Long-term results of extracorporeal peizoelectric shock wave lithotripsy of parotid stones

OBJECTIVE: To evaluate prospectively the recently developed method of extracorporeal shock-wave treatment of stones of the parotid gland. PATIENTS AND METHODS: 76 patients with symptomatic, sonographically proven, solitary stones of the parotid gland (36 females, 40 males; aged 2-80 years) were treated with extracorporeal piezoelectric shock-wave lithotripsy (ESWL) after failed conservative management (sialagogues, gland massage, duct bougie dilation). RESULTS: Parotid stones were no longer demonstrable after a mean follow-up time of 48 (6-71) months in 38 of the 76 patients; they were symptom-free and no new stones had formed. A residual, but symptom-free, stone was found in another 20 patients (26%) of whom 13 (17%) reported marked improvement after ESWL. No change from pretreatment symptoms occurred in five patients (7%) so that operative removal had to be performed. The success rate of the lithotripsy was independent of size and site of the stone. CONCLUSION: ESWL is the method of first choice in the treatment of parotid gland stones after unsuccessful conservative treatment and obviates operative gland removal in most cases.     

One year results after extracorporeal shock wave lithotripsy of gallbladder stones

512 patients with gallbladder stones (393 females, mean age 52.7 years; 119 males, mean age 46.9 years) were treated by extracorporeal shock wave lithotripsy with an electrohydraulic Dornier MPL 9000 lithotripter. The Munich criteria were used for patients selection. Midazolam (15 mg im) and piritramid (mean 7.5 mg iv) were administered as analgetics. Stone fragmentation was achieved after an average of 1.92 treatment sessions. In 12 cases (2.3%) there was no fragmentation. Ursodeoxycholic acid (10 mg/kg/day) was administered as adjuvant litholytic therapy until 3 months after total fragment clearance. During a period of a year the patients returned for follow-up investigations in decreasing number. The total fragment clearance rate was 43.3%, for the I. group (single stone of 5 to 20 mm) was 58%, for the II. group (single stone of 21 to 30 mm) was 28.6%, for the III. group (2 or 3 stones of 30 mm maximum diameter) was 21.4%. In 12 cases (1.2%) vasovagal reactions, in 31 cases (3.1%) atrial and ventricular extrasystoles, in 27 cases (2.7%) transient gross hematuria were observed. During a period of a year 18 cholecystitis (3.5%), 8 pancreatitis (1.56%) and 5 obstructive jaundice (0.97%) developed. 28 cholecystectomies (5.4%), 1 necrectomy because of necrotic pancreatitis (0.19%) and 5 endoscopic sphincterotomies (0.97%) were required.     

Outpatient treatment of middle and lower ureteric stones: extracorporeal shock wave lithotripsy versus ureteroscopic laser lithotripsy

The aim of this retrospective study was to evaluate the efficacy of ureteroscopic lithotripsy (URSL) and extracorporeal shock wave lithotripsy (ESWL) in the treatment of middle and lower ureteric stones. From January 1996 to March 1997, 61 patients treated by URSL and 49 patients treated by ESWL were studied, both were conducted as outpatient procedures. URSL using Holmium laser and semirigid ureteroscope (Fr.8.5) performed under general anaesthesia had single session stone clearance rates of 100% and 95% for middle and lower stones respectively. There were 6 complications including 5 readmissions (2 febrile episodes, 2 severe pain spells, and 1 stent migration) and 1 stricture formation. ESWL using the Dornier MFL 5000 lithotriptor had a single session success rate of 51% and overall success rate of 78% after retreatment (retreatment rate 35%). No significant complication or readmission was noted. Seventy-two per cent of patients required intravenous fentanyl for pain control. The efficiency quotients calculated for the URSL group and the ESWL group were 97% and 58% respectively. In summary, in the treatment of middle and lower ureteric calculi, ESWL carries reasonable success rate, especially with retreatment; and minimal morbidity. On the other hand, URSL is highly effective in rapidly clearing the stones, a low risk of complication is noted. Both can be conducted as an outpatient treatment modality.     

Quality of semen after extracorporeal shock wave lithotripsy for lower urethral stones

Purpose: We investigated whether extracorporeal shock lithotripsy (ESWL) of stones in the distal ureter can cause decreased in male fertility. Materials and Methods: In vivo and in vitro examinations were performed to clarify possible changes in semen after ESWL of lower urethral stones. For the in vivo examination semen from 10 patients was examined on the day before and 3 days after ESWL. For the in vitro examination semen from 12 healty volunteers was divided into 2 portions after ejaculation, with half immediately examined according to World Health Organization criteria and half directly exposed to the ESWL focus. Results: The in vitro and in vivo examinations revealed a decrease in sperm density and sperm motility after ESWL. Macroscopic analysis revealed hemospermia in 30% of the patients after ESWL compared to 0% before ESWL. In addition, after ESWL all patients had microscopic hemospermia compared to 10% before ESWL. Conclusions: The in vivo and in vitro examinations demonstrated deterioration in semen quality. Sperm density and sperm motility returned to normal 3 months after ESWL, indicating at least a transitory decrease in male fertility may occur.     

Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation

Extramedullary hematopoiesis associated with thalassemia causing spinal cord compression is an extremely rare event in the course of the disease. Documentation with an imaging technique, such as MRI, is mandatory. A patient with thalassemia intermedia, who developed paraparesis in spite of transfusion, underwent surgical decompression. Rapid neurological improvement was observed postoperatively and this neurological condition was protected with adequate hemoglobin level. Management of these patients remains controversial. Various modes of therapy such as surgical decompression, radiotherapy, and transfusion are discussed and the related literature is reviewed.     

Single application extracorporeal shock wave lithotripsy is the first choice for patients with pancreatic duct stones

OBJECTIVES: We performed extracorporeal shock wave lithotripsy (ESWL) as the treatment of first choice on 32 chronic pancreatitis patients with main pancreatic duct (MPD) stones prospectively to establish more convenient and safer treatment. METHODS: All patients were treated in a prone position, and shock waves were discharged from the ventral side. ESWL was performed once or twice a week, and no other treatments before ESWL had been applied. RESULTS: Disintegration of all MPD stones to 3 mm or less in diameter could be achieved in all treated patients. Complete clearance of the stones was obtained in 24 patients (75%) without the necessity of endoscopic extraction of fragments. Reduction of MPD diameters after ESWL was statistically significant (p < 0.01). Epigastric and/or back pain complaints before ESWL were completely alleviated in 79% (periods of follow-up: 16-63 months, mean 44), and the pancreatic exocrine function also improved in 61%. No severe complications occurred in any of the patients. CONCLUSIONS: ESWL, which is comparatively easy to perform, is a safe and efficient approach that changes endoscopy's status as an indispensable pretreatment. Therefore, ESWL can be recommended as the first choice treatment for patients with chronic pancreatitis accompanied by MPD stones that should be tried before consideration of either surgical or endoscopic procedures.     

Treatment of lithiasis in patients with one kidney by extracorporeal shock wave lithotripsy

OBJECTIVE: To describe the efficacy of extracorporeal shock wave lithotripsy in the treatment of lithiasis in patients with solitary functioning kidney. METHODS: The study comprised 56 patients with solitary kidney that had been treated by extracorporeal shock wave lithotripsy. These patients had a solitary kidney for the following reasons: 30 had undergone nephrectomy due to lithiasis, 11 had lost renal function arising from lithiasis, 9 had undergone nephrectomy for other pathologies and 6 had renal agenesis. Nine stone variables and treatment were analyzed. The same variables were analyzed and compared for statistical significance in a representative sample of 125 lithiasic patients with two kidneys who were treated by ESWL. RESULTS: Patients with solitary kidney frequently had a single calculus of < or = 1 cm located in calyces, unobstructive and did not require complementary endourological procedures. The mean number of shock waves was 8535. The psot-lithotripsy success rate was 82.1%; 98.2% had no complications. Comparison of these variables in both groups of patients showed statistically significant differences for stone location, indication for complementary endourological procedures and the number of shock waves utilized. CONCLUSIONS: In our view, ESWL is the treatment of choice in patients with lithiasis in a solitary kidney due to its high success rate and low morbidity. Stringent criteria must be employed before indicating prior endourological procedures to preserve the patency of the excretory tract and to minimize the risk of ureteral obstruction.     

Long-term stone recurrence rate after extracorporeal shock wave lithotripsy

PURPOSE: We followed patients who were stone-free after extracorporeal shock wave lithotripsy (ESWL) to investigate the factors that contributed to recurrent calculi. MATERIALS AND METHODS: For longer than 5 years 903 patients without residual fragments 3 months after ESWL were enrolled in this study. Plain abdominal films and/or excretory urograms were evaluated every 6 months for recurrent stones on the side of ESWL. Patients who presented with colic pain or other complaints and who were suspected of having recurrent stones were also examined. Stone recurrence rates were calculated with the Kaplan-Meier method. We assessed the influence of patient age; size, location, composition and configuration of the original stones, and pyuria after ESWL on stone recurrence. RESULTS: Mean followup was 25 months and stones recurred in 183 of 903 renal units (20.3%). Kaplan-Meier recurrence rates were 6.7, 28.0 and 41.8% after 1, 3 and 5 years, respectively. There was a significant correlation between stone recurrence and multiple stones on one hand, and pyuria after ESWL on the other hand. Stones recurred most frequently in the lower calix. Recurrent stones were passed without intervention in 33 cases, while ESWL was repeated in 53. CONCLUSIONS: These data demonstrate the importance of long-term followup and the search for an effective prophylactic therapy to prevent recurrence.     

Treatment of pancreatic stones with extracorporeal lithotripsy with sonographic localization

BACKGROUND: Pancreatic stones may be treated by endoscopic extraction or by surgery. Extracorporeal shock wave lithotripsy increased possibility of noninvasive steps to their elimination. The aim of this study was to describe our first experience with this method. METHOD AND RESULTS: 10 patients (6 men and 4 women) in average age 47 years (between 19 to 72 years) were treated. The lithotriptor MEDILIT with sonographic targeting was used for fragmentation of pancreatic stones. Fragmentation was achieved in 8 patients, in 4 cases we observed spontaneous disappearnace, in 3 cases an endoscopic extraction of fragments was necessary. In one case good fragmentation was observed at control ECRP, but the repeated Wirsungography showed a big pseudocyst which had not been diagnosed at the first examination and surgery was necessary. In 2 cases no fragmentation was achieved and in these cases surgery was also indicated. No serious side effects were observed, nor elevation of amylase values compared with the situation before the shock wave treatment. CONCLUSIONS: Extracorporeal shock wave lithotripsy of pancreatic stones revealed good fragmentation and disappearance stone from ductus Wirsungi without serious side effects on clinical course and surrounding soft tissues.     

Effect of extracorporeal shock wave lithotripsy on implantable cardioverter defibrillator

Extracorporeal shock wave lithotripsy (ESWL) is frequently used for nephrolithiasis of the upper urinary tract. Because of the powerful shock wave and electromechanical forces created, this therapy has been contraindicated in the patient with an implantable cardioverter defibrillator (ICD). To determine whether or not ESWL affects ICD devices, we subjected ten devices to a full course of ESWL. The devices were then returned to the manufacturer to undergo bench analysis, which revealed no abnormalities in function. Additionally, one device was placed in the pathway of the shock wave, resulting in a discharge of the device despite a frequency of ESWL of 100 shocks/min (well below the rate cutoff of that device). Manufacturer analysis of this device, likewise, revealed no abnormalities even though the device had been exposed to the focal point of the shock wave. We conclude that contralateral ESWL is not contraindicated for the patient with an ICD. We do, however, recommend a post-procedure evaluation to ensure appropriate function of the ICD.     

Clinical study on antimicrobial prophylaxis following extracorporeal shock wave lithotripsy

One hundred and sixty one patients with upper urinary stones were examined for antimicrobial prophylaxis following extracorporeal shock wave lithotripsy (ESWL). They were divided into two groups, the low-risk group (n = 133) and high-risk group (n = 28), according to the risk factors of urinary tract infection. The patients in the low-risk group were further randomized into two groups which were orally given ofloxacin for 7 days after ESWL (Group A, n = 66), no antimicrobial (Group B, n = 67). The patients in the high-risk group were randomly subdivided into three groups which were given flomoxef intravenously for 2 or 3 days and ofloxacin for 4 or 5 days thereafter (Group C, n = 10), flomoxef only for 2 or 3 days and no drugs later (Group D, n = 10), ofloxacin for 7 days (Group E, n = 8). In all of the patients in the low-risk group, during the 7 days after ESWL, fever elevation was observed in only 1.5% of patients, and bacteriuria in 10.0% on the 7th day. There was no difference in frequency of fever elevation and bacteriuria following ESWL between Group A and Group B. These findings indicate that prophylactic antimicrobial after ESWL treatment is not necessary for low risk patients with urinary tract infections. In the high-risk group, the over-all rates of fever elevation and bacteriuria were 21.4% and 24.0% respectively. The difference of effectiveness among the prophylactic regimens of the three groups (Group C, D, E) was not shown.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy

We have studied the effect of ectopic overexpression of a ras gene on the expression of the other two members of the ras gene family. We obtained NIH3T3 cell lines stably transfected with inducible H-ras and N-ras oncogenes. The expression of these genes is driven by a glucocorticoid-responsive promoter and the addition of dexamethasone resulted in a dramatic induction (10-20-fold) of H- or N-ras mRNA, peaking 4 h after hormone addition. The induction of the expression of ras oncogenes resulted in a transformed phenotype. In quiescent NIH3T3 cells transfected with inducible H-ras oncogenes, the induction of H-Ras was followed 12 h later by a 3-fold increase in the mRNA expression of endogenous K-ras and N-ras. Similarly, in NIH3T3 transfected with inducible N-ras oncogene, the induction of N-ras was followed by an increase in the expression of endogenous K- and H-ras genes. Interestingly, the effect was not limited to the mutated N-ras, as a similar result was obtained in cells transfected with N-ras proto-oncogene. The induction of ras genes expression was not linked to cell cycle progression as it was reproduced in cells arrested in S-phase by pretreatment with hydroxyurea. These results suggest the presence of a positive cross-regulation in the expression among the members of the Ras family. This effect could play a role in Ras-mediated carcinogenesis.     

Clinical implications of clinically insignificant store fragments after extracorporeal shock wave lithotripsy

PURPOSE: We determined the natural history and clinical significance of small, asymptomatic, noninfection related stone fragments after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: We prospectively followed 160 patients with 4 mm. or less asymptomatic calcium oxalate/phosphate stone fragments after ESWL for 1.6 to 88.8 months (mean 23) to stone-free status, censorship or intervention. Kaplan-Meier estimates of probability to anatomical stone-free, decreased or stable status were determined as well as the probability of symptomatic episodes or required urological intervention. RESULTS: Stone-free status or a decreased, stable or increased amount of residual stone occurred in 38 (23.8%), 26 (16.3%), 67 (41.9%) and 29 (18.1%) of the 160 patients, respectively. At 5 years after ESWL the probability of a stone-free, stone-free or decreased status, or stone-free, decreased or stable status was 0.36, 0.53, and 0.80, respectively. A total of 91 patients (56.9%) remained asymptomatic while 69 (43.1%) had a symptomatic episode or required intervention 1.6 to 85.4 months (mean 26) after ESWL (probability estimated at 0.71 at 5 years). CONCLUSIONS: While patients with small noninfection related stone fragments after ESWL may be followed expectantly, a significantly number will require intervention or have symptomatic episodes within 2 years. The term clinically insignificant applied to any residual stone after ESWL is likely a misnomer.     

Long-term clinical outcome of extracorporeal shock wave lithotripsy monotherapy for staghorn calculi

The thickness (TBmt) and fiber pennation angle (TBpen) of triceps brachii as well as isokinetic force developed during elbow extension were measured in Olympic athletes to investigate the relationship between muscle fiber pennation and force generation capability. The subjects were male members of the 1996 Japanese Olympic team who competed in seven different events; 9 wrestlers, 16 soccer players, 11 sprinters, 5 judo athletes, 7 gymnasts, 9 rowers and 18 baseball players. The TBmt and TBpen, measured by a B-mode ultrasound, ranged between 29 mm and 50 mm and between 11 degrees and 30 degrees, respectively, and on average were larger in the judo athletes, wrestlers and gymnasts compared to the other groups. A significant correlation (r=0.580, p < 0.05) was found between TPpen and TBmt per unit of the upper arm length, and so the observed event-related differences in TBpen tended to reflect the differences in TBmt. The isokinetic forces relative to the cross-sectional area (CSA) estimated from TBmt, measured at two constant velocities of 1.05 rad/s (F1.05/CSA) and 3.14 rad/s (F3.14/ CSA), were negatively correlated to the CSA; r=-0.617 (p < 0.05) for F1.05/CSA and r=-0.635 (p < 0.05) for F3.14/CSA. In addition, low but significant negative correlations existed between TBpen and both F1.05/CSA (r=-0.365, p < 0.05) and F3.14/ CSA (r=-0.336, p <0.05). Even when the effect of TBpen was statistically normalized, the F1.05/CSA and F3.14/CSA were still negatively correlated to the CSA, r=-0.530 (p < 0.05) for F1.05/ CSA and r=-0.561 (p < 0.05) for F3.14/CSA. Therefore, at least in the Olympic athletes tested in this study, the magnitude of the pennation angles reflects muscle size, but it does not seem to be a factor that explains extensively the lower F/CSA in athletes with large muscle size.     

Patient maintained alfentanil target-controlled infusion for analgesia during extracorporeal shock wave lithotripsy

PURPOSE: The purpose of this study was to determine whether alfentanil given by a pharmacokinetic-based target controlled infusion (TCI) system under patient control is a suitable analgesic technique for extracorporeal shock wave lithotripsy (ESWL). METHODS: The design was an open, unblinded, noncomparative, prospective study. Forty outpatients undergoing ESWL were given patient maintained alfentanil TCI. Pain, nausea and sedation were assessed every 300 shocks. Vital signs were recorded every three minutes, pulse oximetry and electrocardiography being monitored continuously. Blood alfentanil concentration was measured for comparison with the predicted value. RESULTS: Alfentanil consumption (median 1.34 mg, range 0.8-3.6) and measured levels following treatment (median 60 ng.ml-1, range 15.6-134.3) varied widely. The precision of the TCI system and the median prediction error (bias) were both 49%. The median of pain scores recorded during treatment was 4 (range 0-8). The median respiration rate was 15 bpm (range 10-23), three patients required oxygen (SaO2 < 92%) cardiovascular measurements were stable and there was no excessive sedation. The incidence of nausea was 15%. All patients were ready for hospital discharge within one hour following treatment. CONCLUSIONS: Patient maintained alfentanil TCI provides good analgesia for ESWL in the majority of patients with little sedation. Respiratory depression is uncommon but supplementary oxygen should be given prophylactically. There is considerable interindividual variation in demand for alfentanil indicating the usefulness of the patient control method. The TCI system underestimated alfentanil blood concentrations but this did not affect its clinical usefulness.     

The effects of general versus epidural anesthesia for outpatient extracorporeal shock wave lithotripsy

Although many anesthetic techniques are described for immersion extracorporeal shock wave lithotripsy (ESWL), regional and i.v. techniques are the most commonly reported. This randomized, prospective study compared general anesthesia (GA) and epidural anesthesia (EPID) with regard to effectiveness, side effects, induction time, and recovery in patients undergoing ESWL using an unmodified Dornier HM-3 lithotriptor. Twenty-six healthy outpatients were randomized to GA (propofol, N2O, laryngeal mask airway) or EPID (lidocaine 1.5% with epinephrine). Intraoperative and postoperative supplemental medications, side effects, and complications were noted. Induction times and times required to meet standard recovery criteria were compared between groups. Patients were surveyed regarding their satisfaction with anesthesia. All patients in the EPID group had effective blocks with a single catheter insertion and local anesthetic injection. In the GA group, the LMA was inserted successfully in all patients. Time from room entry to procedure start was significantly less in the GA group (23 +/- 11 vs 34 +/- 9 min; P < 0.05). Patients in the GA group were ready for discharge home earlier (127 +/- 59 vs 178 +/- 49 min; P < 0.05). Only three patients experienced nausea (one in the GA group, two in the EPID group). There were no differences in patient or urologist satisfaction with anesthesia. We conclude that GA is associated with a rapid recovery compared with EPID. Implications: General anesthesia with propofol, nitrous oxide, and a laryngeal mask airway is comparable to epidural anesthesia with lidocaine for outpatient extracorporeal shock wave lithotripsy procedures. However, early recovery is more rapid after general anesthesia compared with epidural anesthesia.