Endoscopic sphincterotomy for lithotripsy (EST-L) of bile duct stones

We performed EST-L for 555 patients with choledocholithiasis between 1981 and 1992. With the aid of conventional occlusion balloons and dormia-type baskets, calculi < or = 1.5 cm was extracted with relative ease. In patients with larger stone (> 1.5 cm), the mechanical lithotripter, extracorporeal shock wave lithotripsy (ESWL) and electrohydrolic lithotripsy were used for the lithotripsy. The overall success rate was 95%. Important early and late complications from these procedures occurred in 6.9% and 9.1% of all cases respectively. This result reveal that EST-L is safe and effective therapeutic procedures for choledocholithiasis. We would recommend EST-L is adopted as an initial measure to remove common bile duct stones.     

S100a0 protein as a marker for tissue damage related to extracorporeal shock wave lithotripsy

We assayed serum and urine S100a0 protein levels in patients with renal stones (n = 21) or ureteral stones (n = 18), before and after extracorporeal shock wave lithotripsy (ESWL) to evaluate tissue injury. Serum S100a0 protein levels increased significantly immediately after, and at 2 and 24 h after ESWL in patients with renal stones, and at 2 and 24 h after ESWL in patients with ureteral stones. Significant increases in urine S100a0 protein levels were observed immediately and 2 h after ESWL in both groups of patients. The patients receiving a higher number of shock waves had a more pronounced increase in serum S100a0 protein especially in the case of more than 3,500 shock waves. Because S100a0 protein exists at relatively high concentrations in the proximal renal tubules and skeletal muscles, serum and urine S100a0 protein levels appear to be useful markers of tissue injury, including damage in the kidney and skeletal muscles, in the early post-ESWL phase.     

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.     

Extracorporeal shock wave lithotripsy in children

An experience with 103 children treated with extracorporeal shock wave lithotripsy (ESWL) is reviewed in this report. The success rate was 63%. The stone volume was of major importance for the result. There was a continuous decrease in success rate with increasing stone size. It was also shown that stone-free rates decreased with an increasing number of stones. Short-term complications were minor and hospitalization times were short. It is concluded that ESWL is a first-choice treatment in children with urinary calculi smaller than 200 mm2 in size.     

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.     

Lower caliceal stone clearance after shock wave lithotripsy or ureteroscopy: the impact of lower pole radiographic anatomy

PURPOSE: We determine whether there is a significant relationship between the spatial anatomy of the lower pole, as seen on preoperative excretory urography (IVP), and the outcome after shock wave lithotripsy or ureteroscopy for a solitary lower pole caliceal stone 15 mm. or less. MATERIALS AND METHODS: Between January 1992 and June 1996, 34 patients with 15 mm. or less solitary lower pole stone underwent ureteroscopy with intracorporeal lithotripsy (13) or extracorporeal shock wave lithotripsy (ESWL) with a Dornier HM3 lithotriptor (21). On pretreatment IVP lower pole infundibular length and width, infundibulopelvic angle of the stone bearing calix were measured. Stone size and area were determined from an abdominal plain x-ray. A plain x-ray of the kidneys, ureters and bladder was obtained in all patients at a median followup of 12.3 and 8 months in the ureteroscopy and ESWL groups, respectively. RESULTS: After initial therapy the overall stone-free rate was 62 and 52% in the ureteroscopy and ESWL groups, respectively. Stone-free status after ESWL was significantly related to each anatomical measurement. Infundibulopelvic angle 90 degrees or greater, and infundibular length less than 3 cm. and width greater than 5 mm. were each noted to correlate with an improved stone-free rate after ESWL. In contrast, the stone-free rate after ureteroscopy was not statistically significantly impacted by these anatomical features, although a clinical stone-free trend was identified relating to a favorable infundibular length and infundibulopelvic angle. The infundibulopelvic angle was 90 degrees or greater in 4 stone-free patients (12% overall), including 2 who underwent ureteroscopy and 2 who underwent ESWL. On the other hand, in 2 and 4 stone-free patients (18% overall) who underwent ureteroscopy and ESWL, respectively, favorable radiographic features consisted of a short, wide but acutely angulated infundibulum with the infundibulopelvic angle less than 90 degrees, and infundibular length less than 3 cm. and width 5 mm. or greater. In contrast, in 4 and 6 patients (29% overall) who underwent ureteroscopy and ESWL, respectively, all 3 radiographic features were unfavorable with the infundibulopelvic angle less than 90 degrees, and infundibular length greater than 3 cm. and width less than 5 mm. In these cases the stone-free rate was 50 and 17% after ureteroscopy and ESWL, respectively. CONCLUSIONS: The 3 major radiographic features of the lower pole calix (infundibulopelvic angle, and infundibular length and width) can be easily measured on standard IVP using a ruler and protractor. Each factor individually has a statistically significant influence on stone clearance after ESWL. A wide infundibulopelvic angle or short infundibular length and broad infundibular width regardless of infundibulopelvic angle are significant favorable factors for stone clearance following ESWL. Conversely, these factors have a cumulatively negative effect on the stone clearance rate after ESWL when they are all unfavorable. In ureteroscopy spatial anatomy has less of a role in regard to stone clearance but it may have a negative impact when there is uniformly unfavorable anatomy.     

In vitro study of the mechanical effects of shock-wave lithotripsy

Impulsive stress in repeated shock waves administered during extracorporeal shock-wave lithotripsy (ESWL) causes injury to kidney tissue. In a study of the mechanical input of ESWL, the effects of focused shock waves on thin planar polymeric membranes immersed in a variety of tissue-mimicking fluids have been examined. A direct mechanism of failure by shock compression and an indirect mechanism by bubble collapse have been observed. Thin membranes are easily damaged by bubble collapse. After propagating through cavitation-free acoustically heterogeneous media (liquids mixed with hollow glass spheres, and tissue) shock waves cause membranes to fail in fatigue by a shearing mechanism. As is characteristic of dynamic fatigue, the failure stress increases with strain rate, determined by the amplitude and rise time of the attenuated shock wave. Shocks with large amplitude and short rise time (i.e., in uniform media) cause no damage. Thus the inhomogeneity of tissue is likely to contribute to injury in ESWL. A definition of dose is proposed which yields a criterion for damage based on measurable shock wave properties.     

Bacteremia associated with extracorporeal shockwave lithotripsy of gallbladder stones

BACKGROUND/AIMS: The possible induction of bacteremia by extracorporeal shock wave lithotripsy (ESWL) of gallbladder stones was studied. MATERIALS AND METHODS: Seventy-six patients undergoing a total of 107 ESWL treatments were studied. RESULTS: Twenty-four (22%) of the 107 treatments were associated with bacteremia. Staphylococcus epidermidis was cultured during and/or after 23 (96%) of the treatments associated with bacteremia. The ESWL-induced tissue damage of the skin in the pass-way of the shock-waves was the most likely cause of bacteremia in these patients. There was no correlation between the occurrence of bacteremia and the age or body mass index of the patients. Neither was there any correlation of bacteremia related to the duration of the treatment, the number of shock waves, the energy delivered, the stone volume or the occurrence of calcified stones. No patient developed sepsis or endocarditis. Transient fever shortly after treatment was recorded in 5 patients (5%), one of whom had bacteremia. CONCLUSIONS: Routine antibiotic prophylaxis is not indicated in patients undergoing ESWL for gallbladder stones. The question whether such prophylaxis should be given to patients at special risk, for instance patients with artificial heart valves or known valvular heart disease, remains to be answered in larger controlled and randomized studies.     

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.     

Endourologic complication: endourologic resolution

OBJECTIVES: To report an uncommon endourological complication that was also resolved by endourological methods. METHODS/RESULTS: We report on a patient with a right solitary kidney, radiolucent renal stone and an indwelling double-J catheter. While removing the double-J catheter after ESWL, it broke at the level of its distal third. The proximal two thirds remaining in the ureter were successfully removed by ureteroscopy after several attempts by ureteroscopy and percutaneous nephroscopy. CONCLUSIONS: Except for special circumstances, most of the endourological complications can be resolved by an endourological procedure.     

Repair of congenital H-type vestibuloanorectal fistula through the posterior midsagittal approach: case report

In this study we attempt to evaluate the advantages and disadvantages of extracorporeal shock wave lithotripsy (ESWL) in situ versus retrograde stone manipulation before ESWL (ESWL+push back) in patients with proximal ureteral stones with regard to tissue damage and inflammatory processes. Several studies have revealed that C-reactive protein (CRP) is a useful marker for tissue damage and inflammation. Thirty patients following primary ESWL in situ, with residual calculi, were randomized to retreatment with ESWL in situ or ESWL+push back. Four of 15 patients in the ESWL+push back group demonstrated an increase in CRP levels after treatment compared with no significant increase in 15 patients in the ESWL in situ group. We conclude that ESWL+push back did not cause significantly higher CRP values than ESWL in situ. ESWL+push back may cause irritation, inflammation, and slight tissue damage in some cases; however, these effects are probably minor and would not contraindicate its use. The implications of this study are that serum CRP levels may be utilized to monitor tissue injury in patients undergoing auxiliary procedures.     

Ureteroscopic management of intrarenal calculi

PURPOSE: To determine its potential role in stone therapy, we evaluated our experience with the ureteroscopic removal of intrarenal calculi in 100 patients. We review the indications, techniques, stone-free and overall success rates, and complications. MATERIALS AND METHODS: From July 1994 to December 1996 ureteroscopic stone removal was attempted in 100 patients a mean of 52 years old who had renal calculi. Indications for treatment included concurrent ureteral stones in 56 cases, and failed extracorporeal shock wave lithotripsy, medical or percutaneous management as well as obesity and anatomical anomalies. There were 2 or more calculi in the affected kidney in 68 patients and stones greater than 6 mm. in 67. Treatment of intrarenal calculi was performed with flexible ureteroscopes, a laser or electrohydraulic lithotriptor and endoscopic graspers. The number and size of calculi were noted in each patient. Stone-free and overall success rates defined as 1 residual fragment less than 3 mm. were noted at 1 and 3-month followup visits. RESULTS: The overall success rate was 89%. Ureteroscopic treatment of intrarenal calculi resulted in a 77% stone-free rate. Of the 23 patients with residual calculi 12 (52%) had a single residual fragment less than 3 mm. The targeted stone was removed or fragmented in 98 patients (98%) and no ureteral calculi remained postoperatively. As expected, the number and size of the original stones inversely correlated with the success rate. There were no intraoperative complications, and only 3 urinary tract infections and 3 fevers were noted postoperatively. CONCLUSIONS: The use of smaller diameter ureteroscopes, better working instruments and more effective lithotriptors allow calculi in all parts of the collecting system to be engaged and treated. Success rates throughout the whole collecting system are comparable to if not better than those of extracorporeal shock wave lithotripsy and percutaneous approaches.     

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.     

Nomegestrol acetate contraceptive implant use by women with sickle cell disease

In a retrospective analysis the results of extracorporeal shock wave lithotripsy (ESWL) treatment were evaluated in patients with renal stones according to calyceal localization of treated stones. The 198 patients who underwent ESWL with the Dornier MPL 9000 were analyzed for success rate, complication rate, residual fragments, regrowth and recurrence rates. Totally 210 calyceal calculi located in different portions of the kidney have been comparatively evaluated. No major complications were noted during or after ESWL. Some minor complications such as flank pain, renal colic, haematuria were observed. Flank pain was observed during ESWL treatment especially in patients with upper calyceal stones. Although stone-free and residual fragment rates were similar in pelvic, upper and middle calyces, patients with lower calyceal and pelvicalyceal stones had high residual fragment rate and lower stone-free rate. Patients with stones in the lower calyces or pelvicalyces had high recurrence and regrowth rates (p < 0.05). ESWL has been considered as the optimal treatment modality for most upper urinary tract calculi. It is especially effective in patients with pelvic, upper and middle calyceal stones. Patients with lower calyceal stones often failed to eliminate the fragments, hence had high recurrence and regrowth rates.     

Management of traction wire fracture complicating mechanical basket lithotripsy

BACKGROUND AND STUDY AIMS: The application of basket catheters has become the main method of removing calculi from the biliary and pancreatic duct. However, larger or impacted stones have to be crushed and fragmented by mechanical lithotriptors before removal is possible. Sometimes, fracture of the traction wire occurs as a severe and fraught complication. We describe a precautionary measure which helps to manage this complication. PATIENTS AND METHODS: In a series of 569 consecutive patients suffering from bile or pancreatic duct stones we found 60 (10.5%) who required mechanical lithotripsy for oversized or impacted calculi. Mechanical lithotripsy was always performed initially with a long metal sheath (80 cm) in combination with a standard traction wire. If the traction wire fractured we replaced the long metal sheath stepwise by shorter ones (70cm, 60cm and 50 cm, respectively), allowing immediate continuation of the lithotriptic procedure using the same traction wire. RESULTS: During the lithotriptic procedure three of our patients (5%) were afflicted by traction wire fracture. Two patients could be relieved directly by changing the initial metal sheath to shorter ones. Because of the exceptional hardness of a pancreatic duct stone the third patient needed stone fragmentation by extracorporeal shock wave lithrotripsy (ESWL) before complete mechanical clearance of the duct could be accomplished. CONCLUSION: We advocate the initial use of a long metal sheath (80cm) to perform mechanical lithotripsy. In case of traction wire fracture the use of a shorter metal sheath allows immediate successful continuation of the procedure, thereby frequently avoiding procedures such as ESWL or surgery.     

Serum progesterone levels in patients with gastric adenocarcinoma before and after gastrectomy

We experienced a case of a hepatic subcapsular hematoma after extracorporeal shock wave lithotripsy (ESWL) for a right renal stone. To our knowledge this presentation is the second case in the Japanese literature. A 63-year-old female with a right renal stone received 2,800 shots of 14.0 kilo-volts shockwave with Sonolith 3,000. Preoperative examination of the blood disclosed no abnormalities in the coagulating system except slight reduction of platelet count and slight impairment of liver function. Postoperative routine ultrasound echograms revealed a hepatic subcapsular hematoma although she had no symptom. The size of the hematoma measured 11.0 x 5.0 cm in computed tomograms (CT). She was carefully observed without any treatments because the hematoma did not increase in size. CT scans 6 months after the ESWL treatment demonstrated neither hematoma nor masses in the liver. As a complication of ESWL for urolithiasis a hepatic subcapsular hematoma is very rare. We herein presented the case and discussed the complications of ESWL briefly in the literature.     

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.     

Renal hematoma after shockwave extracorporeal lithotripsy

OBJECTIVE: Renal haematomas after shock wave extracorporeal lithotripsy (SWEL) represent a potentially serious complication. This paper examines those cases of post-SWEL renal haematoma seen in our Centre, analyzing the likely risk factors. PATIENTS AND METHODS: Between May 1988 and June 1996, 12,800 patients were treated with 15100 lithiasis at some level of the urinary tract requiring 16,000 SWEL sessions. All treatments were done with a Dornier HM-4 lithotripter. Voltage applied ranged from 18 to 26 Kv, averaging 2500 waves/session. Complementary testing (ultrasound/computerised tomography) was requested immediately after treatment if clinical complications were suspected. RESULTS: A total of 10 renal haematomas (0.078%) were diagnosed. Six cases were mild, but 4 presented extensive haematoma with significant haemodynamic consequence. Although in one case nephrectomy was undertaken to control haemorrhage, death finally occurred by disseminated intravascular coagulation. Four patients who developed haematoma were hypertensive and 3 had a previously corrected haemostasis alteration. CONCLUSIONS: The possibility of renal haematoma should be taken into account in the face of persistent and unjustified pain after SWEL treatment. Normalization of blood pressure values, correction of urinary infection as well as adequate correction of haemostatic disorders is advisable.     

A randomized controlled trial to assess the incidence of new onset hypertension in patients after shock wave lithotripsy for asymptomatic renal calculi

PURPOSE: To answer the question of whether extracorporeal shock wave lithotripsy (ESWL*) induces hypertension, a prospective, randomized controlled trial of normotensive patients with asymptomatic renal calculi was designed. MATERIALS AND METHODS: Patients were randomized to receive immediate ESWL versus observation, reserving ESWL for the onset of symptoms. The rates of new onset hypertension were evaluated for both groups. RESULTS: There was no observed difference in the incidence of hypertension between the treatment and observation groups. CONCLUSIONS: The risk of hypertension in patients undergoing ESWL therapy is similar to that of a control cohort of initially observed asymptomatic patients.     

Self-reported health and function status of elderly Turkish immigrants in Copenhagen, Denmark

Tissue damage by extracorporeal shock wave lithotripsy (ESWL) is assumed to be attributable to ischemic changes in the treated region surrounding the particular vessel which is first ruptured by shock waves. Such changes cannot take place without being accompanied by acceleration of coagulation and fibrinolysis. In the literature on renal damage by ESWL, no parameters of the coagulation and fibrinolysis of blood were used. The present study was designed to investigate renal damage by shock waves through the quantification of sequential changes in the following parameters between before and after ESWL: thrombin antithrombin III complex (TAT), alpha 2-plasmin inhibitor-plasmin complex (PIC), fibrin and fibrinogen degradation products (FDP) and D-dimer (D-D). In ESWL for renal stones, a significant acceleration of TAT occurred on the 1st postoperative day, followed by acceleration of PIC on the 3rd postoperative day. A transient acceleration was observed for FDP and D-D after operation. The levels of these parameters, however, returned to normal by the 1st postoperative week. In ESWL for ureteral stones, unlike for renal stones, none of the parameters showed statistically significant acceleration. In the construction of percutaneous nephrostomy (PNS) cases for ureteral stones before ESWL, none of the parameters showed significant acceleration either. Changes in these parameters of coagulation and fibrinolysis due to ESWL for renal stones were greater than those of construction of PNS or ESWL for ureteral stones. The reason for the difference of the alteration in these parameters between renal stones and ureteral stones were more abundant vessels in the kidney than the ureter. All these changes in the parameters, however, disappeared within almost 1 week.