|Year : 2019 | Volume
| Issue : 3 | Page : 131-136
Is extracorporeal shock wave lithotripsy still the treatment of choice for renal and upper ureteric calculi: Our experience with 274 cases and its comparison with retrograde intrarenal surgery literature
Aman Agarwal, Piyush Singhania, Ajinkya Patil, Kush Shah
Department of Urology, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India
|Date of Submission||20-Jan-2020|
|Date of Acceptance||21-Jan-2020|
|Date of Web Publication||16-Mar-2020|
Dr. Piyush Singhania
Dr. Piyush Singhania, Prof and HOD, Department of Urology, MGM Medical College and Hospital, Mumbai – Pune Hwy, Kamothe, Navi Mumbai 410209, Maharashtra.
Source of Support: None, Conflict of Interest: None
Background: Extracorporeal shock wave lithotripsy (ESWL) is used in the management of renal calculi <2cm in size using shock waves under ultrasound/X-ray guidance. Nowadays, with the advancement of endourology the use of ESWL has become less. Newer techniques such as retrograde intrarenal surgery and percutaneous nephrolithotomy have replaced ESWL for treatment of renal stones. Materials and Methods: A total of 274 patients between age group of 15 months and 78 years from Department of Urology, MGM Medical College were enrolled in the study for 3 years from October 2015 to October 2018. All patients underwent intravenous pyelogram. The inclusion criteria of the study were patients with calculi between 6 and 20mm. The exclusion criteria of the study were patients having untreated urinary tract infection, pregnancy, musculoskeletal deformity, and deranged coagulation profile. Double J stenting was performed prior to the procedure for stones >1cm. A maximum of three sessions of ESWL were given. The procedure was performed under local anesthesia for adults and under general anesthesia for children. Results: There was no effect of age and sex on stone clearance. Overall success rate was 91.97%. Success rate for smaller calculi was more (6–10 mm: 97.7%; 10–15 mm: 90.1%; 15–20 mm: 87.5%) with P value <0.05. Success rate of calculi in lower calyx (83.63%) were less as compared to calculi in upper calyx (96.77%), middle calyx (96.15%), renal pelvis (90%), and upper ureter (88.23%) with P value <0.05. Complications of the procedure included pain (28 patients required no treatment and 3 patients required admission and treatment) and hematuria (15 patients required no treatment and 2 patients required admission and treatment), and 1 patient with perinephric hematoma who was treated conservatively. Conclusion: ESWL is a safe and effective procedure in treatment of renal and upper ureteric calculi. It can still be regarded as treatment of choice for appropriate cases of renal and upper ureteric stones especially in developing countries where cost is still a major factor.
Keywords: Extracorporeal shock wave lithotripsy, renal calculus, ureteric calculus
|How to cite this article:|
Agarwal A, Singhania P, Patil A, Shah K. Is extracorporeal shock wave lithotripsy still the treatment of choice for renal and upper ureteric calculi: Our experience with 274 cases and its comparison with retrograde intrarenal surgery literature. MGM J Med Sci 2019;6:131-6
|How to cite this URL:|
Agarwal A, Singhania P, Patil A, Shah K. Is extracorporeal shock wave lithotripsy still the treatment of choice for renal and upper ureteric calculi: Our experience with 274 cases and its comparison with retrograde intrarenal surgery literature. MGM J Med Sci [serial online] 2019 [cited 2020 Mar 28];6:131-6. Available from: http://www.mgmjms.com/text.asp?2019/6/3/131/280751
| Introduction|| |
In 1950, Russia first used shock waves for fragmentation of stones. The use of extracorporeal shock wave lithotripsy (ESWL) for the treatment of renal and upper ureteric calculi was started in 1980s and was considered to be the treatment of choice for calculi <2cm in size. Nowadays, with the advancement of endourology the use of ESWL has become less. Newer techniques such as retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) have replaced ESWL as the treatment of choice for renal stones. In this study, we discuss our experience with ESWL in 274 cases of renal and upper ureteric calculi and also the relevance of ESWL in developing countries such as India, where cost is still one of the major factors determining the mode of treatment for stone diseases.
Advantages of ESWL include avoidance of anesthesia, reduced hospital stay, minimally invasive as compared to open and other endoscopic surgeries, and reduced cost. In ESWL, shockwaves are generated using electrohydraulic, piezoelectric, or electromagnetic generators and are focused on calculi using ultrasound (USG) and X-ray guidance, thereby breaking calculi into small fragments which can be easily passed out in urine. Fragmentation of calculi is due to compressive forces that are transferred to the calculi surface when shockwaves travel from human tissues into calculi (dense medium) and tensile forces that are generated when shockwaves travel through calculi and leave calculi surface to human tissues (less dense).
| Materials and methods|| |
A total of 274 patients between age group of 15 months and 78 years from Department of Urology, MGM Medical College, Navi Mumbai were enrolled in our study for 3 years from October 2015 to October 2018. Of 274 patients, 164 were men and 110 were women. The mean age of patients was 42.7 years for men and 43.5 years for women. The inclusion criteria of the study included patients having renal calculi having size between 6 and 20mm. The exclusion criteria of the study included patients having untreated urinary tract infection (UTI), pregnancy, musculoskeletal deformity, and patients having deranged coagulation profile.
Patients were registered on the basis of age, sex, size of calculi (6–10, 10–15, and 15–20mm), and on the basis of location (upper calyx, middle calyx, lower calyx, pelvic, and upper ureteric).
ESWL was given using Siemens Variostar under USG/Xray guidance [Figure 1]. Preoperative workup of patients included complete blood count (CBC), Prothrombin Time/International Normalized Ratio (PT/INR), and urine routine and culture. All patients underwent intravenous pyelogram (IVP) before the procedure to delineate the anatomy. Antibiotic coverage was given only when the patient had a history of UTI. Double J (DJ) stenting was performed prior to the procedure for stones >1cm. Up to 3000 shocks were given in each session and a maximum of three sessions of ESWL were given to patients. Success rates after each session of ESWL were accessed after 2 weeks of ESWL on the basis of USG kidney ureter and bladder (KUB) and X-ray KUB. Clearance and success were defined as residual stones of <3mm. Results of this study were calculated as per clearance of calculi after each session of ESWL. The procedure was performed under local anesthesia (LA) and general anesthesia (GA) (for children under 8 years of age). DJ stent removal was performed once patient achieved calculi clearance. For the treatment of patients in whom ESWL failed, PCNL was performed. To determine significance of results, chi-square test was performed. A value of P < 0.05 was considered significant for the test.
|Figure 1: Ultrasound-guided ESWL machine used in our study (Siemens Variostar)|
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| Results|| |
As per this study, 274 patients were treated. Male:female ratio in our study was 1:49. There was no effect of age (P > 0.05) [Table 1] and sex (93.90% in male and 89.09% in female, P > 0.05) [Table 2] on the clearance of renal and upper ureteric calculi. In our study, 240 patients (87.59%) had renal calculus and 34 patients (12.41%) had upper ureteric calculus [Table 3]. Overall success rate was 91.97%. Success rate after three sessions of ESWL in renal calculi was 92.5% and in upper ureteric calculi it was 88.23%. A total of 198 (72.26%) patients required only one session for clearance as compared to 40 (14.59%) patients who required two sessions and 14 (5.10%) patients who required three sessions for clearance. In total, 22 (8.02%) patients did not achieve clearance even after three sessions. Cumulative success rate for smaller calculi was more (6–10 mm: 97.7%; 11–15 mm: 90.1%; 16–20 mm: 87.5% with P value [0.0446] < 0.05) [Table 4]. Average numbers of sessions required for clearance of calculi (6–10, 10–15,, and 15–20mm) were 1.22, 1.45, and 1.57, respectively, and the average number of sessions required by each patient was 1.40. Mean cumulative success rates was least for calculi in lower calyx (upper calyx 96.77%, middle calyx 96.15%, lower calyx 83.63%, renal pelvis 90%, and upper ureter 88.23% with P value [0.0377] < 0.05) [Table 5]. The average numbers of sessions required for calculi in upper calyx, middle calyx, lower calyx, pelvis, and upper ureter were 1.24, 1.30, 1.63, 1.1, and 1.44, respectively. Complications of the procedure included pain (minimal in 28 patients requiring no treatment and severe in 3 patients requiring admission and analgesic treatment) and hematuria (minimal in 40 patients requiring no treatment and severe in 2 patients requiring admission), and 1 patient with perinephric hematoma who was treated conservatively., , ,
|Table 4: Clearance of calculi based on size of calculus and number of sessions required|
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|Table 5: Clearance of calculus based on calculus location and number of sessions required|
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| Discussion|| |
Today with the advent of newer endourologic techniques such as PCNL and RIRS, ESWL is losing its status as treatment of choice for calculi <20mm. In this study, we concluded that ESWL is an effective modality for the treatment of calculi <20mm with overall success rate of 91.97% and also it has very low morbidity. It also saves patient from anesthesia complications. Also the cost of ESWL is approximately one-third the cost of PCNL and RIRS.
Our overall success rate was 91.97%, which is consistent with the findings of Nielsen and Jensen (93%) and Joshi et al. (96.3%). As per our study, no effect of age and sex was observed on the efficacy of ESWL, which was also proved in a study conducted by El-Assmy et al. Some studies by Nafie et al. (43.3%) and Chung and Turney (66.4%) have reported lower stone clearance rates up to 43.3%, which is in contrast to our study. Clearance of stone was found to be inversely proportional to the size of calculus in our study, which is similar to studies conducted by Tarawneh et al. Average number of ESWL sessions in our study was directly proportional to the stone size, which is similar do studies conducted by Tarawneh et al. and Junuzovic et al. Success rate for calculi fragmentation was least in lower calyx as compared to calculi in other sites in our study, which is similar to study conducted by Tarawneh et al. Drawback of our study was calculus density and composition was not taken into consideration. Studies have revealed inverse relation of calculi clearance to density of stones. AL-Hakary et al. showed that cystine and brushite calculi are the most resistant to ESWL, followed by calcium oxalate monohydrate, struvite, calcium oxalate dihydrate, and uric acid stones.
Various predictors of efficacy of ESWL success include energy dissipated (ESWL should be started with low energy and should be gradually increased), pulse frequency (lower frequency 60 Hz has better results than higher frequency 120 Hz), coupling (air in the path of shockwaves have a negative effect), kidney movement during respiration (negative effect) with high-frequency ventilation giving better results,, and sedation (positive effect). However, there is no effect on efficacy of ESWL by the making of ESWL machines (electrohydraulic, piezoelectric, or electromagnetic generators).
Indications of ESWL include calculi <20mm in size. Absolute contraindications for the use of ESWL are untreated UTI, urosepsis, pregnancy, coagulation disorders and deranged coagulation profile, obstruction in genitourinary tract distal to calculi, uncontrolled arrhythmia, and abdominal aortic aneurism. Relative contraindications of ESWL include obesity, spinal deformity, renal malformations (renal ectopia and horse shoe kidney), uncontrolled hypertension, complex intrarenal drainage (infundibular stenosis), previous history of open renal calculi surgery, and renal insufficiency.
Complications of ESWL include flank pain, petechiae and subcutaneous bruising at the entry point of shock waves, hematuria (microscopic to gross), UTI, sepsis, urinary obstruction, perirenal, and subcapsular hematoma. Some less-common complications of ESWL have been reported, which include renal atrophy, developing hypertension and diabetes, pulmonary contusion, splenic hematoma, pancreatitis, elevated liver functions, biliary colic (due to fragmentation of adjacent biliary stones), and disruption of calcified vessels (leading to plaque formation and rupture).
We compared the results of our study with results of RIRS studies conducted previously by El-Nahas et al., Bozkurt et al., Aboutaleb et al., Ozturk et al., Ozgor et al., Singh et al., Kumar et al., Bozzini et al., Gyawali et al., Javanmard et al., and Lim et al. All the results are tabulated in [Table 6]. As shown by our study, ESWL rarely needs admission in hospital, whereas previous held studies of RIRS suggested that the mean hospital stay was 0.88 days to 3 days. The overall success rate of our study was 91.97% as compared to various studies of RIRS where success rates ranged from 70% to 90.40%. The complication rate of our study was also significantly less, that is, 2.18% as compared to results of RIRS studies where success rate ranged from 5.30% to as high as 46.20%. Overall cost was found significantly high for RIRS as compared to ESWL in a study by Koo et al. (£2602 vs. £426).
| Conclusion|| |
ESWL is a safe and effective procedure in the treatment of renal calculi of size <20mm. ESWL was also found to better than RIRS in terms of less hospital stay and significantly less complications. In developing countries such as India where cost is still considered a deciding factor, ESWL can be considered as treatment of choice for appropriate cases of renal and upper ureteric calculi. Limitation of this study was density and composition of calculi was not taken into consideration.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]