Extracorporeal Shock Wave Lithotripsy Research Articles

Extracorporeal Shock Wave Therapy (eSWT) in Spinal Cord Injury-A Narrative Review.

Injury of the spinal cord causes motor and sensory dysfunction as well as pathological reflexes, leading to paraplegia or tetraplegia. The sequelae of traumatic spinal cord injury (SCI) are a significant burden and impact on healthcare systems. Despite constant progress in medicine, traumatic SCI still remains irreversible. To date, no satisfying treatment that can enable neuronal regeneration and recovery of function at the damaged level has been found. Hundreds of experiments have been conducted on various possibilities of influencing spinal regeneration; some of them have yielded promising results, but unfortunately, the successes obtained in experimental animals have not translated into humans. This narrative review article presents the application of extracorporeal shock wave therapy (eSWT) in patients with SCI. The article has been divided into parts: 1) use of extracorporeal shock wave therapy for regeneration of the spinal cord after traumatic spinal cord injury; 2) application of extracorporeal shock wave therapy in spasticity after spinal cord injury. In both cases, the hypotheses of possible mechanisms of action will be described. A small number of clinical trials have demonstrated the potential of eSWT to influence the regeneration of the spine, as an innovative, safe, and cost-effective treatment option for patients with SCI. Some reports have shown that eSWT can improve spasticity, walking ability, urological function, quality of life, and independence in daily life.

Response to the Commentary on "Clinical and Sonographic Evaluation of the Effectiveness of Extracorporeal Shock Wave Therapy in Patients with Lateral Epicondylitis".

Response to the Commentary on "Clinical and Sonographic Evaluation of the Effectiveness of Extracorporeal Shock Wave Therapy in Patients with Lateral Epicondylitis".

Efficacy of non-pharmacological treatments for knee osteoarthritis: A systematic review and network meta-analysis

This study aims to conduct a network meta-analysis to compare the clinical efficacy of seven distinct non-pharmacological therapies for knee osteoarthritis. We hope that our research findings can provide reference for clinical practitioners in formulating treatment plans. Through a computer-based search, we systematically retrieved randomized controlled trials (RCTs) on non-pharmacological therapies for knee osteoarthritis from eight databases, including CNKI, Wanfang, VIP, PubMed, Web of Science, Embase, Scopus, and The Cochrane Library. Following screening, data extraction, and methodological quality assessment, relevant data were included and analyzed using R 4.2.3 software. A comprehensive analysis of 24 RCTs involving 2582 patients encompassed seven diverse non-pharmacological therapies. The efficacy rankings, based on Visual Analog Scale (VAS) scores, were as follows: shock wave therapy>needle-knife>laser therapy>acupuncture>ultrasound>exercise>transcutaneous electrical nerve stimulation. Similarly, based on Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores, the efficacy rankings were as follows: shock wave therapy>needle-knife>laser therapy>acupuncture>ultrasound>transcutaneous electrical nerve stimulation>exercise. Among the three WOMAC subscales, the efficacy rankings for non-pharmacological therapies were as follows: For stiffness: laser therapy>exercise>shock wave therapy>acupuncture>needle-knife>ultrasound>transcutaneous electrical nerve stimulation; For daily activities: shock wave therapy>laser therapy>needle-knife>acupuncture>ultrasound>transcutaneous electrical nerve stimulation>exercise; For pain: shock wave therapy>needle-knife>laser therapy>acupuncture>exercise>transcutaneous electrical nerve stimulation>ultrasound. Based on the currently limited research, we can prioritize the use of shockwave therapy to treat patients with knee osteoarthritis. However, it is essential to emphasize that further rigorous and well-designed randomized controlled trials are necessary to validate the conclusions drawn from this study.

Intralesional and topical treatments for Peyronie's disease: a narrative review of current knowledge.

Peyronie's disease (PD) presents a multifaceted challenge in contemporary urological practice, marked by penile deformity, pain, and the potential for erectile dysfunction. We meticulously explored the existing literature of intralesional/topical interventions, aiming to provide clinicians with a nuanced understanding of available options for comprehensive PD management. To conduct this review, we performed a systematic search using the PubMed, Scopus, and ScienceDirect databases, including the keywords of combination of the "Peyronie's disease/plastic induration of the penis (PIP) and intralesional/topical treatments". The study selection was based on adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, resulting in the inclusion of 16 articles. We delve into the effectiveness and safety profiles of collagenase Clostridium histolyticum (CCH), interferon, platelet-rich plasma (PRP), hyaluronic acid, botulinum toxin, stem cell, extracorporeal shock wave therapy (ESWT), and traction therapy, assessing their impact on penile curvature, length improvement, and patient-reported symptoms and outcomes. The best options evaluated are intralesional injections of CCH and penile traction devices, alone or in combination. Despite PD remains a challenge for urologists, the objective of this review is to contribute to the evolving landscape of PD management, fostering informed decision-making, and personalized care for individuals grappling with this challenging condition.

Effects of supplementing extracorporeal shockwave therapy to hyaluronic acid injection among patients with rotator cuff lesions without complete tear: a prospective double-blinded randomized study.

The study investigates the combined efficacy of subacromial hyaluronic acid (HA) injections and extracorporeal shockwave therapy (ESWT) in managing rotator cuff lesions without complete tears. Eligible patients were randomized into three groups: three HA injections combined with two sham ESWT (HA), three HA injections combined with one ESWT and one sham ESWT (HA + 1 ESWT), or three HA injections combined with two ESWT (HA + 2 ESWT) with an allocation ratio of 1:1:1. Visual Analogue Scale (VAS), Constant-Murley Score (CMS), range of motion (ROM), and muscle power of shoulder abduction (MP) were assessed preintervention and at 1, 3, 6, and 12 months postinitial HA injection. Shoulder MRI was conducted before and 12 months after the intervention. All pertinent parameters showed no significant between-group differences at baseline but demonstrated significant within-group improvement throughout the study. The HA + 1 ESWT group demonstrated superior improvements in MP ( P =0.011) and CMS ( P =0.018) at 1 month, and in MP ( P =0.014) and CMS ( P =0.005) at 6 months, compared to the HA group. The HA + 2 ESWT group showed greater improvements in FF ( P =0.027), IR ( P =0.019), and SROM ( P =0.025) at 1 month, and in ABD ( P =0.022) at 6 months, compared to the HA group. Notably, the HA + 2 ESWT group exhibited greater improvements in FF ( P =0.013), IR ( P =0.019), and SROM ( P =0.025) at 1 month, and in FF ( P =0.007) at 3 months, than the HA + 1 ESWT group. Moreover, no deterioration in tendinopathy grading or tear status occurred in the HA + 1 ESWT group on MRI scans. ESWT provides additional benefits when combined with HA injections for patients with rotator cuff lesions lacking complete tears.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy and endoscopic retrograde cholangiopancreatography for pancreatic duct stone treatment in patients with chronic pancreatitis.

Extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred therapeutic approaches for painful chronic pancreatitis (CP) with pancreatic stones. This study aimed to report the short- and long-term outcomes following P-ESWL and ERCP in a large cohort with CP. Patients with painful CP and pancreatic stones >5 mm in size, who underwent P-ESWL and subsequent ERCP between March 2011 and June 2018, were included in this retrospective-prospective mixed observational study. The total stone clearance rates were recorded. All patients were followed up until the end of March 2024, with the visual analogue scale (VAS) for pain, pain type, quality-of-life scores and other relevant information recorded. A total of 2071 patients underwent P-ESWL, and 93.1% of them subsequently underwent ERCP during the study period. Patients were followed up for an average of 11.8 years from the onset of CP and 6.7 years from the first P-ESWL procedure. Complete stone clearance was achieved in 73.7% of the patients. At the end of the follow-up period, 70.1% of the patients achieved complete pain remission. Significant pain type conversion and lower VAS scores were observed in the patients after treatment. Quality-of-life scores and body mass indices increased after P-ESWL and ERCP. P-ESWL and ERCP are effective and minimally invasive treatments for pancreatic stones in patients with painful CP. Most patients achieved complete pain relief, and pain-type conversion was common after treatment. (ClinicalTrials.gov: NCT05916547).

Combined Extracorporeal Shock Wave Lithotripsy and Endoscopic Retrograde Pancreatography for Painful Chronic Pancreatitis: Is It Effective?

AbstractManagement of pain in chronic pancreatitis (CP) is challenging, and surgery used to be the intervention of choice in patients having pain refractory to medical therapy. Advancement in minimally invasive interventions resulted in a paradigm shift in the management of pain in CP. Pancreatic endotherapy is currently considered the intervention of choice for the management of ductal hypertension in CP. However, multiple mechanisms including ductal hypertension and neurogenic as well as psychological factors contribute to the causation of pain in CP and therefore no single intervention is effective in all patients. The precise role of interventional procedure in a complex disease like CP with multiple pathogenic mechanisms requires a prospective comparative study with a sham group and there are no such comparative studies in the literature. In this news and views, we discuss a recently published sham-controlled randomized trial (Combined extracorporeal shock wave lithotripsy and endoscopic treatment for pain in chronic pancreatitis (SCHOKE) trial) that examined the efficacy of extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with the sham procedure.

Endoscopic interventions in pancreatic strictures and stones-A structured approach.

Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.

Current Non-Surgical Curative Regenerative Therapies for Knee Osteoarthritis.

Osteoarthritis (OA) is a prevalent musculoskeletal disease affecting middle-aged and elderly individuals, with knee pain as a common complaint. Standard therapy approaches generally attempt to alleviate pain and inflammation, using various pharmacological and non-pharmacological options. However, the efficacy of these therapies in long-term tissue repair remains debated. As an alternative, regenerative medicine offers a promising strategy, with decreased adverse event rates and increasing evidence of safety and efficacy. This review will outline current advances in regenerative medicine for knee OA, emphasizing outpatient clinic-based therapies that use orthobiological and non-biological products. Different strategies based on orthobiologics are discussed as potential regenerative options for the management of knee OA. Cell-free therapies including platelet-rich plasma, autologous anti-inflammatories, exosomes, human placenta extract, and mitochondrial transplantation are discussed, focusing on their potential for cartilage regeneration. Additionally, cell-based therapies with regenerative properties including bone marrow aspirate concentrate, adipose stromal vascular fraction, microfat, nanofat, stem cell therapy, and genetically modified cells as part of orthobiologics, are being investigated. Also, this study is looking into non-biological approaches such as using gold-induced cytokines, extracorporeal shockwave therapy, and ozone therapy. The mechanisms of action, effectiveness, and clinical applications of each therapy are being explored, providing insights into their role in the management of knee OA.

Retrospective analysis of the efficacy of low-intensity extracorporeal shock wave therapy on young and middle-aged patients with erectile dysfunction responsive to PDE5Is: reducing the use of PDE5Is.

Low-intensity extracorporeal shock wave therapy (Li-ESWT) is a new method for treating erectile dysfunction (ED), but there are no standards yet for its indications. The study aimed to suggest the early clinical efficacy of Li-ESWT and explore its related factors in young and middle-aged patients with ED who responded to phosphodiesterase type 5 Inhibitors (PDE5Is). Data from 61 patients with ED who had previously responded to oral PDE5Is and subsequently underwent Li-ESWT were collected. This included information on age, body mass index, total testicular volume, sex hormones, as well as IIEF-EF scores before treatment and at 1, 3, and 6months after treatment. The treatment regimen involves a weekly session for four consecutive weeks, with each session administering 5000 shock wave pulses. Linear regression analysis was utilized to identify factors associated with the efficacy of Li-ESWT treatment. Additionally, the improvement in different severity groups of ED before and after treatment, along with their IIEF-EF scores, was compared. Li-ESWT was more targeted and effective for young and middle-aged patients with erectile dysfunction who responded to PDE5Is. The age of enrolled patients ranges from 22 to 53years old, and the IIEF-EF scores at 1month, 3months, and 6months after treatment were compared to baseline for efficacy assessment, showing significant improvements (P < .0001) in all instances. Linear regression analysis using baseline data revealed predictive factors associated with treatment efficacy: treatment efficacy was negatively correlated with baseline IIEF-EF scores (t = -2.599, P = .013) and positively correlated with baseline LH levels (t = 2.170, P = .036). Given the considerable cost of Li-ESWT treatment and the emphasis on treatment continuity, we hope to identify the most suitable candidates for Li-ESWT therapy, thereby optimizing its application. Our findings provide a better solution for nonelderly ED patients who are responsive to PDE5Is. This study was limited by our sample size and follow-up time. After 3months of Li-ESWT, the IIEF-EF score gradually stabilizes and short-term maintenance of PDE5Is medication increases the responsiveness to shock wave therapy.

(310) THE HISTORY OF SHOCKWAVE THERAPY IN UROLOGY- FROM STONES TO DECREASING GROANS

Abstract Introduction Extracorporeal shockwave lithotripsy (ESWL) was first described in the literature in 1980 as a treatment for nephrolithiasis. Low intensity-extracorporeal shockwave therapy (Li-ESWT), a lower energy derivative of ESWL, has been suggested to have regenerative tissue effects and has been investigated as a minimally invasive option for a myriad of reproductive and sexual health conditions. Objective Here, we present a brief history of shockwave therapy in urology from its inception as a treatment for nephrolithiasis to its investigative uses today in the field of reproductive and sexual health. Methods A literature review was performed via PubMed on ESWT in the field of urology. An additional search was conducted on clinicaltrials.gov to find ongoing clinical trials for ESWT and men’s health related urology topics. Key words included ESWL, ESWT, shockwave, erectile dysfunction, Peyronie’s Disease, sexual health. Results ESWL has been accepted as a standard of care for nephrolithiasis via mechanically disruptive effects, with the first lithotripters utilizing a water bath to transmit energy to the target area. After ESWL, ESWT was next described for usage in Peyronie’s Disease (PD), first in 1999. By then, devices had evolved from a lithotripter transmitting energy in a water bath to a handheld probe in the clinic setting. The first randomized control trials (RCT) were published on this topic in 2009 and 2010 respectively. Both trials did not show clinically relevant improvements in penile curvature, however suggested that ESWT provided pain relief. Current American Urological Association (AUA) guidelines state that ESWT can be offered to improve penile pain in active-phase PD. Around the same time, investigation into the lower energy Li-ESWT as a regenerative treatment for vasculogenic erectile dysfunction (ED) began. The first study was published in 2010 and the first RCT published in 2022, both of which suggest effectiveness of Li-ESWT for ED treatment, however current AUA guidelines however describe this treatment as investigational. Today, there are over 10 active clinical trials assessing ESWT in this space, and many current urology clinics that offer this treatment to men off-label. EWST has further been investigated as a treatment for chronic pelvic pain (CPP), interstitial cystitis (IC) with findings of improvement in pain and symptoms for both. Most recently, ESWT has been explored preliminarily in overactive bladder (OAB), stress urinary incontinence (SUI) and female sexual dysfunction (FSD). Conclusions ESWL is a well-established treatment for nephrolithiasis dating back over 40 years. Its use has prevailed to this day as a minimally invasive alternative other stone treatments, such as ureteroscopy. Secondary to its regenerative properties, the lower energy derivative Li-SWT has been explored in the men’s health landscape through treatment of PD and ED, but also most recently as alternatives to surgical intervention or adjunctive medical therapy for CPP, IC, SUI, OAB, FSD. This demonstrates the gaining traction of ESWT in recent years as a topic of multiple current studies, and that usage will likely continue to grow in the field of reproductive and sexual health. Disclosure No.

(322) PATIENT OUT-OF-POCKET COSTS FOR GUIDELINE-RECOMMENDED TREATMENTS FOR ERECTILE DYSFUNCTION: A MEDICARE COST MODELING ANALYSIS

Abstract Introduction Patient out-of-pocket (OOP) cost represents a barrier to accessing treatment for erectile dysfunction (ED). Many physicians have limited insight into the costs and insurance coverage of the treatment options that they recommend. Objective We sought to evaluate OOP costs incurred by men with ED covered by Fee-for-Service Medicare. Methods The 2018 American Urological Association (AUA) guidelines were used to identify recommended ED treatments. Coverage policies were obtained from the Medicare Coverage Database. OOP costs were retrieved from the 2023 CMS Final Rule. For treatments not covered by Medicare, OOP costs were extracted from GoodRx® or published literature and inflated to 2022 dollars. Annual prescription costs were calculated using a published estimate of 52.2 instances of sexual intercourse per year. The estimated number of Medicare patients with ED (n = 254,650) was used to evaluate healthcare system implications. Results Medicare has established coverage for inflatable penile prostheses (IPP; strong recommendation), non-coverage for vacuum erection devices (VED; moderate recommendation) and phosphodiesterase type-5 inhibitors (PDE5i; strong recommendation), and no existing policies for intracavernosal injections (ICI; moderate recommendation), intraurethral alprostadil (IA; conditional recommendation), or extracorporeal shock wave therapy (ESWT; conditional/investigational recommendation; Table 1). Annual IA prescription is associated with the highest patient OOP cost ($4,022), followed by annual ICI prescription ($3,947), one ESWT treatment course ($3,445), IPP ($1,600; inpatient deductible), annual PDE5i prescription ($696), and one VED ($213; Fig. 1). Among PDE5i, avanafil is associated with the highest annual OOP cost ($3,455), followed by vardenafil ($2,102), tadalafil ($723), and sildenafil ($459). One-year projections demonstrate IA is associated with the highest national healthcare OOP cost ($1.02 billion), followed by ICI ($1.0 billion), ESWT ($877 million), IPP ($407 million), PDE5i ($177 million), and VED ($54 million). Conclusions PDE5i and IPP are cost-effective options with strong guideline recommendations. Better understanding of patient financial burden may improve shared decision making with patients who suffer from ED. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

Assessing the effectiveness of complex programs for adaptation and preparation for the functioning of the biomechanical «human-prosthesis» system, taking into account the level of lower limb amputation

Abstract. The relevance of the problem of adaptation and preparation for the effective functioning of the biomechanical «human-prosthesis» system is dictated by the high need caused by the growing number of patients with lower limb amputations, both due to chronic diseases or domestic injuries, and due to trauma as a result of combat operations. Objective to evaluate. The effectiveness of complex adaptation and preparation programs for the functioning of the biomechanical «human-prosthesis» system, taking into account the level of lower limb amputation. Material and methods. 60 patients who underwent primary prosthetics at JSC CITO took part in the study, of which 26 patients had amputations at the hip level and 34 patients with amputations at the tibia level. All patients received comprehensive adaptation programs, including: stabilometric training on the COBS platform (Physiomed, Germany); practicing linear walking in a body weight unloading system on a treadmill and in a ceiling rail system; walking training on the «CMill» track (Physiomed, Germany and in the robotic complex «G-EO System» (Physiomed, Germany). The course of physiotherapy included: electrical myostimulation; shock wave therapy of the postoperative scar area; vacuum lymphatic drainage of the limb stump; local magnetic therapy of the limb stump. Results. Under the influence of the complex adaptation course, high clinical effectiveness was noted, which was manifested in achieving better functioning of the biomechanical «human-prosthesis» system and was confirmed by the high effectiveness of restoration of biomechanical, speed and coordination parameters of walking during podometric assessment of the walking stereotype. Also, as a result of the study, predictors of a favorable outcome were identified, both with any type of prosthetics, and specifically taking into account the level of amputation, and the optimal duration of the adaptation course was determined, taking into account the level of amputation. Conclusion: the use of developed programs for adaptation and preparation for the effective functioning of the biomechanical «human-prosthesis» system is a highly effective method of restoring patients after primary prosthetics of the lower limb and requires not only an integrated, but also a personalized approach to implementation, taking into account the level of amputation.

(276) DISRUPTION OF BIOFILM BY LOW INTENSITY SHOCKWAVE THERAPY TO SUCCESSFULLY TREAT AN INFLATABLE PENILE IMPLANT INFECTION: THREE YEAR FOLLOW-UP

Abstract Introduction Bacterial infection of an inflatable penile implant (IPP) is usually managed by device explantation that is often associated with severe penile fibrosis and decreased length. The decision of device explantation is based on the observation that the infecting bacteria secrete an extracellular biofilm polymer matrix that protect them from systemic intravenous/oral antibiotic therapies. A variety of other infected medical devices, including breast and hip prostheses, and the lines from ventricular assist devices have been successfully treated with low intensity shockwave therapy (LiSWT). To the best of our knowledge, this is the first report of LiSWT successfully treating an infected IPP. Objective To report a case of an infected IPP successfully managed using LiSWT combined with systemic antibiotics. Methods A 49 year old patient presented 4 weeks post-operatively with an obvious IPP infection: fever (101°F), elevated WBC count (15,400), purulent drainage from a swollen, tender scrotum, and IPP device tenderness. Culture of scrotal drainage prior to antibiotic administration grew serratia marcescens, enterococcus faecalis and citrobacter freundii. He was admitted for broad spectrum IV antibiotics and antifungal agents. Within 6 days, he became afebrile and WBC count normalized (8,000), however his renal and liver function tests became abnormal and he continued to have persistent scrotal drainage/device tenderness. The patient adamantly refused device explanation. He wished to try conservative treatment and was offered LiSWT combined with oral levofloxacin. LiSWT (SoftWave TRT/Urogold 100 MTS, energy flux density 0.13 mJ/mm2, Hz 3.0) was applied to the reservoir, penile shaft and scrotum (600 shocks each) daily for 2 weeks, twice weekly for 2 weeks, and once weekly for 4 weeks. Results At 1 week post-LiSWT and systemic antibiotic treatment, the patient remained afebrile with normal WBC count; liver and renal function tests normalized. At 2 weeks, scrotal drainage stopped. At 2.5 weeks, pain/tenderness of IPP components and scrotum stopped. At 3 weeks, inflation/deflation of the IPP occurred without pain. At 5 weeks, intercourse with orgasm was achieved. With greater than 3-year follow-up, he continues to have a fully functional, infection-free IPP. Conclusions This obvious IPP infection did not require device explanation. It is hypothesized that LiSWT induced rupture of the biofilm polysaccharide matrix, resulting in bacteria being exposed and thereby enabling systemic antibiotic therapy to access and treat the bacterial infection. LiSWT is a non-invasive, non-operative strategy that has already shown efficacy in treating other medical device infections and may be considered before performing IPP explanation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Softwave/TRT.

(253) REGENERATIVE THERAPIES FOR ERECTILE DYSFUNCTION: A SYSTEMATIC REVIEW, BAYESIAN NETWORK META-ANALYSIS, AND META-REGRESSION

Abstract Introduction Current guidelines advocate a shared decision-making process approach to erectile dysfunction (ED) management. There is growing interest in regenerative therapies such as stem cell therapy (SCT), platelet-rich plasma (PRP) injections, and low-intensity shockwave therapy (LiSWT) for ED. However, comparative data on the efficacy of these modalities are limited. Objective This systematic review and network meta-analysis aims to compare SCT, PRP injections, and LiSWT for managing ED and quantify their impact on the International Index of Erectile Function (IIEF). Methods In January 2024, a systematic search of online databases was performed to identify randomized clinical trials related to SCT, PRP and LiSWT for ED. Eligible articles reported outcomes using the IIEF score. Data was inputted into Review Manager 5.4 for pairwise meta-analysis. Data was then used to build a network in R Studio. These networks were used to model 200,000 Markov Chains via MonteCarlo sampling. The results are expressed as mean difference (MD) with 95% credible intervals (CrI). Meta-regression was used to determine coefficient of change and adjust for PDE5is use. Results A total of 17 studies involving 1,020 patients were analyzed. PRP with LiSWT led to the greatest increase in IIEF at a MD vs control of 8.2 IIEF [95% CrI 3.8, 13.0], followed by LiSWT alone with a MD vs control of 3.4 IIEF [95% CrI 2.1, 4.9], these findings are summarized in Fig. 1A. When stratifying interventions by dose, PRP with LiSWT led to the greatest increase in IIEF at a MD vs control of 10.0 IIEF [95% CrI 5.0, 16.0], followed by LiSWT 0.15 mJ/mm2 MD vs control of 5.7 IIEF [95% CrI 2.9, 8.6]. SCT showed no significant difference in IIEF scores, these findings are summarized in Fig. 1B. Meta-regression adjusting for the administration of PDE5 inhibitors yielded non-significant results. Conclusions Our findings underscored the effectiveness of LiSWT, PRP, and their combination as promising interventions for ED, with limited efficacy for SCT at this time. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Disclosures: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast, Halozyme Investor: Sprout.

(214) A REVIEW OF BASIC SCIENCE STUDIES SUPPORTING LOW INTENSITY SHOCKWAVE THERAPY AS A DISEASE MODIFYING TREATMENT FOR VASCULOGENIC ERECTILE DYSFUNCTION

Abstract Introduction Low intensity shockwave therapy (LiSWT) for ED attempts to address the underlying vascular pathophysiology of poor cavernosal tissue expandability and reduced cavernosal arterial inflow, unlike ED symptomatic treatments (PDE5 inhibitors, vasoactive agent self-injections) that aim to maximize smooth muscle relaxation. LiSWT induces mechanotransduction expansion/contraction effects on erectile tissue cells. The mechanotransduction mechanical stimuli are then converted into biochemical signal activation in these erectile tissue cells. The activations of biochemical signals in erectile tissue cells acts to increase the density of endogenous mesenchymal stem cells, increase downstream cavernosal smooth muscle synthesis and increase the release of vasodilating factors such as nitric oxide. Objective To review contemporary basic science studies delineating the biochemical changes induced by LiSWT through mechanotransduction for disease modification of vascular pathology causing ED. Methods Pubmed and Google Scholar were searched between January 2024 and May 2024 for articles containing the following keywords individually and in combination: LiSWT and animal models of ED, mechanotransduction, mesenchymal progenitor/penile stem cells, cavernosal smooth muscle synthesis, vasodilating factors, angioneogenesis, and nitric oxide. Results A total of 22 articles were reviewed, with a focus on animal models of ED. LiSWT to the penis induces mechanotransduction and resultant biochemical changes in the erectile tissue cells of animal models of ED. LiSWT to the penis was found to improve erectile function in streptozotocin-induced and Goto-Kakizaki diabetic rats, obesity rats, spontaneously hypertensive rats, bilateral cavernous nerve injury and internal pudendal bundle ligation rats, and naturally aged Wistar rats. LiSWT significantly increased endogenous mesenchymal stem cell density, cavernosal neuronal nitric oxide synthase expression, and cavernosal smooth muscle content in treated versus untreated diabetic rats (Qiu et al). LiSWT in diabetic rats showed increased cavernosal α-smooth muscle actin concentration; and nitric oxide and guanosine 3',5'-cyclic monophosphate levels mediating vasodilation significantly increased in cavernosal smooth muscle (Shin et al). LiSWT differentiated penile progenitor cells into smooth muscle through activation of the Wnt/b-catenin signaling pathway (Peng et al). LiSWT increased cavernosal smooth muscle content and improved cavernosal smooth muscle/collagen ratio in 12-week-old Zucker fatty rats compared to controls (Ruan et al) and in spontaneous hypertensive rats (Assaly et al). LiSWT had an anti-fibrotic effect in streptozotocin-induced diabetic rats (Lei et al). Conclusions A review of basic science studies reveal that the mechanism of action of LiSWT for ED appears related, in part, to mechanotransduction. In the penis, mechanotransduction is the shockwave energy-induced contraction and expansion of cavernosal erectile tissue inducing biologic changes including increases in endogenous mesenchymal stem cell density. It is hypothesized that these progenitor stem cells differentiate into various downstream cells, including cavernosal smooth muscle and endothelial cells, resulting in improved veno-occlusive function and vasodilation respectively in the corpora cavernosa. LiSWT for ED is a disease modifying strategy that addresses the underlying vascular pathophysiology of ED. Future studies should address use of LiSWT for ED in combination with symptomatic ED treatments, such as PDE5 inhibitors and penile self-injection therapy, as both strategies maximize conservative, non-operative ED management. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Softwave/TRT.

(060) DOES THE TYPE OF SHOCKWAVE GENERATOR MATTER? A SYSTEMATIC REVIEW AND BAYESIAN NETWORK META-ANALYSIS ASSESSING RANDOMIZED SHAM CONTROLLED TRIALS USING FOCUSED SHOCKWAVE LITHOTRIPSY FOR MODERATE ERECTILE DYSFUNCTION

Abstract Introduction Focused low-intensity shockwave therapy (LiSWT) has been demonstrated to improve erectile function in some randomized controlled trials (RCTs). However, significant heterogeneity exists when comparing RCTs for LiSWT as shockwaves can be generated via three methods: electromagnetic, electrohydraulic, and piezoelectric generators. No study has directly assessed whether the type of LiSWT generator impacts clinical outcomes for erectile dysfunction. Objective The objective of this study is to perform a network meta-analysis to compare the effect of different LiSWT generators on change in IIEF scores for men with moderate erectile dysfunction. Methods A systematic review of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov was performed for randomized sham-controlled trials from database inception through June 2024. Studies were included if they evaluated changes in international index of erectile function (IIEF) scores in men with moderate erectile dysfunction (baseline IIEF-5: 8-11 or baseline IIEF-EF: 11-16) at either 1 month or at 3-6 months follow-up. Studies were not included if they assessed erectile dysfunction after prostatectomy. The analysis was limited to studies with a baseline of moderate erectile dysfunction as this is the most studied population and limits heterogeneity by focusing on a single severity cohort. Randomized sham-controlled trial data for piezoelectric, electromagnetic, and electrohydraulic LiSWT devices were pooled via network meta-analysis with random effect modeling. Results A total of 16 RCTs were identified with 1036 men included. 6 studies report changes in IIEF scores only at 1 month, 3 studies at both 1 month and 3-6 months, and 7 studies only at 3-6 months. After 1 month, the mean difference from baseline between treatment and sham group found that electrohydraulic had the greatest improvement in IIEF score (mean difference between treatment and sham therapy from baseline: 5.19, 95% Confidence Interval 2.08-8.29, number of studies = 5), while electromagnetic also had significant improvement from baseline when comparing treatment versus sham (MD: 3.72, 95% CI 3.36-4.07, n = 2), piezoelectric did not significantly improve IIEF scores when comparing treatment vs sham (MD: 0.34, 95% CI -4.72-5.39, n = 2) (Fig. 1). After 3-6 month, the mean difference from baseline between the treatment and sham group for electromagnetic was significant (MD: 5.15, 95% CI 3.90-6.40, n = 5) while piezoelectric generators did not see an improvement between therapy and sham from baseline (MD: 2.08, 95% CI -1.28-5.43, n = 4). Only 1 study assessed electrohydraulic generators at the 3-6 month interval (MD: 3.68, 95% CI 3.07-4.29). Conclusions Piezoelectric generators for LiSWT do not significantly improve IIEF scores at 1 or 3-6 months for men with moderate erectile function while electromagnetic generators appear to have significant improvement in IIEF scores in this same population at both 1 and 3-6 months. While electrohydraulic appears to significantly improve IIEF scores at 1 month, more studies are needed to assess the long-term impact of these LiSWT generators on erectile function. Disclosure No.

(251) WHICH PATIENTS CHOOSE SHOCKWAVE THERAPY? AN ANALYSIS OF PATIENT DIRECTED UTILIZATION OF LISWT AT AN ACADEMIC INSTITUTION

Abstract Introduction Low-intensity shockwave therapy (LiSWT) is an increasingly popular treatment for mild to moderate erectile dysfunction (ED). While considered investigational, a wide range of patients are progressively seeking and obtaining LiSWT in a variety of settings overseen by a wide range of providers in various medical and non-medical settings. Objective Assess which patients are more likely to elect for LiSWT when administered and overseen by fellowship trained sexual medicine providers in an academic medical setting. Methods Retrospective review of consecutive patients suspected of having arterial insufficiency predominant ED presenting for diagnostic Duplex Doppler ultrasound of the penis with intention to undergo LiSWT. Patient demographics, comorbidities, baseline, in-treatment, and post treatment sexual health inventory for men (SHIM) score, prior ED treatments, and insurance status was collected. Patients who elected to undergo LiSWT were compared to those who did not. Patients were specifically counseled on expected outcomes based on prior published efficacy data for baseline SHIM score and ED severity based on peak systolic velocity. All patients who utilized LiSWT underwent a standard protocol using the Storz Duolith SD1 with 6 consecutive weekly sessions of 3,000 shocks per session at 0.25 mJ/mm2 at 6 Hz divided between the penile shaft and crura. Results 100 consecutive patients with vasculogenic ED received a diagnostic Duplex Doppler ultrasound in the office. Of these patients, 22 elected to undergo LiSWT. Patients who elected to have LiSWT were older compared those who did not (58 versus 52 years old, p &amp;lt; 0.05). There was no statistically significant difference in ethnicity, baseline SHIM score, maximum arterial blood flow on doppler US, or insurance type/status. The most commonly cited barrier to pursuing treatment was cost compared to expected outcomes. Baseline mean PSV in the LiSWT cohort was 37.5 cm/s versus 42.9 cm/s in the non LiSWT group. 100% of patients in either group had prior PDE5i exposure. Conclusions In an academic practice with fellowship trained sexual medicine urologists, there does not appear to any significant differences patients who decide to undergo LiSWT. Many patients choose to pursue LiSWT despite low normal PSV or mild arterial insufficiency ED. Despite extensive counseling, most patients appear eager for non-invasive treatment alternatives to PDE5i, even with a lack of definitive evidence in efficacy. The biggest barrier to treatment remains cost for many patients. Disclosure No.

Evaluation of the Effectiveness of Shock Wave Therapy in the Treatment of Peyronie's Disease among Patients Visiting Imam Rezai Hospital in Tabriz between 2021-2023

Background and Objective: Peyronie's disease is a relatively rare urological disorder that can cause pain during erection, penile angle deviation, and sexual dysfunction due to the formation of plaque in the tunica albuginea part of the male penis. Extracorporeal shock wave therapy (ESWT) for the management of Peyronie's disease is one of the emerging interventions. In this study, we aim to explore the effects of ESWT on Peyronie's disease. Materials and Methods: We studied patients with the acute phase of Peyronie's who were treated with ESWT during the past two years, from 2021 to 2023. All patients were referred to the urology clinic of Imam Reza Hospital. Information including age, characteristics of fibrotic plaques, concurrent treatments other than ESWT, International Erectile Dysfunction Index (IIEF-5), and the severity of pain was extracted and documented from the patients' records by the urologist before and after the treatment. Results: The average age of the studied patients was 54.1 years. Eight percent of patients had a history of trauma to the penis, 30% suffered from diabetes, and 36% had high blood pressure. According to the statistical analysis, ESWT reduced pain and elevated the IIEF-5 score. However, this treatment had no impact on the length of the plaque. Conclusion: ESWT, as a non-invasive intervention, can lessen pain sooner than the normal progression of the disease and improve the sexual performance of the individual. However, this approach had no significant effect on the length of Peyronie's plaque.

Multiple pancreaticobiliary fistulas combined with acute necrotizing pancreatitis: a rare complication of pancreatic extracorporeal shock wave lithotripsy.

Multiple pancreaticobiliary fistulas combined with acute necrotizing pancreatitis: a rare complication of pancreatic extracorporeal shock wave lithotripsy.