Lithostar Plus Research Articles

Long-term experiences with high-energy shock wave therapy in the management chronic phase Peyronie’s disease using two different electromagnetic lithotripters

BackgroundExtracorporeal shock wave lithotripsy represents one option for the non-surgical management of Peyronie’s disease. Despite promising results, several questions are still pending. We want to present the long-term results of a retrospective study using high-energy extracorporeal shock wave lithotripsy.Material and methodsWe evaluated retrospectively 110 patients treated between 1996 and 2020 at the Department of Urology, SLK Kliniken Heilbronn for chronic phase Peyronie’s disease using two electromagnetic lithotripters (Siemens Lithostar Plus Overhead Module, Siemens Lithoskop) applying high-energy shock waves under local anesthesia and sonographic or fluoroscopic control. A standardized questionnaire focused on the change in pain, curvature, sexual function and the need of penile surgery.ResultsIn 85 of the 110 patients (mean age 54 years) we had sufficient data for evaluation. The median follow-up was 228 (6–288) months. There were no significant complications. Pain reduction was achieved in all patients, 65 (76%) patients were free of pain. Improvement of penile curvature was achieved in 43 patients (51%) ranging from 25% improvement (deflected angle < 30°) to 95% (angle 30–60°). 59 patients (69%) reported problems with sexual intercourse, 40 of those (68%) reported improvement. Only 9 (10.5%) patients underwent surgical correction. We did not observe any significant differences between both electromagnetic devices with stable long-term results.ConclusionsHigh-energy shock wave therapy delivered by two standard electromagnetic lithotripters is safe and efficient providing stable long-term results. In cases with significant plaque formation, the concept of high-energy ESWT should be considered in future studies.

The clinical role of X-ray computed tomography to predict the clinical efficiency of extracorporeal shock wave lithotripsy

To evaluate the clinical efficiency of computed tomography for diagnostics of patients with urolithiasis and the choice of treatment strategy. The study was carried out at the Urological Clinic of I.M. Sechenov First Moscow State Medical University and included 1044 patients with urinary stones. The ultimate goal of this study was to predict the clinical efficiency of extracorporeal shock wave lithotripsy using a combination of computed tomography and densitometry. Extracorporeal shock wave lithotripsy was performed on "Siemens Lithostar Plus," "Siemens Modularis Uro," and "Dornier Gemini" lithotripters. Statistical analysis of clinical data included evaluation of individual sampling groups and calculation of weighted arithmetic mean ( M). The efficiency of extracorporeal shock wave lithotripsy has been determined primarily using X-ray analysis of the concrement outlines and the structure (homogeneous or heterogeneous) of its central zone. However, in terms of efficiency and repetition rate (the number of fragmentation procedures required for complete clearance) of extracorporeal shock wave lithotripsy, the mean density of the concrement along the whole length of its three-dimensional structure (expressed in Hounsfield units) appeared to be the most reliable and informative predictive index in this study. The combination of computed tomography with densitometry in the treatment of patients with urolithiasis allows one (1) to determine the exact localization, size, X-ray structure, and structural density of urinary stones and (2) to predict, on the basis of densitometric data histograms, the clinical efficiency and repetition rate of extracorporeal shock wave lithotripsy with due regard to the X-ray structure of peripheral and central zones, and mean density (in Hounsfield units) of urinary concrements.

Extracorporeal shock wave lithotripsy for difficult common bile duct stones: a comparison between 2 different lithotripters in a large cohort of patients

Extracorporeal shock wave lithotripsy (ESWL) for difficult common bile duct (CBD) stones is a safe and effective treatment strategy allowing for bile duct clearance in approximately 90% of patients with a low incidence of mild adverse events. To compare the CBD clearance rates achieved after ESWL performed with 2 different lithotripters (Siemens Lithostar Plus and Storz Modulith SLX-F2) in a large cohort of patients with difficult CBD stones. A retrospective analysis of a prospectively collected database. Tertiary care center. All of the consecutive patients who underwent ESWL because of difficult CBD stones between 1990 and 2012 were considered suitable for inclusion. ESWL with Lithostar Plus or with Modulith SLX-F2. CBD clearance. Three hundred ninety-two patients with difficult CBD stones were treated; 199 patients were treated with the Lithostar Plus and 193 patients with the Modulith SLX-F2. CBD clearance was achieved in 349 patients (89.0%) with no significant difference between the patients treated with Lithostar Plus and those treated with Modulith SLX-F2 (90.5% vs 87.6%; P= .45). Patients treated with Modulith SLX-F2 underwent a significantly lower number of ESWL sessions (3 [range, 2 to 4] vs 3 [range, 2 to 4]; P= .0015), had a lower incidence of ESWL-related adverse events (5.2% vs 13.6%; P= .009), and never required opioid analgesia (P< .001). Retrospective design. The Modulith SLX-F2 allows the same clearance rate as the Lithostar Plus but has a significantly lower incidence of adverse events and requires fewer ESWL sessions.

Extracorporeal shock wave lithotripsy of lower ureteric stones: Outcome and criteria for success

ObjectiveTo evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) for distal ureteric calculi (DUC) and to determine variables that could affect the outcome results. Patients and methodsBetween April 2004 and February 2008, 100 patients with a solitary DUC were treated with in situ ESWL using a lithotripter (Lithostar Plus, Siemens, Erlangen, Germany). The outcome of treatment was evaluated after 3months. The patients’ clinical and radiological findings, as well as stone characteristics, were reviewed and correlated with the stone-free rate (SFR). ResultsAfter in situ ESWL, 84 patients (84%) were stone-free (after one session in 57 and after two in 27). From a univariate analysis only three factors had a significant impact on the SFR, i.e. the body mass index (BMI), stone length and stone width. The SFR was significantly lower in obese patients than in normal and overweight patients (P=0.019). Stone width ⩾8mm was associated with a SFR of 64% (14/22), compared with 89.7% (70/78) for those with a stone width of <8mm (P=0.007). The SFR was 86.8% (66/76) for a stone length of ⩽10mm and 71% (17/24) for a stone length of >10mm (P=0.016). On multivariate analysis, BMI, stone width and stone length maintained their statistical significance. ConclusionPrimary in situ ESWL remains an effective and safe form of treatment for DUC. The length and transverse diameter of the stone, together with the BMI of the patient, were the only significant predictors of the overall success of ESWL.

ESWL for difficult bile duct stones: A 15-year single centre experience

To evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) for the management of refractory bile duct cholelithiasis in a third level referral centre. The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus, SIEMENS) from October 1990 to April 2005 were evaluated. All patients were monitored during the procedure and antibiotics were administered in case of cholangitis. The chi(2) test and logistic regression analysis were performed as appropriate. Two hundred and fourteen patients (102 males, 112 females; mean age 74.8 +/- 0.84 years--single stone 97, multiple stones 117) underwent ESWL. The mean number of sessions and shock waves were 3.5 +/- 0.13 and 3477.06 +/- 66.17, respectively. The maximum stone size was 5 cm. Complete stone clearance was achieved in 192 (89.7%) patients. Of the remaining patients 15 required surgery, 2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance. Age, sex and stone characteristics were not related to treatment outcome. Major complications occurred in two patients (haemobilia and rectal bleeding) and minor complications in 25 (3 vomiting, 22 arrhythmias). No procedure-related deaths occurred. ESWL is a safe and effective technique for clearance of refractory bile duct stones.

Development of a Mathematical Model to Predict Extracorporeal Shockwave Lithotripsy Outcome

To determine statistically significant parameters that influence shockwave lithotripsy (SWL) outcome and to develop a mathematical equation to predict the possibility of a successful outcome. Radiopaque ureteral and renal stones (1997) underwent SWL in a single center using the Siemens Lithostar Plus lithotripter. Investigated variables were stone size and location; presence of multiple stones; patient sex, age, body mass index (BMI), and ureteropelvic junction (UPJ) diameter; and Double-J catheter presence. The investigation included intravenous urography or ultrasonography and plain radiography of the kidneys, ureters, and bladder (KUB). Ten percent of the patients also underwent unenhanced CT to determine stone volume and density. Patients were evaluated 3 months postoperatively by plain radiography of the KUB. Student t test, chi-square test, and multiple logistic regression analysis were used to determine statistically significant variables and to create predictive mathematical equations. Kidney, ureter, total stone-free rate, and re-treatment rate were 71%, 80.9%, 74.9% and 18%, respectively. Complications included two perirenal hematomas, one significant cardiac arrhythmia, and 3.7% stein-strasse. Statistically significant variables were patient age, sex, BMI, stone size, volume, density, multiple lithiasis, and UPJ diameter. By using statistical analysis, coefficients were calculated for each significant variable. The mathematical model calculating the probability (P) of success with a mean predictive value of about 80% is: P = 1/1 + e(-z) where e is the base of the natural logarithm and z = ct + the total of products of each coefficient multiplied by each variable value. Using the described method, similar predictive equations can be created for different lithotripters and used by computer software to aid both patient counseling and doctor decision and ensure an optimal combination of maximum efficacy and safety and minimum cost.

Percutaneous Nephrolithotomy Success in the Transplant Kidney

Treatment for symptomatic calculi in the transplanted kidney can be problematic. Percutaneous nephrolithotomy has routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We report our experience with percutaneous nephrolithotomy in the transplant kidney. A retrospective chart review from 1988 to the present was performed of all cases of a renal transplant and subsequent renal calculi treated with percutaneous nephrolithotomy. We identified 13 patients with a renal transplant who underwent percutaneous nephrolithotomy. Presenting symptoms included renal failure in 46.1% of cases, hematuria in 23.1%, urinary tract infection/pyelonephritis in 23.1%, pain in 15.4%, fever in 7.7% and hydronephrosis in 7.7%. Average calculus size was 1.36 cm (range 0.2 to partial staghorn). A single access tract was used in 12 cases and 2 access tracts were used in 1. Ultrasonic lithotripsy was performed in 10 cases, basket extraction was performed in 3 and the 2 techniques were performed in 1. No intraoperative complications occurred. Nephrostogram 24 hours after the procedure demonstrated no residual fragments in 10 patients (76.9%). Repeat endoscopy was required in 3 patients to achieve subsequent stone-free status. Postoperative complications developed in 3 patients, including sepsis, gastrointestinal bleeding and herpes esophagitis, respectively. Mean followup was 5.3 years (range 0.6 to 9). The single stone recurrence was treated with shock wave lithotripsy. Mean creatinine was stable at 2.0 mg/dl (range 0.9 to 3.9) preoperatively to 1.7 mg/dl (range 0.9 to 2.6) at the last visit (p = 0.311). Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone-free status was achieved in all cases. At long-term followup there were few stone recurrences with stable graft function after the procedure.

Predictive Factors of Lower Calyceal Stone Clearance After Extracorporeal Shockwave Lithotripsy (ESWL): The Impact of Radiological Anatomy

This study was carried out to determine whether or not there is a significant relationship between the radiologic anatomy of the lower calyx, as seen on preoperative intravenous urography (IVU), and the outcome of stone clearance after extracorporeal shockwave lithotripsy (ESWL) for lower renal calyceal stones. Between June 1998 and April 2007, 112 patients with a solitary lower renal calyceal stone measuring 20 mm or less in size were enrolled in this retrospective study. Pretreatment IVU was reviewed for measuring the anatomical predictors, such as lower pole infundibular length, infundibular width (IW) and infundibulopelvic angle, while the stone location and size were determined on plain abdominal X-ray. All patients were treated with ESWL using a Siemens Lithostar Plus lithotriptor and were followed-up for the outcome of stone clearance 3 months after ESWL with plain abdominal X-ray films and ultrasonography. Three months after ESWL, only 49 (43.7%) patients were stone-free. Under multivariate analysis with logistic regression, smaller stone size (10 mm or less, p = 0.005) and greater IW (4 mm or more, p = 0.029) were significant favourable predictors for better stone clearance. In addition to the influence of stone size, lower pole anatomy, especially IW, has a significant impact on stone clearance for lower calyceal stone after ESWL.

Extracorporeal shock wave lithotripsy for clearance of refractory bile duct stones

Background and study aims Following endoscopic sphincterotomy, 90% of bile duct stones can be removed with a Dormia basket or balloon catheter. The removal can fail in patients with large stones, intrahepatic stones, bile duct strictures or a difficult anatomy. The aim of this retrospective study is to investigate the efficacy and safety of extracorporeal shock wave lithotripsy in fragmenting and allowing the extraction of bile duct stones that could not be cleared by routine endoscopic means including mechanical lithotripsy. Patients and methods From 1989 to January 2005, we treated with extracorporeal shock wave lithotripsy 376 patients (133 males and 243 females, median age 71.4 years) with bile duct stones that were not removable following endoscopic sphincterotomy, using the extracorporeal shock wave lithotripsy Lithostar Plus machine built by Siemens Co. of Erlangen, Germany. Stone targeting was performed fluoroscopically following injection of contrast via nasobiliary drain or T-tube in 362 patients and by ultrasonography in eight patients. Residual fragments were cleared at endoscopic retrograde cholangiopancreatograhy. Two hundred and ten of the 370 patients treated (56.7%) showed only 1 stone, 57 (15.4%) showed 2, 45 (12.1%) showed 3, 58 (15.6%) showed more than 3 stones. The median diameter of the stones was 21 mm (range 7–80 mm). Results Complete stone clearance was achieved in 334 of the 376 patients who underwent the extracorporeal shock wave lithotripsy procedure (90.2%). Six patients (1.5%) dropped out of treatment during their first sessions, mainly because of intolerance. Each patient averaged 3.7 treatments (1–12), at an average rate of 3470 shocks per session (1500–5400), at an average energy level of 3.4 mJ (1–7). Complications were recorded in 34 patients (9.1%); 22 patients experienced symptomatic cardiac arrhythmia, 4 haemobilia, 2 cholangitis, 3 haematuria, 3 dyspnoea; no deaths were associated with the procedure. Conclusions Extracorporeal shock wave lithotripsy is a safe and effective therapy in those patients in whom endoscopic techniques have failed with a clearing rate of 90.2% of refractory bile duct stones with a low rate of complications.

Extracorporeal Shock Wave Lithotripsy for Large Ureteral Stones Using HM3 Lithotriptor

We assessed the efficacy of extracorporeal shock wave lithotripsy for large (more than 10 mm) ureteral calculi with the unmodified Dornier HM3 lithotriptor. A total of 96 consecutive patients with large ureteral stones were treated with shock wave lithotripsy using an unmodified HM3 lithotriptor. Patients, stone characteristics, preliminary treatment before shock wave lithotripsy, additional procedures after shock wave lithotripsy, complications and clinical outcomes were assessed. Between 2000 and 2003 a total of 96 patients (75 males, 21 females, mean age 51 years [range 16 to 81]) with large ureteral stones underwent shock wave lithotripsy. Average stone size was 14 mm (range 10 to 22), 90 stones were calcified, and 66 stones were located in the upper ureter, 20 in the mid ureter and 10 in the distal ureter. A total of 77 (80.2%) patients underwent a single shock wave lithotripsy session, 18 (18.7%) underwent 2 sessions and 1 (1.1%) patient underwent 3 sessions. The overall stone-free rate was 86.5% (83 patients). Complications occurred in 10 (10.4%) patients. Shock wave lithotripsy failed in 13 (13.5%) patients who were successfully treated with ureteroscopy. Our data show that shock wave lithotripsy for large ureteral stones along the entire ureter with the unmodified HM3 lithotriptor has a high success rate with minimal morbidity. We recommend it as first line treatment.

Efficacy of extracorporeal shock wave lithotripsy for ureteric stones in children

Management of ureteral stones in children represents a challenging problem. In this study, we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (ESWL) in 192 children with ureteric stones. Between 1990 and 2003, 192 children (<or= 14 years old) with ureteric calculi were treated with the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, NJ). There were 39 stones in the proximal ureter, 19 in the mid-ureter and 134 in the distal ureter. Mean patient age was 7.3+/-4.1 years (6 months-14 years). There were 122 boys (64.2%) and 70 girls (35.8%). All procedures were performed on an outpatient basis with intravenous sedation in 73 cases (38.1%), general anesthesia in 68 cases (35.7%) and no anesthesia in 51 cases (26.2%). A maximum of 3500 shocks and 18 kV per session were used. A 94% success rate was achieved in proximal (n: 39) and mid-ureteral stones (n: 19). Stone free rates for distal ureteral calculi were 90.6% for stones less than 1 cm in diameter (n: 94) and 91.7% for stones between 1 and 2 cm (n: 26). Overall re-treatment and efficacy quotient rates for proximal ureteral stones were 45.1% and 68.9%, 62.5% and 61.5% for mid-ureteral calculi, and 49.6% and 60.0% for distal ureteral stones. Our results indicate that ESWL with highly satisfactory stone free rates ranging between 90 and 100% and negligible complications can be considered as a first line treatment for ureteric stones in the pediatric age group.

Extracorporeal shockwave lithotripsy and litholytic therapy in cholelithiasis.

Extracorporeal shockwave lithotripsy (ESWL) and litholytic therapy were used in 100 patients over a period of 16 months. ESWL was carried out with a Lithostar Plus and chenodeoxycholic acid was used as the lytic agent, given until 3 months after complete disappearance of stones. Within a period of 8-12 months, stones disappeared completely in 82 per cent of the patients who had a single stone less than or equal to 20 mm in diameter and in 50 per cent of those with a single stone greater than 20 mm in size or with multiple stones. Complications requiring surgery developed in five patients: three had acute cholecystitis and two developed acute pancreatitis. Of the patients in whom complete stone clearance was achieved, two of 11 followed up developed recurrence of stones 4 months after cessation of lytic therapy.

IS NEWER ALWAYS BETTER? A COMPARATIVE STUDY OF 3 LITHOTRIPTOR GENERATIONS

At a single center we compared the efficacy of 3 generations of lithotriptors using identical protocol inclusion and followup criteria but with different modes of anesthesia. We compared stone disintegration and dilatation of the pyelocaliceal system achieved in a prospective, randomized trial comparing the original HM3 (Dornier Medtech, Kennesaw, Georgia) and Lithostar Plus (LSP) lithotriptors, and a matched, consecutive series of 107 treatments with the Modulith SLX. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasonography 1 day and 3 months after treatment. A total of 82 treatments with the HM3, 75 with the LSP and 107 with the SLX were analyzed, matched for stone burden and location within the pyelocaliceal system. On postoperative day 1, 91%, 65% and 48% patients treated with the HM3, LSP and SLX, respectively, were stone-free or had fragments that were 2 mm or less (HM3 vs LSP p <0.001, HM3 vs SLX p <0.001 and LSP vs SLX p = 0.015). Three to 5 mm fragments were found in 7%, 21% and 35% of patients (p = 0.006, <0.001 and 0.06), and fragments 6 mm or greater were found in 1%, 14% and 15% (p = 0.002, <0.001 and 0.1, respectively). The re-treatment rate was 4% in the HM3 group, 13% in the LSP group and 38% in the SLX group (HM3 vs LSP p = 0.05, HM3 vs SLX p <0.001 and LSP vs SLX p <0.001). Obstructive pyelonephritis occurred in 1% of the HM3 group, 8% of the LSP group and 5% of the SLX group (HM3 vs LSP p = 0.02, HM3 vs SLX p = 0.12 and LSP vs SLX p = 0.4). All re-treatments except those in 5 patients were performed with the HM3. Therefore, the 3-month stone-free rate was comparable in all 3 groups (HM3 87%, LSP 80% and SLX 81%). This study indicates that the HM3 lithotriptor disintegrates caliceal and renal pelvic stones better than the LSP and SLX machines, resulting in fewer complications and re-treatments. Disintegration with the LSP machine was also superior to that of the SLX with a need for fewer re-treatments.

Extracorporeal Shock Wave Lithotripsy as First Line Treatment Alternative for Urinary Tract Stones in Children: A Large Scale Retrospective Analysis

Management of urinary tract stones in children represents a challenging problem. In this study we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (SWL) in children. During a 12-year period 408 urinary tract calculi in 344 children (mean age 8.7 +/- 3.9 years, range 6 months to 14 years) were managed with the Lithostar Plus lithotriptor (Siemens Medical Systems, Iselin, New Jersey). There were 57 caliceal stones, 167 in the renal pelvis, 31 in the proximal ureter, 16 in the mid ureter and 121 in the distal ureter, and 16 bladder stones. All patients were treated on an outpatient basis, with intravenous sedation being used in 138 (40.1%), general anesthesia in 132 (38.4%) and no anesthesia in 74 (21.5%). A maximum of 3,500 shocks and 18 kV per session was given. A total of 780 SWL sessions were applied (mean 1.9 sessions per stone). Overall, a stone-free rate of 79.9% and clinically insignificant residual fragments in 13.2% of cases were observed at 3-month followup with a re-treatment rate of 53.9%. Overall efficacy quotient was 50.9%. Significantly more favorable results were achieved in ureteral calculi and stones 2 cm or smaller (p <0.05). Complications were observed in 33 patients (9.6%). Our results indicate that SWL, with satisfactory stone-free rates and efficacy quotients in stones 2 cm or smaller can be offered as a first line treatment in children.

A Prospective Randomized Trial Comparing 2 Lithotriptors for Stone Disintegration and Induced Renal Trauma

We compare the efficacy and resulting kidney trauma of the HM3 (Dornier Medical Systems, Inc., Marietta, Georgia) and Lithostar Plus (Siemens, Issaquah, Washington) lithotriptors in a prospective randomized trial treating calix and renal pelvis stones. Patients with a solitary renal pelvic stone 2 cm. or less in diameter or a solitary calix stone 1 cm. or less in diameter were randomized for treatment with the HM3 or Lithostar Plus. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasound 1 day and 3 months after treatment. Kidney trauma was determined by measurement of N-acetyl-beta-glucosaminidase and beta-galactosidase (NAG) in pretreatment urine and 4, 12-hour urine samples collected within the first 2 days after extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc.). Of 167 patients with 176 stones 91 were randomized to the HM3 and 85 to the Lithostar Plus lithotriptor group. The preoperative stone burden was comparable in both groups. On postoperative day 1 patients treated with the HM3 or Lithostar Plus were stone-free or had fragments 2 mm. or less (91% and 65%, p <0.001), 3 to 5 mm. (8% and 25%, p = 0.003) and 6 mm. or greater (1% and 10%, p = 0.008), respectively. Patients treated with the HM3 had less posttreatment dilatation of the collecting system (p = 0.01). Obstructive pyelonephritis occurred in 1% of the HM3 and 8% of the Lithostar Plus group (p = 0.02). Re-treatment rate was 4% in the HM3 and 13% in the Lithostar Plus group (p = 0.05). Mean excretion of urinary NAG per treatment (including re-treatments) was comparable in both groups but NAG excretion in relation to stone volume and shock wave number 12 to 24 hours after ESWL was significantly higher in the HM3 group (p <0.05). At 3-months postoperatively 89% of the patients treated with the HM3 and 87% treated with the Lithostar plus were stone-free with no dilatation of the collecting system. This prospectively randomized study indicated that the HM3 is still the gold standard in regard to disintegration of pelvicaliceal stones. Stone disintegration with the HM3 is better with fewer shock waves, re-treatment rate is lower, and posttreatment dilatation of the collecting system and complications such as obstructive pyelonephritis are less than those with the Lithostar Plus. ESWL induced kidney trauma is minor and resolves within 2 days. The HM3 delivers more energy per shock wave into the kidney as assessed by urinary NAG.

Extracorporeal Shock Wave Lithotripsy in Children

Extracorporeal Shock Wave Lithotripsy in Children

Impact of power index, hydroureteronephrosis, stone size, and composition on the efficacy of in situ boosted ESWL for primary proximal ureteral calculi

Objectives. The efficacy, safety, feasibility, and outcome of in situ treatment applied to select proximal ureteral calculi was assessed and analyzed with a view to avoiding auxiliary interventions and providing high clearance rates in the shortest possible time. We studied the impact of several clinically important variables, including power index, degree of hydroureteronephrosis (HDUN), stone size, and composition on the efficacy of sequential in situ boosted extracorporeal shock wave lithotripsy (ESWL) in a select group. The power index requirement for the in situ boosted protocol and the impact of the stone size/composition, degree of HDUN, and clearance rates were also analyzed. Methods. An in situ (no instrumentation) boosted protocol was applied to 130 primary unimpacted proximal ureteral calculi with no prior intervention. A typical session with the Siemens Lithostar Plus comprised 3000 shock waves, in installments of 500, deployed at a power setting of 1 to 4 kV with a gradual stepwise escalation. Sequential boosted additional sessions of ESWL were administered on days 2, 7, and 14, tailored to the degree of fragmentation, clearance status, and amount of residual stone bulk. Several parameters (shock waves, kilovolts used, fluoroscopy time, number of sessions, stone size, composition, fragmentation, clearance, and HDUN) were recorded and the results analyzed statistically. Results. The results were excellent in 83.8%, with a mean duration to complete clearance of 11.3 days. In situ ESWL failed in 7.69%, and the auxiliary intervention rate was 10.7%. Pre-ESWL HDUN was present in 78.3%, the mean power index was 184.6/session/case, and the average stone burden was 8.9 mm 2. Calcium oxalate monohydrate was the most common stone (56%). Renal colic was the most common side effect observed. The power index, fragmentation at the first session, and stone size were found to be the most favorable significant variables affecting stone clearance. The degree of HDUN, number of sessions, and stone composition did not significantly impact the clearance rates. Conclusions. In situ boosted ESWL should be the first-line therapeutic modality in select unimpacted primary proximal ureteral stones.

EXPANDING THE LIVING RELATED DONOR POOL IN RENAL TRANSPLANTATION: USE OF MARGINAL DONORS

In a living related transplantation program it is not always possible to find an ideal donor. Sometimes the only available donor in the family has some benign disease or suboptimal renal anatomy or physiology, or is too old to be accepted and defined as a marginal donor. However, with proper screening the donor pool can be increased by accepting these marginal donors and treating the benign diseases which is beneficial to the donor. We evaluate the outcome of grafts from marginal donors. From July 1988 to August 1997, 581 live related transplantations were performed. Of the donors 52 were older than 60 years and 34 had associated benign renal or nonrenal anomaly or disease. These donors were accepted after thorough questioning and consultation with family members. The recipients of graft from elderly donors were evaluated for the number of rejections, serum creatinine at last followup and graft survival. Of the recipients 52 received grafts from elderly donors with a mean age of 62.6+/-3.7 years. Mean followup was 34.14+/-0.7 months. The 2 and 5-year actuarial graft survival was 96% and 74%, respectively. Creatinine was normal (less than 1.5) in 37% of recipients and 1.5 to 2.5 mg.% in 46%. The rejection rate in postoperative month 1 was 29%. All donors underwent simultaneous surgery to treat the benign disease, and all did well after surgery. By accepting these marginal donors a 14.6% increase in the living related donor pool was achieved without compromising recipient or donor safety. Otherwise these recipients would have been forced to undergo unrelated transplantation or be maintained on dialysis, which is particularly difficult in a developing country. Donors with associated disease benefited from cure.

Extracorporeal Shock Wave Lithotripsy for Lower Caliceal Calculi

Objective: The aim of the study is to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL) therapy for isolated lower caliceal calculi. Patients and Methods: We analyzed 165 patients who were treated with the Siemens Lithostar Plus on an outpatient basis between March 1993 and August 1997. The age of patients ranged from 17 to 70 (mean 39.11) years. The stone size varied from 4 to 42 mm, and patients who had stones larger than 21 mm had a double-J stent inserted prior to treatment. Results: The overall stone-free rate at 3 months was 53.33%; whereas it was 61.79, 48.27, and 27.27% according to the stone size, ≤10, 11–20 and ≥21 mm, respectively. Complications were rare, including 2 pyelonephritis, 2 subcapsular hematoma formation, 24 renal colics and 8 stone streets, which were managed by ureteral stenting or additional ESWL and resulted in complete stone clearance. Conclusion: ESWL therapy is a reasonable and effective method for small lower caliceal stones, but due to its relatively low stone-free and high complication rates, percutaneous nephrolithotripsy or open surgery should be considered for stones larger than 21 mm.

What Are the Parameters for Predictive Selection of Patients Requiring Anesthesia for Extracorporeal Shockwave Lithotripsy?

Objective: Additional anesthesia is required to minimize the tolerable pain level in efficiently performed extracorporeal shockwave lithotripsy (ESWL) with electrohydraulic and electromagnetic sources. In order to assess optimum anesthesia for each patient undergoing a standardized ESWL protocol, pain measurement and scoring were carried out. We attempted to determine the individual type and amount of analgesia prior to treatment. Methods: Patients (n = 95) with urolithiasis underwent pain measurement and scoring prior to ESWL. ‘Threshold of pain’ (TP) and ‘maximal tolerable pain (MTP) were assessed by inducing ischemia pain with the submaximum effort tourniquet technique. Pain intensity was assessed by a verbal rating scale (VRS). The results of pain measurement and amount of analgosedation were correlated in two phases. Patients were administered an oral premedication of 0.1 mg/kg midazolam. Phase 1: 60 patients were randomized into three groups: (1) piritramide (0.1–0.3 mg/kg) and midazolam (1–3 mg) i.v. (2) Lidocaine/prilocaine cream topically (30 g) to skin and diclofenac supp. 100 mg. (3) No analgesia. Phase 2: Based on the data of phase 1, cut-off points for TP and MTP were set for female and male patients. In accordance with these results, 35 patients comprised group 1 for anesthesia with piritramide/midazolam, group 2 with lidocaine/prilocaine cream and diclofenac supp. and group 3 for no analgesia at all. The electromagnetic shockwave sources Modulith SLX and Lithostar Plus were utilized. Results: Phase 1: All patients randomized for group 1 (intravenous analgosedation) were treated in accordance with the protocol. 65% of group 2 (cream/suppository) tolerated treatment as planned. 35% of patients selected for ESWL without analgesia (group 3) remained within this group. Patients requiring additional analgosedation displayed lower TP and MTP. The cut-off points for females and males were TP ≥25/35 s and MTP ≥45/60 s, respectively. Phase 2: 20/35 patients were preselected for a nonintravenous protocol. Five out of these 20 violated the protocol. The rate of additionally administered analgesia was lower than in phase 1: 35:10% in group 2 (cream/supp.), 65:40% in group 3 (no analgesia). Conclusions: The TP and MTP levels are lower in patients requiring stronger analgesia. The determined parameters are suitable for patient preselection and individual assessment of anesthesia prior to ESWL. It may be assumed that 50% of patients administered intravenous opioids are overtreated. Routine pain measurement for patient depends on the individual pain tolerance level. A third phase of this study recruiting a large number of patients will contribute to the confirmation of these results.