Average Number Of Shock Waves Research Articles

A randomized study to compare extracorporeal shockwave lithotripsy with or without intravenous anaesthesia

Background: The lifetime prevalence of kidney stone disease is estimated at 1-15%. The various treatment options available for urinary calculus disease are open surgery, ureterorenoscopy, percutaneous nephron-lithotomy retrograde intra-renal surgery & extracorporeal shock wave lithotripsy. The aim of the study was to study whether performing extracorporeal shockwave lithotripsy (ESWL) under intravenous anesthesia can reduce no. of sessions by increasing intensity of shockwaves and its comparison with ESWL under local anesthesia and also to study the safety of higher intensity shock waves. Methods: The nucleus of this prospective study done between March 2011 to February 2015 was 60 patients with renal or upper ureteric solitary calculus less than or equal to 2 cm in size, in which ESWL is elected as the treatment. These were randomized into one of the two groups with 30 patients in each - Group I: in which patients underwent ESWL under IV anesthesia & group II: in which patients underwent ESWL under local anesthesia. Results: For age group, P value of age difference of the two groups was 0.6 and not significant. During the study it was found that there was statistically significant reduction in number of sessions required for complete stone clearance in Group I. In group I the average number of shock waves used was 3800, whereas in group II it was 5967. The P value of difference between the means was extremely significant (P =0.003). Time taken for clearance of stone in group I was 1 month in 22 patients and 3 months in 8 patients with the average being 1.53. In group II time taken for clearance was 1 month in 9 patients and 3 months in 21 patients and the mean was 2.4. Conclusions: The use of total intravenous anesthesia (TIVA) for ESWL reduces the number of sessions significantly by allowing higher intensity and number of shock waves & improved fragmentation due to regular and controlled respiratory excursions, and immobility of the patient, leading to significantly less wastage of shockwaves when compared to ESWL without TIVA.

Extracorporeal Shock Wave Lithotripsy Monotherapy for Renal Stones >25 mm in Children

To determine the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) as monotherapy for renal stones >25 mm in children. Our prospective study included 24 children <14 years old with radiopaque renal stones >25 mm treated by ESWL as first-line treatment using the electromagnetic Dornier DoLi S device. Pretreatment kidney, ureter, and bladder plain films and intravenous urography and post-treatment ultrasonography and kidney, ureter, and bladder plain films were used to monitor the clearance of fragments. Stone clearance was assessed at 1 and 3 months. A stone-free state was defined as no radiologic evidence of stone. Asymptomatic noninfectious and nonobstructive fragments <3 mm were considered insignificant. The 24 children, aged 2-14 years (mean 7) underwent 53 ESWL sessions. Of the 24 children, 10 had stones located in the left kidney and 14 had stones located in the right kidney. The stone size was 25-35 mm (average 31). The average number of shock waves was 3489 per session. All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. The overall stone-free rate was 83.3%. Four patients had clinically insignificant fragments and were followed up for the possibility of stone regrowth, microscopic hematuria, and urinary tract infection. Complications affected 25% of patients. ESWL is highly effective for treatment of large renal stones in children as a first-line treatment with minimal morbidity. The placement of a stent is not a prerequisite for success of treatment.

Extracorporeal shock-wave lithotripsy monotherapy in renal pelvic ectopia

Objectives To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of urinary stones in pelvic kidneys. Methods Fourteen male patients with renal pelvic ectopia and stones were treated with ESWL monotherapy using the unmodified Dornier HM3 lithotriptor with its original generator and ellipsoid. Twelve patients were treated in the prone position using cystoscopically placed ureteral catheters to aid in fluoroscopic localization, whereas 2 patients were treated in the supine position. A review of their stone disease, ESWL treatment, ancillary procedures, outcome, and complications is presented. Results All pelvic kidneys were free of infection and obstruction in this group. The mean stone burden was 30.2 ± 37.8. Most patients required a single session (9 of the 14 [64%]), 2 patients required two sessions, and 2 patients required multiple sessions. The average number of shock waves per session was 1689 (range 450 to 3500), with average kilovoltage of 21.5 (range 18 to 24). Eighty-two percent of the patients followed (9 of 11 ) were stone-free at 3 months. No ancillary endourologic procedures were required to deal with the presenting stones. Obstructive steinstrasse complicated treatment in only 2 patients (14%) and was successfully treated by further ESWL in both patients; in 1 of them, ureteroscopy was needed. Conclusions ESWL monotherapy of renal pelvic ectopia stones is very effective and should be considered as the first therapeutic option for these patients, provided that accurate localization of the stone treated and proper positioning of patients that ensures adequate delivery of shock-wave energy can be maintained.

In situ extracorporeal shock wave lithotripsy (ESWL) for the management of primary ureteric calculi in children

Lithotripsy was used to treat 19 children (3 to 16 years of age) with primary ureteric calculi. No attempts were made to mobillize the stones to the kidney. Stones were located in the upper ureter in seven patients, middle ureter in three, and lower ureter in nine. Stone size ranged from 5 to 25 mm (average, 10.4 mm). All treatments were performed in the outpatient unit. Two children required general anesthesia, and 17 received intravenous sedation. The mean amount of energy used was 17.8 kV, and the average number of shock waves was 5,489. Before commencement of lithotripsy, two patients needed ureteric catheterization, and two had placement of double pigtail catheters. Of the 18 children who had adequate follow-up, 17 (94.4%) were completely stone-free, without any complication. The authors conclude that in situ extracorporeal shock wave lithotripsy is a safe and effective method for the treatment of primary ureteric calculi in children.

Extracorporeal Shock Wave Lithotripsy for Obstructed Proximal Ureteral Stones

In an attempt to assess the usefulness of a ureteral stent in facilitating disintegration of obstructed proximal ureteral stone with extracorporeal shock wave lithotripsy (ESWL), a prospective randomized study on 120 patients with ultrasonic evidence of hydronephrosis whose stone sizes were greater than 1.0 x 0.6 cm on KUB film and located above the level of L5 were allocated into three distinct treatment strategies: group 1: in situ without stone manipulation; group 2: bypass stones with stent, and group 3: placement of a catheter below stone with continuous saline irrigation. Of 77 patients, 26, 27 and 24 in each group, followed up for a period of 6 months with sufficient data for analysis, the stone-free rates were 76.9, 59.3 and 62.5%, respectively. The average number of shock waves delivered to accomplish a stone-free state were 3,245, 3,250 and 3,880 for individual groups and the comparisons among them were statistically insignificant (p's > 0.1). ESWL retreatment was common, being 33.3, 29.4 and 43.8%, respectively. Hydronephrosis has a major impact on the outcome of ESWL treatment, as more stone-free cases were found in the mildly hydronephrotic category than in the severer counterparts. About 90% of cases who finally were stone-free, passed all their stone fragments within 28 days. Ancillary procedures were needed in 13 (16.9%), 7 received ureterolithotomy, whilst 6 were removed of their stones by ureteroscopy.

Extracorporeal Shock Wave Lithotripsy with Dornier MPL-9000 in 2005 Patients

From October 1988 through December 1990, we treated 1221 male and 784 female patients aged 2 to 84 years for urolithiasis using the Dornier MPL-9000 lithotripter. Stones were located in calices or the renal pelvis in 34% of cases each, in the ureter in 17%, and in the bladder in 0.8%. Twelve per cent of the stones were branched renal calculi. The mean volume of the stones was 16 cm3 for branched calculi, 8 cm3 for renal pelvic calculi, 1.8 cm3 for caliceal calculi, 1.5 cm3 for ureteral calculi, and 19 cm3 for vesical calculi. In the 35% of patients who had stone volumes larger than 5 cm3, a ureteral stent was introduced before treatment. The kilovoltage was adjusted according to the size and location of the calculi. The average number of shock waves was 2150. It was necessary to re-treat 35% of the patients, with some having as many as 10 sessions, and the total number of sessions in the series was 3380. However, it proved possible to fragment 94% of the stones, with 80% of the patients being stone free at 3 months. The most frequent complications were ureteral obstruction and hydronephrosis (5.4%), infection hydronephrosis (3.5%), and pyonephrosis necessitating open operation (0.8%). The real-time imaging provided by the Dornier MPL-9000 lithotripter assures correct targeting of every shock wave. Many patients were repositioned during the session to maximize stone destruction.

Treatment of Ureteral Calculi with Extracorporeal Shock Wave Lithotripsy using the Lithostar Device

Shock wave requirements for fragmentation and the ultimate outcome after extracorporeal shock wave lithotripsy (ESWL†) with the Lithostar device were analyzed in 107 renal units with solitary ureteral calculi. In situ treatment was done in 54 stones without prior manipulation and in 15 after failure of endoscopic manipulation. A total of 25 ureteral calculi was treated after bypass with a ureteral catheter or stent and 13 after push back to the pelvicaliceal system. Shock wave requirement for fragmentation was significantly higher for calculi of 101 to 400mm. × mm. when compared with the requirement for smaller calculi. Shock wave requirement was also significantly higher for patients with similar sized stones treated in the prone compared to the supine position. The average number of shock waves required for disintegration was not significantly different among in situ or any of the manipulation categories of similar sized stone populations. Over-all satisfactory clearance was achieved in 77.5% of the treated ureteral calculi. Clearance status was unaffected by size up to 400mm. × mm. and the position of the patient during treatment (prone or supine). Clearance of ureteral stones treated in situ without prior manipulation (76.5%) was numerically inferior, although statistically insignificant, to that for successfully manipulated calculi (bypassed 88% and pushed back 92.3%) but it was significantly better than the outcome obtained after failed manipulation (46.2%). ESWL with the Lithostar device is a successful mode of treatment within the entire ureteral length, and a vigorous attempt at push back before lithotripsy is unnecessary.

Evolution of Pre-Treatment Stenting and Local Anesthesia for Extracorporeal Shock Wave Lithotripsy at a Single University Center

Evolution of the extracorporeal shock wave lithotripsy technique involves not just second generation technology but operator innovations and experience. Retrospective analysis of the first 512 treatments at a university medical stone unit using the Dornier HM3 lithotriptor was compared to 3 intervals of 100 consecutive treatments during the next 2-year period (1985 to 1987). Patient referral and selection as well as treatment techniques and rates of endourological interventions were analyzed.Patient demographics, stone types and retreatment rates remained constant during 2,500 treatments. However, the use of local anesthesia and internal ureteral stents became increasingly common. Of the 1987 cohort 29% were treated with the patient under local anesthesia, and 23 of the 44 with a stent (52%) received internal ureteral stents. Other treatment trends identified during the study period included increasing number of large (greater than 2cm.) and multiple stones treated; increasing use of internal and external ureteral catheters before treatment, fewer stents for small, mobile renal calculi and decreasing length of hospital stay (2.7 to 2.1 days) with increasing use of stents before lithotripsy. The increasing average number of shock waves per treatment (1,382 versus 1,580) during the study period can be attributed to the larger proportion of patients with high stone burdens and the impact of an increased number of operators with more varied criteria for endoscopy and treatment end point. (J. Urol, 143: 257–260, 1990).

Treatment of Proximal and Midureteral Calculi: A Randomized Trial of In Situ and Pushback Extracorporeal Lithotripsy

In the application of extracorporeal shock wave lithotripsy for proximal ureteral and midureteral stones, both the in situ and the pushback or "push-bang" treatments are recommended. In our center, 47 patients (38 males, 9 females) with uncomplicated ureteral stones were randomized to one of these methods and evaluated after 3 months. The group having in situ treatment consisted of 23 patients and the group having the pushback treatment of 24 patients. All patients were treated with the Siemens Lithostar. In the in situ group, only seven patients needed intravenous analgesia or sedation. The average number of shock waves delivered was 3100. After 3 months, 21 patients (91%) were free of stones. No major complications were noted. In the pushback group, 15 patients (all males) needed epidural anesthesia and two intravenous analgesia or sedation. The pushback was successful in only 9 patients (37.5%); the average number of shock waves delivered was only 2000. Those nine patients were free of stones after 3 months. The pushback failed in 15 patients, and they were treated with the stones in situ. The average number of shock waves was 3100; 11 of the 15 (73%) were free of stones after 3 months. In the pushback group, one serious complication occurred: one patient suffered a severe headache after epidural anesthesia. Epidural anesthesia is mandatory for all men in this group. We conclude that, in spite of the higher number of shocks, in situ treatment of proximal and midureteral calculi is preferable to pushback, especially in men.

The Role of Lithotripsy and Its Side Effects

The relative roles of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy currently are being debated. Both treatment modalities are applicable to most upper urinary tract calculi. However, there are some important distinctions between the 2 techniques. Over-all, extracorporeal shock wave lithotripsy is associated with significantly lower morbidity than percutaneous nephrostolithotomy but stone-free rates are lower for extracorporeal shock wave lithotripsy than for percutaneous nephrostolithotomy. This difference is slight for kidneys containing minimal stone burden but increases in direct proportion to increasing stone burden. The morbidity of extracorporeal shock wave lithotripsy also increases with increasing stone burden. When applied to the treatment of staghorn calculi the morbidity of both techniques is comparable but the stone-free rates are significantly better with percutaneous nephrostolithotomy.Treatment with extracorporeal shock wave lithotripsy produces changes in the kidney similar to that of renal trauma, consisting primarily of intraparenchymal and perirenal hemorrhage and edema. While the acute effects of extracorporeal shock wave lithotripsy are well tolerated by most patients, the long-term sequela of this form of therapy is not well established. Potential long-term adverse effects reported include loss of renal function, hypertension and an increased rate of new stone occurrence. The effect of shock waves on renal parenchyma in experimental animals is dose-dependent (number of shock waves). Magnetic resonance imaging of patients treated with extracorporeal shock wave lithotripsy demonstrates morphological abnormalities in or around the kidney in 63 to 85 per cent of the cases (average number of shock waves 1,200). Despite these observations the safe limits of extracorporeal shock wave lithotripsy in humans have yet to be established. Further study regarding this issue and the potential long-term adverse effects of extracorporeal shock wave lithotripsy is needed urgently.