors predicting transition from a single SWL session to multiple sessions. Patients who underwent SWL due to kidney stones were prospectively included. Demographics, pre-procedural BIA parameters (fat percentage, obesity degree, muscle mass, total water and metabolic rate), stone parameters, and number of SWL sessions were recorded. Univariate and multivariate regression analyzes were made to determine independent risk factors for success. Then, the successful group was divided into two subgroups according to their SWL session number as one session or multiple sessions and multivariate regression analysis was made to determine independent risk factors. Stone-free status was achieved in 114 (61.2%) of 186 patients. Stone Hounsfield Unit (HU) (OR: 0.998, p = 0.004), stone volume (OR: 0.999, p = 0.023) and fat percentage (OR: 0.933, p = 0.001) were independent risk factors for stone-free status in multivariate analysis. HU value of the stone (OR: 1.003, p = 0.005) and age (OR: 1.032, p = 0.031) were determined as independent risk factors for transition to multiple sessions in the subgroup analysis of the successful group. Fat percentage, stone volume, and stone density were determined as factors affecting success in SWL. Routine use of BIA may be considered to predict success before SWL. The probability of SWL success in a single session decreases as the age and stone's HU value increase.

High-frequency shock wave lithotripsy: stone comminution and evaluation of renal parenchyma injury in a porcine ex-vivo model

BACKGROUND

The electrohydraulic high-frequency shock wave (Storz Medical, Taegerwilen, Switzerland) is a new way to create small fragments with frequencies up to 100 Hertz (Hz). This study evaluated the efficacy and safety of this method in a stone and porcine model.

MATERIALS AND METHODS

BEGO stones were put in a condom in a specifically designed fixture treated with different modulations to see stone comminution. Standardized ex vivo porcine model with perfused kidneys with 26 upper and lower poles of 15 kidneys was treated with the following modulations: voltage 16-24 kV, capacitor 12 nF and frequency up to 100 Hz. 2000-20,000 shock waves were applied to each pole. The kidneys were perfused with barium sulfate solution (BaSO4) and x-ray was performed to quantify the lesions using pixel volumetry.

RESULTS

There was no correlation between the number of shock waves and the powdering degree or the applied Energy and the grade of pulverization in the stone model. Regarding the perfused kidney model, the number of shock waves, applied voltage and frequency had no direct correlation with the occurrence of parenchymal lesions The detected lesions of the renal parenchyma were minimal, technical parameters had no significant impact and the lesions did not differ from the results of former experiments using 1-1.5 Hz in the same model.

CONCLUSIONS

High-frequency shock wave lithotripsy can produce small stone fragments to pass in a very short time. The injury to the renal parenchyma is comparable to the results of the conventional SWL using 1-1.5 Hz.

Shockwave Lithotripsy for De-Novo Urolithiasis after Kidney Transplantation: A Systematic Review of the Literature

BACKGROUND

Allograft urolithiasis is an uncommon, challenging, and potentially dangerous clinical problem. Treatment of allograft stones includes external shockwave lithotripsy (SWL), flexible ureteroscopy and lasertripsy (fURSL), or percutaneous nephrolithotomy (PCNL). A gap in the literature and guidelines exists regarding the treatment of patients in this setting. The aim of this systematic review was to collect preoperative and treatment characteristics and evaluate the outcomes of post-transplant SWL for stone disease.

METHODS

A systematic search in the literature was performed, including articles up to March 2023. Only original English articles were selected.

RESULTS

Eight articles (81 patients) were included in the review. Patients were mainly male, with a mean age of 41.9 years (±7.07). The mean stone size was 13.18 mm (±2.28 mm). Stones were predominantly located in the kidney (n = 18, 62%). The overall stone-free rate and complication rates were 81% (range: 50-100%) and 17.2% (14/81), respectively, with only one major complication reported. A pre-operative drainage was placed in eleven (13.5%) patients. Five patients (6.71%) required a second treatment for residual fragments.

CONCLUSIONS

SWL is a safe and effective option to treat de novo stones after transplantation. Larger studies are needed to better address allograft urolithiasis management.

Outcomes of Paediatric Cystine Stone Management: Results of a Systematic Review

PURPOSE OF REVIEW

We wanted to analyse the outcomes of surgical (SWL, URS, PCNL) and medical management of cystine stones in the paediatric population in terms of stone-free status and complication rates, based on all the available literature evidence.

RECENT FINDINGS

A systematic review of literature was performed for all studies with paediatric cystine stone management. Twelve studies met the eligibility criteria, of which 4 analysed outcomes of SWL, 2 of URS and 3 of PCNL and 3 focused on the effect of either alkalising agents (potassium citrate, citric acid) or cysteine-binding thiol (CBT) agents (tiopronin, penicillamine). The reported SFR in studies ranged from 50 to 83%, 59 to 100% and 63 to 80.6%, with a complication rate of 2.8-51%, 14-27% and 12.9-15.4% with SWL, URS and PCNL, respectively. Paediatric cystine stones treatment should aim at complete stone clearance, preservation of renal function and prevention of further recurrences. SWL achieves inferior results in case of cystine stones. URS and PCNL are safe and effective procedures in the paediatric population, with a low rate of major complications. Adherence to medical prevention therapies may prolong recurrence-free periods.

Outcomes of alpha-blockers as medical expulsive therapy following shockwave lithotripsy: a systematic review and meta-analysis

OBJECTIVES

To determine stone-free rate following shockwave lithotripsy (SWL) with/without alpha-blockers as well as complication rates (individual and classified using the Clavien-Dindo system).

MATERIALS AND METHODS

We performed a systematic review of all randomized controlled trials that included more than 20 patients (age > 18 years) and examined the use of alpha-blockers after SWL. Meta-analysis was performed using 'metafor' in R. We report risk ratios (RRs) with 95% confidence intervals (95% CIs). The PROSPERO ID for the trial was: CRD42021248108.

RESULTS

We assessed 158 full-text articles and included a total of 21 studies in our review. There were 1445 patients receiving alpha-blockers and 1478 control patients. Those receiving alpha-blockers were significantly more likely to be stone-free (RR 1.12, 95% CI 1.07-1.16; P < 0.001). This effect was robust to 'trim-and-fill' adjustment. In those taking alpha-blockers there was a significant reduction in Clavien III-V complications and, on trim-and-fill adjustment, a significant reduction in Clavien I-II complications. There were also significant reduction in rates of steinstrasse, pain and requirement for auxiliary procedures. There was no significant difference in retreatment rates. These effects were robust to trim-and-fill adjustment.

CONCLUSIONS

There is a modest increase in stone-free rates in those receiving alpha-blockers following SWL, with a reciprocal modest risk reduction for steinstrasse, pain and auxiliary procedures. However, alpha-blockers do not reduce the risk of requiring retreatment.

Flexible Ureterorenoscopy Versus Shockwave Lithotripsy for Kidney Stones ≤2 cm: A Randomized Controlled Trial

BACKGROUND

No clear recommendations are available on whether retrograde intrarenal surgery (RIRS) via flexible ureterorenoscopy or shockwave lithotripsy (SWL) should be preferred for kidney stones ≤2 cm, except for lower-pole stones.

OBJECTIVE

To compare outcomes between RIRS and SWL.

DESIGN, SETTING, AND PARTICIPANTS

This was a single-center randomized controlled trial from March 2015 to May 2018. Patients with a single 6-20-mm kidney stone were enrolled (NCT02645058).

INTERVENTION

Patients were randomized to RIRS or SWL.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the single-procedure stone-free rate (SFR) at 1 mo. Two levels of success were set: fragments ≤4 mm (SFR-4) and no residual fragments (SFR-0). Secondary endpoints were the SFR at 6 mo and 1 yr and rates of complications and further treatments.

RESULTS AND LIMITATIONS

A total of 138 patients underwent treatment (70 RIRS vs 68 SWL). In comparison to SWL, RIRS SFR results were higher at 1 mo (SFR-4 70.0% vs 45.6%; p = 0.004; SFR-0 50.0% vs 26.5%; p = 0.004) and 6 mo (SFR-4 79.7% vs 63.6%; p = 0.038; SFR-0 59.4% vs 40.9%; p = 0.032). There was no difference in SFR measures between the groups at 1 yr (SFR-4 p = 0.322; SFR-0 p = 0.392). Overall complications were comparable (p = 0.207), but the complication rate for stones >10 mm was higher for the SWL group (p = 0.021). The need for further treatment was comparable (p = 0.368). In terms of patient satisfaction, 86.8% and 77.1% of patients would choose SWL and RIRS again, respectively (p = 0.24).

CONCLUSIONS

RIRS achieved better SFRs in comparison to SWL at 1 and 6 mo, but not at 1 yr. The RIRS complication rate was lower for stones >10 mm. SWL remains a viable alternative, especially for 6-10-mm stones, providing comparable results to RIRS in the long term.

PATIENT SUMMARY

We compared outcomes for the treatment of kidney stones ≤2 cm with two techniques: flexible ureteroscopy, in which a flexible telescope is passed through the urethra and bladder to reach the ureter between the bladder and kidney; and shockwave lithotripsy, in which shockwaves are applied to the skin over the location of the kidney stone. Ureteroscopy achieved better stone-free results at 1 and 6 months, but not at 1 year.

Design, synthesis, and in vivo evaluation of GO-SWL-Ahx-K-SWL

In order to acquire both expanded binding ability with the EphA2 receptor and superior drug delivery capacity, we designed and synthesized the modified GO-SWL-Ahx-K-SWL conjugate as a potential targeted therapeutic drug for non-small cell lung cancer (NSCLC). Various characterization methods have confirmed that the conjugate is consistent with the theoretical peptide. The cytotoxicity test results showed that the conjugate was slightly more toxic to A549 cells than in 3 T3 cells, and the toxicity increased in a concentration-dependent manner. Single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging was performed to evaluate the conjugate binding to EphA2 receptor in vivo. The images showed obvious radioactive concentration in tumor tissues and significantly higher ratios of the tumor and muscle in the ¹²⁵I-GO-SWL-Ahx-K-SWL group (10.78) than in the ¹²⁵I-SWL-Ahx-K-SWL group (5.21) at all three time points (P < 0.01).

[Follow-up after urolithiasis management]

BACKGROUND

Urinary stones often affect younger people. Because the risk of recurrence is high, regular follow-up is important for individuals at risk.

OBJECTIVE

To summarize the extent of urinary stones and the health and economic impact in the population; to provide recommendations for general and stone-specific follow-up.

MATERIALS AND METHODS

Analysis and discussion of publications and guideline recommendations.

RESULTS

The risk of recurrence after a stone attack can be high depending on the risk profile. An initial metabolic workup should be performed promptly after stone therapy. General dietary management should be intensified by stone-specific dietary management depending on the risk profile. Nutritional counseling may be helpful. Imaging after stone therapy is used to monitor the success of treatment and detect recurrences early. Since the risk of recurrence can vary greatly depending on the stone composition, not only the type of imaging but also its frequency should be adjusted accordingly. The same applies to the various stone therapies, which help determine the frequency and type of imaging follow-up. Exact guidelines and cost-effectiveness analyses of follow-up examinations after stone therapy are unfortunately missing.

CONCLUSIONS

Acute urolithiasis represents an excruciating experience for patients. Accordingly, their willingness to undergo metaphylaxis and follow-up shortly after the event is strong. Since the risk of recurrence after a stone attack can be very high, regular follow-up after stone therapy is essential. The frequency of follow-up should be adapted to the probability of stone recurrence.

No-show after extracorporeal shock wave lithotripsy treatment in endourology clinic: Can we build a typical patient profile?

Objectives

Patients “no‐show” in outpatient clinics is a worldwide challenge. Healthcare providers and patients suffer from negative impacts that include increased expenditure, clinical management ineffectiveness, and decreased access to care. This study aims to evaluate no‐show rate among extracorporeal shock wave lithotripsy patients visiting endourology clinic and to identify the demographic and clinical predictors of no‐show.

Methods

A cross‐sectional and historical cohort study using electronic medical records. We included 790 patients aged >18 years old referred for endourology clinic following shock wave lithotripsy during 2010–2017 at Hadassah Medical Center in Israel. We predicted no‐show rate following shock wave lithotripsy by various patient characteristics by a multivariate logistic regression model.

Results

Overall, 291 (36.8%) patients did not arrive for postoperative clinic. Of these, 91 (11.52%) patients referred to Emergency Department. Patients who were younger in age (odds ratio 1.49, 95% confidence interval 1.08–2.04), patients who underwent hospitalization ≥3 days (odds ratio 1.63, 95% confidence interval 1.11–2.41) and patients who had undergone a stent‐free shock wave lithotripsy (odds ratio 5.71, 95% confidence interval 2.40–13.57) were significantly associated with higher no‐show rate. Larger stone size was associated with reduction in no‐show rate with every millimeter increase of stone diameter was associated with a reduction of 6.1% probability for no‐show (odds ratio 0.94, 95% confidence interval 0.89–0.99).

Conclusions

Predicting patients' characteristics and no‐show patterns is necessary to improve clinical management efficiency, access to care, and costs. We showed that patients who were younger, patients who underwent stent‐free shock wave lithotripsy, patients who had a smaller stone, and patients who underwent a longer hospitalization were more prone to miss their appointment. Paying attention to the characteristics of individual patients may assist in implementing intervening program of patient scheduling.

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.

Percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy for renal insufficiency

OBJECTIVE

To assess the effect and outcome of percutaneous nephrolithotomy (PNL) versus extracorporeal shock wave lithotripsy (SWL) in patients with renal insufficiency.

PATIENTS AND METHODS

A prospective randomized clinical study of 104 renal insufficiency patients with renal stones (serum creatinine 2-4 mg/dl and eGFR < 60 ml/min/1.73 m² more than 3 months) randomized into two groups: Group A underwent PNL; Group B underwent shock wave lithotripsy (SWL). Treatment effects and outcomes compared between the two groups.

RESULTS

Between Group A of 50 patients and Group B of 54 cases, demographic data showed no statistically significant differences. The stone-free rate was 84% in Group A versus 26.6% in Group B after the first SWL session. After completion of all SWL sessions, the rate was 88.9% for Group B. Comparing pre and postoperative results of Group A, there is significant improvement of serum creatinine concentrations by 9.1% (p = 0.001), significant improvement of creatinine clearance (p = 0.000) and eGFR (p = 0.003). Although regarding Group B preoperatively and 3 months after SWL there is significant improvement by 8.7% (p = 0.0001), which is less than that of Group A, there is also, improvement of eGFR by 6.7% (p = 0.001), which is less than the eGFR improvement in Group A (12.3%). But there is no statistically significant difference is noted for creatinine clearance in Group B (p = 0.09).

CONCLUSION

The outcomes for PNL and SWL in patients with renal insufficiency and renal stones are encouraging as minimally invasive procedures with no negative effects on kidney function.

Minimally Invasive Surgery for the Treatment of Ureteric Stones - State-of-the-Art Review

The landscape of managing ureteric stones has evolved over the last few decades and several treatment options exist depending on the stone size, location, and other patient and stone factors. While open surgery is now rarely performed, the use of medical expulsive therapy (MET) has been controversial and perhaps only recommended for large distal ureteric stones. The mainstay treatment balances between shockwave lithotripsy (SWL) and ureteroscopy (URS), with the latter usually recommended for larger stones. While the principles of ureteric stone management have remained largely unchanged, the modern era has generated new methods and means to deliver it. Advancements have occurred in all domains of endourology to try and refine treatment and balance it with cost, patient choice and quality of life. Dissemination of technologies and demonstration of their efficacy and safety will eventually result in new recommendations among international guidelines and evolution of new gold standards.

Contralateral Coupling During Extracorporeal Shockwave Lithotripsy for Stones in Ectopic Kidney: Is It Feasible?

Purpose: Extracorporeal shockwave lithotripsy (SWL) results in a lower stone-free rate (SFR) for ectopic kidneys when using the standard technique, directing the shock wave from the same side of the stone; however, this may not be the optimal approach when the ectopic kidney is located more medial and anterior than the normally positioned kidney. Thus, contralateral coupling where waves come from the opposite direction may result in a better outcome. We tested the feasibility and outcome of contralateral coupling during SWL for stone in ectopic kidney. Materials and Methods: We prospectively recruited 20 patients with simple renal ectopia, who presented with renal stones that were amenable for SWL in the period between 2014 and 2018 at outpatient clinic of urology department, Minia University. Patients received SWL in Private Nile SWL Center were included to benefit from the ability of the electromagnetic SWL lithotripter. We did SWL in a supine position, and then contralateral coupling was performed from the opposite side of the affected kidney, rather than using the standard ipsilateral coupling approach. The SFR and various pre-, intra-, and postprocedural SWL variables were assessed, including stone characteristics, body habitus, shock wave numbers, and auxiliary measures. Count and percentages were calculated. Results: The mean stone radius was 14.7 mm with a mean S.T.O.N.E. (size, topography, obstructions, number of stones, and evaluation of HUs) of 9.6 points. Effective SWL was achieved in 80% of cases, 65% of them were stone free with effective single SWL session in 56% of cases. Hematuria, infection, and obstruction occurred in 50%, 20%, and 15% cases, respectively. One case required ureteral stent insertion. Conclusions: SWL applied through contralateral coupling is feasible, with comparable safety profile to the standard ipsilateral approach. Better SFR was achieved with the contralateral approach, in fewer sessions. However, the recruitment of more cases is necessary.

Value of early second session shock wave lithotripsy in treatment of upper ureteric stones compared to laser ureteroscopy

PURPOSE

The safety and efficacy of early second session shock wave lithotripsy (SWL) compared with laser ureteroscopy (URS) for the treatment of upper ureteric stones were evaluated.

METHODS

From January to October 2019, 108 patients with upper ureteric stones (< 1.5 cm and ≤ 1000 Hounsfield unit (HU)) were randomized into SWL and laser URS groups. The second SWL session was performed within 48-72 h of the first session. Using plain abdominal X-ray and ultrasonography, patients were evaluated 48-72 h after the first SWL session and one week after the second and third SWL sessions or one week after URS. The procedure was considered a success when no additional procedures were needed to clear the stone. To determine the stone-free rate (SFR), noncontrast computed tomography of the urinary tract was performed three months postoperatively.

RESULTS

In the SWL group, the success rates were 92.6% and 94.4% after the second and third sessions. The SFR was 96.2% in the laser URS group. The success rates were not significantly different between the second and third SWL sessions versus the laser URS (p = 0.418 and 0.660, respectively). Operative and fluoroscopy times were significantly longer in the SWL group (p = 0.001), and JJ stent insertions were needed after laser URS.

CONCLUSION

Ultraslow full-power SWL treatment of patients with upper ureteric stones (< 1.5 cm and ≤ 1000 HU) with an early second session is safe and effective compared to laser URS. Patients who do not respond to early second SWL session should be shifted to another treatment modality.

Immediate Shockwave Lithotripsy vs Delayed Shockwave Lithotripsy After Urgent Ureteral Stenting in Patients with Ureteral or Pyeloureteral Urolithiasis: A Matched-Pair Analysis

Introduction: The most common cause of acute renal colic is a ureteral obstruction caused by ureterolithiasis. Urgent intervention is often necessary due to intractable pain. Early extracorporeal shockwave lithotripsy (SWL) as an alternative treatment option to ureteral stenting becomes forgotten in times of rising ureterorenoscopy. However, definitive guidelines are lacking, in which urgent treatment should be preferred in the absence of signs of infection. Therefore, we assessed efficacy and safety of early SWL (eSWL) to secondary SWL (sSWL) after urgent ureteral stenting. Patients and Methods: One hundred four patients treated between January 2015 and November 2017 for obstructive ureterolithiasis were matched regarding stone size, stone localization, and assigned to group eSWL (n = 52) or group sSWL (n = 52). The eSWL group received shock waves (without prior ureteral stenting) and sSWL group ureteral stenting within 48 hours from diagnosis. Thereafter, patients in group sSWL were treated with shock waves for a median of 23 ± 14.6 days after ureteral stenting. Stone-free rates, complication rates, and reintervention rates were assessed. Univariable and multivariable logistic regression was applied to find predictors of outcomes in the two treatment groups. Results: Overall, there was no statistically significant difference between both groups regarding stone-free rate and complication rate. Reinterventions were more often addressed for patients in group sSWL (p = 0.05). eSWL was significantly superior to sSWL regarding stone-free rates for stones between 6 and 9 mm (p = 0.04). At the multivariable multinomial logistic regression none of the two treatment modalities was associated with better outcomes. A body mass index ≥30 was associated with a reduced 6-week stone-free status (p = 0.04), whereas stones ≥8 mm were associated with an increased need of reintervention (p = 0.04). Conclusion: eSWL seems to be an effective and safe emergency procedure compared with sSWL after urgent stenting within 6 weeks and should be considered as a treatment option in patients without absolute indications for immediate ureteral drainage. Clinical trial registration number: 2019-00155.

Comparison of the Effects of Four Treatment Techniques Commonly Used in Ureteral Stone Treatment on Patients' Daily Physical Functioning: An Observational Randomized-Controlled Study

Objective: To investigate the effect of four different techniques used in the treatment of ureteral stones on patients' daily physical functioning (PF) and quality of life (QoL). Materials and Methods: Patients who underwent ureterorenoscopy (URS)-with or without Double-J stenting (DJS)-and extracorporeal shock wave lithotripsy (SWL) were divided into four groups: Group I: SWL (n = 29), Group II: URS (n = 43), Group III: URS +4.8F DJS (n = 39), Group IV: URS +6F DJS (n = 42), and Group V: Control (n = 30). Short Form-36 (SF-36) was administered to each participant both preoperatively and 14 days after operation. Based on the SF-36 results, the changes in patients' PF and QoL were evaluated. Results: Ureteral stone treatment was performed in 202 patients. Of these, 153 patients who underwent an effective SWL or URS procedure in the first attempt were included in the study. Success rates in the first session were 53.7% (29/54) and 83.8% (124/148) for SWL and URS, respectively (p < 0.001). All the four groups were similar with regard to age, gender, body mass index, stone size, preoperative PF, and QoL. However, although postoperative PF, role limitations due to physical health, and energy/fatigue scores were similar in Group I, III, and IV, they were significantly higher in Group II. No major complication associated with SWL or URS occurred in any patient. However, in Group 2, DJS was inserted in three (7.7%) patients in the early postoperative period (within the first 48 hours) due to renal colic attacks secondary to ureterovesical junction mucosal edema. Conclusion: URS without DJS seems to be the most advantageous technique in the treatment of ureteral stones in terms of daily PF and QoL. However, it should be noted that patients undergoing URS may require postoperative emergency stenting, although rarely.

Management of Migrated or Residual Stones Following Laparoscopic Pyelolithotomy and Ureterolithotomy in Abnormal Kidneys: A Prospective and Randomized Comparison

Objective: To conduct a prospective and randomized controlled trial comparing contemporaneous transabdominal rigid ureteroscopy (TRU) with postoperative extracorporeal shockwave lithotripsy (SWL) in the management of migrated or residual stones during laparoscopic pyelolithotomy and ureterolithotomy in kidneys with either intrinsic or extrinsic abnormalities. Materials and Methods: From February 2016 to December 2019, 45 patients with migrated or residual stones following laparoscopic pyelolithotomy and ureterolithotomy were accrued and randomly divided into two groups. These patients all had either urinary tract obstruction distal to the stone or concomitant ipsilateral intrinsic or extrinsic pathology requiring laparoscopic intervention. Twenty-three patients underwent contemporaneous TRU, and 22 patients underwent postoperative SWL. Patients' demographics, perioperative variables, and follow-up data were collected. The primary outcome was the final stone-free rate (SFR) at the 2-month follow-up. Secondary outcomes included blood loss, operative time, change in serum creatinine, complications per Clavien-Dindo grading system, renal colic occurrence rate (RCOR), and postoperative hospitalization. Results: There was no significant difference in gender, age, body mass index, location, or stone burden between the two groups (p > 0.05). At the 2-month follow-ups, the SFR was higher in the TRU than the SWL group (p = 0.002), and the RCOR was lower in the TRU than the SWL group (p = 0.005). Postoperative hospitalization was also shorter for the TRU group. No significant difference was noted in the operative time, blood loss, change in serum creatinine, or perioperative complications (p > 0.05). Conclusion: Contemporaneous TRU is more effective and equally safe compared to postoperative SWL in the management of residual or migrated stones during laparoscopic pyelolithotomy and ureterolithotomy in kidneys with either intrinsic or extrinsic abnormalities.

[Strategies and recommendations for urolithiasis treatment and follow-up in COVID-19 pandemia.]

The health crisis caused by COVID-19 pandemic has led to a restructuring of urological activity in order not to delay priority situations. An important part to prioritize within Urologyis Urolithiasis. The objective of this article is to establish strategies and recommendations for the treatment and follow-up in COVID-19 pandemic in phases I, II and III, based on available scientific evidence and the consensus of a group of experts in these pathologies. MATERIAL AND METHODS: The document is based on the evidence available in the literature so far on SARSCoV-2 and the experience of the authors in the management of COVID-19 in their institutions. A narrative review of the literature was conducted, and a modified nominal group technique was used due to the extraordinary restrictions of assembly and mobility during the pandemic. RESULTS: Recommendations are made regarding the epidemiological evaluation of patients before surgery ,the management of positive patients, the epidemiological measures for healthcare personnel, the management of renal colic, the type of anesthesia, endourological surgery, shockwave lithotripsy, hospitalization, clinicalt ests, out-patient service and priorities on the surgical waiting list. CONCLUSION: Treatment of Urolithiasis in COVID-19 pandemic calls for prioritization of patients, maximum efficiency in treatments, adequate protection of healthcare personnel, and the implementation of telemedicine as a measure to reduce patient attendance to the hospital.

Anterior or posterior SWL in proximal ureteral stones opposite to 4th and 5th lumbar vertebrae?

BACKGROUND

Results of SWL in treatment of upper ureteral calculi are conflicting which is definitely affected by stone locations along the proximal ureter, which is may be due to the more deep and medial course of the ureter distally over the thick and strong abdominal back wall which may hinder shock waves.

METHODOLOGY

One hundred patients with radiopaque proximal ureteral stone opposite 4th and 5th lumbar vertebrae who had SWL were randomized into two groups. First group had SWL through anterior belly wall in supine position with countertraction, the second group had standard posterior SWL. Patient's demographics and stone characters were evaluated assessing stone burden and calculating S.T.O.N.E score. Patients were followed up to assess stone-free rate using serial digital plain X-ray KUB.

RESULTS

Anterior approach needed less power to reach SFR (p = 0.05) in less number of sessions where 90% of cases in anterior group had only one session to reach SFR versus 52% in posterior group (p = 0.001). Also, post-SWL pain, hematuria, obstruction and infection were significantly less in anterior group (p = 0.005). Although patients who had anterior approach showed statistically significant shorter time to stone expulsion. SFR does not differed significantly between study groups (p = 0.02). On further analysis; anterior SWL had a better chance to reach SFR (HR = 1.6, p = 0.001).

CONCLUSION

It seems that anterior SWL approach in supine position is safe and effective especially in mild obese patient with floppy abdomen. Patients who had anterior SWL approach had a better chance to achieve stone-free rate.

Health questionnaire analysis and development of satisfaction questionnaire for patients treated with extracorporeal shock wave lithotripsy (SATISLIT)

INTRODUCTION

Due to the absence of specific instruments to study the psychosocial sphere of patients undergoing extracorporeal shock wave lithotripsy (SWL), the objective of this study is to develop a satisfaction questionnaire regarding the SWL treatment from a health questionnaire which was already designed and had been previously validated.

MATERIAL AND METHODS

The design of the satisfaction questionnaire was carried out in 5 phases, based on a previously validated health scale in patients treated with SWL (ESPTL), including a total cohort of 135 patients treated at our center who received a phone interview. Phase 1: descriptive analysis of the series and scores of the 8 items of ESPTL. Phase 2: U-Mann Whitney comparison of ESPTL based on the patients' sex. Phase 3: study of ESPTL correlation with age using Spearman's Rho. Phase 4: grouping by factors of ESPTL, comparison by sex and correlation with age, as performed in phases 2 and 3 with the global score. Phase 5: obtaining the satisfaction subscale -SATISLIT-, descriptive analysis, comparison according to sex, correlation with age and linear regression model of SATISLIT with respect to ESPTL.

RESULTS

135 patients, 85(63%) men, 50(37%) women. Median (minimum-maximum) age 56 (27-79) and ESPTL score 31 (8-39). Differences in global ESPTL score between men and women (p <.001), as well as in items 1 (p =.029), 3 (p =.002), 6 (p =.006), 7 (p =.005) and 8 (p =.025). Non-significant correlation of ESPTL regarding age. Significant correlation in items 2, 4, 5 and 8 but, very weak (<0.2). 4 factors, each one with 2 items, with statistically significant differences regarding sex in F2 (p =.001), F3 (p =.007) and F4 (p =.001). Significant correlation with age only in F1 and F3, but very weak (<0.2). Median (minimum-maximum) SATISLIT 18 (4-20). Statistically significant differences regarding patients' sex (p =.001). Non- significant correlation with age (p =.836). Significant linear regression of SATISLIT with respect to ESPTL (p <.001).

CONCLUSIONS

Based on validated health questionnaire, the present work has provided a new instrument called SATISLIT for assessing patients' satisfaction after treatment with SWL. Future studies with external and temporal validation will be necessary to contrast its real clinical usefulness.

The effect of focus size and intensity on stone fragmentation in SWL on a piezoelectric lithotripter

Purpose

We aim to analyze the efficacy of different focus sizes and the influence of pulse pressure (intensity) during shock wave lithotripsy (SWL) in terms of stone fragmentation.

Methods

Combination of three focal sizes (F1 = 2 mm, F2 = 4 mm, F3 = 8 mm) and 11 output pressure settings (intensity 10–20) of a piezoelectric lithotripter (Wolf PiezoLith 3000) were tested on artificial stones (n = 99). The stones were placed within a 2 mm mesh cage. The needed number of shockwaves (SW) to first visible crack, 50% and 100% stone disintegration were recorded.

Results

Similar number of SW’s were observed until the first crack 10, 11 and 11 SW’s for F1, F2, and F3, respectively (p > 0,05). The median number of SW needed for 50% stone disintegration was 245 for F1 group, 242 for F2 group and 656 for F3 group. F1 vs F2 p = 0.7, F1 vs F3 and F2 vs F3 p < 0.05. Similarly, with larger focus size a higher number of shockwaves were necessary for 100% stone disintegration. 894, 877 and 1708 SW’s for F1, F2 and F3, respectively. Only for F1 vs F3 and F2 vs F3 (all p < 0.05) a statistical difference was observed. These findings were consistent in all different power settings, with an increased difference in lower power levels (≤ 14).

Conclusions

A smaller focus size, as well as a higher peak pressure results in a more effective stone fragmentation. However, these results need to be confirmed in an in vivo setting with multiple parameters interfering the efficacy, like BMI, respiration or stone migration.

Does the presence or degree of hydronephrosis affect the stone disintegration efficacy of extracorporeal shock wave lithotripsy? A systematic review and meta-analysis

The aim of this study was to determine whether the presence or degree of hydronephrosis (HN) affects the stone disintegration efficacy of shock wave lithotripsy (SWL). A comprehensive literature search using PubMed, Embase, Cochrane Library, and Web of Science was conducted to retrieve relevant studies. Risk ratios (RRs) and mean differences (MDs) with corresponding 95% confidence intervals (CIs) were calculated for comparisons of outcomes of interest. In total, seven comparative studies with 2033 patients were included. Overall results indicated no significant difference in stone-free rate (SFR) and retreatment rate between two groups. Subgroup analysis further revealed: (1) compared with moderate or severe HN, non-HN SWL brought significantly lower retreatment rate (RR 0.67, 95%CI 0.52-0.87, P = 0.002 and RR 0.55, 95%CI: 0.40-0.76, P = 0.0003, respectively) and shorter clearance time (MD - 3.80, 95%CI - 5.81 to - 1.79, P = 0.0002 and MD - 5.93, 95%CI - 10.29 to - 1.57, P = 0.008, respectively); (2) SWLs performed without stone-induced HN or with artificial HN were associated with significantly higher SFR (RR 1.11, 95%CI 1.04-1.18, P = 0.001 and RR 0.93, 95%CI 0.87-0.99, P = 0.02, respectively); (3) non-HN SWL brought significantly higher SFR than HN group when treating proximal ureteral stones (RR 1.14, 95%CI 1.04-1.24, P = 0.005). Generally, SWLs performed with HN were shown to offer similar stone disintegration efficacy to those without HN. However, it seemed preferable to perform SWL: (1) without severe to moderate HN or stone-induced HN; (2) with artificial HN; (3) without HN when treating proximal ureteral stones.

Endourologic Management (PCNL, URS, SWL) of Stones in Solitary Kidney: A Systematic Review from European Association of Urologists Young Academic Urologists and Uro-Technology Groups

Introduction: Urolithiasis in solitary kidney (SK) presents significant management dilemma as any insult to the kidney or its drainage can lead to significant morbidity. The treatment options include shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS). Our aim was to conduct a systematic review of literature on all available endourologic techniques reporting on the management of stones in an SK. Materials and Methods: We conducted a systematic review according to the Cochrane and PRISMA checklist for all English-language articles from inception to December 2018. All studies with a minimum of 10 patients that reported on endourologic management (SWL, PCNL, or URS) were included. Data were extracted for patient and stone demographics, outcomes including stone-free rate (SFR), adverse events, and renal function. Results: After an initial search of 553 articles, 27 were included for the final review (10 PCNL, 1 mini-PCNL, 9 URS, 1 SWL, and 6 comparative studies). The choice of treatment seemed to be based on stone size, with PCNL, URS, and SWL offered for mean stone sizes between 25-50, 10-28, and 12-15 mm, respectively. PCNL, URS, and SWL were reported in 1445, 792, and 186 patients, respectively, with a final SFR of 67%-97.7%, 43%-100%, and 73%-80% and a complication rate of 26.4%, 15%, and 16.7% across the three groups. The renal function deterioration was reported in 4/16 PCNL studies and in 1/15 URS studies, while it remained unaffected in the SWL study. Conclusions: Our review shows a rise of endourologic techniques in the management of stones in SK. Although PCNL was used for larger stones, it had a higher risk of major complications, including blood transfusion. While a good SFR was obtained for patients irrespective of the treatment modality, the selected intervention needs to be balanced with its safety profile and the need for ancillary procedures.

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease

PURPOSE

Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery.

MATERIALS AND METHODS

A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery.

RESULTS

Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression.

CONCLUSIONS

Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.

Pinpointed Stimulation of EphA2 Receptors via DNA-Templated Oligovalence

DNA nanostructures enable the attachment of functional molecules to nearly any unique location on their underlying structure. Due to their single-base-pair structural resolution, several ligands can be spatially arranged and closely controlled according to the geometry of their desired target, resulting in optimized binding and/or signaling interactions. Here, the efficacy of SWL, an ephrin-mimicking peptide that binds specifically to EphrinA2 (EphA2) receptors, increased by presenting up to three of these peptides on small DNA nanostructures in an oligovalent manner. Ephrin signaling pathways play crucial roles in tumor development and progression. Moreover, Eph receptors are potential targets in cancer diagnosis and treatment. Here, the quantitative impact of SWL valency on binding, phosphorylation (key player for activation) and phenotype regulation in EphA2-expressing prostate cancer cells was demonstrated. EphA2 phosphorylation was significantly increased by DNA trimers carrying three SWL peptides compared to monovalent SWL. In comparison to one of EphA2’s natural ligands ephrin-A1, which is known to bind promiscuously to multiple receptors, pinpointed targeting of EphA2 by oligovalent DNA-SWL constructs showed enhanced cell retraction. Overall, we show that DNA scaffolds can increase the potency of weak signaling peptides through oligovalent presentation and serve as potential tools for examination of complex signaling pathways.

SWL outcome in artificial hydronephrotic vs. non-hydronephrotic kidney for preschool children with high-density renal stones

OBJECTIVE

To assess the effect of artificial hydronephrosis on the result of shock wave lithotripsy (SWL) in preschool children.

MATERIALS AND METHODS

A prospective randomized trial was performed between January 2013 and January 2017 with 300 pediatric patients, having kidney stones with a size of 1-2 cm and a density of 750-1100 HU. The patients were randomized into two groups: group A, in which a ureteric catheter was fixed and artificial hydronephrosis was performed by fluid irrigation prior to SWL, and group B which did not undergo hydronephrosis. SWL outcomes were compared between two groups.

RESULTS

In total, 153 cases were assigned to group A, and 147 cases were assigned to group B. Regarding demographic data, there was no statistically significant difference between the two groups. There were also no statistically significant differences in the number of shocks and energy power needed for each group. The results of SWL after the first session favored group A with a stone-free rate (SFR) of 90.8% vs. 75.5% for group B. The SFR after SWL was significantly in favor of group A (94.1%) vs. (86.4%) for group B.

CONCLUSION

The use of an artificial hydronephrosis technique to make interface around the stone improves stone-free rate and decreases the need for retreatment after SWL.

Mortality from kidney stone disease (KSD) as reported in the literature over the last two decades: a systematic review

INTRODUCTION

Current trends show a rising incidence of kidney stone disease (KSD) globally, with a lifetime risk of 10% and increasing hospital admissions. However, it is not perceived as a life-threatening condition and there are no publications examining its mortality rate. The aim of this review was to report on the number of KSD mortalities in the literature from the past two decades, identify risk factors, and to summarize their key learning points.

METHODS

A search was conducted for full-text English language articles that reported on KSD associated mortality, following intervention or conservative treatment, published between 1999 and 2017, using PubMed, MEDLINE, EMBASE, Scopus, CINAHL, Clinicaltrials.gov, Google Scholar and The Cochrane Library. Study quality and risk of bias assessment was undertaken using a validated critical appraisal tool from the Joanna Briggs Institute.

RESULTS

Of the 2786 articles identified, 34 were included. Of the total number of reported mortalities (2550), 21% were related to intervention. Sepsis was the leading cause of mortality. Risk factors identified were patients with multiple co-morbidities, spinal cord injury or neurogenic bladder and high stone burden. The main recommendations suggested were to treat pre-operative UTI or use prophylactic antibiotics and to reduce operative duration. The included studies were of moderate to good quality.

CONCLUSION

Pre-procedural optimization of the patients is the key to avoiding KSD mortality, and care should be taken in patients with multiple co-morbidities. Surgeons should meticulously plan for patients with high stone burden to reduce their operative time, as mortality can be procedural related.

Trends in the treatment of urinary stone disease in Turkey

Introduction

In this study, a survey was prepared for urologists that asked about their primary choice of treatment for urolithiasis in daily practice and their answers were evaluated.

Methods

The survey was prepared on the Google Docs website and it was sent to 1,016 urologists via email with 752 confirmed deliveries. In addition to the demographic questions about each participant's age, gender, and institution, the survey presented case scenarios focusing on their preferred treatment modalities for distal ureteric, proximal ureteric, and renal calculi. The participating urologists were divided into two groups according to the frequency that they treat urolithiasis patients.

Results

Of the 752 surveys delivered, 211 urologists (28.05%) responded and 204 answered all questions. According to the results, there were no significant differences between the treatment approaches and the other localizations, but there was a statistically significant difference for treatment approaches to lower pole stones between two groups. In response to the question of which stone treatment method was used less frequently, 124 (60.7%) participants answered that they used shock wave lithotripsy less in the last 10 years.

Conclusion

The present study has shown that while the management of renal and ureteric calculi by Turkish urologists is highly varied, the overall treatment patterns are in accordance with the European Association of Urology guidelines. However, similar to the global trend extracorporeal shock wave lithotripsy is less preferred by Turkish urologists.

Advanced non-contrasted computed tomography post-processing by CT-Calculometry (CT-CM) outperforms established predictors for the outcome of shock wave lithotripsy

OBJECTIVES

To evaluate the predictive value of advanced non-contrasted computed tomography (NCCT) post-processing using novel CT-calculometry (CT-CM) parameters compared to established predictors of success of shock wave lithotripsy (SWL) for urinary calculi.

MATERIALS AND METHODS

NCCT post-processing was retrospectively performed in 312 patients suffering from upper tract urinary calculi who were treated by SWL. Established predictors such as skin to stone distance, body mass index, stone diameter or mean stone attenuation values were assessed. Precise stone size and shape metrics, 3-D greyscale measurements and homogeneity parameters such as skewness and kurtosis, were analysed using CT-CM. Predictive values for SWL outcome were analysed using logistic regression and receiver operating characteristics (ROC) statistics.

RESULTS

Overall success rate (stone disintegration and no re-intervention needed) of SWL was 59% (184 patients). CT-CM metrics mainly outperformed established predictors. According to ROC analyses, stone volume and surface area performed better than established stone diameter, mean 3D attenuation value was a stronger predictor than established mean attenuation value, and parameters skewness and kurtosis performed better than recently emerged variation coefficient of stone density. Moreover, prediction of SWL outcome with 80% probability to be correct would be possible in a clearly higher number of patients (up to fivefold) using CT-CM-derived parameters.

CONCLUSIONS

Advanced NCCT post-processing by CT-CM provides novel parameters that seem to outperform established predictors of SWL response. Implementation of these parameters into clinical routine might reduce SWL failure rates.

Worldwide Trends of Urinary Stone Disease Treatment Over the Last Two Decades: A Systematic Review

INTRODUCTION

Numerous studies have reported on regional or national trends of stone disease treatment. However, no article has yet examined the global trends of intervention for stone disease.

METHODS AND MATERIALS

A systematic review of articles from 1996 to September 2016 for all English language articles reporting on trends of surgical treatment of stone disease was performed. Authors were contacted in the case of data not being clear. If the authors did not reply, data were estimated from graphs or tables. Results were analyzed using SPSS version 21, and trends were analyzed using linear regression.

RESULTS

Our systematic review yielded 120 articles, of which 8 were included in the initial review. This reflected outcomes from six countries with available data: United Kingdom, United States, New Zealand, Australia, Canada, and Brazil. Overall ureteroscopy (URS) had a 251.8% increase in total number of treatments performed with the share of total treatments increasing by 17%. While the share of total treatments for percutaneous nephrolithotomy (PCNL) remained static, the share for extracorporeal shockwave lithotripsy and open surgery fell by 14.5% and 12%, respectively. There was significant linear regression between rising trends of total treatments year on year for URS (p < 0.001).

CONCLUSION

In the last two decades, the share of total treatment for urolithiasis across the published literature has increased for URS, stable for PCNL, and decreased for lithotripsy and open surgery.

How can and should we optimize extracorporeal shockwave lithotripsy?

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.

Electromagnetic and Electrohydraulic Shock Wave Lithotripsy-Induced Urothelial Damage: Is There a Difference?

PURPOSE

To evaluate and compare the acute effect of electromagnetic and electrohydraulic extracorporeal shockwave lithotripsy (SWL) on the urothelial layers of kidney and ureter.

MATERIALS AND METHODS

Fifty patients, 29 males (58%) and 21 females (42%), with an average age of 51.68 years (range: 37-70) who underwent SWL application in two different centers were included. Twenty-eight patients (56%) were treated with electrohydraulic and 22 (44%) were treated with electromagnetic lithotripsy. Urinary cytologic examinations were done immediately before and after SWL therapy and 10 days later. The average numbers of epithelial cells, red blood cells (RBC), and myocytes were counted under 40 × magnification.

RESULTS

There were significant differences in the number of epithelial cells and RBC before and after immediate application of SWL: 1.66 and 14.9 cells/field, (p = 0.001), 5.44 and 113.45 cells/field, respectively (p = 0.001). The number of RBC was significantly higher in patients treated with electromagnetic lithotripsy than those treated with electrohydraulic: 141.9 and 93.4 cells/field, respectively (p = 0.02). No myocyte or basement membrane elements were detected in any of the cytologic examinations. Cytologic examinations done after 10 days of SWL therapy revealed recovery of all abnormal cytologic findings.

CONCLUSIONS

The acute increments in the number of epithelial cells and RBC after SWL were statistically significant but it was not permanent. SWL-induced urinary urothelial lesion is limited to the mucosal layer and there was no evidence of damage to the basal membrane or muscle layer. Electromagnetic lithotripsy caused high numbers of RBC than the electrohydraulic device on the postimmediate urine cytologic examination.

A prospective randomized comparison among SWL, PCNL and RIRS for lower calyceal stones less than 2 cm: a multicenter experience : A better understanding on the treatment options for lower pole stones

PURPOSE

To prospectively evaluate the efficacy and safety of RIRS, SWL and PCNL for lower calyceal stones sized 1-2 cm.

MATERIALS AND METHODS

Patients with a single lower calyceal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicenter, randomized, unblinded, clinical trial study. Patients were randomized into three groups: group A: SWL (194 pts); group B: RIRS (207 pts); group C: PCNL (181 pts). Patients were evaluated with KUB radiography (US for uric acid stones) at day 10 and a CT scan after 3 months. The CONSORT 2010 statement was adhered to where possible. The collected data were analyzed.

RESULTS

The mean stone size was 13.78 mm in group A, 14.82 mm in group B and 15.23 mm in group C (p = 0.34). Group C compared to group B showed longer operative time [72.3 vs. 55.8 min (p = 0.082)], fluoroscopic time [175.6 vs. 31.8 min (p = 0.004)] and hospital stay [3.7 vs. 1.3 days (p = 0.039)]. The overall stone-free rate (SFR) was 61.8% for group A, 82.1% for group B and 87.3% for group C. The re-treatment rate was significantly higher in group A compared to the other two groups, 61.3% (p < 0.05). The auxiliary procedure rate was comparable for groups A and B and lower for group C (p < 0.05). The complication rate was 6.7, 14.5 and 19.3% for groups A, B and C, respectively.

CONCLUSIONS

RIRS and PCNL were more effective than SWL to obtain a better SFR and less auxiliary and re-treatment rate in single lower calyceal stone with a CT diameter between 1 and 2 cm. RIRS compared to PCNL offers the best outcome in terms of procedure length, radiation exposure and hospital stay. ISRCTN 55546280.

[What is the current status of shock wave lithotripsy?]

BACKGROUND

Shock wave lithotripsy (SWL) became the therapy of choice for the majority of patients with urolithiasis early after its introduction in the early 1980s. Since then, SWL remains the only noninvasive therapy modality for the treatment of urinary stones. Although lithotripters became more versatile and affordable-making them available worldwide-indications for SWL have shifted as well. In most western countries, endoscopic techniques took the lead in stone therapy due to high (early) stone-free and better reimbursement rates. Notwithstanding SWL remains the first-line therapy for most intrarenal and many ureteral stones.

PURPOSE

This contemporary review illuminates technical aspects and improvements of lithotripsy over recent years in context with the current guideline recommendations.

RESULTS

Technical advances in lithotripsy such as shock wave generation, focusing, coupling, stone localization and modifications in therapy regimens are reviewed and presented.

CONCLUSIONS

Urologists are recommended to carefully select the appropriate therapy modality for a patient with urolithiasis. A more comprehensive understanding of the physics of shock waves could lead to much better results, thus, endorsing SWL as first-line therapy for urolithiasis instead of contemporary endourology treatment options.

Hospital admission for treatment of complications after extracorporeal shock wave lithotripsy for renal stones: a study of risk factors

The objective of this study was to determine risk factors of hospital admission for treatment of complications after extracorporeal shock wave lithotripsy (SWL). The electronic files and images of all patients who underwent SWL for treatment of renal stones between January 2011 and December 2015 were retrospectively reviewed. All patients underwent SWL with the same electromagnetic lithotripter (Dornier Lithotripot S). The data of those who needed hospital admission for treatment of complications within 30 days after SWL were compared with patients who did not require hospital admission. Compared data included patients' demographics (age, gender, BMI, ASA score, and pre-SWL stenting), renal characters (side, hydronephrosis, and solitary kidney), and stone characters (site, length, density, and previous treatment). Univariate and multivariate statistical analyses were used to identify risk factors. The study included 1179 patients. Complications that required hospital admission were observed in 108 patients (9.2%). They included obstructing steinstrasse in 91 (7.7%), peri-renal hematoma in 3 (0.25%), and fever (>38.0 °C) in 14 (1.2%). Independent risk factors on multivariate analysis were solitary kidney (OR 2.855, P = 0.017), pre-SWL stenting (RR 2.03, P = 0.044), ASA II (OR 1.965, P = 0.007), hydronephrosis (RR 1.639, P = 0.024), and stone length (RR 1.083, P < 0.001). Patients with medical co-morbidities, pre-SWL ureteral stents, large stones and those with obstructed and/or solitary renal unit are more liable to post-SWL complications that need hospital admission. The probability of hospital admission has to be explained to patients with these risk factors.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Immediate versus delayed shockwave lithotripsy for inaccessible stones after uncomplicated percutaneous nephrolithotomy

Objective

To evaluate the efficacy and safety of immediate versus delayed shockwave lithotripsy (SWL) for inaccessible stones after uncomplicated percutaneous nephrolithotomy (PCNL).

Patients and methods

Between December 2011 and June 2014, patients with residual inaccessible stones after uncomplicated PCNL were prospectively randomised into two treatment groups; Group I, immediate SWL and Group II, delayed SWL at 1 week after PCNL. Patients with residual stones of ⩾1.5 cm, a stone density of >1000 Hounsfield units and body mass index of >40 kg/m² were excluded from the study. The following data were reported: patients’ demographics, stone characteristics after PCNL, hospital stay, perioperative complications, stent duration, and stone-free rate (SFR).

Results

In all, 84 patients (51 males and 33 females) with mean (SD) age of 39 (8.5) years were included in the study. Group I included 44 patients, whilst Group II included 40 patients. There was no statistically significant difference amongst the groups for patients’ demographics, stone characteristics, and perioperative complications. The hospital stay was significantly shorter in Group I, at a mean (SD) of 34 (3.7) vs 45 (2.9) h (P < 0.001). The duration of ureteric stenting was significantly lower in Group I as compared to Group II, at a mean (SD) of 12 (4.2) vs 25 (3.5) days (P < 0.001). The SFR was 93.2% and 95% in Groups I and II, respectively (P = 0.9).

Conclusions

Immediate SWL after PCNL is as effective and safe as delayed SWL with a lesser hospital stay and duration of ureteric stenting.

Miniperc vs Shockwave Lithotripsy for Average-Sized, Radiopaque Lower Pole Calculi: A Prospective Randomized Study

Introduction: To detect safety and feasibility of miniperc and extracorporeal shockwave lithotripsy (SWL) for treatment of average-sized (1-2 cm), radiopaque lower pole calculi in a prospective randomized manner. Patients and Methods: In the period from January 2014 to June 2015, 150 patients were attached to this study with single lower pole radiopaque stone ranging from 10 to 20 mm. Patients were divided randomly into two groups using computer-generated randomization in an equal manner. First group patients were subjected to miniperc procedure, while second group patients underwent SWL. Patient's characters, stones' characters, fluoroscopic time, operative time, blood transfusion, hospital stay, retreatment, auxiliary procedure (AP), and complications using modified Clavien grading are tabulated and analyzed. Results: This study included two equal groups with 75 patients in each group. With regard to age (37.75 ± 11.25 vs 40.55 ± 10.55), body mass index (26.92 ± 2.26 vs 27.29 ± 2.87), and stone size (1.55 ± 0.28 vs 1.57 ± 0.26), there was no significant statistical difference in both groups. Stone-free rate (SFR) (76% vs 96%), operative time (44.81 ± 7.06 vs 93.37 ± 12.29 minutes), fluoroscopy time (53 ± 2.45 vs 180 ± 7.31 seconds), hospital stay (5.72 ± 1.01 vs 45.19 ± 8.48 hour), and blood transfusion were significantly more in the miniperc group. Retreatment rate (45.3% vs 2.7%) and AP (24% vs 4%) were significantly greater in the SWL group. Conclusion: SWL is less invasive than percutaneous stone removal, but it is also less effective for lower pole radiopaque calculi. Miniperc has better SFR and lower auxiliary and retreatment rates; however, it resulted in more drawbacks.

Effect of anxiety and pain on success of shockwave lithotripsy (SWL) for treatment of proximal ureteral and renal pelvic stones

The aim of this study is to evaluate the impact of anxiety and pain on success of shockwave lithotripsy (SWL) for treatment of proximal ureteral and renal pelvic stones smaller than 15 mm. One hundred thirty-two patients with proximal ureteral or renal pelvic stones <15 mm who were treated by a SWL and forty controls were enrolled in the study. State-trait anxiety inventory (STAI) was used to assess anxiety of the controls and patients (before every SWL session). Pains of the patients were measured by a visual analog scale (VAS) at three times (T) of the sessions (T11 at 11 kV, T15 at 15 kV and T end of treatment). The mean STAI scores of the patients at the first SWL session and controls were 40.61 ± 8.71 and 36.11 ± 8.18, respectively (p < 0.05). There was statistically positive moderate relationship between STAI and VAS scores at the first SWL session. The mean size of stone in men and women were 11.16 ± 2.88 and 11.00 ± 3.41, respectively (p = 0.88). In the first session, the mean STAI and VAS scores of the men were significantly lower than the women. The stone-free rate (SFR) of SWL was 72.7 % in this study. The SFR of SWL in the men and women were 78 and 64 %, respectively (p < 0.05). Our data showed that the severity of anxiety and pain in the women were higher than the men. SFR of SWL in the men was higher than the women. The severity of anxiety and pain in the patients may affect SFR of SWL.

A new optical coupling control technique and application in SWL

The objective of this study was to compare the results of shock wave lithotripsy (SWL) between patients treated with optical coupling control (OCC) and those treated with "blind" coupling during SWL to treat renal stones. Enrolled in the study were patients with urinary stones who underwent SWL between January 2014 and February 2015. The lithotripter used in the study was an electromagnetic Dornier Compact Delta II UIMS. The closed envelope method was used to randomize the enroled patients to OCC (Group A) or "Blind" coupling group (Group B). The stone-free rates (SFRs) were determined using KUB film with or without ultrasonography after 3 months. Treatment failure was defined as radiologically confirmed persistence of the stone with no fragmentation after second SWL sessions. Complications during the intraoperative or post-operative periods were recorded. A total of 336 patients satisfied the inclusion criteria for the study, of which 169 patients were treated in the Group A and 167 in the Group B. There was no significant difference in patient and stone characteristics between the two groups (Table 1). The locations of treated stones are shown in Table 2. The treatment results were stratified by stone location in Table 3, significant differences existed in all treatment results between the two groups (P < 0.05). The overall stone-free rates after 3 months were 78.2 % for kidney stones and 81.7 % for ureteral stones in patients from Group A. The corresponding SFRs for patients in Group B were 62.8 and 67.9 % for stones in the kidneys and ureters, respectively. There were statistical differences in these results between the two groups (P < 0.05). The lithotripter with OCC had excellent shock wave transmission properties with the least possible loss of energy; it can lead to the optimization of SWL treatment outcome and reduce the incidence of SW-induced adverse effects. We are confident that the OCC used in this study should be a standard feature in future lithotripters. Table 1 Patients' and stones' characteristics Group A Group B P value Number of patients 169 167 Patients' gender (M/F) 97/72 109/58 0.138 Stone location (left/right) 86/83 89/78 0.659 Patients' age (years) 36.3 ± 7.1 34.2 ± 6.8 0.521 Size of stones  Kidney (cm) 1.4 ± 0.6 1.3 ± 0.7 0.452  Ureter (cm) 1.1 ± 0.5 1.1 ± 0.4 0.354  Average size (cm) 1.2 ± 0.8 1.2 ± 0.7 0.372 Table 2 The distribution of location of stones treated Group A % Group B % Upper calyx 21 12.4 25 15.0 Middle calyx 28 16.6 23 13.8 Lower calyx 7 4.1 5 3.0 Renal pelvis 31 18.3 33 19.8 Upper ureter 28 16.6 31 18.6 Middle ureter 6 3.6 4 2.4 Lower ureter 48 28.4 46 27.5 Overall 169 100.0 167 100.0 Table 3 The treatment results were stratified by stone location Group A Group B %Stone-free %Re-treatment %Ancillary procedure %Stone-free %Re-treatment %Ancillary procedure Kidney  Upper calyx 76.2 33.3 14.3 60.0 48.0 12.0  Middle calyx 75.0 35.7 7.1 56.5 56.5 13.0  Lower calyx 71.4 42.9 28.6 60.0 60.0 40.0  Renal pelvis 83.9 29.0 9.7 69.7 45.5 12.1  Overall 78.2 33.3 11.5 62.8 50. 0 14.0 Ureter  Upper ureter 82.1 28.6 10.7 74.2 32.3 16.1  Middle ureter 66.7 66.7 33.3 50. 75.0 50.0  Lower ureter 83.3 25.0 10.4 65.0 41.3 13.0  Overall 81.7 29.3 12.2 67.9 39.5 16.0.

Management behaviors of the urology practitioners to the small lower calyceal stones: the results of a web-based survey

Lower pole calyceal stones (LPS) represent lower spontaneous passage rates and, therefore, require several interventional treatment approaches. The aim of this survey study was to investigate the attitudes of the urology practitioners and the factors affecting their decision making in the management of small asymptomatic LPS. A total of 149 urologists participated to the study via email through the internet-based website. Participating urologists were asked to complete a 29-question survey including personal and academic data, level of surgical experience, available equipment for interventional approaches, which treatment do they prefer for small LPS (≥5 mm and <1 cm), and factors affecting their treatment decision. All data were analyzed to make inferences related with treatment decision and factors affecting decision-making. Mean participant age was 41.57 (26-62) years. The most preferred approach was observation/medical treatment option (52.3 %), subsequently SWL (25.5 %), RIRS (16.1 %), miniPNL (5.4 %) and standard PNL (0.7 %) were chosen by the participants. On the other side, SWL and medical treatment were at the forefront (52 and 16.1 %) among children. In the multivariate analysis of participants' age, academic status, surgical experience and institution, none was significantly associated with treatment decision-making (p > 0.05). The most important factors associated with decision making were calyceal dilatation (85.9 %) and patient preferences (81.2 %). The other factors effecting treatment decision were reported to be recurrent disease (70.5 %), the duration of the stone (74.5 %), patient age (95.3 %), current guidelines (87.9 %), stone density (50.3 %), body mass index (BMI) (73.8 %) and other morbid diseases (91.9 %). Our surveys' greatest value is in demonstrating the preferred treatment options and factors effecting decision-making in the treatment of LPS. The most preferred option in our population was follow-up and medical treatment. The most influencing factors on decision-making were age, patients' preferences, presence of calyceal dilatation, body mass index, comorbid conditions, available options for stone treatment and the surgeon's experience on the existing opportunities.

COMPARISON BETWEEN EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AT 120 AND 60 SHOCKWAVES PER MINUTE FOR TREATMENT OF URINARY STONES

(Purpose) It has recently been suggested that a slow delivery rate of shockwaves by extracorporeal shock wave lithotripsy (SWL) improved treatment outcomes for urinary stones. We retrospectively analyzed the treatment outcomes of different shockwave delivery rates at 120 and 60 shockwaves per minute. (Patients and method) A total of 88 patients were treated at a fast delivery rate of 120 shockwaves per minute between July 2010 and April 2012, and 139 patients were treated at a slow delivery rate of 60 shockwaves per minute between May 2012 and May 2014 (n=227) using a Sonolith^® Praktis lithotripter. The treatment outcome of stone-free rate (SFR) after one SWL session was assessed at four weeks. (Result) SWL at 60 shockwaves per minute resulted in a significantly higher SFR compared with SWL at 120 shockwaves per minute (39.8% and 59.0%, respectively, p=0.0047), particularly for upper ureter (U1) stones (53.1% and 72.0%, respectively, p=0.028). Multivariate analysis showed that younger age, stone sizes of 10 mm or less, U1 stones, and slow delivery rate were significant predictors of a stone-free outcome. There were fewer adverse events after the delivery rate of 60 shockwaves per minute (p=0.058). (Conclusion) Our study suggests that SWL at 60 shockwaves per minute should be recommended to successfully treat urinary stones using the Sonolith^® Praktis lithotripter.

Extracorporeal shock wave lithotripsy in infants less than 12-month old

There is a lack of literature on children compared to adults regarding the long-term effects of extracorporeal shock wave lithotripsy (SWL), specifically in infants. The aim of the present study was to analyze the efficacy and safety of SWL in infants and also evaluate its potential adverse effects in the mid-term. Between May 1999 and December 2013, 36 infants with 39 renal units underwent SWL treatment for kidney stones with an electrohydraulic lithotripter (Dornier MPL 9000/ELMED Multimed Classic). All children were less than 12-month old. The mid-term effects of SWL were examined at the last follow-up by measuring arterial blood pressure, random blood glucose level and ipsilateral kidney size. Evaluation of treatment and its consequences was based on clinical examination, blood tests and conventional imaging (plain abdominal radiography and ultrasound). Overall stone-free rate was 84.6 % after 3-month follow-up without any major complications. Mid-term follow-up was available in 20 of 36 children with a mean follow-up of 3.2 ± 2.8 years (range 0.5-15.3). None of the infants were found to develop new onset of hypertension or diabetes. All treated infant kidneys' sizes were in the normal percentile range. SWL for management of infant kidney stones is effective and safe in the mid-term.

Does ureteral stenting matter for stone size? A retrospectıve analyses of 1361 extracorporeal shock wave lithotripsy patients

Introduction

The aim of our study was to determine the efficacy of ureteral stents for extracorporeal shock wave lithotripsy (SWL) treatment of pelvis renalis stones and to compare the results and complications in stented and non-stented patients.

Material and methods

Between 1995 and 2011, 1361 patients with pelvis renalis stones were treated with SWL. Patients were subdivided into three groups according to stone burden: ≤1 cm² (group 1; n = 514), 1.1 to 2 cm² (group 2; n = 530) and >2 cm² (group 3; n = 317). Each group was divided into subgroups of patients who did and did not undergo ureteral stent implantation before SWL treatment. The efficacy of treatment was evaluated by determining the effectiveness quotient (EQ). Statistical analysis was performed by chi-square, Fisher's exact and Mann-Whitney U tests.

Results

Of the 514, 530 and 317 patients in groups 1, 2 and 3 respectively, 30 (6%), 44 (8%) and 104 (33%) patients underwent auxiliary stent implantation. Steinstrasse rates did not differ significantly between stented and non-stented patients in each group. The EQ was calculated as 62%, 33% and 70% respectively in non-stented, stented and totally for group 1. This ratio calculated as 58%, 25% and 63% for group 2 and 62%, 26% and 47% for group 3. Stone-free rates were significantly higher for non-stented than for stented patients in groups 2 and 3.

Conclusions

Stone free rates are significantly higher in non-stented than in stented patients with pelvis renalis stones >1 cm², whereas steinstrasse rates are not affected.