Classification of patients subjected to extracorporeal shock wave lithotripsy

A new system for descriptive classification of stones in the upper urinary tract

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

Comparison of 2 pulsed lasers for lithotripsy of ureteral calculi: report on 154 patients

Extracorporeal lithotripsy does not always provide satisfactory results for the treatment of ureteral stones. Such cases appear to be excellent indications for endocorporeal lithotripsy based on an association of ureteroscopy and laser. To compare the performances of 2 pulsed lasers, the pulsed dye laser (Candela) and solid Q switched laser (HMT), for the treatment of these calculi 161 ureteral stones were treated successively from November 1990 to March 1992 by a combination of ureteroscopy and laser. Endocorporeal lithotripsy was performed in 102 cases with the Candela laser, in 47 with the HMT laser and in 7 with both lasers. With a stable success rate greater than 90%, both lasers demonstrated equivalent performances regardless of the location of the stone along the ureter. However, while stone fragmentation was more rapid with the Candela laser, the HMT laser appeared to be more effective for dark stones (monohydrate calcium oxidate).

Cutaneous anesthesia with lidocaine-prilocaine cream: a useful adjunct during shock wave lithotripsy with analgesic sedation

A comparative randomized double-blind study between 99 patients with (group 1) and 100 without (group 2) cutaneous anesthesia with a lidocaine-prilocaine cream during extracorporeal shock wave lithotripsy (ESWL*) with an unmodified Dornier HM3 lithotriptor was done. The application of the anesthetic cream or a placebo preparation was used in addition to premedication with meperidine hydrochloride and diazepam. In case of pain experience additional doses of analgesic sedation were administered. The requirement of additional analgesic sedation at a generator voltage of 14 kv. was significantly higher in group 2 than in group 1 (42 versus 26 patients, p < 0.05). The ESWL treatment was completed with only premedication in 39% of the patients in group 2 compared with 50% in group 1. The pain experience at 14 kv. was significantly lower for male patients in group 1 (p < 0.01). The most pronounced difference between groups 1 and 2 was recorded during treatment of stones in the upper calices, whereby 22% and 79%, respectively, required additional analgesic sedation at a generator voltage of 14 kv. (p < 0.05). A less pronounced but still significant difference was also recorded at 14 kv. for patients with stones in the other parts of the kidney and ureter (p < 0.05). The maximal median energy settings in groups 1 and 2 were 15.9 kv. and 15.4 kv., respectively. There were 27 patients in group 2 and 18 in group 1 who were treated with a maximum of 14 kv. The overall requirement of additional analgesic sedation was 62% in group 2 and 51% in group 1. Cutaneous anesthesia with lidocaine-prilocaine cream obviously has clinically significant effects on pain experience during ESWL. It cannot replace the need for analgesic sedation but it can be used advantageously to reduce the dosage of analgesic and sedative drugs during ESWL treatments performed without regional or general anesthesia in the unmodified Dornier HM3 lithotriptor.

Extracorporeal lithotripsy of ureteric calculi using the Dornier HM-3 lithotriptor

Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporeal shock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n = 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required pre-ESWL drainage of the urine. X-ray localisation required intravenous urography during lithotripsy in 52 cases (30%). On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.

Cost effectiveness of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for medium-sized kidney stones. A randomised clinical trial

To evaluate percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL) for their clinical effects, their cost effectiveness, their complication rates, and the patients' experiences, 55 consecutive patients were randomised to have one or other operation between October 1986 and October 1988. Six patients were excluded, 21 were treated with PNL and 28 with ESWL as primary treatment. Mean hospital stay and length of treatment were longer for PNL than for ESWL. Since 1 July 1987 all patients having ESWL have been treated without anaesthesia (n = 15), whereas epidural anaesthesia was used for all PNL. Slightly more of the ESWL patients experienced some pain during treatment. Minor complications or pain were more common after ESWL during the first 10 days after discharge from hospital. If patients with stone fragments of 4 mm or less were regarded as having a successful outcome, the success rates after one year were 94% for PNL and 77% for ESWL. The overall total cost was lower for ESWL than for PNL, the cost per successfully treated patient being 2172 pounds for PNL and 1810 pounds for ESWL. Medium sized kidney stones (6-30 mm, or 2-3 stones of 20 mm or less) can be efficiently and cheaply treated by both PNL and ESWL, though the cost of ESWL is lower. Even if effects other than cost (such as complications and patients' experience) are borne in mind, ESWL was superior to PNL for this group of patients.

Evaluation of extracorporeal shock wave lithotripsy without anesthesia using a Dornier HM3 lithotriptor without technical modifications

In 210 patients with urolithiasis extracorporeal shock wave lithotripsy was performed without regional, general or infiltration anesthesia by means of a technically unmodified Dornier HM3 lithotriptor. The stone burden varied from small ureteral stones to complete staghorn stones. All patients were given premedication with pethidine and diazepam, and a lidocaine-prilocaine-containing cream was applied on the skin at the entry site of the shock wave. Energy usually varied between 14 and 16 kv. More than 90% of the patients reported the pain to be at most of moderate intensity and acceptable. Less than 3% found the treatment unpleasant. The results were compared to those obtained in 250 patients treated with anesthesia according to the original procedure, with a generator voltage of 18 to 23 kv. The number of extracorporeal shock wave lithotripsy sessions for ureteral and large stones was somewhat higher with the low energy method than with the original procedure. However, the therapeutic result in terms of renal units without stones after 4 weeks was similar to that recorded for patients treated with the anesthesia method. According to these promising results we believe that extracorporeal shock wave lithotripsy without anesthesia in an unmodified Dornier HM3 lithotriptor can be performed successfully in a majority of patients and is an attractive alternative to other technical modifications of the equipment.

Are prophylactic antibiotics necessary during extracorporeal shockwave lithotripsy?

A randomised clinical study was carried out on patients admitted for ESWL treatment in order to establish the requirement for prophylactic treatment with antibiotics during this procedure. Patients with clinical signs of urinary tract infection, evidence of infectious stones or a positive urine culture were excluded. All other patients were consecutively randomised into 3 groups which were given either trimethoprim + sulphamethoxazole or mecillinam (Group A), methenamine hippurate (Group B), or no treatment at all (Group C). Evaluation with respect to clinical signs of infection was done immediately after the treatment and 4 weeks later. In addition, a urine culture was performed 2 weeks after ESWL, i.e. 1 week after completing treatment with antibiotics and methenamine hippurate. With respect to infectious complications there were no differences between Groups A and C, between Groups B and C or between Group A and B+C, whereas an unexplained slightly higher infectious rate was recorded for Group B compared with Group A. In all patients the occurrence of bacteriuria was low (6.7%) despite the fact that almost 30% of patients had a ureteric catheter during the ESWL procedure. Patients with ureteric catheters did not present with more infectious complications than those without. All patients had a bladder catheter during ESWL. It was concluded that prophylactic treatment with antibiotics during ESWL treatment is unnecessary in all situations where an infectious aetiology is unlikely.