Shock Wave Lithotripsy For Ureteral Stones Research Articles

Treatment modalities for small-sized urolithiases and their impact on health-related quality of life.

Health-related quality of life (HRQoL) is often reduced in patients with urolithiasis. The objective of this study was to perform a systematic review to describe impact on HRQoL based on different modalities of treatment for small urolithiases with a diameter smaller or equal to 10 mm. Electronic databases were searched with no language or date restrictions to identify studies which were included if they reported: adult patients (≥18 years old), renal or ureteral stone(s) confirmed on imagery, validated reporting of HRQoL, and stone diameter equal or smaller than 10 mm undergoing active surveillance, medical expulsive therapy (MET), shockwave lithotripsy (SWL), or ureteroscopy (URS). Of 672 citations, nine articles were eligible. Five studies (all ureteral) reported HRQoL according to medical stone management. Three of them found that HRQoL in MET patients was better than in active surveillance patients and two studies found no difference in HRQoL between MET and active surveillance groups. Four studies (three ureteral, one renal) reported HRQoL according to surgical stone management. Of the ureteral stone studies, two reported better HRQoL in URS patients than in SWL patients, while one study found no difference between URS and SWL groups. In the renal stone study, SWL patients had better HRQoL than URS patients. Patients with urinary stones 10 mm or smaller have better HRQoL when treated with MET vs. active surveillance, when treated with SWL vs. URS for renal stones, and when treated with URS vs. SWL for ureteral stones. There is an important need for more studies on this topic.

Extremely slow, half-number shockwave lithotripsy for ureteral stones.

To elucidate and compare the efficacy and safety of the reduced (30 shocks/min with 1200 shocks/session) and standard protocols (60 shocks/min with 2400 shocks/session) of extracorporeal shockwave lithotripsy (SWL) for ureteral stones treatment. This study was a retrospective review of 2410 SWL procedures with reduced or standard protocols (groups R and S) in 1106 patients for ureteral stones between March 2014 and March 2021. The primary outcome was treatment success, defined as the absence of residual fragments on ultrasonography and plain radiography within 30 and 90days. A multivariate logistic regression and propensity score matching analysis evaluated the association between the reduced protocol and treatment success. This study included 311 and 544 patients in the reduced (R) and standard (S) protocol groups, respectively. The patient's characteristics were comparable, excluding the lithotripter machine. No significant difference was observed between groups R and S in treatment success rates within 30 (63.3 vs. 65.8%, p = 0.50) and 90days (88.7 vs. 91.5%, p = 0.18). The multivariate analysis indicated no significant association between reduced protocol and treatment success within 30 and 90days (p = 0.44 and p = 0.68, respectively). Propensity score matching showed no significant difference in the treatment success rates within 30 and 90days. The Extremely slow, half number protocol outcomes are comparable to those of the standard protocol for treating ureteral stones.

Acute extracorporeal shockwave lithotripsy for ureteric stones - 7-years' experience from a busy district general hospital.

To demonstrate the efficacy and cost-effectiveness of acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones we present our experience of ESWL in 530 ureteric stone cases, in the largest UK series we are aware of to date. ESWL is underutilised in ureteric stone management. The Getting It Right First Time (GIRFT) report showed just four units nationally treated >10% of acute ureteric stones with ESWL. Despite guideline recommendations as a first-line treatment option, few large volume studies have been published. Retrospective review of prospectively collected data between December 2012 and February 2020 was performed. Data relating to patient demographics, stone characteristics, skin-to-stone distance, and treatment failure were collected. Cost analysis was conducted by the Trust's surgical financial manager. Multivariable analyses were performed to assess for predictors of ESWL success. A success rate of 68% (95% confidence interval 64%-72%) at 6 weeks was observed (n = 530). The median (interquartile range) number of treatment sessions was 2 (1, 2). Stone diameter was observed to be a predictor of ESWL success. The small number of stones treated of >13 mm or >1250 HU had an ~50% chance of successful treatment. Acute ureteric ESWL was less costly than acute ureterorenoscopy, consistent with findings from previous NHS studies. Acute ESWL is a safe, reliable, and financially viable treatment option for a wider spectrum of patients than reflected in international guidelines based on our large, heterogenous series. In the coronavirus disease 2019 (COVID-19) era, with theatre access reduced and concerns over aerosol generating procedures, acute ESWL remains an attractive first-line treatment option.

Shockwave Lithotripsy Versus Ureteroscopic Treatment as Therapeutic Interventions for Stones of the Ureter (TISU): A Multicentre Randomised Controlled Non-inferiority Trial

BackgroundRenal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways. ObjectiveTo report a pragmatic multicentre non-inferiority RCT comparing SWL with URS. Design, setting, and participantsThis trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention. Outcome measurements and statistical analysisThe primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned. Results and limitationsThe study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL. ConclusionsThis RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition. Patient summaryWe present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition.

A model to guide patient selection when managing ureteric stones with shockwave lithotripsy

Introduction: The aim of this study was to create a model based upon significant prognostic factors to guide patient selection for shockwave lithotripsy. Patients and methods: We identified 150 patients attending for shockwave lithotripsy for ureteric stones between October 2010–February 2016. Data was collected retrospectively from electronic case notes and radiological images. All patients were treated with an on-site Storz Modulith SLX-F2 lithotripter. A model was created using computer software ‘R’. Results: One hundred and thirty-three patients were treated and 66% of those were deemed radiologically stone-free with shockwave lithotripsy. Four factors were found to be independently statistically significant with regards to stone-free status; age ( p=0.003), Hounsfield units ( p=0.002), prior nephrostomy insertion ( p=0.022) or prior stent insertion ( p=0.002). Our resulting model is:[Formula: see text] Discussion and conclusions: Our shockwave lithotripsy success would likely increase with improved patient selection. Age appears to be a novel significant factor in stone passage. This is an interesting observation worthy of further study given ageing populations in the developed world. The model will require further validation in order to confirm our findings, however the results have proven very encouraging. Level of evidence: 2c

Does the degree of stone-induced hydronephrosis affect the outcome of shock-wave lithotripsy in patients with proximal ureteral stones?

Background Shock-wave lithotripsy (SWL) is an effective, well-established approach for treating ureteral calculi. Some studies have shown that patients with collecting system obstruction and ureteral stones had lower stone-free rates after SWL than patients with nonobstructed stones. In contrast, other studies acknowledge that stone-induced urinary obstruction does not decrease success with SWL for ureteral stones. The purpose of this study was to assess whether the degree of stone-induced hydronephrosis in patients with solitary proximal ureteral stones influences the outcome and clearance rates after SWL. Patients and methods This prospective study included 30 patients, with solitary proximal ureteric stones and different degrees of hydronephrosis, who were treated with SWL. Patients were divided into three groups according to the degree of stone-induced hydronephrosis. Group 1 (33.33%) had mild dilation, group 2 (33.33%) had moderate dilation, and group 3 (33.33%) had severe dilation. The Dornier MFL 5000 lithotripter was used to treat the patient groups. The results were compared in terms of stone-free rates, number of shock waves, number of sessions, incidence of complications, number of secondary interventions, and time to stone clearance. Results The average stone size was between 8 and 18 mm. The overall success rate was found to be 80% in patients with severe back pressure compared with 90 and 86.6% success rate in moderate and mild hydronephrosis groups, respectively (P=0.749). Furthermore, there was no statistical significance between the three studied groups regarding clearance time (P=0.721). Conclusions The degree of hydronephrosis secondary to proximal ureteral stones of between 6 and 20 mm has shown not to affect the duration till stone clearance or overall treatment success following SWL treatment.

Role of clinical and radiological parameters in predicting the outcome of shockwave lithotripsy for ureteric stones.

Introduction:Shockwave-lithotripsy (SWL) provides a noninvasive and effective option for the management of ureteric calculi. Several factors may affect the success of SWL. Identification of these predictive factors will both increase the efficacy and decrease the cost. This study was designed to identify factors affecting the outcome of SWL for ureteral stones.Materials and Methods:This study was conducted from March 2012 to November 2014 in patients with solitary ureteric calculi who were managed with SWL. Data were analyzed to identify clinical and radiological factors associated with treatment outcome. Success after SWL was described as complete stone clearance or clinically insignificant residual fragments <3 mm at 3 months after SWL.Results:A total of 110 patients with ureteric calculi were divided into two groups depending on the outcome of SWL, Group A (successful - 76%) and Group B (failed - 24%). Stone size, Skin to stone distance (SSD), secondary signs of obstruction, and presence of double J (DJ) Stent, all were significantly associated with the outcome of SWL on univariate analysis. On multivariate analysis, stone size, hounsfield unit, SSD, and DJ stent were the independent factors affecting the outcome of SWL. On Receptor-Operator Characteristic curve analysis, a cutoff value of 8.2 mm for the stone size was found which best predicts a successful outcome, with a sensitivity of 54% and specificity of 96%.Conclusion:The findings of this study suggest that Stone size, SSD, the presence of DJ stent, and stone attenuation values are the significant factors that influence the outcome of SWL in patients with ureteral stones.

049 - Emergency extra-corporeal shockwave lithotripsy for ureteric stones: Improved stone free rates & reduced length of stay

049 - Emergency extra-corporeal shockwave lithotripsy for ureteric stones: Improved stone free rates & reduced length of stay

Medical Expulsive Therapy Following Shock Wave Lithotripsy in Ureteral Calculi: An Effective Approach for the Improvement of Health-Related Quality of Life

Objective: To evaluate the possible effects of medical expulsive therapy (MET) on the health-related quality of life (HRQOL) of patients undergoing shock wave lithotripsy (SWL) for ureteric stones. Methods: Eighty patients treated with SWL for ureteric stones were included in this study. Patients were divided into 2 groups; Group 1 received medical therapy only for colic pain and Group 2 received MET in addition to medical therapy. Patients requiring DJ stenting and auxiliary measures after SWL procedure were excluded. The remaining 54 patients were further evaluated (Group 1: n = 26, Group 2: n = 28) and followed up during the 4-week period for analgesic requirement, number of renal colic attacks, emergency department (ED) visits and the HRQOL scores by using EQ-5D index and EQ-5D visual analogue scale (VAS) values. Results: During the 4-week follow-up period, cases undergoing SWL only required significantly higher amount of analgesics. In addition to the lower number of renal colic attacks and ED visits, EQ-5D index and EQ-5D VAS values also demonstrated higher mean values in patients undergoing SWL + MET. Conclusion: In addition to the increased spontaneous stone passage rates, MET following SWL for ureteral calculi could increase the HRQOL scores by lowering the number of both renal colic attacks and ED visits along with decreased analgesic need.

Can stone density on plain radiography predict the outcome of extracorporeal shockwave lithotripsy for ureteral stones?

PurposeThe objective was to determine whether stone density on plain radiography (kidney-ureter-bladder, KUB) could predict the outcome of extracorporeal shockwave lithotripsy (ESWL) for ureteral stones.Materials and MethodsA total of 223 patients treated by ESWL for radio-opaque ureteral stones of 5 to 20 mm were included in this retrospective study. All patients underwent routine blood and urine analyses, plain radiography (KUB), and noncontrast computed tomography (NCCT) before ESWL. Demographic, stone, and radiological characteristics on KUB and NCCT were analyzed. The patients were categorized into two groups: lower-density (LD) group (radiodensity less than or equal to that of the 12th rib, n=163) and higher-density (HD) group (radiodensity greater than that of the 12th rib, n=60). Stone-free status was assessed by KUB every week after ESWL. A successful outcome was defined as stone free within 1 month after ESWL.ResultsMean stone size in the LD group was significantly smaller than that in the HD group (7.5±1.4 mm compared with 9.9±2.9 mm, p=0.002). The overall success rates in the LD and HD groups were 82.1% and 60.0%, respectively (p=0.007). The mean duration of stone-free status and average number of SWL sessions required for success in the two groups were 21.7 compared with 39.2 days and 1.8 compared with 2.3, respectively (p<0.05). On multivariate logistic analysis, stone size and time to ESWL since colic and radiodensity of the stone on KUB were independent predictors of successful ESWL.ConclusionsOur data suggest that larger stone size, longer time to ESWL, and ureteral stones with a radiodensity greater than that of the 12th rib may be at a relatively higher risk of ESWL failure 1 month after the procedure.

Predictive Factors of the Outcome of Extracorporeal Shockwave Lithotripsy for Ureteral Stones

PurposeExtracorporeal Shock Wave Lithotripsy (ESWL) has shown successful outcomes for ureteral stones. We investigated predictive factors for failure of ESWL for treating ureteral stones.Materials and MethodsA total of 153 patients who underwent ESWL between July 2006 and July 2009 for ureteral stones diagnosed by non-enhanced spiral computed tomography were divided into two groups: (group A, stone size ≤10 mm; and group B, stone size >10 mm). The failure was defined as remnant stones >4 mm. We assessed age, sex, body mass index, stone size, laterality, location, skin-to-stone distance (SSD), Hounsfield unit, and the presence of secondary signs (hydronephrosis, renal enlargement, perinephric fat stranding, and tissue rim sign). We analyzed predictive factors by using logistic regression in each group.ResultsThe success rates were 90.2% and 68.6% in group A and B, respectively. In the univariate analysis of each group, stone size, SSD, and all secondary signs showed statistically significant differences in terms of the outcome of ESWL (p<0.05). In the multivariate logistic regression, stone size (odds ratio [OR], 50.005; 95% confidence interval [CI], 6.207 to 402.852) was an independent predictive factor in group A. The presence of perinephric fat standing (OR, 77.634; 95% CI, 1.349 to 446.558) and stone size (OR, 19.718; 95% CI, 1.600 to 243.005) were independent predictive factors in group B.ConclusionsStone size is an independent predictive factor influencing failure of ESWL for treating ureteral stones. In larger ureteral stones (>10 mm), the presence of perinephric fat stranding is also an independent predictive factor.

Stenting or not prior to extracorporeal shockwave lithotripsy for ureteral stones? Results of a prospective randomized study

To determine the need for pre-treatment stenting in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for ureteral stones sized 4-10 mm. A prospective randomized study was conducted between September 2009 and March 2011. Included 156 patients randomized in stented and non-stented groups and underwent a maximum of 3 ESWL sessions. Radiographic follow-up was used to assess the stone fragmentation and clearance. Results were compared in terms of stone-free rates, post-treatment morbidity and complications. Overall efficacy was 76.9%. Stone-free rates were statistically significantly lower (P = 0.026) in the stented group (68.6%) compared to the non-stented ones (83.7%). Furthermore, stenting was significantly correlated with post-treatment lower urinary tract symptoms (P ≤ 0.001), need for more ESWL sessions (P = 0.019) and possibility for operation due to ESWL failure (P = 0.026). A multivariate analysis was conducted to identify the parameters which may predict complete stone removal after ESWL. Stone size (P = 0.026), stone location (P = 0.011) and stenting (P = 0.007) were the most significant factors. ESWL is an efficient and safe treatment for 4- to 10-mm ureteral stones. Pre-treatment stenting is limiting stone-free rates and is significantly influencing post-ESWL morbidity and quality of life in a negative manner, while it contributes minimally to the prophylaxis of complications.

Editorial Comment

The main objective of the treatment of ureteral stones is to achieve the immediate relief of the symptoms, decompression of the urinary tract, and stone disintegration/expulsion, with an acceptable rate of complications. Shock wave lithotripsy (SWL), retrograde lithotripsy, and medical expulsive treatment are each valuable options. At present, no high-quality, randomized study has been published showing the superiority of 1 treatment over the other 2. Given the particular clinical setting, it is unlikely such a study will ever be performed. In contrast, retrospective and prospective series have undoubtedly shown that each approach is safe. 1 Parsons J.K. Hergan L.A. Sakamoto K. et al. Efficacy of alfa-blockers for the treatment of ureteral stones. J Urol. 2007; 177: 983-987 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar , 2 Seitz C. Tanovic E. Kikic Z. et al. Impact of stone size, location, composition, impactation, and hydronephrosis on the efficacy of holmium:YAG laser ureterolithotripsy. Eur Urol. 2007; 52: 1751-1757 Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar , 3 Salem H.K. A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi. Urology. 2009; 74: 1216-1221 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar The authors describe a large retrospective experience of immediate versus delayed ureteroscopic treatment of ureteral stones. The latter group was treated first with appropriate medical treatment that failed to be effective. The results of the ureteroscopic procedures were similar. The main difference is practical and obvious. The delayed group surely experienced more pain, a later return to daily activities, and required more medical treatment. Nevertheless, it should be underlined that the report was not a comparison between immediate ureteroscopic treatment and medical expulsive therapy, because the patients who experienced successful medical treatment were not included in the analysis. Therefore, according to the authors, the main conclusion that can be drawn is that ureteroscopic lithotripsy is a safe option, even when performed immediately after the first colic attack, with results comparable to those for treatment delayed until expectant therapy has failed. In conclusion, when ureteral stones are complicated by hydronephrosis and/or fever or when the colic cannot be controlled by drugs, emergency ureteroscopic treatment can (and I believe should) be adopted. In most settings, emergency treatment means within 24 hours, a reasonable compromise, allowing time for a correct evaluation of the general condition of the patient. Patients with only 1 colic attack controlled by drugs and without hydronephrosis do not require hospitalization; thus, emergency ureteroscopic treatment could result in unnecessary overtreatment. One might finally debate in these cases the usefulness of emergency SWL (if available). Theoretically, SWL could improve the chance of spontaneous resolution, even if the fragmentation is partial. However, SWL of ureteral stones is not always easy, and, after colic, the visualization of the stone is even more difficult owing to intestinal meteorism, such that it would probably end as a fruitless attempt, with considerable cost. Emergency Ureteroscopic Removal of Ureteral Calculi After First Colic Attack: Is There Any Advantage?UrologyVol. 78Issue 3PreviewTo comparatively evaluate the efficacy of ureteroscopic stone treatment immediately after the first colic attack and in an electively planned manner. Full-Text PDF ReplyUrologyVol. 78Issue 3PreviewObstructing ureteral calculi have been the most common cause of severe colic pain evaluated and treated in an emergent manner. Regarding the management alternatives, because of its noninvasive and practical nature, shock wave lithotripsy is currently the preferred therapeutic option and can be performed after the onset of renal colic to relieve stones and related problems.1-5 However, although the success rates are high in the management of proximal ureteral calculi, these rates tend to decrease in distal stones and for those treated in an emergency setting. Full-Text PDF

A Clinical Nomogram to Predict the Successful Shock Wave Lithotripsy of Renal and Ureteral Calculi

Although shock wave lithotripsy is dependent on patient and stone related factors, there are few reliable algorithms predictive of its success. In this study we develop a comprehensive nomogram to predict renal and ureteral stone shock wave lithotripsy outcomes. During a 5-year period data from patients treated at our lithotripsy unit were reviewed. Analysis was restricted to patients with a solitary renal or ureteral calculus 20 mm or less. Demographic, stone, patient, treatment and 3-month followup data were collected from a prospective database. All patients were treated using the Philips Lithotron® lithotripter. A total of 422 patients (69.7% male) were analyzed. Mean stone size was 52.3±39.3 mm2 for ureteral stones and 78.9±77.3 mm2 for renal stones, with 95 (43.6%) of the renal stones located in the lower pole. The single treatment success rates for ureteral and renal stones were 60.3% and 70.2%, respectively. On univariate analysis predictors of shock wave lithotripsy success, regardless of stone location, were age (p=0.01), body mass index (p=0.01), stone size (p<0.01), mean stone density (p<0.01) and skin to stone distance (p<0.01). By multivariate logistic regression for renal calculi, age, stone area and skin to stone distance were significant predictors with an AUC of 0.75. For ureteral calculi predictive factors included body mass index and stone size (AUC 0.70). Patient and stone parameters have been identified to create a nomogram that predicts shock wave lithotripsy outcomes using the Lithotron lithotripter, which can facilitate optimal treatment based decisions and provide patients with more accurate single treatment success rates for shock wave lithotripsy tailored to patient specific situations.

Ureteral obstructions in dogs and cats: a review of traditional and new interventional diagnostic and therapeutic options

To describe and review both traditional and newer diagnostic and therapeutic options for canine and feline ureteral obstructions currently being performed clinically in veterinary medicine. A Medline search with no date restrictions was used for this review. The human literature would support the use of minimally invasive endourological techniques for the treatment of nearly all causes of ureteral obstructions, whenever possible. This typically includes extracorporeal shockwave lithotripsy, intracorporeal lithotripsy via retrograde ureteroscopy or antegrade percutaneous nephroureterolithotomy, ureteral stenting, percutaneous nephrostomy tube placement, and laparoscopic endopyelotomy. Typically open surgery is only suggested in cases of ureteral or gynecological malignancy when en bloc resection is considered a good option, or when various methods of endourological techniques have failed. The veterinary literature is scarce on the use of interventional endourological techniques for the treatment of ureteral obstructions and has been growing over the last 5 years. The current literature reports the use of extracorporeal shockwave lithotripsy for ureteral stones, as well as the use of ureteral stents for the treatment of trigonal obstructive transitional cell carcinoma, ureterolithiasis, and ureteral strictures. Traditional surgical interventions, like ureterotomy, ureteronephrectomy, and ureteral reimplantation is more vastly reported and accepted. This review will focus on new clinical data using interventional endourological techniques for ureteral obstructions. Various treatment options for ureteral obstructions are now available for veterinary patients, and the trend away from traditional surgical techniques will hopefully be followed now that they are technically and clinically available for dogs and cats.

Ureteric stents compromise stone clearance after shockwave lithotripsy for ureteric stones: results of a matched-pair analysis

To identify the effect of the presence of a ureteric stent on the outcome of extracorporeal shockwave lithotripsy (ESWL), by comparing patients with ureteric stones with matched-pair analysis. Patients undergoing ESWL with the Sonolith Vision lithotripter (Technomed Medical Systems, Vaulx-en-Velin, France) were identified from our prospectively maintained database. Only adult patients with a solitary, radio-opaque, previously untreated ureteric stone were considered for further analysis. A follow-up of >or=3 months with a plain abdominal film was used to identify residual fragments. Patients were exactly matched for gender, side, location in the ureter and size (in two dimensions, within +/-2 mm). If both diameters could not be matched exactly, the size was extended to +/-1 mm and then to +/-2 mm of both diameters. An effort was finally made to match patients by age. The treatment outcome in terms of stone-free rates was assessed and compared using McNemar's test. In all, 45 patients with a ureteric stent in place during ESWL were identified. The only patient who could not be adequately matched was a 40-year-old man with an 8 x 3 mm stone in the upper ureter. The best/closest match for age was selected. Most stones were in the upper ureter (77%); the mean stone size was 8.5 and 8.6 mm, respectively, with no statistical differences between the groups for age and size of stones (P = 0.41 and 0.86, Student's t-test). In 12 pairs, only patients with no stent were stone-free, compared to two pairs where the patient with a stent was stone-free. Using McNemar's test, the odds ratio was 6.0 (95% confidence interval 1.3-55.2) and the difference between the groups was statistically significant (P = 0.016). These results show that the presence of a stent is associated with a worse outcome after ESWL for ureteric stones. Ureteric stents should still be used in cases of obstruction, when there is a risk of sepsis, and in patients with intolerable pain or deteriorating renal function. However, their use in patients offered ESWL for ureteric stones should be considered with caution.

Shock wave lithotripsy for ureteral stones in elderly male patients

Introduction. Age has never been considered as a factor in the treatment of ureteral stones, but elderly male patients may suffer from concomitant illnesses that may affect SWL results, such as voiding difficulties and musculo-skeletal and cardio-vascular disorders. The aim of this study was to assess the success rate and complications of shock wave lithotripsy (SWL) for all size and location ureteral stones in patients older than 70 years of age.Patients and Methods. We retrospectively reviewed the charts and radiology films of all patients who had undergone SWL for ureteral stones with the HM3 lithotriptor and compared the results of patients younger than 70 years to those older than 70 years.Results. During 2000–2003, 238 consecutive male patients (23 older than 70 years) underwent SWL under regional anesthesia for all size and locations ureteral stones. Stone sizes, locations, opacity, and pre-operative drainage procedures matched in both groups. The overall stone-free rate was 91% for both groups. Complications were recorded in 1% of the older patients and 3.7% of the younger ones. No treatment-related mortality was recorded.Conclusions. Age itself has no effect on the success rate of SWL with the HM3 lithotripter for ureteral stones. In general, SWL treatment showed a high success rate with minimal morbidity and no treatment-related mortality.

Progress in Management of Ureteric Stones

Most symptomatic urinary stones are found within the ureter. Depending on stone localisation and size, a substantial portion is able to pass the upper urinary tract spontaneously. This process may take days to weeks and the patient has to receive sufficient analgetic and spasmolytic medication. There is some evidence, that alpha-adrenoreceptor blockade supports expulsion of praevesical stones. Standard and least invasive treatment for ureteric stones is extracorporeal shockwave lithotripsy (SWL). However, stone free rate after SWL of ureteric stones after single SWL is lower than for kidney stones and many patients require more than one shockwave application. Recent developments in ureteroscopy (URS) like small-calibre scopes and Ho:YAG laser lithotripsy have changed treatment algorithms as URS is highly efficient, has lower costs than SWL and is still minimally invasive. Especially for larger stones (>10 mm), URS seems to have advantages compared to SWL. Today, open or laparoscopic ureterolithotomy are reserved for special indications and are not used routinely. In summary, SWL offers minimal-invasiveness but a higher risk of treatment failure compared to URS which reaches immediate high stone free rates. Treatment decisions have to be drawn individually taking into account patients preference, personal experience and local equipment.

Independent predictors of failure of shockwave lithotripsy for ureteral stones employing a second-generation lithotripter.

To define factors associated with the failure of shockwave lithotripsy (SWL) in the treatment of ureteral stones. We retrospectively studied 405 men and 283 women (mean age 52.6 years) who underwent SWL with a second-generation lithotripter in the period 1994 to 2001. We evaluated available clinical and radiologic features that might have been related to failure of SWL therapy. Treatment was successful in 502 patients (73%). The 186 patients (27%) in whom treatment failed underwent endourologic alternatives or open surgery. Multivariate logistic regression analysis revealed that unsuccessful outcome was significantly related to: (1) pelvic ureteral stones (odds ratio [OR] 4.02; 95% CI 1.97, 8.19); (2) stone size >10 mm (OR 3.46; 95% CI 2.16, 5.53); (3) obstruction (OR 1.93; 95% CI 0.99, 3.77); and (4) obesity (OR 1.87; 95% CI 0.95, 3.77). Although the predictive value of each individual parameter was relatively low (15.3%-27.9%) the cumulative risk was 82.95% when patients had all four features. The strongest independent predictors of failure were pelvic stones and stones >10 mm (cumulative predictive value 57.3%). These variables may enable identification of a subgroup of patients who will fail initial SWL. These patients may be candidates for endourologic alternatives as first-line treatment.

Independent predictors of failure following shockwave lithotripsy for ureteral stones, employing a second-generation lithotriptor

Purpose: To define factors associated with the failure of shockwave lithotripsy (SWL) in the treatment of ureteral stones. Patients and Methods: We retrospectively studied 405 men and 283 women (mean age 52.6 years) who underwent SWL with a second-generation lithotripter in the period 1994 to 2001. We evaluated available clinical and radiologic features that might have been related to failure of SWL therapy. Results: Treatment was successful in 502 patients (73%). The 186 patients (27%) in whom treatment failed underwent endourologic alternatives or open surgery. Multivariate logistic regression analysis revealed that unsuccessful outcome was significantly related to: (1) pelvic ureteral stones (odds ratio [OR] 4.02; 95% CI 1.97, 8.19); (2) stone size >10 mm (OR 3.46; 95% CI 2.16, 5.53); (3) obstruction (OR 1.93; 95% CI 0.99, 3.77); and (4) obesity (OR 1.87; 95% CI 0.95, 3.77). Although the predictive value of each individual parameter was relatively low (15.3%-27.9%) the cumulative risk was 82.95% when p...