Cost-Effectiveness Study of the Extracorporeal Shock-Wave Lithotriptor

Nephrolithiasis is a common urological disease worldwide. Extracorporeal shock wave lithotripsy (ESWL) has been used for the treatment of renal stones since the 1980s, while retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) are newer, more invasive treatment modalities that may have higher stone-free rates. The complications of RIRS and PCNL have decreased owing to improvement in surgical techniques and instruments. We re-evaluated the best evidence on this topic in an update of a Cochrane Review first published in 2014. To assess the effects of extracorporeal shock wave lithotripsy compared with percutaneous nephrolithotomy or retrograde intrarenal surgery for treating kidney stones. We performed a comprehensive search in CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov with no restrictions on language or publication status. The latest search date was 6 December 2022. We included randomized controlled trials (RCTs) and quasi-RCTs that compared ESWL with PCNL or RIRS for kidney stone treatment. Two review authors independently classified studies, extracted data, and assessed risk of bias. Our primary outcomes were treatment success rate at three months (defined as residual fragments smaller than 4 mm, or as defined by the study authors), quality of life (QoL), and complications. Our secondary outcomes were retreatment rate, auxiliary procedures rate, and duration of hospital stay. We performed statistical analyses using a random-effects model and independently rated the certainty of evidence using the GRADE approach. We included 31 trials involving 3361 participants (3060 participants completed follow-up). Four trials were only available as an abstract. Overall mean age was 46.6 years and overall mean stone size was 13.4 mm. Most participants (93.8%) had kidney stones measuring 20 mm or less, and 68.9% had lower pole stones. ESWL versus PCNL ESWL may have a lower three-month treatment success rate than PCNL (risk ratio [RR] 0.67, 95% confidence interval [CI] 0.57 to 0.79; I2 = 87%; 12 studies, 1303 participants; low-certainty evidence). This corresponds to 304 fewer participants per 1000 (397 fewer to 194 fewer) reporting treatment success with ESWL. ESWL may have little or no effect on QoL after treatment compared with PCNL (1 study, 78 participants; low-certainty evidence). ESWL probably leads to fewer complications than PCNL (RR 0.62, 95% CI 0.47 to 0.82; I2 = 18%; 13 studies, 1385 participants; moderate-certainty evidence). This corresponds to 82 fewer participants per 1000 (115 fewer to 39 fewer) having complications after ESWL. ESWL versus RIRS ESWL may have a lower three-month treatment success rate than RIRS (RR 0.85, 95% CI 0.78 to 0.93; I2 = 63%; 13 studies, 1349 participants; low-certainty evidence). This corresponds to 127 fewer participants per 1000 (186 fewer to 59 fewer) reporting treatment success with ESWL. We are very uncertain about QoL after treatment; the evidence is based on three studies (214 participants) that we were unable to pool. We are very uncertain about the difference in complication rates between ESWL and RIRS (RR 0.93, 95% CI 0.63 to 1.36; I2 = 32%; 13 studies, 1305 participants; very low-certainty evidence). This corresponds to nine fewer participants per 1000 (49 fewer to 48 more) having complications after ESWL. ESWL compared with PCNL may have lower three-month success rates, may have a similar effect on QoL, and probably leads to fewer complications. ESWL compared with RIRS may have lower three-month success rates, but the evidence on QoL outcomes and complication rates is very uncertain. These findings should provide valuable information to aid shared decision-making between clinicians and people with kidney stones who are undecided about these three options.

Lithotripsie extracorporelle et obésité avec un IMC supérieur à 35

The continued evolution of stone treatment modalities, such as endourologic procedures, open surgery and shock wave lithotripsy, makes the assessment of continuous outcomes are essential. Pediatric urolithiasis are an important health problem allover the world, especially in Middle East region. We evaluate the safety, efficacy and factors affecting success rate and clearance of stones in children treated with shock wave lithotripsy. Between 2005 and 2010, a total of 500 children with stones in the upper urinary tract at different locations were treated by Extracorporeal shock wave lithotripsy (ESWL) in our department, Sohag University, Egypt. We have used the Siemn's Lithostar Modularis machine, Germany. A total of 371 boys and 129 girls with the average age of 8.63 ± 5 years, and a range from 9 months to 17 years were included in this study. Diagnosis of their urinary calculi was established either by the use of abdominal ultrasound, plain X-ray, intravenous urography, or CT scan. The stones were located in the kidney in 450 (90%) patients; 298 (66%) pelvic, 26 (5.7%) upper calices, 57 (12.6%) mid calices, and lower calices in 69 (15.3%) patients. The average of their stone sizes was 12.5 ± 7.2 mm. The other 50 children their stone were located in the proximal ureteral stones in 35 patients (70%); middle third in 5 (10%) patients and in the distal ureter in 10 (20%) patients. The average ureteral stone size was 7.5 ± 3.2 mm. All children were treated under general anesthesia with adequate lung and testes shielding using air foam. We treated the distal ureteral stones of young children in the supine position through greater sciatic foramen and lesser sciatic foramen as the path of shockwave instead of prone position, which is not a comfortable or natural position and could adversely affect cardiopulmonary function especially under general anesthesia. Localization was mainly done by ultrasound, and X-ray was only used to localize ureteral calculi. For follow-up, we have used abdominal ultrasound, plain X-ray, and CT scan if needed to confirm stone disintegration and clearance. The overall success rate for renal and ureteral calculi was 83.4 and 58.46%, respectively. The re-treatment rate was 4% in renal group and 28% for the ureteral group. No serious complications were recorded in our patients. Minor complications occurred in 15% of our patients; renal colic was reported in 10% of our treated patients, and repeated vomiting was reported in 5% that respond to antiemetics. In the renal group; children with history of pervious urologic surgical procedures had low success rate of stone clearance after ESWL. In the ureteral group stone burden, stone location, had a significant impact on stone clearance outcome. This study showed that SWL in pediatric age group for both renal and ureteral stone is cost effective, safe with an acceptable re-treatment rate; however children with large stone burden or previous urologic surgery have low success rate.

Changes of renal blood flow after ESWL: Assessment by ASL MR imaging, contrast enhanced MR imaging, and renal resistive index

1813 EVALUATION OF RISK FACTORS FOR PROGNOSIS OF TEMPORARY RENAL IMPAIRMENT AFTER SECONDARY EXTRACORPORAL SHOCK WAVE LITHOTRIPSY (ESWL) IN RENAL STONE TREATMENT

The objective of the study is to compare the efficacy and safety of extracorporeal shock wave lithotripsy (ESWL) and mini-percutaneous nephrolithotomy (MPCNL) in treating renal stones sizing 15-25 mm in infants <3 years. Forty-six infants with renal stones sizing 15-30 mm were treated by either ESWL (22 renal units in 22 infants) using Dornier compact delta lithotripter or MPCNL (25 renal units in 24 infants) using 14F-18F renal access under general anesthesia. The operation time, stone-free rate, re-treatment rate, and complications between the two groups were compared with the χ(2), Mann-Whitney U, and Student's t tests. No significant differences in mean age and stone size were observed between the two groups. The 1- and 3-month postoperative stone-free rates were 84 and 96% in MPCNL group and were 31.8 and 86.4% in ESWL group. The re-treatment and complication rates were significantly higher in ESWL group than in MPCNL group (50 vs. 12%, P = 0.004; 16.0 vs. 45.5%, P = 0.028). The stone recurrence rate was similar between the two groups. No significant changes of serum creatinine (Cr) level and glomerular filtration rate were observed in both groups. In conclusion, MPCNL is an effective and feasible alternative monotherapy for large renal stones (15-25 mm) in infants, with a higher stone-free rate and a lower complication rate when compared with ESWL.

Purpose: We estimated scattered radiation doses to the patients and medical practitioneer and revealed risk factors associated with increasing radiation doses during extracorporeal shock wave lithotripsy (ESWL). Materials and Methods: At first, we measured radiation doses 2 times using thermoluminescence dosimeter to simulative patients and medical practitioneer without any shield during 10 minutes of ESWL and determined mean radiation dose/minute. From June to August 2007 at our institution, we prospectively measured radiation exposured time during respective ESWL for treatment of urinary stones. Thereafter, we calculated practical radiation doses to patients and medical practitioneer from respective mean radiation dose/minute. We also analyzed which factors were associated with increasing radiation doses. Results: A total of 50 ESWL were analyzed from 38 patients. Mean radiation dose/minute to simulative patients and medical practitioneer was 16.20, 0.006mSv respectively. At 1 time ESWL, median radiation exposured time was 360 seconds (130-980), therefore, median radiation dose to patients and medical practitioneer was calculated as 97.20mSv (35.10-264.60), and 0.04mSv (0.01-0.08) respectively. Larger stone size had a correlation with increasing radiation dose and additional pain control group had higher radiation dose than otherwise. Conclusions: During ESWL, patients were relatively exposed to high radiation which were roughly corresponded to that of 3 times of computed tomography. But the radiation dose to medical practitioneer was insignificant consider international guideline. Medical practitioneer should be aware of radiation hazard and try to minimize radiation dose to the patients at the time of ESWL. (Korean J Urol 2008;49:155-159) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

To evaluate factors affecting the success rate of stone fragmentation and stone-free rate after extracorporeal shockwave lithotripsy (SWL) in treatment of upper urinary tract stones. A total of 121 patients with upper urinary tract calculi underwent SWL treatment. Success rate of stone fragmentation after SWL was 73.6% (89/121). In 89 patients who had success of breaking stones, 71 patients were followed up for the assessment of stone-free status, of whom 51 (71.8%) patients were stone-free at 3-month follow-up. Among four prognostic factors, including body mass index (BMI), stone size, stone position, and hydronephrosis, BMI and stone position had a significant impact on the success rate of stone fragmentation (P = .04 and U1: P = .0108, respectively). Among five prognostic factors of BMI, stone size, stone position, hydronephrosis, and times of SWL treatments, stone size was the only factor with significant impact on the stone-free rate (middle: P = .0229). Our study suggests that stone fragmentation and stone-free rate after SWL treatment for upper urinary tract stones can be predicted.

Background: The main question when comparing ESWL and PCNL for lower pole stones is one of clinical effectiveness, which includes consideration of the stone-free rate, secondary procedure rate, complications, hospitalization, disability period and recurrent stone rate. Many factors are contributed to lower pole stones clearance such as size of stone, composition, infundibulo-pelvic angle and patient clinical factors should all be considered in conjunction with the various surgical modalities and the availability of equipment’s before the preferred treatment option is selected. Stone-free rate with ESWL were inversely correlated to the stone burden treated. The introduction of ESWL in the early 1980s temporarily limited the indications for percutaneous procedures for stones but after limitations of shock wave lithotripsy were realized, percutaneous surgery regained its merited role in the stone management. On the other hand, lower pole stones contraindication for ESWL which were largely treated by open surgery in the past, now mostly replaced by PCNL. Objectives: To assess and compare relative efficacy and the overall lower calyceal stone clearance in between Percutaneous Nephrolithotomy (PCNL) and Extracorporeal Shock Wave Lithotripsy (ESWL). In relation to stone size. To compare the anatomical factor infundibulo-pelvic angle among, required adjuvant procedure and morbidity in between PCNL and ESWL in treating lower calyceal. Study Design: Hospital based prospective comparative interventional study. Setting: Study was carried out in the Department of urology, Bangabandhu Sheikh Mujib Medical University (BSMMU), and different private hospital of Dhaka city, during the period of January 2006 to July 2007. Methods: Purposive sampling method was followed as per inclusion and exclusion by criteria to select 60 patients. They were divided into two groups by alternate method, into PCNL and ESWL groups. Result: In this study, for the smaller stones &lt;10mm, it was seen that the rate of stone clearance in PCNL and ESWL group were 85.71% and 77.77% respectively. Statistical analysis shows no significant difference of stone clearance between the two groups. (P&gt;0.05). For treating larger stones &gt;10-20mm, present study showed that the rate of stone clearance in PCNL and ESWL group were 93.75% and 41.66 % respectively. There are statistical analysis shows significant difference of clearance (P&lt;0.05). Conclusion: Percutaneous Nephrolithotomy (PCNL) is better option than Extracorporeal Shock Wave Lithotripsy (ESWL) in treating lower calyceal stone. J Com Med Col Teachers Asso July 2024; 28(2): 92-95

To compare the efficiency of different machines for extracorporeal shock wave lithotripsy (ESWL) of renal stones and to analyze treatment strategies and stone characteristics as determinants of treatment failure. Prospective cohort study. Nationwide study in Sweden. All 11 hospitals in Sweden using 1 of 7 lithotriptors in 1991 were included. The study cohort comprised 1171 (97.6%) of the 1200 patients in Sweden who underwent ESWL for the first time because of renal stones between February 18, 1991, and December 31, 1991. Treatment failure, defined as 1 or more residual renal stone fragments larger than 4 mm 1 of 3 months after the end of treatment, was analyzed after ESWL monotherapy and after ESWL plus auxiliary treatment using a multivariate analysis. Treatment failure varied by center from 12% to 48% (mean, 24%) after ESWL monotherapy and from 4% to 40% (mean, 18%) after ESWL plus auxiliary procedures. After adjusting for differences in the patient mix, the risk of treatment failure, measured as the odds ratio, varied by center almost 7-fold after ESWL monotherapy and 20-fold after ESWL plus auxiliary treatment. Substantial differences also existed for the same equipment used at different centers. The risk of treatment failure increased rapidly for renal stones larger than 15 mm, and it was at least 2-fold higher in patients who had multiple stones or a cavity. When ESWL is used for the treatment of renal stones, the treatment policy has as great an effect on the success rate and need for auxiliary treatment as optimal equipment and proper patient selection. Meaningful comparisons of different lithotriptors require multivariate analyses with adjustment for patient selection.

To compare the outcomes of flexible ureterorenoscopy (F-URS) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper or mid calyx kidney stones of 10 to 20 mm.A total of 174 patients with radioopaque solitary upper or mid calyx stones who underwent ESWL or F-URS with holmium:YAG laser were enrolled in this study. Each group treated with ESWL and F-URS for upper or mid calyx kidney stones were retrospectively compared in terms of retreatment and stone free rates, and complications.87% (n = 94) of patients who underwent ESWL therapy was stone free at the end of 3rd month. This rate was 92% (n = 61) for patients of F-URS group (p = 0.270 p > 0.05). Retreatment was required in 12.9% of patients (n = 14) who underwent ESWL and these patients were referred to F-URS procedure after 3rd month radiologic investigations. The retreatment rate of cases who were operated with F-URS was 7.5% (n = 5) (p = 0.270 p > 0.05). Ureteral perforation (Clavien grade 3B) was occured in 3 patients (4.5%) who underwent F-URS. Fever (Clavien grade 1) was noted in 7 and 5 patients from ESWL and F-URS group, respectively (6.4% vs 7.5%) (p = 0.78 p > 0.05).F-URS and ESWL have similar outcomes for the treatment of upper or mid calyx renal stones of 10–20 mm. ESWL has the superiority of minimal invasiveness and avoiding of general anethesia. F-URS should be kept as the second teratment alternative for patients with upper or mid caliceal stones of 10–20 mm and reserved for cases with failure in ESWL.

BackgroundUrinary stone disease is a common urological disorder, particularly among middle-aged individuals. Extracorporeal Shock Wave Lithotripsy (ESWL) is often the first-line treatment for kidney and ureteral stones. Traditionally, fluoroscopy is used for stone targeting in ESWL, but it exposes patients and clinicians to radiation and cannot visualize non-opaque stones. Ultrasonographic targeting eliminates these issues. This study compares the advantages and disadvantages of fluoroscopy and ultrasound-targeted ESWL.MethodsAt Düzce University Hospital, 100 patients with radio-opaque stones indicated for ESWL between February 2023 and February 2024 were divided into two groups. Group A underwent ESWL with fluoroscopic targeting, while Group B used ultrasonographic targeting. Patient demographics, stone size (measured by CT), and stone locations were recorded. The number of shocks per session, energy intensity (kV), and fluoroscopy time were noted for Group A. One week after each ESWL session, patients were evaluated by ultrasound or direct radiography. Success was defined as being stone-free or having ≤ 4 mm asymptomatic residual stones after up to four sessions. Failure was defined as no results after two sessions or the need for additional treatment.ResultsThe procedure success rate was 66% for men and 78% for women, with no statistically significant gender difference (p > 0.05). Stone locations were similar in both groups. Success rates were 66% in Group A and 74% in Group B, with no significant difference (p > 0.05). Successful procedures were associated with an average patient weight of 76.6 kg, stone size of 8.9 mm, and total energy of 12.2 kV, with significant differences compared to unsuccessful procedures (p < 0.04, p < 0.04, p < 0.001, respectively). No significant differences were found between Group A and Group B in terms of age, height, BMI, stone density (HU), and number of sessions (p > 0.05).ConclusionUltrasonography is as effective as fluoroscopy for imaging and focusing during ESWL treatment. It enhances the success of ESWL for non-opaque stones and reduces radiation exposure disadvantages.

186 patients with partial and 55 patients with complete renal staghorn calculi were treated with primary extracorporeal shock wave lithotripsy (ESWL) at the Department of Urology, University of Würzburg Medical School. Partial staghorn calculi required an average of 1.4, complete staghorn calculi an average of 2.2 treatment sessions using the Dornier HM 3 lithotriptor. 55% of all patients and 46% of the patients with complete staghorn calculi were rendered stone-free within 1 year after ESWL. Pretreatment urinary tract infections present in 50.6% of all patients could be reduced to 22.5% 1 year after ESWL. The most frequent complications after ESWL were ureteral obstruction caused by 'steinstrasse' (41.4%), fever (38.4%), and renal colics (29.4%). Severe complications needing open operative procedures or blood transfusions did not occur. 50% of all patients underwent auxiliary procedures (e.g. insertion of indwelling ureteral stents: 25.3%, percutaneous nephrostomy: 20.3%, percutaneous nephrolithotripsy: 2.9%). Pretreatment insertion of an indwelling ureteral stent was found to reduce posttreatment complications as well as the need for percutaneous nephrostomy only in patients with partial staghorn calculi. The data presented in this study demonstrate that primary ESWL therapy can be safely and successfully performed in the majority of patients with renal staghorn calculi. In patients requiring complete removal of all stone fragments, a percutaneous lithotripsy can be performed following ESWL.

Kidney stones has been known since the time of ancient Babylonians and Egyptians, a urinary tract stones (urolithiasis) are found in the urinary tract, ranging from kidney calix system, pielum, ureters, bladder and urethra. The cause of the formation of urinary tract stones allegedly associated with urinary tract disorders, metabolic disorders, urinary tract infections, dehydration and other circumstances that remain unclear (idiopathic). Urinary tract stones in general contain elements: calcium oxalate, calcium phosphate, uric acid, magnesium-ammonium-phosphate (MAP), xanthyn and cystine. Understanding the composition of rock found important in the prevention of the possibility of recurrent stone. Presence or absence of a definitive diagnosis of kidney stones can be known through the analysis of urine routine examination (urinalis) and the X-ray examination stomach and abdomen area. Prevention can be done by reducing the types of foods that contain purine like sardines, organ meats, liver, brain, shellfish and other food. Treatment can be done by taking certain drugs for the stones are still small, whereas for large-sized stones that already can be done by way of ESWL (Extra-corporeal Shock Wave Lithotripsy), or by performing surgery.Kata kunci : Urollithiasis, Batu Ginjal, Saluran Kemih, Kalsium Oksalat, KalsiumFosfat, Asam Urat

Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrostolithotomy (PCNL) have largely replaced open surgical operations for the management of upper urinary tract calculi. ESWL is generally preferred for calculi less than or equal to 2 cm as morbidity is lower than PCNL and success rates comparable. However, the morbidity of ESWL rises substantially for stones greater than 2 cm, while the stone-free rate is lessened compared to PCNL (41% vs. 82%, p<0.01), suggesting that PCNL is preferred for most larger stones. Results for staghorn calculi comparable to anatrophic nephrolithotomy with lowered morbidity may be achieved with PCNL followed by ESWL. PCNL is also preferred for stone-containing, calyceal diverticula.