|Year : 2001 | Volume
| Issue : 2 | Page : 118-120
Acute complications during and after extracorporeal shock wave lithotripsy
ME Schmidt, S Sharma, G Schoeneich, P Albers, SC Muller
Department of Urology, University of Bonn, Germany & Department of Surgery, Govt. Gandhi Nagar Hospital, Jammu, J&K, India
M E Schmidt
Klinik and Poliklinik fur Urologie, Rheinische Friedrich-Wilhelms-Universitat Bonn, Sigmund-Freud-Strabe 25, D-53105 Bonn, Germany
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: ESWL is an effective noninvasive method to treat urolithiasis. Only in rare occasions, complications requiring treatment have been described.
Methods: We report three acute major complications during and after ESWL using a Siemens Lithostar plus model (Retroperitoneal haematoma - Rupture of spleen - Cardiac arrest) and compare our experience with the literature.
Conclusion: The rate of clinically relevant complications is very love. To recognize severe complications laboratory examination and a sonographic control should be performed after each ESWL.
Keywords: Urolithiasis; ESWL; Retroperitoneal Haematoma; Rupture of Spleen; Cardiac Arrest.
|How to cite this article:|
Schmidt M E, Sharma S, Schoeneich G, Albers P, Muller S C. Acute complications during and after extracorporeal shock wave lithotripsy. Indian J Urol 2001;17:118-20
|How to cite this URL:|
Schmidt M E, Sharma S, Schoeneich G, Albers P, Muller S C. Acute complications during and after extracorporeal shock wave lithotripsy. Indian J Urol [serial online] 2001 [cited 2019 Jun 25];17:118-20. Available from: http://www.indianjurol.com/text.asp?2001/17/2/118/21039
| Introduction|| |
Today more than 90% of therapy of renal and ureteral concrements are treated with extracorporal shock wave lithotripsy (ESWL). 
However, treatment of urolithiasis by means of ESWL is not always without complications. Temporary haematuria, subcapsular haematoma and "steinstrasse" (disturbance of urinary transport) are well-known early complications of stone disintegration by ESWL. Serious acute complications, however, are rare. Three of them are being described here. In all cases a Siemens Lithostar plus model was used.
| Case Reports|| |
Case number 1: Cardiac arrest during ESWL treatment
A 54-year-old patient with an asymptomatic concrement in the midcalyceal group of the left kidney was treated with ESWL.
In his history, syncopal episodes occurred in his adolescence during blood withdrawals. His physical checkups were negative and laboratory parameters were within normal range.
An ECG carried out before and while treatment was without pathological findings.
While being prepared for ESWL treatment, the patient was given 100 mg of dimenhydrinat for slow intravenous application during ESWL. At the beginning of the session, analgesics were renounced.
After administering 125 shock waves of 19.5 kV, it came to a cardiac arrest. The patient was unconscious and after closed chest compression for 20 seconds combined with the application of atropine i.v., a bradycardiac sinus rhythm returned spontaneously. A short time later the patient was well off.
A detailed cardiological examination showed no pathological alterations. Thus, the cardiac arrest during extracorporal shock wave lithotripsy has to be interpreted as an exceeding vasovagal reaction.
Case number 2: Retroperitoneal haematoma after ESWL treatment
A 60-year-old patient, suffering from acute left-sided flank pain due to a blocking concrement in the proximal part of the ureter and a consecutive third-degree hydronephrosis, was admitted to the hospital.
The physical check-up at admission showed negative findings except for left-sided flank pain. No signs of infection, no temperature, no hypertension. Lab values within the normal range.
An initial pushback manoeuvre of the concrement into the left renal pelvis was performed under i.v. antibiotics. Urine transport was secured via a transureteral double-J-splint.
Next day ESWL treatment was done without complications. 2000 shock waves of a maximal doses of 21.5 kV were applied. According to sonography, a good desintegration of concrements was achieved and no haematoma was seen directly after ESWL.
One day later, temperature rose to 38° C, leukocytes increased to l5000/µ1 and CRP rose to 6.5 mgs/dl. At the same time the haemoglobin value dropped continuously from 14.6 mgs/dl to 10.5 mgs/dl. But the patient didn't show clinical symptoms like flank pain.
A retroperitoneal haematoma was suspected by sonography, and computer tomography showed a rupture of the renal capsule with a haematoma of 7 x 8 x 7 cms.
Under conservative therapy including i.v. antibiotic therapy, the patient was discharged one week later in stable condition. A control examination two weeks later showed no signs of infection, lab values within normal range. Haemoglobin rose to 12.1mgs/dl. The sonography examination showed a decreasing retroperitoneal haematoma.
Case number 3: Rupture of the spleen following ESWL treatment
Admission of a 61-year-old female for auxiliary ESWL with a pelvic cast calculus on the left side. By means of a percutaneous nephrolithotripsy (PNL), 75% of the stone mass had been removed already 6 days before in another urological department and a nephrostomy was draining the kidney. No complications were reported. Postoperative laboratory values showed an elevation of liver enzymes (gamma GT 51 U/1; ALT 81 U/1; AST 42 U/1), the haemoglobin value of the patient was 10.6 g/dl; red blood cells (RBC) had decreased to 3600/µ1. The haematocryt was at 32%, platelets were increased up to 510G/l. The coagulation parameters were at a normal range, showing a Quick value of 104% (INR 0.9) and a PTT of 23 seconds.
The sonography examination showed a well-located nephrostomy. There were no signs of any organ injury. Under antiemetic and analgesic protection, two ESWL treatments were performed on the left side on two consecutive days with 2000 shock waves of a power of 21.5 kV, each.
One day after the second ESWL treatment, haemoglobin decreased to 7.9g/dl and white blood cells (WBC) increased to 15100/µl. The patient only complained of increased tiredness.
Sonographically, the left kidney was without findings except for the already known nephrolithiasis and the welllocated nephrostomy catheter. A heterogeneous sonomorphological pattern of the spleen was alarming. An abdominal computer tomography confirmed the suspected rupture of the spleen.
At the same day, a splenectomy had to be carried out, since attempted repair of the spleen failed. The histological findings showed a recent traumatic rupture of the spleen with a big subcapsular haematoma and circumscribed parenchymal lacerations.
| Discussion|| |
Since Chaussy et al  reported on the first complications after ESWL, the number of cases with complications has increased in the course of the years.
Considering complications induced by ESWL, obstructions of urine transport caused by stone fragments should be separated from those caused by shock waves. The most frequent complications induced by shock waves are the subcapsular and the retroperitoneal haematomas.
According to the method of examination, haematomas following ESWL occur between 0.2 and 23%. While by means of CT or MRT, haematomas are found in 23% of patients after ESWL treatment, follow-up examinations by means of sonography only show haematomas in 0.2 to 2.8% of cases. ,,,
Newman and Saltzinan  demonstrated in a study that patients with severe subcapsular haematomas are usually detected only by clinical symptoms, such as pain, anuria and cardiac symptoms as well as anaemia.
One case was reported, in whom a life-threatening retroperitoneal haematoma appeared when half an hour after ESWL, an intravenous anticoagulation was started due to an acute myocardial infarction.  Another case has been published where renal haematomas appeared in both kidneys after synchronous ES WL, which lead to acute renal failure. The patient was treated with multiple concrements in the calyceal systems on both sides in one session (1000 shock waves on the left, 1200 shock waves on the right, 19kV), after having discontinued warfarin 5 days earlier which the patient had to take due to an artificial cardiac valve. 
In most cases, haematomas do not have clinical or therapeutical consequences. Only in a few cases blood transfusions are necessary (<1%) and even more seldom surgical intervention is required. One single case has been known in which nephrectomy had to be performed after ESWL.,
Other complications induced by shock waves have been registered at a much lower scale. So far, splenectomy in connection with ESWL has not been reported. Only two cases have been described in which pancreas trauma or acute pancreatitis occurred after ESWL treatment. ,
The cardiac arrest during ESWL is extremely rare. In the literature, only one more case has been published. 
In our case there was no history of cardiac problems and vasovagal reactions due to ESWL have not been described yet. The exact mechanism by which vasovagal reactions are triggered by ESWL are unknown. Arrhythmias like sinus tachycardia and sinus bradycardia as well as supraventricular or ventricular extra systoles can be observed far more often  and can mostly be avoided by ECG-triggered shock wave application. However even in these cases arrhythmia can be observed on a few occasions.
Comparing the number of complications to the number of ESWL treatments the rate of clinically relevant complications is very low. Consequently, ECG monitoring during ESWL, a laboratory examination and a sonographic control should be performed after each ESWL treatment so that severe complications can be recognized early and put under control. Pain after ESWL is alarming and in these cases sonographic follow-up should be considered for several days.
Table: Complications during and after ESWL treatment
- Hematuria (95 - 100%)
- "stein stras se" with consecutive urinary obstruction (30%) [Kellum et al., Radiology 165:431-438, 1987]
- Urinary tract infection / urosepsis (0.3%) [Roth et al, Urol Clin North Am 15:155-166, 1986]
- Subcapsular / retroperitoneal hematoma (0.25 - 30%) [Newman et al, Urology 1991; 38: 35]
- Injury of neighbour organs (less than I%) [Drach et al, J Urol 135: 1127-1133, 1986]
- Cardiac complications (less than 1%)
| References|| |
|1.||Tuteja AK. Pulliam JR Lehman TH. Elzinga LW. Anuric renal failure from massive bilateral renal hematoma following ESWL. Urology 1997; 50: 606-608. |
|2.||Baurngartner B, Dickey K, Ambrose S. Kidney changes after extracorporeal shock wave lithotripsy: appearance on MR imaging. Radiology 1987: 163: 531. |
|3.||Chaussy C. Schmiedt E. Jocharn D et al. Extracorporeal shock wave lithotripsy for treatment of urolithiasis. Urology 1984; 23: 59-66. |
|4.||Donahue LA, Linke CA, Rowe JM. Renal loss following extracorporeal shock wave lithotripsy. J Urol 1989; 142: 809-811. |
|5.||Grote R, Dohring W. Aeikens B. Computertomographischer and sonographischer Nachweis von renalen undperirenalen Veranderungen nach einer ESWL. Fortschr Rontgenstr 1986: 144: 434. |
|6.||Katz R, Admon D. Pode D. Life threatening retroperitoneal hematoma caused by anticoagulant therapy for myocardial infarction after ESWL. J Endourol 1997; 11: 23-25. |
|7.||Kaude J, Williams C, Millner M. Renal morphology and function immediately after ESWL. AJR 1985: 145: 305. |
|8.||Knopf H, Alefelder J. Graff H, Senge T. Schwere akute Pankreatitis nach ESWL Behandiung. Akt Urol 1991; 22: 172-174. |
|9.||Knorr PA.Woodside JR. Large perirenal hematoma after extracorporeal shock wave lithotripsy. Urology 1990: 35: 151-153. |
|10.||Mullen K. Hooffnagle J, Jones A. Shock-wave-induced pancreatic trauma. Am J Gastroent 1991; 86: 5. |
|11.||Newman LH, Saltzman B. Identifying risk factors in development of clinically significant post-shock-wave lithotripsy subcapsular hematomas. Urology 1991; 38: 35-38. |
|12.||Trombetta C, Berretta A, Siracusano S, Gabriele M, Belgrano E. Evaluation of hematochemical parameters and renal echography after ESWL. Eur Urol 1992; 21 (Suppl 1): 53-56. |
|13.||Umewake T, Yamate T. Amasaki N et al. Continuous evaluation for retroperitoneal hematoma following extracorporal shock wave lithotripsy. Urol Int 1993; 51: 114. |
|14.||Zeng Z, Lindstedt R. Olsson S. Arrhythmia during extracorporal shock wave lithotripsy. Br J Urol 1993; 71: 10-16. |