Extracorporeal shock wave lithotripsy: the first 50 patients treated in Britain.

Fifty patients have been treated for upper tract urinary calculi by extracorporeal shock wave lithotripsy (ESWL) at the Devonshire Hospital lithotripter centre since November 1984. The average stay for an inpatient was 3 X 7 days. All patients suffered minimal postoperative discomfort and nearly all resumed normal activity within one day after discharge. Complications requiring auxiliary procedures were few. The procedure was found to be safe, cost effective, extremely well received by patients, and superior to all other methods of removing renal stones. This study confirms that treatment by ESWL is a specialised urological procedure that requires operators who are also trained in open, percutaneous, and ureteroscopic surgery and with a back up of a radiological team skilled in percutaneous renal puncture.     

Selecting Treatment for Distal Ureteral Calculi: Shock Wave Lithotripsy versus Ureteroscopy

Shock wave lithotripsy (SWL) and ureteroscopy (URS) are both effective treatments for removal of distal ureteral calculi, associated with high success rates and limited morbidity. The American Urological Association Ureteral Stones Clinical Guidelines Panel has found both to be acceptable treatment options for patients, based on the stone-free results, morbidity, and retreatment rates for each respective therapy. However, costs and patient satisfaction or preference were not addressed, and the report was based on data derived from older endoscopic and lithotripsy technology. Each of these treatment options has valid advantages and disadvantages. Both modalities are reasonable treatment options for the majority of patients with distal ureteral calculi. Whereas SWL is less invasive, the high, immediate success rate with minimal morbidity and decreased cost makes URS a very valid competitor. The results of treating patients with larger stones favor URS.     

The effect of shock wave lithotripsy on nitric oxide and malondialdehyde levels in plasma and urine samples

Shock wave lithotripsy (SWL) is accepted as the first treatment choice for most urinary stones, but it has adverse effects on the kidneys. The mechanisms underlying shock wave-induced renal injury have been discussed and include shear stress, thermal and cavitation effects and free radical formation. We investigated the effects of SWL on plasma and urinary nitrite, a stable metabolite of nitric oxide (NO), and malondialdehyde (MDA) concentrations. Between February and October 2004, 12 men and 8 women with renal calculi were treated using a Dornier MPL-9000 lithotriptor. The ages ranged from 22 to 45 years (average age: 33.7 years). Plasma and urinary NO and MDA levels were analysed before, immediately after, 30 and 60 min and 24 h after SWL. Plasma NO levels were higher than baseline levels immediately, and at 30, 60 min and 24 h after treatment (p = 0.016, p = 0.031, p = 0.033 and p = 0.045, respectively). Simultaneously, the mean urinary NO levels also showed significant elevation after SWL compared with baseline values, except for 24 h (p = 0.021, p = 0.023 and p = 0.048, respectively). The mean levels of plasma MDA showed statistically significant elevation immediately, and 30 and 60 min after SWL termination compared with pre-SWL values (p = 0.012, p = 0.008 and p = 0.012, respectively). Urinary MDA levels obtained immediately (p = 0.035), and 30 (p = 0.006) and 60 (p = 0.045) min after SWL were increased compared to pre-SWL values. We speculate that SWL treatment causes oxidative stress caused by renal ischemia-reperfusion (I/R) injury. Additionally, the increase of NO production may have prevented renal damage caused by vasoconstriction.     

侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的临床应用价值

目的：探讨侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的可行性及临床应用价值。方法：回顾性分析2009年8月至2011年9月我院采用侧卧体住下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石患者52例的临床资料：患者同时存在肾脏铸型结石或多发结石和或输尿管上段结石,单个结石最大径8-30mm。结果：平均手术时间60分钟（50—120分钟）;术前血红蛋白116±30g／L,术后第一天复查105±26g／L,无大出血需要输血病例;一次结石取净率为86．5％（45／52）,总取净率为92．3％（48／52）。结论：侧卧体位下经皮肾穿刺取石术及经尿道输尿管镜取石术两种术式联合应用具有可行性及互补性,在预防及减少术中出血、获得清晰的手术视野、减少灌注液外渗、增加结石清除速度及碎石成功率、缩短手术时间、减少术后发热等方面疗效显著,为治疗复杂上尿路结石提供了一个可行的新方法。     

Clinical Nomograms to Predict Stone-Free Rates after Shock-Wave Lithotripsy: Development and Internal-Validation

Purpose

Shock-wave lithotripsy (SWL) is accepted as the first line treatment modality for uncomplicated upper urinary tract stones; however, validated prediction models with regards to stone-free rates (SFRs) are still needed. We aimed to develop nomograms predicting SFRs after the first and within the third session of SWL. Computed tomography (CT) information was also modeled for constructing nomograms.

Materials and Methods

From March 2006 to December 2013, 3028 patients were treated with SWL for ureter and renal stones at our three tertiary institutions. Four cohorts were constructed: Total-development, Total-validation, CT-development, and CT-validation cohorts. The nomograms were developed using multivariate logistic regression models with selected significant variables in a univariate logistic regression model. A C-index was used to assess the discrimination accuracy of nomograms and calibration plots were used to analyze the consistency of prediction.

Results

The SFR, after the first and within the third session, was 48.3% and 68.8%, respectively. Significant variables were sex, stone location, stone number, and maximal stone diameter in the Total-development cohort, and mean Hounsfield unit (HU) and grade of hydronephrosis (HN) were additional parameters in the CT-development cohort. The C-indices were 0.712 and 0.723 for after the first and within the third session of SWL in the Total-development cohort, and 0.755 and 0.756, in the CT-development cohort, respectively. The calibration plots showed good correspondences.

Conclusions

We constructed and validated nomograms to predict SFR after SWL. To the best of our knowledge, these are the first graphical nomograms to be modeled with CT information. These may be useful for patient counseling and treatment decision-making.     

The treatment of lower pole renal calculi in 2003

The optimal treatment of patients with lower pole renal calculi is still being defined. Shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopy are all currently utilized to treat patients with this condition. These methods have yielded varying degrees of success. The influence of collecting system anatomy on shock wave lithotripsy results remains controversial. Ongoing randomized, prospective trials evaluating the efficacy of all of these respective therapeutic options will, it is hoped, determine the best approaches for this patient cohort.     

ESWL treatment of urinary stones in children--the overview of 14 years of experience

Extracorporeal shock wave lithotripsy (ESWL) treatment has been used at Department of Urology, University Hospital "Osijek", Croatia, since July 1988. Until December 2001 seven thousand and eight hundred patients underwent ESWL for urinary stones, 68 of them were children (0.87%). Sixty-eight children aged 4 to 15 years (average 10.14 years) underwent ESWL. They were treated for the total of 91 stones: 35 (38.46%) caliceal, 23 (25.27%) in pyelon, 7 (7.69%) in pyeloureteric segment and 14 (15.38%) ureteral. Staghorn calculi were found in 6 (6.59%) patients and multiple stones (four or more stones in the same kidney) in 6 (6.59%). There was total of 95 ESWL sessions performed in 68 patients (1.39 session per patient). Fifty-six patients (82.35%) without residual stones found at the control plain film and sonography of urinary tract were considered "stone free". Addition of 5 patients with clinically insignificant residual fragments (less than 4 mm) increases overall success rate to 89.70%. ESWL is a simple, safe and effective procedure in the management of urolithiasis in childhood. Clinical experience of our institution confirms ESWL as the first line treatment for kidney stones in the pediatric age patients.     

Clinical comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in treating renal calculi.

STUDY OBJECTIVE: To compare extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for efficacy in treating renal calculi. DESIGN: Non-randomised multicentre cohort study with 3 month follow up and 13 month data collection period. SETTING: Lithotripter centre in London, tertiary referral hospital, and urological clinics in several secondary and tertiary care centres. PATIENTS: 933 of 1001 patients treated by lithotripsy at the lithotripter centre were compared with 195 treated by nephrolithotomy. Missing patients were due to incomplete collection of data. Age and sex distributions and characteristics of the stones were similar in the two treatment groups. Two patients died in the lithotripsy group. Three month follow up was achieved in about 84% of both groups (783/933 for lithotripsy; 163/195 for nephrolithotomy). INTERVENTIONS: The nephrolithotomy group had surgical nephrolithotomy alone. In the lithotripsy group 83% (774/933) had lithotripsy alone, 11% (103/933) had combined lithotripsy and nephrolithotomy, and 6% (56/933) had lithotripsy plus ureteroscopy. Single and combined lithotripter treatments were analysed as one group and compared with nephrolithotomy. END POINT: Presence of stones three months after treatment. MEASUREMENTS AND MAIN RESULTS: Presence of residual stones was assessed by plain radiography, ultrasonography, or intravenous urography. After adjustment for age and size and position of stone for patients with single stones the likelihood of being free of stones three months after treatment was significantly greater in the nephrolithotomy group than the lithotripsy group (odds ratio 6.6; 95% confidence interval 3.0 to 14.6) and the response was particularly pronounced with staghorn calculi (62% (8/13) v 15% (141/96) patients free of stones after nephrolithotomy and lithotripsy, respectively). OTHER FINDINGS: 19%(146/775) of patients who had had lithotripsy had to be readmitted within three months after treatment compared with 14%(23/162) who had nephrolithotomy; and 64%(94/146) of readmissions after lithotripsy were for complications compared with 30%(7/23) of readmissions after nephrolithotomy. CONCLUSIONS: Nephrolithotomy may be preferable to lithotripsy for treating renal stones and it may not be wise to invest heavily in lithotripsy facilities.     

Extracorporeal Shock Wave Lithotripsy for Management of Residual Stones after Ureterolithotripsy versus Mini-Percutaneous Nephrolithotomy: A Retrospective Study

Purpose

To compare the efficacy of extracorporeal shock wave lithotripsy in managing residual stones after ureterolithotripsy and mini-percutaneous nephrolithotomy.

Materials and Methods

A retrospective study was carried out of 71 patients with proximal urinary tract stones (greater than 10 mm) who underwent ureterolithotripsy or mini-percutaneous nephrolithotomy at a single institution from 2009 to 2011. The 71 patients were divided into two groups: group I (n = 37) comprised patients who underwent ureterolithotripsy, and group II (n = 34) comprised patients who underwent mini-percutaneous nephrolithotomy. Clinical characteristics, stone-free rates, stone demographics, and complications were evaluated.

Results

The overall stone-free rate was 90.1%. The stone-free rates in groups I and II were 97.3% and 82.4%, respectively. There was a statistically significant difference in the stone-free rates between groups I and II (P = 0.035). Neither serious intraoperative nor postoperative complications were observed. No significant difference in complications was observed between the two groups (P = 0.472).

Conclusions

The results of our study suggest that extracorporeal shock wave lithotripsy is an effective and safe auxiliary procedure for managing residual stones after primary endoscopic surgery. This procedure is associated with a satisfactory stone-free rate and a low complication rate, particularly for residual stones after ureteroscopic procedures.     

A Pilot Study to Evaluate Haemostatic Function,following Shock Wave Lithotripsy (SWL) for the Treatment of Solitary Kidney Stones

PurposeThe number of patients undergoing shock wave lithotripsy (SWL) in the UK for solitary unilateral kidney stones is increasing annually. The development of postoperative complications such as haematuria and sepsis following SWL is likely to increase. Comparing a range of biological markers with the aim of monitoring or predicting postoperative complications following SWL has not been extensively researched. The main purpose of this pilot-study was to test the hypothesis that SWL results in changes to haemostatic function. Subsequently, this pilot-study would form a sound basis to undertake future investigations involving larger cohorts.MethodsTwelve patients undergoing SWL for solitary unilateral kidney stones were recruited. From patients (8 male and 4 females) aged between 31–72 years (median—43 years), venous blood samples were collected pre-operatively (baseline), at 30, 120 and 240 minutes postoperatively. Specific haemostatic biomarkers [platelet counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer, von Willebrand Factor (vWF), sE-selectin and plasma viscosity (PV)] were measured.ResultsPlatelet counts and fibrinogen concentration were significantly decreased following SWL (p = 0.027 and p = 0.014 respectively), while D-dimer and vWF levels significantly increased following SWL (p = 0.019 and p = 0.001 respectively). PT, APTT, sE-selectin and PV parameters were not significantly changed following SWL (p>0.05).ConclusionsChanges to specific biomarkers such as plasma fibrinogen and vWF suggest that these represent a more clinically relevant assessment of the extent of haemostatic involvement following SWL. Analysis of such markers, in the future, may potentially provide valuable data on “normal” response after lithotripsy, and could be expanded to identify or predict those patients at risk of coagulopathy following SWL. The validation and reliability will be assessed through the assessment of larger cohorts.     

输尿管软镜结合输尿管硬镜治疗复杂上尿路结石的效果评价及对预后的影响

目的 探讨输尿管软镜协同输尿管硬镜治疗复杂上尿路结石的临床效果.方法 选择我院收治的复杂上尿路结石患者96例,按入院顺序分为对照组和观察组,每组48例.对照组采取输尿管硬镜钬激光碎石术治疗,观察组采取输尿管软镜协同输尿管硬镜钬激光碎石术治疗.比较两组患者1次性碎石成功率、结石彻底清除率、炎症反应情况以及生活质量、住院时...     

Electrohydraulic lithotripsy with peroral choledochoscopy.

OBJECTIVE--To determine the efficacy of peroral electrohydraulic lithotripsy performed with an extra large duodenoscope (outside diameter 14.8 mm) and a choledochoscope with a diameter of 4.1 mm (Olympus "mother and baby" endoscope system) in the removal of very large stones from the common bile duct. DESIGN--Prospective study of patients with giant stones in the common bile duct that were resistant to extraction by conventional means. SETTING--Endoscopy unit at a university hospital. PATIENTS--Four women and one man aged 48-82 (mean 66.4 years) with a total of nine stones in their common bile ducts ranging from 2.2 to 3.6 cm in diameter. INTERVENTIONS--Peroral electrohydraulic lithotripsy was performed after intravenous sedation and under antibiotic cover. Two endoscopists took part in each procedure, coordination being achieved by means of a video monitor. The procedures were performed with a Lithotron EL-23 lithotripter and a 3 French lithotripsy probe inserted through the choledochoscope under direct vision. MAIN OUTCOME MEASURE--Complete clearance of the common bile duct confirmed by occlusion cholangiography. RESULTS--All nine stones (mean minimal diameter 2.6 cm; mean maximal diameter 3.1 cm) were successfully fragmented by electrohydraulic lithotripsy, allowing subsequent extraction with the aid of endoscopy and clearance of the common bile duct. A median of three (range two to five) sessions of endoscopic retrograde cholangiopancreatography were required to achieve complete clearance of the ducts. Patients stayed a median of eight days in hospital after lithotripsy (range eight to 14). There were no complications. CONCLUSION--Peroral electrohydraulic lithotripsy offers a safe and effective alternative for the management of patients with large stones in the common bile duct.     

Optimizing Stone-free Rates With Ureteroscopy

Ureteroscopy is being increasingly utilized in the treatment and management of patients with renal and ureteral stones. Improving stone-free rates with ureteroscopy decreases the need for ancillary procedures and improves patient outcomes and satisfaction. This article reviews contemporary literature regarding the efficacy of a wide range of currently available techniques for improving stone-free rates with this procedure.Key words: Ureteroscopy, Upper urinary tract stones, Stone-free rateNephrolithiasis is a common ailment affecting approximately 1 in 11 Americans, and its rates are increasing.¹ Many patients have small stones that pass spontaneously; this process can be accelerated with medical expulsive therapy, primarily α-blockade. The majority of patients who are unsuccessful with α-blockade are treated with minimally invasive procedures such as shock wave lithotripsy (SWL) and ureteroscopy (URS).² In recent years, there has been a shift in the utilization of these procedures—URS is now more commonly used. Data from the Urologic Diseases in America project show that rates of URS have risen among Medicare beneficiaries and privately insured individuals over time.³ A study examining stone management in Australia shows similar findings; the proportion of stones treated with URS has doubled in the past decade.⁴ Additionally, it has been shown that physicians who have recently entered practice or recently completed training are more likely to use URS.^5,6 With increased utilization of URS and changing physician reimbursement models, patient outcomes and satisfaction with URS are of utmost importance. It is hoped that improving stone-free rates is one way to improve patient outcomes by decreasing future stone episodes and the need for further intervention. To date, there has not been a comprehensive review of modalities suggested to optimize stone-free rates with URS. We review existing literature on methods of increasing stone-free rates, ranging from methods with supporting level 1 evidence to those that are anecdotal.     

Extracorporeal shockwave lithotripsy: urine cytology findings

Objectives:  To describe the urine cytology findings before and after stone therapy with extracorporeal shock wave lithotripsy (ESWL) and discuss its importance.
Methods:  The study consisted of 100 patients with a urinary tract stone (79 renal pelvic stones and 21 upper ureteric stones), 74 were male and 26 were female. The ages ranged 30–55 years. The average duration of symptoms was 3–8 years. The size of the stones varied from case to case ranging from 10.2 to 40 mm. Urine samples were obtained on three consecutive days before and after lithotripsy. The smears were stained by the Papanicolaou method.
Results:  The smears before lithotripsy revealed a few red blood cells, inflammatory cells, epithelial cells and crystals (calcium oxalate, uric acid and triple phosphate). Atypical malignant looking cells and epithelial cell clusters were not noticed. After lithotripsy, the urine samples were examined at different periods, 24 hours, 2 weeks, 1 month, 2 months and 3 months. The smears revealed papillary clusters in all 100 patients within 24 hours and were always associated with inflammation. Atypical malignant looking cells appeared later, within 1–2 months in 21 patients, and were associated with inflammation (19 patients), RBC, crystals and papillary clusters. Most of the papillary clusters and atypical malignant looking cells disappeared before 3 months.
Conclusion:  The epithelial cell clusters and atypical cells were seen in urine smears after ESWL. Without knowing the previous history these findings can be confused with urothelial neoplasms.     

Percutaneous Renal Stone Manipulation—A Nonoperative Alternative

Nephrostomy tube tracts, established operatively or percutaneously, can provide access to stones in the upper urinary tract. A variety of rigid or flexible urologic instruments can be used to percutaneously disintegrate or extract calculi, thus sparing a patient an operative procedure. This is most important in the case of high-risk patients, those previously operated upon or those who have active nephrolithiasis, in whom recurrent stones are prone to form. Our early experience in percutaneous renal stone disintegration and stone manipulation enabled us to remove most (in four patients) or all (again in four patients) calculi in nine patients. The procedure offers lower morbidity, shorter hospital stay and earlier return to employment than conventional operative stone procedures.     

Regional variations in the incidence of upper urinary tract stones in England and Wales.

Data from the Hospital In-patient Enquiry were used to define the regional patterns of hospital discharge rates for upper urinary tract stones and renal colic in England and Wales. By combining the rates for stones and colic, and by distinguishing emergency from planned admissions, the biases produced by repeated admissions of the same patient and by regional variations in diagnosis and coding may be reduced. There are regional variations in incidence of upper urinary tract stones: Wales and the southern regions of England have a generally higher incidence than northern regions. These variations may be related to regional differences in diet or occupation; or they may partly depend on associations between stone incidence and atmospheric temperature, exposure to ultraviolet irradiation, and hardness of drinking water.     

Adjunctive Medical Therapy with α-Blocker after Extracorporeal Shock Wave Lithotripsy of Renal and Ureteral Stones: A Meta-Analysis

Background

Although some trials assessed the efficacy and safety of the α-blocker in facilitating renal and ureteral stones expulsion after extracorporeal shock wave lithotripsy (ESWL), the role of the α-blocker in facilitating upper urinary calculi expulsion after ESWL remain controversial.

Aims

To determine the efficacy and safety of the α-blocker in facilitating renal and ureteral stones expulsion after ESWL.

Methods

A literature search was carried out using the PubMed database, EMBASE and the Cochrane Library database to identify relevant studies. Two reviewers independently extracted data and assessed methodological quality. Pooled effect estimates were obtained using a fixed- and random-effects meta-analysis.

Results

The meta-analysis included 23 RCTs, α-blocker significantly enhanced expulsion rate of upper urinary tract calculi after ESWL (P<0.00001; RR 1.21; 95% CI 1.12–1.31), significantly promoted steinstrasse expulsion (P=0.03; RR 1.25; 95% CI 1.03–1.53), significantly shortened the discharge time of upper urinary tract calculi (P=0.0001; MD -2.12; 95% CI -3.20–-1.04), significantly reduced the patient''s pain VAS score (P=0.001; RR -1.0; 95% CI -1.61–-0.39). Compared with the control group, dizziness (P=0.002; RR 5.48; 95% CI 1.91–15.77), anejaculation (P=0.02; RR 12.17; 95% CI 1.61–91.99) and headache (P=0.04; RR 4.03; 95% CI 1.04–15.72) in the α-blocker group was associated with a higher incidence.

Conclusions

Treatment with α-blocker after ESWL appears to be effective in enhancing expulsion rate of upper urinary tract calculi, shortening the discharge time of upper urinary tract calculi, reducing the patient''s pain. The side effects of α-blocker were light and few.     

微通道经皮肾镜碎石术治疗感染性结石合并尿液CRPA感染两例

目的:总结一期行微通道经皮肾镜碎石术(microchannel percutaneous nephrolithotripsy,m PCNL)治疗上尿路感染性结石合并尿培养为耐碳青霉烯铜绿假单胞菌(carbapenem resistant pseudomonas aeruginosa,CRPA)的经验。方法:选择我院收治两例左肾结石合并尿培养为CRPA的患者,经积极抗感染治疗后,病例一行左侧经皮肾镜碎石术,病例二先行右肾穿刺造瘘术成功后行左侧经皮肾镜碎石术,观察分析两例患者术后结石清除情况,术中术后出现发热、腰痛、大出血、尿路损伤及肾功能衰竭等并发症情况。结果:两例患者术后复查双J管位置良好,结石基本清除;术中、术后均未出现发热、腰痛、大出血、尿路损伤及肾功能衰竭等并发症。结论:经过合适的围手术期处理,一期微通道经皮肾镜碎石术治疗感染性结石合并尿培养为耐药菌的患者是安全可行的。     

Ultrasonic Destruction of Kidney Stones

Kidney stones may be removed without using a surgical incision by a combination of techniques and skills recently developed in the fields of urology and radiology. Percutaneous access to the kidney is established under fluoroscopic control. A guide wire placed into the renal pelvis allows a nephroscope to be inserted and the collecting system visualized. A long hollow metal probe is advanced through the nephroscope and placed in contact with the stone. This probe conducts the ultrasonic energy. The stone absorbs the energy and breaks into fine granules, which are evacuated by suction.Twenty-three consecutively seen patients presenting with 27 upper urinary tract calculi for which removal was indicated underwent successful percutaneous ultrasonic lithotripsy. Fifteen stones were located in the renal pelvis, eight in a calix, three at the ureteropelvic junction and one in the upper ureter. One infected staghorn calculus was removed. Two complications resulted in extended hospital stays, but in no patients were surgical incisions required. Of the 23 patients, 9 had previously had a surgical lithotomy. The authors believe that most renal and upper ureteral calculi for which removal is indicated may be extracted percutaneously with the aid of the ultrasonic lithotriptor. The patients may expect a rapid convalescence with diminished pain.     

Ureteroscopic management of upper urinary tract urothelial malignancies

The endoscope has made the transition from diagnostic tool to therapeutic aid in the upper urinary tract in recent years. Because of success using the ureteropyeloscope in the treatment of patients with upper tract stones and strictures, investigators are now looking at endoscopic management of urothelial malignancies above the bladder.