Use Of Extracorporeal Shock Wave Lithotripsy Research Articles

Efficacy of extracorporeal shock wave lithotripsy for post-transplant kidney stones. Hope or Disappointment?

Nephrolithiasis in a transplanted kidney is an important medical and social problem. The presence of renal calculi may not manifest clinically for a long time due to the peculiarities of the surgical intervention during organ transplantation. Development of chronic urinary tract infection and deterioration of the functional ability of the renal transplant in the presence of kidney stones can lead to graft death, which is an immediate threat to the patient’s life. Existing Russian guidelines on the treatment of urolithiasis currently lack a clear strategy for the management of kidney transplant recipients.Objective: to systematize literature data on analysis of the outcomes of extracorporeal shock wave lithotripsy (ESWL) and other methods in patients with post-transplant kidney stones.Results. Thirty-five publications on the research topic were selected. We summarized the information on various therapy options for patients with stones in transplanted kidney: endourological approach, ESWL, percutaneous nephrolithotripsy (PCNL), open surgical treatment (nephrostomy, pyelolithotomy). A modern foreign algorithm for the management of patients with post-transplant kidney stones depending on the severity of obstruction with sepsis and the size of the renal calculi is presented.Conclusion. 1. The presence of stones in a kidney graft is a clinical situation that requires surgical treatment. 2. In clinical practice, different methods of treatment can be used, such as open intervention, ESWL, PCNL, retrograde transurethral manipulations. 3. In most cases, patient management tactics depend on the clinical picture (presence/absence of obstruction) and the size of the calculi. 4. The use of ESWL, as the most frequently used method, testifies to its efficiency and low-traumatic effect.

Treatment of Sialolithiasis: What Has Changed? An Update of the Treatment Algorithms and a Review of the Literature.

Treatment for sialolithiasis has undergone significant changes since the 1990s. Following the development of new minimally invasive and gland-preserving treatment modalities, a 40–50% rate of gland resection was reduced to less than 5%. Extracorporeal shock-wave lithotripsy (ESWL), refinement and extension of methods of transoral duct surgery (TDS), and in particular diagnostic and interventional sialendoscopy (intSE) are substantial parts of the new treatment regimen. It has also become evident that combining the different treatment modalities further increases the effectiveness of therapy, as has been especially evident with the combined endoscopic–transcutaneous approach. In the wake of these remarkable developments, a treatment algorithm was published in 2009 including all the known relevant therapeutic tools. However, new developments have also taken place during the last 10 years. Intraductal shock-wave lithotripsy (ISWL) has led to remarkable improvements thanks to the introduction of new devices, instruments, materials, and techniques, after earlier applications had not been sufficiently effective. Techniques involving combined approaches have been refined and modified. TDS methods have been modified through the introduction of sialendoscopy-assisted TDS in submandibular stones and a retropapillary approach for distal parotid sialolithiasis. Recent trends have revealed a potential for significant changes in therapeutic strategies for both major salivary glands. For the submandibular gland, ISWL has replaced ESWL and TDS to some extent. For parotid stones, ISWL and modifications of TDS have led to reduced use of ESWL and the combined transcutaneous–sialendoscopic approach. To illustrate these changes, we are here providing an updated treatment algorithm, including tried and tested techniques as well as promising new treatment modalities. Prognostic factors (e.g., the size or location of the stones), which are well recognized as having a strong impact on the prognosis, are taken into account and supplemented by additional factors associated with the new applications (e.g., the visibility or accessibility of the stones relative to the anatomy of the duct system).

Predictors of success following extracorporeal shock-wave lithotripsy in a contemporary cohort.

Objectives:The objectives of this study are to determine the predictors of success following extracorporeal shock-wave lithotripsy (ESWL) in a contemporary cohort at a high-volume stone center.Methods:We conducted a retrospective review all patients who underwent an elective ESWL within our institution over a 24-month period (January 2014 to December 2015). Data on patient demographics, stone variables, and inpatient treatment outcomes were evaluated.The presence of residual stone fragments larger than 4 mm on follow-up imaging was considered to be treatment failure. Using this threshold, clinically relevant variables between the treatment success and failure groups were identified. Multivariable logistic regression analyses (MVA) of clinically relevant variables were used to determine the independent factors predicting ESWL success.Results:Of 446 study eligible patients, 421 patients had complete follow-up data and were included in the analysis. Treatment was successful in 72.2% of patients in this study. Stone size, number of shocks delivered, and maximum treatment intensity were statistically different in the two groups. In a MVA where stone size, location, density, presence of ureteric stent, skin-stone distance (SSD), number of shocks, and maximum shock intensity were included, only stone size of <10 mm (odds ratio [OR] 3.4 [95% confidence interval [CI]: 1.98–5.84]) and SSD <15 cm (OR: 0.133, [95% CI: 0.027–0.65]) were the independent predictor of ESWL success.Conclusion:We have demonstrated “real world” outcomes with high-volume use of ESWL. In our experience that with diligent patient selection, ESWL remains an effective tool for the management of upper tract calculi.

Modern Ideas About the Pathogenesis, Diagnosis and Treatment of Ureterolithiasis on the Background of Diabetes Mellitus (Analytical Literature Review)

When analyzing available literature sources, we encountered isolated scientific papers whose authors provide their own data for comparing the methods of minimally invasive surgical treatment of ureterolithiasis and its postoperative complications (POC) in patients with diabetes mellitus (DM). Unfortunately, we have not encountered serious studies on the comparison of the effectiveness of various techniques of minimally invasive intervention in cases of ureterolithiasis, which proceeds against the background of diabetes. We also did not find a justification for the relationship and comparison of data from various systems of homeostasis, which are considered to be leading in determining the state of the kidneys in diabetes. Thus, the determination of the correlation between the data of ultrasound, X-ray radiology, radiation, enzyme and clinical and biochemical parameters, depending on the degree of violation of carbohydrate metabolism.Analysis of the literature suggests that transureteral contact lithotripsy (TUCL) and extracorporeal shock wave lithotripsy (ECHL) are more common and effective methods of ureterolithotripsy, although the level of POC in each patient is different. According to modern scientists, the use of ECHL in ureterolithiasis is limited by narrow indications and a high risk of complications in diabetes.So, the provided research facts, respectively, of established diagnostic and therapeutic measures in patients with ureterolithiasis on the background of diabetes, allow us to conclude that there is no complete understanding of this problem. Thus, for the indisputable value and dedication of medical science in this direction, the question of determining the capabilities of various methods of minimally invasive technology and the optimal approach for each individual patient remains relevant. This requires further improvement of diagnostic measures and methods of treatment of this cohort of patients.

Analysis of the factors influencing the success of the second extracorporeal shock wave lithotripsy in the treatment of upper urinary calculi

Objective To investigate the factors influencing the success of the second extracorporeal shock wave lithotripsy (ESWL) in the treatment of upper urinary calculi. Methods Clinical data of 120 patients with upper urinary tract calculi who underwent second ESWL in our hospital between January 2008 and December 2012 were retrospective analyzed.According to stones were completely discharged, all patients were divided into the successful group (n=80) and failed group (n=40). A retrospective analysis of the medical records of all patients and analysis of related factors included gender, age, duration, body mass index, stone side, stone location, stone length, stone width and number of stones, renal colic, hematuria, degree of hydronephrosis, the value of non enhanced spiral CT, impact frequency, impact energy index were performed. Risk factors for the success of second ESWL in the treatment of patients with upper urinary tract calculi were analyzed by single factor and multiple factor non-conditional logistic regression analysis. Results There were significant differences in the course of the disease, body mass index, length, width, stone, hydronephrosis, renal colic, CT value, the impact number between the two groups (P 0.05). Univariate and multivariate logistic regression analysis showed that body mass index was high, the stone length >2 cm, renal colic, hydronephrosis severity, CT value>750 HU could increase the risk of failure in second ESWL for upper urinary tract calculi (P<0.05). Conclusions We should pay attention to the patient's body mass index, stone length, renal colic, the degree of renal water, CT value, and other key indicators in the process of second use of ESWL in the treatment of upper urinary tract calculi. Key words: Urinary Calculi; Lithotripsy

Cost-effectiveness of extracorporeal shock wave lithotripsy in a poor resource setting: The Okada, Nigeria experience.

Background:The first extracorporeal shock wave lithotripsy (ESWL) used in Nigeria was at Igbinedion Hospital and Medical Research Centre (IHMRC), Okada in 1992 and it functioned for 6 consecutive years. The objectives of this study were to analyze the cost-effectiveness of the procedure and highlight the associated factors that led to its failure.Methods:A retrospective study of medical records and publications associated with the use of ESWL at IHMRC, Okada, for the period of 1992 to 1998. The study was conducted between January 2003 and November 2008. Unclassified authentic information relating to the use of ESWL and treatment of upper urinary tract stones was obtained from the IHMRC Okada and some government hospitals on hospital bills. Relevant documents in public domains related to the national and international wages and emoluments of medical workers and socioeconomic development of Nigeria within the time the ESWL functioned were studied.Result:A total of 32 patients were treated with 51 treatment sessions which is an average of nine patients per year and an average of two treatment sessions per patient were involved. The reasons for the low patronage were the extremely low stone formation rate of Nigerians, poverty, and out-of-pocket payment system. In addition, each treatment session of ESWL at Okada cost an average of $681.8 compared to $227.3 for open nephrolithotomy in a nearby high profile teaching hospital. The IHMRC, Okada, paid an average annual salary of ₦180,000 ($8,181.8) for each medical consultant compared to ₦120,000 ($5,454.5) paid by federal teaching hospitals in Nigeria within the period. Expatriate consultant doctors from Europe and USA who initially manned the lithotriptor at IHMRC, Okada, were paid much higher salaries. Average annual income of $5,909 for each of the 6 years amounting to a total of $34,771.7 for the six years was realized which could not maintain staff salaries in the hospital leading to staff emigration, decline of the hospital services, and eventual closure of the ESWL procedure center in the hospital in 1998.Conclusion:ESWL at Okada was not cost-effective both to patients and the hospital management. Despite these, ESWL is desirable in poor-resource countries because of its noninvasiveness, low morbidity, and usability in patients who are unfit for open surgery. Purchasing high technological medical equipment as commodities by sub-Saharan Africans without considering the prevalence of diseases they are meant to cater for, their maintenance for steady function during useful lifespan, their cost-effectiveness and how to recoup the money spent on investments depletes the scarce foreign exchange reserve of the home countries and is eventually counterproductive as exemplified by this case.

Mo1390 Is There a Benefit in Exocrine and Endocrine Function With the Use of Extracorporeal Shock Wave Lithotripsy in Chronic Calcific Pancreatitis Management: a Meta-Analysis and Systematic Review

Morbidity in chronic calcific pancreatitis has been attributed to calcified pancreatic duct (PD) stones. Extracorporeal shock wave lithotripsy (ESWL) is one of the management options for chronic calcific pancreatitis. The effect of ESWL on endocrine and exocrine functions of pancreas is not clear. This is a meta-analysis and systematic review to assess the overall endocrine and exocrine outcomes with the use of ESWL in chronic calcific pancreatitis.

The clinical efficacy of extracorporeal shock wave lithotripsy in pediatric urolithiasis: a systematic review and meta-analysis.

The aim was to investigate the clinical efficacy and safety of extracorporeal shock wave lithotripsy (ESWL) in pediatric urolithiasis. A comprehensive systematic review and meta-analysis were performed. PubMed, Embase, and the Cochrane central register of controlled trials (CENTRAL) were searched, and the stone-free rates (SFRs) of various stone sizes and stone positions were extracted from the eligible articles. The quality of the original articles was assessed according to the McHarm Scale. The risk ratios (RRs) and 95% confidential intervals (CIs) were pooled, and the sensitive analysis was performed to evaluate the heterogeneity among all eligible studies. In total, 14 studies with 1842 patients were identified. The pooled RR for the SFR of stones less than 10 mm and greater than 10 mm was 1.14 (95% CI: 1.07, 1.21, P < 0.001); the RR for the SFR of stones in the renal pole calix (PC) and the renal pelvis was 0.95 (95% CI: 0.893, 1.009, P < 0.01); the RR for the SFR of stones in the upper/middle PC and the lower PC was 1.07 (95% CI: 0.997, 1.156, P < 0.061); and the RR for the SFR of stones in the proximal ureter and middle/distal ureter was 1.077 (95% CI: 1.005, 1.154, P = 0.036). Heterogeneity was low in all the analyses. Major complications in ESWL of pediatric urolithiasis were steinstrasse and abdominal colic, the incidences of which were 6.00 and 6.29 %, respectively. The SFR of stones <10 mm was significantly higher than stones >10 mm, and the SFR of stones located in proximal ureter was statistically greater than stones in middle or distal ureter in pediatric urolithiasis, leaving no significant between stones in renal PC and renal pelvis, or between upper/middle PC and lower PC. The use of ESWL in children is highly efficient, with negligible complications; ESWL therapy could be considered the first-line treatment for pediatric urolithiasis.

Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones.

Stones in the urinary tract are a common medical problem in the general population. At present, the great expansion in minimally invasive techniques has led to the decrease in open surgery. Extracorporeal shock wave lithotripsy (ESWL) has been introduced as an alternative approach which disintegrates stones in the kidney and upper urinary tract through the use of shock waves. Nevertheless, as there are limitations with the success rate in ESWL, other minimally invasive modalities for kidney stones such as percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) are also widely applied. This is an update of a review first published in 2009. This review aimed to assess the effectiveness and complications of ESWL for kidney stones compared with PCNL or RIRS. We searched the Cochrane Renal Group's Specialised Register to 3 March 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Randomised controlled trials (RCTs) assessing the use of ESWL compared to PCNL or RIRS for kidney stone management. Two authors independently assessed all the studies for inclusion. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). Five studies (338 patients) were included, four studies compared ESWL to PCNL and one compared ESWL with RIRS. Random sequence generation was reported in three studies and unclear in two. Allocation concealment was not reported in any of the included studies. Blinding of participants and investigators could not be undertaken due to the nature of the interventions; blinding of outcome assessors was not reported. Reporting bias was judged to be low risk in all studies. One study was funded by industry and in one study the number of participants in each group was unbalanced.The success of treatment at three months was significantly greater in the PCNL compared to the ESWL group (3 studies, 201 participants: RR 0.46, 95% CI 0.35 to 0.62). Re-treatment (1 study, 122 participants: RR 1.81, 95% CI 0.66 to 4.99) and using auxiliary procedures (2 studies, 184 participants: RR 9.06, 95% CI 1.20 to 68.64) was significantly increased with ESWL group compared to PCNL. The efficiency quotient (EQ; used to assess the effectiveness of procedures) higher for PCNL than ESWL; however EQ decreased when stone size increased. Duration of treatment (MD -36.00 min, 95% CI -54.10 to -17.90) and hospital stay (1 study, 49 participants: MD -3.30 days, 95% CI -5.45 to -1.15) were significantly shorter in the ESWL group. Overall more complications were reported with PCNL, however we were unable to meta-analyse the included studies due to the differing outcomes reported and the timing of the outcome measurements.One study compared ESWL versus RIRS for lower pole kidney stones. The success of treatment was not significantly different at the end of the third month (58 participants: RR 0.91, 95% CI 0.64 to 1.30). Mean procedural time and mean hospital stay was reported to be longer in the RIRS group. Results from five small studies, with low methodological quality, indicated ESWL is less effective for kidney stones than PCNL but not significantly different from RIRS. Hospital stay and duration of treatment was less with ESWL. Larger RCTs with high methodological quality are required to investigate the effectiveness and complications of ESWL for kidney stones compared to PCNL if there is any technological progress in the non-invasive elimination of the residual fragments. Moreover, further research is required for the outcomes of ESWL and RIRS in lower and non-lower pole studies including PCNL versus RIRS.

Treatment efficacy and outcomes using a third generation shockwave lithotripter

To evaluate the clinical efficiency of a third generation electromagnetic shock wave lithotripter, the Lithoskop(®) (Siemens, Erlangen, Germany), regarding outcomes, stone disintegration, retreatment and complication rates. To compare the results of the Lithoskop with other currently available systems and the reference standard lithotripter, the HM-3 (Dornier MedTech Europe GmbH, Wessling, Germany). We analysed the data from 183 patients, including 13 children, undergoing extracorporeal shock wave lithotripsy (ESWL) for renal and ureteric calculi collected from a prospectively populated database. Outcomes were assessed by plain abdominal film of kidney, ureter and bladder and renal ultrasonography for radiopaque and computerized tomography for radiolucent stones 1 day after treatment and after 3 months. We analysed stone size and location before and after treatment, stone disintegration rate, retreatment rate, stone-free and residual fragment rates after 3 months, along with auxiliary procedures and complications. The mean (range) patient age was 48.6 (1.3-81.4) years, including 13 children with a mean (range) age of 8.4 (1.3-16.7) years, and 77% of the patients were male. In all, 46% of the calculi were localized in the kidney and 54% in the ureter. Renal stones were localized in the upper, middle and lower calyx and in the renal pelvis in 9, 29, 30 and 32% of patients, respectively. Ureteric stones were localized in the upper, mid- and distal ureter in 29, 19 and 52% of patients, respectively. The median (range) stone size before ESWL was 10 (4-25) mm in the kidney and 8 (4-28) mm in the ureteric calculi. The overall stone-free rate after 3 months was 91% (88% for renal and 93% for ureteric calculi); the mean number of sessions to achieve these rates was 1.3. Stone-free rates and the required number of sessions were determined only by stone size. In 7.1% of the patients (n = 13) post-interventional auxiliary procedures were necessary. We observed one perirenal haematoma as a major complication (0.5%), but this did not require any further therapy. Clinical stone-free rates with the Lithoskop are high and similar to those of other available systems, including the reference standard HM-3 lithotripter. Retreatment and complication rates are low, supporting the use of ESWL as first-line therapy for urinary calculi <10 mm, independent of stone location.

Treatment of Symptomatic Gallstones with Chinese Herbs

Purpose: Introduction: The best therapy for symptomatic gallstones is considered to be surgical, preferably with laparoscopic cholecystectomy. Dissolution is considered in patients who cannot tolerate, or refuse, surgery. We present a case of young gentleman who opted alternative medical treatment using chinese herbs successfully. Methods: Case: We are presenting a case of 37 year old male of chinese descent with 6 month history of epigastric/right upper quadrant pain, bloating, gas and dyspepsia. He had an ultrasound done that suggested multiple small mobile gallstones. He consulted a surgeon and was recommended to have cholecystectomy. He was highly skeptical to have surgery, and decided to take Chinese herbal treatment. He received four 15 day sessions, for a total of 60 days. Each session consisted of ½ gallon tea and 42 pills daily. The tea was made in ½ gallon boiling water to be mixed with multiple tea bags including full body cleansing tea, liver formula tea, bladder formula tea, and organic honey. The pills included kidney tonic I, ureter formula, spleen tonic, pancreas formula, liver tonic and stomach formula. The 1st and 2nd sessions were identical. The 3rd and 4th session had a minor change where origanum tea was added and honey was increased. After completion of this therapy, his GI symptoms improved. A repeat ultrasound revealed no further evidence of gallstones. Results: Discussion: The primary treatment of symptomatic gallstones is surgical. Medical therapy is considered in patients who cannot tolerate, or refuse, surgery. Non- surgical treatment consist of oral bile salt dissolution or extracorporeal shock wave lithotripsy (ESWL). Medical management is rarely used because of duration of treatment needed and the high risk of recurrence. Use of ESWL is extremely rare. The most frequently used medicine is UDCA (Ursodeoxycholic acid). The success rate is variable and the duration of treatment may be long, lasting up to 12-24 months. We present a case where Chinese herbal treatment was utilized by the patient that resulted in dissolution of stones within 60 days. Conclusion: Symptomatic gallstone disease is very common. Surgical treatment is the mainstay of therapy. The incidence of gallstone disease is likely to rise in the country in view of the changing population dynamics and increasing obesity. The rising health care cost will make is difficult to cope with escalating demand for cholecystectomies. Medical management of selected cases of symptomatic cholelithiasis need to be studied further. A combined research effort by conventional evidence based medicine with alternative medicine may prove to be helpful in finding novel treatment modalities.

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.

Post-ESWL fragments as core of new kidney stones.

The use of extracorporeal shockwave lithotripsy (ESWL) to treat kidney stones gives excellent fragmentation results. However, the retention of post-ESWL fragments within the kidney remains a serious health problem. A study carried out on calcium stone patients showed that only 32% of these were found to be stone free 12 months after ESWL [1]. Therefore, the persistence and the growth of fragments seem to be common after ESWL [2,3]. After ESWL, stone-free rates are closely related to stone location, size, number and composition, so a complete stone analysis of the first ESWL residual available must be carried out in order to perform the following treatments correctly so as to prevent recidivisms. Kidney stones collected from two patients previously treated with ESWL were chosen for this study (Figures 1 and 2). The main component of these kidney stones is calcium oxalate monohydrate (whewellite, CaC2O4·H2O) mixed with uric acid (C5H4N4O3), identified by X-ray diffraction analysis. A microscopic examination was made on petrographic thin section with a stereomicroscope coupled to polarizing microscope in order to provide information on the internal structure, location and type of core. The results show that these kidney stones were due to a regrowth on post-ESWL fragments. In both cases, the ESWL treatment has not reduced the previous stones in fragments of dimensions easy to be expelled or eliminated with an appropriated pharmacological treatment [4]. In the latter case (Figure 2), the residual fragment is very small (1 mm), not easily visible and recognizable only by a careful analysis, while the former stone (Figure 1) is made of a fragment of remarkable dimensions. Obviously, stone fragment regrowth is an unfavourable factor for spontaneous passage, and consequently an additional serious complication of post-ESWL residual stones.

Extracorporeal Shock Wave Lithotripsy (ESWL) for Obstructive Pancreatic Stones Causing Recurrent Acute Pancreatitis

Purpose: Obstructive pancreatic duct stones may cause recurrent acute pancreatitis and chronic abdominal pain. The use of ESWL for treatment of abdominal pain has been well documented; however, its effect on prevention of recurrent acute pancreatitis has not been studied. We evaluated the utility of ESWL for treatment of patients with recurrent acute pancreatitis caused by obstructive stones not amenable to endoscopic removal. Methods: Consecutive patients with recurrent acute pancreatitis due to obstructive pancreatic duct stones not amenable to endoscopic removal were prospectively evaluated. Stones were obstructive if during ERCP the duct proximal (upstream) to the stone could not be opacified by contrast or if opacification could be achieved only under pressure using an inflated extraction balloon. ESWL was performed by a pancreatologist (M.P.) using an electromagnetic shockwave lithotripter (Modulith SLX2, Storz Medical AG, Kreuzlingen, Switzerland). After ESWL, the patients were followed for recurrence of acute pancreatitis. Diagnosis of acute pancreatitis was based on guidelines proposed by the American College of Gastroenterology (Am J Gastroenterol 2006; 101:2379-2400). Results: Ten patients underwent 13 sessions of ESWL (range 1-3). The mean age was 54 years (range 44-72). The cause of chronic pancreatitis was alcohol abuse in 7 and idiopathic in 3 patients. Ductal calcifications were limited to the head of the gland in 4 patients. In 6 patients, the ductal calcifications were more extensive with involvement of the head, body and tail. The mean size of the largest stone in each patient was 1.5 cm (range 1-2 cm). Complete clearance was achieved in 7 (70%) patients. In the remaining 3 (30%) patients, ductal clearance was partial. However, relief of obstruction assessed by post procedure ERCP was achieved in all patients. The mean length of follow-up was 20 months (range 12-36). Three patients had recurrent acute pancreatitis during the follow-up period, caused by recurrence of obstructive stones in two and presence of main duct stricture in one. Conclusion: ESWL of obstructive pancreatic duct stones can prevent further attacks of acute pancreatitis. Recurrence of acute pancreatitis following ESWL may indicate stone recurrence or presence of strictures.

Extracorporeal shock wave lithotripsy as a first-line therapy for ureteral calculi with impaired renal function due to hydronephrosis

In their recent article on extracorporeal shock wave litho-tripsy (ESWL) as a first-line single therapy for obstructiveureteral stones, Chiara and colleagues indicated that ESWLis an effective therapy for obstructive ureteral calculi,varying degrees of hydronephrosis, and impaired renalfunction [1]. The present article adds further support to thefeasibility and safety of ESWL for calculus clearance andrecovery of renal function [1]. It is evident that ESWL hasbecome standardized and can guarantee acceptable peri-operative morbidity, yielding reproducible results fortreatment of ureteral calculi. Although some authors con-sider that ESWL is clearly indicated in the presence ofhydronephrosis, others consider hydronephrosis to be anindicator of successful outcome after ESWL. Consistentwith the findings of Chiara et al., El-Assmy et al. [2] foundthat the degree of urinary obstruction caused by calculusdid not affect the success of calculus clearance. However, atendency for repeat treatment and a prolonged period forstone clearance were associated with the degree of hydro-nephrosis [2]. Chang et al. conducted a prospective,randomized study of patients with hydronephrosis whosestones were located above the level of L5 [3]. Theyreported that hydronephrosis had a major impact on theoutcome of ESWL, because more stone-free patients werefound among those with mild, than among those withsevere, hydronephrosis, and ancillary procedures wereneeded in 16.9% of all patients [3]. Although ESWL hascertain limitations, its indications are expanding and nowinclude all types of urinary tract calculi. Deliveliotis et al.evaluated the use of ESWL in patients with impactedureteral stones that had remained in the same location for atleast 2 months, and found that 85.7% were rendered stone-free without the need for an open procedure, concludingthat ESWL should be attempted as an initial approach forthe treatment of impacted stones [4]. The use of ESWL,which is minimally invasive compared any other surgicalmethod known currently, should be promoted wheneverpossible for patients with ureteral stones.References

Radiolucent Renal Stones in Children: Combined Use of Shock Wave Lithotripsy and Dissolution Therapy

To provide a noninvasive efficient modality for the treatment of radiolucent renal stones in children. Uric acid calculi comprise a significant proportion of urinary stones. This study included 24 children (10 girls and 14 boys) with radiolucent renal stones. Of the 24 patients, 5 presented with bilateral renal stones, 8 with multiple stones, 4 with staghorn stones, and 7 with a solitary renal stone. Their age range was 2-12 years (mean 6.3 +/- 2.8). The stone size range was 12-65 mm in the largest diameter. All patients were treated with combined extracorporeal shock wave lithotripsy (ESWL) and medical therapy in the form of urinary alkalization using potassium sodium hydrogen citrate and allopurinol for the treatment of hyperuricosuria. Before ESWL, 3 patients had a percutaneous nephrostomy tube inserted and 2 patients had a ureteral stent placed to relieve obstruction. ESWL was performed with a Siemens Lithostar using either general anesthesia or intravenous sedation. The follow-up period after stone clearance was 12-36 months (mean 26 +/- 7.2). The stone-free rate of 100% was achieved in all 24 patients after 3 months of combined use of extracorporeal shock wave lithotripsy and dissolution therapy. Combined ESWL and dissolution therapy accelerated stone clearance and delayed stone recurrence. The use of ESWL and medical therapy as a combined modality is a safe and effective treatment of radiolucent renal stones in children.

Management of urolithiasis in the congenitally abnormal kidney (horseshoe and ectopic)

Urolithiasis in horseshoe and ectopic kidneys presents unique challenges in the decision-making and technical aspects of stone treatment. Specific renal anatomy, stone size and associated conditions such as ureteropelvic junction obstruction are factors that may influence treatment. Detailed review of imaging is important to ensure efficient stone treatment and minimize complications. Widespread use of extracorporeal shockwave lithotripsy for calculi in congenitally abnormal kidneys is now giving way to stone-size and anatomy-appropriate therapeutic decision making. Multiple modalities including shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy and laparoscopy are being employed in this group of patients. Treatment decisions for stones in horseshoe and ectopic kidneys can be challenging, and must be made on an individual basis taking into account multiple variables.

Editorial comment

This important communication by Demirkesen et al. answers several questions regarding pediatric stone treatment, but also raises interesting questions. In their study, the authors found that ESWL was equally effective for stones in all locations, although the stone burdens were less for lower pole caliceal stones compared with renal pelvic stones. The communication supports the use of ESWL, as opposed to percutaneous stone removal, for stones less than 2 cm. This conclusion, however, lacks certain information that makes it difficult to translate to other practices. First, no stone analysis was available. Second, no comparison was made among the types of commercially available lithotriptors, which may have marked differences in efficacy. Third, the infundibulopelvic angle, infundibular length, and infundibular width may also be strong determinants of stone passage. 1 Elbahnasy A.M. Clayman R.V. Shalhav A.L. et al. Lower-pole caliceal stone clearance after shockwave lithotripsy, percutaneous nephrolithotomy, and flexible ureteroscopy impact of radiographic spatial anatomy. J Endourol. 1998; 12: 113-119 Crossref PubMed Scopus (107) Google Scholar The conclusions in this paper leave me somewhat satiated, but still eager for further information on which to feast. Additional studies are needed to determine the efficacy of pediatric ESWL according to stone composition, lithotripter type, and pelvicaliceal anatomy. The development of such a nomogram would truly be an advance in the treatment of urolithiasis. Efficacy of extracorporeal shock wave lithotripsy for isolated lower caliceal stones in children compared with stones in other renal locationsUrologyVol. 67Issue 1PreviewTo evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) monotherapy for isolated lower caliceal calculi in a pediatric age group and compare it with that for isolated middle/upper caliceal and renal pelvic calculi. Full-Text PDF

Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones

A critical review of the experience with extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is needed to clarify whether this method should continue to be applied to patients. Patients with symptomatic gallbladder stones were treated by piezoelectric ESWL according to a prospective protocol between 1988 and 1997. ESWL treatment was limited to a maximum of three (solitary stones <20 mm diameter) to five sessions (larger solitary or multiple stones) and 3000 pulses per session. Univariate and multivariate analyses of pretreatment and treatment variables were performed to investigate their impact on fragmentation efficacy and stone clearance. A tree-based analysis was used to identify prognostically homogenous subgroups of individuals with maximum benefit from ESWL. Four hundred and eight patients, 76% female and 24% male, with a mean age of 46 (SD, 13) years, were selected for evaluation. Cox regression analysis identified three pretreatment variables with significant prognostic impact: (1) number of gallstones >1 (relative risk, 2.6 (95% CI, 1.9-3.5)), (2) size of stones >17 mm (1.7 (1.4-2.2)), and (3) computed tomography (CT) density of stones >55 Hounsfield units (H) (1.4 (1.1-1.8)). According to tree-based analysis, the stone clearance rate after 1 year was 85% (95% CI, 75-91%) for solitary stones <16 mm, 79% (70-86%) for solitary stones > or =16 mm with a CT density <84 H, 45% (32-55%) for solitary stones > or =16 mm with a CT density > or =84 H, and 42% (30-51%) for multiple stones. Five years after stone clearance, recurrence occurred in 43% of patients (95% CI, 39-47%). ESWL treatment showed an acceptable stone clearance in the case of small solitary gallbladder stones (<16 mm) or larger solitary stones with a CT density <84 H, but a very low success rate in the case of multiple stones. The poor long-term success, however, is an important argument against the use of ESWL of gallbladder stones.

Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment

Twenty years ago, in January 1985, extracorporeal shock wave lithotripsy (ESWL) was first applied successfully in a patient with gallbladder stones. In the following years, the conditions which influence the success rate of ESWL have been extensively investigated. It was shown that the characteristics of the stones, gallbladder emptying and the degree of stone fragmentation are the most important factors which determine the clearance of all fragments from the gallbladder after ESWL. Severe side effects, such as biliary pancreatitis and liver haematoma, were found to be rare and no deaths related to the procedure have been reported. One or more episodes of biliary pain were observed in about one third of patients within the first 3-4 months after ESWL. Follow-up studies after successful treatment, however, have shown that stone recurrence is considerable, limiting the use of ESWL as a non-invasive therapeutic option. Stone recurrence varies between different subgroups of patients indicating that gallbladder motor function and other less well defined factors may be of importance. The recurrence of stones after ESWL is one of the reasons why laparoscopic cholecystectomy has become the standard treatment of symptomatic gallbladder stones today. ESWL has kept its role only in the treatment of bile duct stones resistant to endoscopic extraction. Unless stone recurrence can be decreased by better patient selection and/or other measures to prevent gallstone recurrence, ESWL of gallbladder stones has little chance of surviving.