Extracorporeal shock waves lithotripsy versus retrograde ureteroscopy: is radiation exposure a criterion when we choose which modern treatment to apply for ureteric stones?

Which localization method is optimal in ESWL: fluoroscopy or ultrasonography?

BACKGROUND

Urinary 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.

METHODS

At 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.

RESULTS

The 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).

CONCLUSION

Ultrasonography 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.

Radiation exposure of patients during endourological procedures

PURPOSE

Considering the existing gaps in the literature regarding patient radiation dose (RD) and its associated risks, a systematic review of the literature on RD was conducted, focusing on percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy (SWL), and ureteroscopy (URS).

METHODS

Two authors conducted a literature search on PubMed, Web of Science, and Google Scholar to identify studies on RD during endourological procedures. Two thousand two hundred sixty-six articles were screened. Sixty-five publications met the inclusion criteria using the PRISMA standards.

RESULTS

RD was generally highest for PCNL, reaching levels up to 33 mSv, 28,700 mGycm2, and 430.8 mGy. This was followed by SWL, with RD reaching up to 7.32 mSv, 13,082 mGycm2, and 142 mGy. URS demonstrated lower RD, reaching up to 6.07 mSv, 8920 mGycm2, and 46.99 mGy. Surgeon experience and case load were inversely associated with RD. Strategies such as optimizing fluoroscopy settings, implementing ultrasound (US), and following the ALARA (As Low As Reasonably Achievable) principle minimized RD.

CONCLUSIONS

This is the first systematic review analyzing RD, which was generally highest during PCNL, followed by SWL and URS. There is no specific RD limit for these procedures. Implementation of strategies such as optimizing fluoroscopy settings, utilizing US, and adhering to the ALARA principle proved effective in reducing RD. However, further research is needed to explore the factors influencing RD, assess their impact on patient outcomes, and establish procedure-specific reference levels for RD.

Determining whether previous SWL for ureteric stones influences the results of ureteroscopy as the second-line treatment: A clinical study

The purpose of the study was to establish whether shock wave lithotripsy (SWL) is a potential harmful first-line treatment for ureteric stones where ureteroscopy (URS) is necessary as a second-line treatment. Medical records of patients with ureteric stones who underwent either URS as the only therapy applied or SWL followed by URS over two years were retrospectively evaluated. In total, 158 patients were included: 79 patients in Group A (no SWL) and 79 in Group B (prior SWL before URS). There was no difference in major complications, Group A had higher stone-free rates, Group B had higher rates of ureteral edema and similar intraoperative ureteral lesions. In conclusion, the failure of SWL for lumbar or pelvic ureteral lithiasis does not appear to have a negative effect on the rate of intraoperative complications or the success rate of semi-rigid retrograde URS for this category of calculi, with the same safety profile as first-line endourological intervention.

Decreased Radiation Exposure and Increased Efficacy in Extracorporeal Lithotripsy Using a New Ultrasound Stone Locking System

PURPOSE

To compare fluoroscopy duration, radiation dose, and efficacy of two ultrasound stone localization systems during extracorporeal shockwave lithotripsy (SWL) treatment.

PATIENTS AND METHODS

Monocentric prospective data were obtained from patients consecutively treated for renal stones using the Sonolith(®) i-sys (EDAP TMS) lithotripter, with fluoroscopy combined with ultrasound localization using an "outline" Automatic Ultrasound Positioning Support (AUPS) (group A), or the "free-line" Visio-Track (VT) (EDAP-TMS) hand-held three-dimensional ultrasound stone locking system (group B). Efficacy rate was defined as the within-groups proportion stone free or with partial stone fragmentation not needing additional procedures. Statistical analysis used Pearson chi-square tests for categoric variables, nonparametric Mann-Whitney tests for continuous variables, and linear regression for operator learning curve with VT. Continuous variables were reported as median (range) values.

RESULTS

Patients in group A (n=73) and group B (n=81) were comparable in baseline characteristics (age, kidney stone size, others) and in SWL application (duration, number of shocks, energy [Joules]). During SWL, the median (range) duration (seconds) of radiation exposure was 159.5 (0-690) in group A and 3.5 (0-478) in group B (P<0.001) and irradiation dose (mGy.cm(2)), 10598 (0-54843) in group A and 163 (0-13926) in group B (P<0.001). Fluoroscopy time significantly decreased with operator experience using VT. The efficacy rate was 54.5% in group A and 79.5% in group B (P=0.001).

CONCLUSION

VT significantly reduced fluoroscopy use during SWL and the duration and dose of patient exposure to ionizing radiation. Stone treatment efficacy was significantly greater with VT mainly because of a better real-time monitoring of the stone.