Success Of Extracorporeal Shock Wave Lithotripsy Research Articles

Absence of apolipoprotein E4 genotype, good gallbladder motility and presence of solitary stones delay rather than prevent gallstone recurrence after extracorporeal shock wave lithotripsy

Background/Aims : Extracorporeal shock wave lithotripsy (ESWL) with adjuvant bile salt dissolution therapy may be successful in selected gallstone patients, but the considerable risk of recurrence is a major drawback. Apolipoprotein E4 genotype and impaired gallbladder motility have been identified as major risk factors for recurrence during short-term follow up. We have now examined their relevance during long-term follow up. Methods : Eighty-four cholesterol gallstone patients (55 solitary and 29 multiple (two to ten) stones) were followed prospectively up to 10 years after complete stone disappearance. Various potential risk factors for recurrence were evaluated. Results : Gallstone recurrence was found in up to 80% of patients at 10 years follow-up. Absence of the apolipoprotein ε4 allele, initial solitary stones, good gallbladder emptying (i.e. minimal postprandial volume ≤6 ml) and 2-year postdissolution ursodeoxycholic acid prophylaxis (in ten patients) all delayed but did not prevent recurrence. In contrast, regular use of non-steroidal anti-inflammatory drugs (NSAIDs) was identified as an independent protective factor, with greatly decreased recurrence (at 10 years: 58 vs 93% in non-NSAID users, P=0.03 ). Conclusions : Non-apolipoprotein E4 genotype, presence of solitary stones and good gallbladder emptying delay rather than prevent recurrence after initially successful ESWL. Regular use of NSAIDs may prevent recurrence.

Long-term Results after Successful Extracorporeal Gallstone Lithotripsy: Outcome of the First 120 Stone-free Patients

Background: Long-term results after successful extracorporeal shock wave lithotripsy (ESWL) of symptomatic gallbladder stones are determined by stone and complaint recurrence. The long-term outcomes of the first successfully treated patients of our Department are presented. Methods: The first consecutive 120 patients with symptomatic gallbladder stones who became stone-free after ESWL plus oral bile acids in the years 1986 and 1987 were included in this study. They were followed up at 1-to 2-year intervals clinically and by ultrasonography until April 1998. Recurrence of stones and biliary symptoms and subsequent treatment were recorded. The effect of various factors on recurrence was analyzed. Results: Median follow-up time was 6.0 years for all patients and 8.8 years for patients without recurrence (range, 0-11.2 years for both). Actuarial recurrence probability was 1.9%-16.6% per year reaching 60.2% (49.9%, 70.3%) (95% confidence interval) after 10 years. Patients with stone recurrence revealed significantly more stones before ESWL than patients without recurrence (P < 0.03). Other factors were not significantly different. The majority of stone recurrences were symptomatic requiring retreatment, mostly cholecystectomy. Conclusion: The probability of gallbladder stone recurrence after successful ESWL remains high during a decade of follow-up. Many patients require repeated nonsurgical treatment or cholecystectomy. Thus long-term results are unsatisfactory and ESWL should be offered only exceptionally.

Factors Affecting Gallstone Recurrence After Successful Extracorporeal Shock Wave Lithotripsy

Ninety-six patients treated successively for symptomatic cholelithiasis with extracorporeal shock wave lithotripsy (ESWL) and oral bile acid therapy consisting of ursodeoxycholic acid in daily dosages of 600 mg were prospectively followed for gallstone recurrence for a median of 13 months. Ultrasonography was performed to detect stone recurrence at 3, 6, and 12 months, and then yearly after the termination of therapy. Recurrent stones were found in 17 patients (18%). The cumulative probability of gallstone recurrence was 15.8% at 12 months, 26.1% at 24 months, and 30.7% at 36 months. The probability of stone recurrence over the entire period of observation was not dependent on stone number, whereas the median interval to detection of recurrence was significantly shorter in the patients with multiple stones (2 months) than in those with solitary stones (8 months) (p < 0.05). The rate of impaired gallbladder contractility was higher in patients with recurrence (8/15, 53.3%) when compared with those with no recurrence (15/72, 20.8%) (p < 0.01). Neither age, gender, or stone characteristics predicted stone recurrence. Only one patient with a recurrence reported biliary pain. Of the 15 patients with recurrent stones who opted for further nonsurgical treatment, complete stone disappearance was achieved in 10. Impaired gallbladder function may predict gallstone recurrence after ESWL.

Extracorporeal shock wave lithotripsy for a ureteral stone in crossed fused renal ectopia

A 63-year-old woman presented with right flank pain and macroscopic hematuria. A plain film showed a calcific shadow on the right iliac bone. On excretory urography, the right kidney was seen in the normal position, but the left kidney was not. Bilateral retrograde pyelogram revealed the S-shaped kidney and mild obstruction from a 12 x 5 mm calculus in the proximal ureter of the crossed kidney. The patient was successfully treated with in situ extracorporeal shock wave lithotripsy (ESWL) treatment and is stone free at 1 month follow up. We believe this is the first case of successful ESWL in a crossed kidney.

10-year-follow-up of gallstone recurrence after successful extracorporeal shockwave lithotripsy (ESWL)

10-year-follow-up of gallstone recurrence after successful extracorporeal shockwave lithotripsy (ESWL)

Fate of residual fragments after successful extracorporeal shock wave lithotripsy.

The aim of the present study was to investigate the reason residual fragments from upper urinary tract calculi failed to clear after successful extracorporeal shock wave lithotripsy (ESWL). Risk factors were analyzed in 161 patients with residual fragments (< or = 4 mm) that had remained for more than 3 months after ESWL. The factors examined in the present study were gender, a history of urolithiasis, the number, location and size of stones, hydronephrosis 3 months after ESWL and bacteriuria before ESWL. The mean follow-up period was 20.0 months (range 6-69 months). The overall stone-free rate was 14.3%. The stone-free rate in patients with multiple stones or hydronephrosis 3 months after ESWL was significantly lower than that in patients without these conditions (P < 0.05 and P < 0.01, respectively). The cumulative non-clearance rate in patients with hydronephrosis was significantly higher than in patients without this condition (P < 0.05). Results of Cox's proportional hazards model indicated that hydronephrosis was the most important and only significant factor for failure to clear of the seven factors investigated (P < 0.05). Hydronephrosis was most highly correlated with the fate of residual fragments after ESWL.

Gallstone recurrence after successful shock wave therapy: the magnitude of the problem and the predictive factors.

Reports concerning long term recurrence of gallstones after successful extracorporeal shock wave lithotripsy (ESWL) show a high probability of stone recurrence. There is still discussion on the factors influencing stone recurrence. In this study we wanted to evaluate the long term recurrence of gallstones after stone clearance with ESWL and oral bile acids, and to assess possible risk and preventive factors of stone recurrence. A total of 322 consecutive patients with stone clearance between December 1988 and December 1995 were included. All patients were contacted for ultrasonography and were interviewed for additional information on daily intake of aspirin, NSAIDs, cholesterol lowering medication, estrogen therapy, and biliary pain during follow-up. A total of 187 patients were still stone-free after a mean follow-up of 35 months (range: 3-89 months); 135 patients had recurrence. There was a significant association between stone recurrence and estrogen intake (p = 0.04), number of lithotripsy sessions (p = 0.0007), time until stone disappearance (p = 0.0003), and biliary pain (p < 0.0001). There was no difference in recurrence rate between solitary and multiple stones. Long-term recurrence of gallstones after lithotripsy is high: < or = 69% after 6 yr. We found a significant association of stone recurrence with estrogen intake, number of lithotripsy sessions, and time until stone disappearance. Intake of aspirin or NSAIDs was not associated with decreased stone recurrence. Of the patients with recurrent stones, 57% had biliary pain.

Gallstone recurrence after successful shock wave therapy: the magnitude of the problem and the predictive factors

Objective: Reports concerning long term recurrence of gallstones after successful extracorporeal shock wave lithotripsy (ESWL) show a high probability of stone recurrence. There is still discussion on the factors influencing stone recurrence. In this study we wanted to evaluate the long term recurrence of gallstones after stone clearance with ESWL and oral bile acids, and to assess possible risk and preventive factors of stone recurrence. Methods: A total of 322 consecutive patients with stone clearance between December 1988 and December 1995 were included. All patients were contacted for ultrasonography and were interviewed for additional information on daily intake of aspirin, NSAIDs, cholesterol lowering medication, estrogen therapy, and biliary pain during follow-up. Results: A total of 187 patients were still stone-free after a mean follow-up of 35 months (range: 3–89 months); 135 patients had recurrence. There was a significant association between stone recurrence and estrogen intake ( p = 0.04), number of lithotripsy sessions ( p = 0.0007), time until stone disappearance ( p = 0.0003), and biliary pain ( p < 0.0001). There was no difference in recurrence rate between solitary and multiple stones. Conclusions: Long-term recurrence of gallstones after lithotripsy is high: ≤69% after 6 yr. We found a significant association of stone recurrence with estrogen intake, number of lithotripsy sessions, and time until stone disappearance. Intake of aspirin or NSAIDs was not associated with decreased stone recurrence. Of the patients with recurrent stones, 57% had biliary pain.

“Mirror Pain” as an Unusual Presentation of Renal Colic

Although most patients suffering from pain related to upper urinary tract stones feel the discomfort on the same side as the stone, rarely it is perceived on the opposite side. We sought to identify the prevalence of this clinical scenario and to review possible explanations. The charts and x-rays of all patients with unilateral, symptomatic, radiologically identifiable upper urinary tract stones, seen at an outpatient clinic between June 1993 and August 1996, were reviewed retrospectively in terms of the side of the discomfort in comparison to the side of the stone. Three of 631 patients presented with contralateral or “mirror pain” secondary to a renal or ureteric calculus. In each case the symptoms resolved completely following successful extracorporeal shock wave lithotripsy or spontaneous passage of the stone.

Childhood urolithiasis: urological management of upper tract calculi in the era of extracorporeal shock-wave lithotripsy.

To evaluate the management of urolithiasis in children since the development of extracorporeal shock-wave lithotripsy (ESWL). Between 1988 and 1994, 37 children, aged from 2 to 15 years (mean 10), with upper tract urolithiasis were evaluated and treated. Lithogenic metabolic disorders or anomalies of the urinary tract were present in 11 children (30%) Urolithiasis was multiple in 9 cases and bilateral in 2 cases. A total of 47 renal (30) or ureteral (17) stones were managed, of which 5 were partial or complete staghorn calculi. Initial treatment was surgery in 4 cases (1 nephrectomy, partial nephrectomy and 2 pyelolithotomies) and piezoelectric ESWL in 43 cases. The overall ESWL success rate was 82.2%, with auxillary endoscopic procedures in 3 cases. ESWL failures required surgical stone removal in 5 cases, endoscopic ureterolithotripsy in 1 case and electrohydraulic ESWL in 1 case. Residual fragments after pyelolithotomies were also treated by ESWL. ESWL is the mainstay of treatment of childhood upper tract urolithiasis, but other therapeutic methods retain specific indications. Its application requires great vigilance and its long-term effects are uncertain. It is therefore important to rule out any underlying pathology and where possible to prevent further stone formation.

Implications of cavitation phenomena for shot intervals in extracorporeal shock wave lithotripsy

To study the influence of shot intervals and the quality of the coupling medium (degassed water) in extracorporeal shock wave lithotripsy (ESWL). Acoustic scattering and damping (and thereby also the focal size) were modelled with respect to the conditions of the coupling medium, using continuous wave high intensity ultrasound. The influence of the shot interval on rise time and attained shock wave pressure were quantified with a modified ESWL apparatus and a specially designed hydrophone. In tap water, which has a high content of dissolved gases, the focus produced was bulb-shaped, with a diameter of approximately 4 cm, whereas degassed water gave a small focus that produced a water jet only a few millimetres in diameter. The efficacy of the acoustic energy decreased with shot intervals shorter than 1.2s. Longer pauses resulted only in prolonged treatment times. ESWL becomes inefficient if the intervals between pulses are too short, particularly when ECG R-wave triggered pulses are used on patients with tachycardia. The gas content of the coupling medium is also important for successful ESWL. The efficacy of the system used for degassing the water should be checked at regular intervals.

Intracorporeal Shock Wave Lithotripsy (ISWL) in Bile Ducts under Peroral Endoscopy: Progress and Current Status

Abstract:Attempting to use ISWL (intracorporeal shock wave lithotripsy) for treating large and difficult biliary stones was started in the mid 1970s, approximately 10 years before the introduction of ESWL (extracorporeal shock wave lithotripsy). However, in contrast to ESWL, ISWL did not quickly become popular in practise. The main reason for this delayed recognition, undoubtedly, lay in the technical difficulties of the peroral applications until the mid 1980s, when the development of an improved cholangios‐cope system and a thin, flexible probe allowed the use of EHL (electrohydraulic lithotripsy) under direct vision during peroral cholangioscopy. Thanks to recent advances in technology, a powerful pulsed laser has begun to be used for ISWL through a 0.2 mm sized quartz fiber. A laser version of ISWL with such a thin probe is expected to facilitate its use by minimizing the endoscope system. The automatic stone‐tissue recognition system which interrupts the laser discharge in case of wall contact is another useful advance in technology which increases the safety and therapeutic efficacy. Whereas laser techniques are still in development, ISWL with a laser will be the first choice technique for treating difficult bile duct stones after failure of mechanical lithotripsy and it also promises to improve its therapeutic efficacy for intrahepatic stones in combination with ESWL.In this article, the recent progresses and results of ISWL treatment were reviewed with a respect to the success of ESWL.

Prognosis after Extracorporeal Shock Wave Lithotripsy of Radiopaque Renal Calculi: A Multivariate Analysis

To obtain a better understanding of the prognostic factors influencing treatment outcome after extracorporeal shock wave lithotripsy (ESWL), a multivariate logistic analysis of the data from 246 patients has been undertaken. All of the patients were treated with the Dornier lithotriptor HM-3 for radiopaque renal calculi. Treatment success was defined as stone-free within 3 months of one ESWL session and without adjuvant measures after ESWL. In a first analysis, 210 patients with solitary and multiple calculi without adjuvant measures before ESWL were studied. Of 210 patients, 141 (67%) were free from stones after 3 months). Significant influences on the success rate were body mass index and stone number. In a second analysis only those 160 patients with solitary calculi were considered. In this group, age, body mass index, stone location, stone burden and serum calcium significantly influenced the prognosis. When patients with adjuvant measures were added to the analysis an increasing prognostic importance of the stone burden was seen. In patients with a small to medium stone burden (< 4.0 cm3), the number of stones seemed to be more important than the stone burden. Patients appear to have the best chance for successful ESWL when their body mass index is between 20 and 28, their age is between 40 and 60 years, their stones are in the renal pelvis and solitary, the stone burden is < 1.0 cm3, and when their serum calcium is normal.

Electrohydraulic extracorporeal non‐water bath shock‐wave lithotripsy of gallstones: Two years' experience

A prospective study was performed to evaluate the effectiveness of extracorporeal shockwave lithotripsy (ESWL) using a non-water bath lithotripter in combination with oral chemolitholysis on gallstone clearance. Patients were treated without general anesthesia or parenteral analgesia. We treated 74 patients selected according to the widely accepted criteria. Only 2 patients could not be sufficiently treated because of pain. After a 2 year period, 24 (32%) patients showed complete stone clearance, 35 (47%) patients had residual fragments, 5 (7%) patients underwent cholecystectomy, 2 (3%) patients were lost to follow up, and 8 (11%) patients discontinued the treatment before fragment clearance. According to the life-table estimate, 77% of our patients with successful ESWL and uncomplicated oral chemolitholysis are stonefree after 1 year. We consider the major advantage of this nonsurgical treatment of gallstone disease is that general anesthesia or parenteral analgesia has become unnecessary.

Gallbladder stone fragments in feces after biliary extracorporeal shock-wave lithotripsy

All stools passed on the first 3 days after extracorporeal shock-wave lithotripsy of gallbladder stones in 21 patients were collected and examined for the presence of stone fragments. A total of 555 fragments varying in number per patient (4–69) and in size (maximum diameters from 0.5–8.0 mm) were recovered by sieving aqueous suspensions of the feces. All 482 fragments <-3.0 mm left the biliary tract without any clinical symptoms, as did the three largest fragments with maximum diameters of 7.0–8.0 mm and almost all of the 70 fragments measuring 3.5–5.0 mm. During the observation period, four episodes of biliary complaints were recorded in three patients in whom fragments with maximum diameters of 3.5–5.0 mm were found. The only chemical abnormality was a temporary elevation of lipase activity to twice the normal range in 1 case. All fragments were identified as gallbladder stones by infrared spectroscopy on the basis of their (varyingly high) cholesterol content. By macroscopic criteria, most of the fragments were from mixed stones; therefore, provided there is a functioning gallbladder and sufficiently fine fragmentation, successful extracorporeal shock-wave lithotripsy does not seem to be limited to pure cholesterol stones.

Extracorporeal shock-wave lithotripsy in hemophiliac patient

We report on a patient with hemophilia A who underwent successful extracorporeal shock-wave lithotripsy without incident. We are aware of two other reported cases in the literature. The relative risks of alternative methods of stone management and the indications and risks of blood product therapy in this condition are reviewed.

Treatment Options for Proximal Ureteral Urolithiasis: Review and Recommendations

The treatment of proximal ureteral calculi has been altered markedly by recent developments in shock wave lithotripsy (bypass, pushback and in situ), ureterorenoscopy and percutaneous stone removal. In an effort to discern the proper role of these newer treatment options with respect to ureterolithotomy (flank approach or dorsal lumbotomy), we completed a multicentered study in which 142 upper ureteral stone patients in 7 different treatment categories were reviewed retrospectively and contacted for convalescence data. From these data we conclude that before extracorporeal shock wave lithotripsy an upper ureteral stone should be manipulated until it is either pushed back to the kidney or bypassed with a stent. This maneuver should result in successful extracorporeal shock wave lithotripsy in more than 90 per cent of the patients. For those few patients with an impacted upper ureteral calculus ureterorenoscopy is recommended. Given the presently available treatment modalities we conclude that less than 3 per cent of all upper ureteral calculi will require ureterolithotomy. In this last circumstance a dorsal lumbotomy incision appears to be less morbid and yet as effective as anterior ureterolithotomy.

Effects of Extracorporeal Shock Wave Lithotripsy on Cardiac Pacemakers and its Safety in Patients with Implanted Cardiac Pacemakers

Effects of extracorporeal shock wave lithotripsy (ESWL) were studied on 15 pacemakers (standard single chamber n = 5, dual chamber n = 6, rate responsive single chamber [Activitrax] n = 4). In-vitro testing involved suspending the pacemakers in a bath of degassified, deionized water firmly taped to a platform at the point of maximal pressure, i.e., second focal point (F2), where they received pressure shocks (means = 1300) from the HM3 Dornier lithotriptor. The pacemakers, programmed to their most sensitive setting, were continuously pacing at nominal outputs (atrial and ventricular pacing in the DDD mode). All units were assessed by a pacing system analyzer before and after the study, then underwent destructive analysis. During standard single chamber pacing (VVI) the pacing stimulus triggered ESWL. For dual chamber devices, ESWL was triggered by the atrial paced event which induced inhibition of the ventricular output in two pacemaker. This was eliminated by reprogramming to a less sensitive setting. The pacemaker can, hermetic seal and internal circuitry were undamaged in all units. Two rate responsive single chamber pacemakers had their activity sensing piezoelectric elements shattered when placed at F2. Two other units placed 5 cm from F2 were stimulated to their maximum upper programmed pacing rate with ESWL therapy, but were otherwise unaffected. Subsequent to this study, six patients with pacemakers programmed to the VVI (five), DDD (one) modes implanted in the thorax underwent successful ESWL without pacemaker or arrhythmic event. (A) It is generally safe for patients implanted with standard single chamber devices in a ventricular application to undergo ESWL without modifying the pacing/sensing parameters. (B) Patients implanted with dual chamber devices who pace in the atrium should be reprogrammed to the VVI mode during ESWL. (C) Patients with piezoelectric activity sensing rate responsive single chamber pacemakers should have this feature programmed off during ESWL and, if implanted in the abdomen, probably should not undergo ESWL.

Primary choice of intervention for distal ureteric stone: ureteroscopy or ESWL?

Either transurethral ureteroscopy (URS) or extracorporeal shock wave lithotripsy (ESWL) was the primary method of intervention in two series of patients presenting consecutively with stones located in the ureter distal to the radiological marking of the sacroiliac joint. Of 65 patients treated by URS, successful evacuation of the major part of the stone was achieved in 97% in one or two sessions. Of those subsequently attending for review, 93% proved stone-free but 3% required surgery for serious complications. In the ESWL series of 53 patients, successful stone fragmentation was recorded in 94%, with 2 patients requiring a supplementary endourological or surgical procedure. No significant complications were related to ESWL and 90% of those followed up after successful ESWL proved stone-free at 6 weeks. In uncomplicated cases, the mean procedure time for ESWL was one-third of that required for URS and the hospital stay one-half. It is suggested that ESWL should be the primary method of intervention in patients with distal ureteric stone, with URS reserved for the small number that prove refractory to such treatment.

Extracorporeal Shock Wave Lithotripsy and its Effect on Renal Function

Extracorporeal shock wave lithotripsy has become a major treatment modality for symptomatic upper tract renal stone disease. Although proved to be effective in disintegrating stones the short-term and long-term effects on renal function are not yet known.We evaluated several basic physiological parameters, namely creatinine clearance, fractional sodium excretion, protein excretion and urine osmolality before and after extracorporeal shock wave lithotripsy in 26 consecutive patients in an attempt to quantitate changes in renal function. In addition, a 3 to 6-month followup study of patients showing excessive protein excretion with extracorporeal shock wave lithotripsy also is reported.Our data suggest that with extracorporeal shock wave lithotripsy transient nephrotic range proteinuria occurs immediately after treatment, returning to normal values within 3 to 6 months after treatment without a change in the glomerular filtration rate. The glomerular filtration rate increases after successful extracorporeal shock wave lithotripsy in patients with kidneys obstructed by the treated stone before the start of the procedure, and the kidney appears to maintain its ability to dilute urine and to conserve sodium after treatment.