|Year : 2001 | Volume
| Issue : 1 | Page : 25-30
Extracorporeal shock wave lithotripsy in children and adults: Institute experience using stonelith lithotripter
M Gopi Kishore, Arif Hameed, Vipul Tandon, Mufti Mohamad, Harbans Singh, Vibhav Malviya, US Dwivedi, PB Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University Varanasi., India
P B Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: To assess the value of extracorporeal shock wave lithotripsy (ESWL) in treating paediatric and adult urolithiasis, and to determine, factors that may affect the results.
Patients and Methods: Using Stonelith lithotripter (PCK Electronic Industry and Trade Co. Sincan Org San Orhansik, CAO no. 4, Ankara, Turkey), 92 patients (108 stones) with mean age of 35.1 years (4-72 years) were treated for urinary stones. Of these, 89 stones were renal stones and 19 were ureteric stones. The respective mean stone size was 1.86 curs (0.6-3 cms) for renal stones and 1.61 cms (0.6-2.4 curs) for ureteric stones. The patients were assessed 3 months after treatment and the results compared, to detect factors that might be associated with the stone free rate.
Results: Of the 108 stones with 3 months follow-up, the overall stone free rate was 75.9% (82 stones); 14.8% (16 stones) stones showed fragmentation but no clearance of stone fragments (insignificant.fragments of < 5 nun) and 9.25% (10 stones) stones didn't show any fragmentation at all. For renal stones the overall stone free rate was 74.1% (66 stones); 15.7% (14 stones) showed partial clearance (1 lostfollow-up) and 10.1 % (9 stones) didn't show any fragmentation. In patients with ureteric stones 16 (84.2%) were stone free after treatment, 2 (10.5%) cases lost follow-up and no, fragmentation in I (5.26%) stone. In cases of children and adolescents 8 stones were completely cleared, 3 stones were partially cleared and there was no fragmentation in 4 stones. The significant factors associated with the stone free rate were size, site, number and radiological abnormalities: there was no significant effect of the type of lithotripter used.
Conclusions: ESWL is a safe and effective treatment for both paediatric and adult urolithiasis. The stone free rate is influenced significantly by stone size, site, number and radiological features. Irrespective of the make of lithotripter; the clearance rate was 75 - 97%. JJ stent is not required routinely at the time of ESWL.
Keywords: Extracorporeal Shock Wave Lithotripsy; Paediatric and Adult Urolithiasis; Stonelith Lithotripter; Outcome.
|How to cite this article:|
Kishore M G, Hameed A, Tandon V, Mohamad M, Singh H, Malviya V, Dwivedi U S, Singh P B. Extracorporeal shock wave lithotripsy in children and adults: Institute experience using stonelith lithotripter. Indian J Urol 2001;18:25-30
|How to cite this URL:|
Kishore M G, Hameed A, Tandon V, Mohamad M, Singh H, Malviya V, Dwivedi U S, Singh P B. Extracorporeal shock wave lithotripsy in children and adults: Institute experience using stonelith lithotripter. Indian J Urol [serial online] 2001 [cited 2020 May 31];18:25-30. Available from: http://www.indianjurol.com/text.asp?2001/18/1/25/37376
| Introduction|| |
Until the 1980s, treatment of upper urinary tract often involved extensive surgical procedures. With the introduction of the refinements to endoscopic instruments and surgical techniques, it has now become possible to clear stones in most cases without open surgery. ESWL has considerably modified the management of upper urinary tract lithiasis and has become the therapeutic option in most cases, since its introduction by Chaussy et al in 1980. With a follow-up of nearly 20 years, this technique is considered to be efficient, noninvasive and safe for adults and children.,,, The purpose of the present study was to evaluate prospectively the efficacy. factors which might influence the outcome and potential adverse effects of ESWL in both children and adults in our institute setup using Stonelith electrohydraulic Lithotripter.
| Patients and Methods|| |
From June 2000 to December 2000, 93 patients (75 unilateral and 18 bilateral) were treated for renal and ureteric stones. Of the 18 bilateral stones, 15 patients were treated bilaterally and 3 patients were treated unilaterally: total number of stones that were managed are 108. The mean age was 35.1 years raging 4-72 years and male:female ratio was 4.17:1 (75:18). Most of the patients (77 cases) presented with dull aching pain. 7 patients presented with colicky pain. 3 patients presented with hematuria, 2 for residual calculi and 4 patients were asymptomatic (incidental finding in ultrasound). The evaluation before treatment comprised an abdominal plain X-ray, IVP, renal ultrasound. In all, 108 stones (89 renal and 19 ureteric stones) were treated with a mean (range) size of 1.874 (0.5 - 3) ems: multiple stones in 22 patients, comprising 50 left and 58 right renal / ureteric stones (including 1 complete and 4 incomplete staghorn stones), 52 pelvic, 7 upper calyx, 2 middle calyx, 28 lower calyx, 15 upper ureter, 3 middle ureter and 1 lower ureteric stone. 7 patients had stones both in pelvis and ureter. At the time of treatment, all patients had a normal serum creatinine level and blood pressure and sterile urine. An abnormality in urinary tract was detected in 69 cases (caliectasis in 13 cases, hydronephrosic in 53 cases, poor functioning in 3 cases), 1 horseshoe kidney, 12 bifid pelvis, 1 postoperative pyeloplasty and one malrotated kidney. The total number of patients, total number of stones, mean age, mean size and presentation are shown in [Table - 1].
All patients were treated using a Stonelith (PCK Electronic Industry and Trade Co. Sincan Org San Orthansik, CAO no. 4, Ankara, Turkey) electrohydraulic lithotripter, under IV Fortwin (30 mgs) and Phenergan (50 mgs) in cases of adults, Inj Midazolam (0.2-0.3 mg/kg), Inj Fortwin (0.5 mg/kg), Inj Glycopyrrolate 5-10 pg/kg, given slow IV for 5 minutes in cases of children. All the patients received antibiotic prophylaxis (15 mg/kg - Amikacin), injected one hour before the session. A specially designed device was used to reduce the size of the opening above the generator so that children could be positioned safely.
All the 108 stones treated with Stonelith, were targeted using fluoroscopy by a MCh trainee. The number of impacts per session and the total number of sessions were recorded for each patient. Therapy was usually started at a low power (10Kv), until the patient became familiar with the sound and sensation of the shocks; the power was then increased in steps upto 22 Kv. A maximum of 3500 shocks was delivered per session and there was a minimum (range) interval of 2 weeks (2-4 weeks) between sessions. All the patients received good hydration, antibiotics for 5 days, diuretics for 93 days, analgesics for 3 days at the end of each session, to provide optimal conditions for the elimination of stone fragments.
Patients were reviewed 15 days after the first session using a plain film and renal USG (rarely) to assess fragmentation, the presence of obstruction and the need for retreatment. This continued until there was complete stone clearance or failure to disintegrate the stone. All followup data were collected and analyzed after the 3 months visit, together with the findings from IVU and or renal ultrasonography.
| Results|| |
Of the 108 stones with 3 months' follow-up, the overall stone free rate was 75.9% (82 stones); 14.8% (16 stones) stones showed fragmentation but no clearance of stone fragments (insignificant fragments of < 5 mm) and 9.25% (10 stones) stones didn't show any fragmentation at all. For renal stones the overall stone free rate was 74.1% (66 stones); 15.7% (14) showed partial clearance (1 lost follow-up) and 0. 1 % (9 stones) renal stones didn't show any fragmentation. In patients with ureteric stones 16 (84.2%) were stone free after treatment, 2 (10.5%) cases lost to follow-up and no fragmentation in 1 (5.26%) stone. In cases of children and adolescents 8 stones were completely cleared, 3 stones were partially cleared and there was no fragmentation in 4 stones.
[Table - 2]shows the correlation among the different factors like site, size, number, radiological feature and the stone free rate; the significant association was with the diameter of the stone, where those patients with stones of < 20 mm had better stone free rates (77.8%) than those with stones of > 20 mm (47.8%). Secondly, site of the stone: pelvic stones had better clearance (76.4%) than calyceal stones (72.9%) and ureteric stones had better clearance rate (84.2%) than renal stones (74.1 %). Thirdly, single stone had better stone free rate (80.7%) than that of multiple stones (63.3%). Lastly, the stones without any radiologic abnormalities (hydronephrosis, caliectasis or poor functioning) had better clearance (93.7%) than those which presented with abnormalities (75.1 %) and infundibulo-pelvic angle greater than 90 degrees showed better stone free rate (87.5%) than < 90 degree angle (41.6%) in cases of lower calyceal stones.
A single ESWL session was sufficient to clear 40 stones (48.7%), 2 sessions for 20 stones (24.3%) and remaining 22 stones (26.8%) required more than 2 sessions. The last group mainly included the patients with multiple stones (16 cases), simultaneous renal and ureteric stones (4 cases) and 2 partial staghorn calculi. The mean (range) total number of shocks delivered per patient was 5930.50 (86422500) and the total number of shocks per treatment was 3000-3500, when multiple sessions were used. Mean number of session was 2.19 (1-7). Mean voltage (range) used in adults was 17.425 (10-22Kv) and the mean voltage used in children and adolescents < 20 years was 15.6 Kv (10-17 Kv). In patients with renal stones, the mean voltage used was 17.3 Kv (12-22 Kv) and in those with ureteric stones, the mean voltage used was 17.55 Kv (1020 Kv). [Table - 3] shows the correlation among different factors and the shocks / sessions for the stones that are completely cleared; the only significant association was with the diameter of the stone, where those patients with stones of < 15 mm had stone free rate of 62.75 % with < 3000 shocks.
At 3 months after ESWL, 16 (14.8%) stones had small residual fragments of < 0.5 cms (partial clearance); 13 cases remained under regular follow-up and 3 cases (1 pelvic and 2 ureteric stones) were lost to follow-up. Of 13 partially cleared stones, 2 stones were in horseshoe kidney, 8 stones were in lower calyx, I complete staghorn calculus and 2 partial staghorn stones. No fragmentation was observed in 10 (9.25%) stones; 3 underwent pyelolithotomy and stone composition revealed mixed stone (triple phosphate) and remaining were waiting for surgery. One stone was in calyceal diverticulum and under regular follow-up.
During treatment 6 patients developed steinstrasse, which passed off spontaneously in 3 patients with conservative management like good hydration, hyduretic therapy, analgesic and antibiotic for 2 weeks; one patient required insertion of a JJ stent for 2 weeks, one underwent URSL and in one patient 1000 shocks were given to the distal large fragment of the steinstrasse. 5 patients developed ureteric colic, which required URSL in one patient and rest were managed conservatively with antibiotics and analgesics for one week. 2 patients presented with gross hematuria, immediately after ESWL; they were managed conservatively. 1 patient presented with urosepsis: admitted in hospital for one week and managed conservatively.
| Discussion|| |
The introduction of shock wave lithotripsy into clinical practice revolutionized the management of urinary tract stone disease. Since the first report of its efficacy and safety by Chaussy et al in early 1980s, ESWL has become the treatment of choice for most renal stones in adults and children. The stone clearance rate after ESWL is 75-97% in adults and 62-86% in cases of children, although clearance rates are lower for calyceal than for pelvic stones.
Over the past decade, ESWL has become established as the main choice for treating > 80% of all stones in adults and children. Kraft et al reported a stone free rate of 62%, with 8% retreatment rate, in a series of 184 cases using Dornier HM 3 and HM 4 model. In the present series, the overall stone free rate for renal stones was 75.9%, with 14.8% having insignificant gravel of < 5mm (partial clearance), and the treatment failed in only 9.25%; the significant factors associated with sucess are the stone size, stone burden (number), site of the stone and radiological abnormalities. In the series of Lingeman et al stone size was the most significant factor affecting the success rate. Newman D et al- studied 1910 stones: showed stone free rate after ESWL dropped from 80% in up to 10mm stones to about 60% in stones greater than 30mm. In the present series the stone free rate for 10mm stone was 92.1%, for 11-20mm was 71.6% and for 21-30mm was 50%, which revealed a significant correlation between stone size and stone free rate. Drash et al (1986) reported: when 4 stones or more were present, the resulting stone free rate was only about 30%. In present study, 63.3% multiple stones were stone free and 80.7% single stones were stone free after 3 months' follow-up.
In case of lower calyx stones, the stone free rate was 67.8% with 28.5% partial clearance and no fragmentation in 3.57%; the significant factors associated with the success are infundibulopelvic angle, infundibular neck and caliectasis. In the series of Lojanapiwat B et al reported 44% of patients presented with an infundibulopelvic angle of less than 90 degrees become stone free and 86% of patients with > 90 degrees become stone free. In the present study, the stones without any radiological abnormalities showed 93.7% stone free rate, whereas the stones with radiological abnormalities showed 75.1 % stone clearance. In various studies (Jocham et al, Rassweiler et al, Newman et al), the stone free rate after 3000 shocks or one session was ranging from 55-95% and retreatment rate was 1530%.,In the present study, 48.7% were stone free with < 3000 shocks or single sitting. 24.3% were stone free by 2 sittings / < 6000 shocks and 26.8% were stone free by > 6000 shocks. 60% of stones were stone free by 3000 shocks in cases of < 10 mm whereas only 14.2% were stone free in > 20 mm.
Concern about the potential long term renal damage, radiation exposure associated with ESWL in children has delayed the acceptance of ESWL into paediatric practice. Despite these concerns, many authors have reported their experience of using ESWL for treating urolithiasis in children. Ooge et al reported a stone free rate of 62%, with 28% having partial clearance, in a series of 126 children. In the present series, the stone free rate in children and adolescents was 53.3%. 20% had partial clearance and 26.6% had no fragmentation. The size of the stone was the only significant factor associated with success. Esen et al reported that stone size should be a limiting factor for undertaking ESWL in children, because a large stone burden necessitates more treatment sessions and consequently more shock waves. Nazli et al reported that 59.6% of stones needed only one session of ESWL to clear stones and 85.7% of children were stone free after a mean treatment session of 1.8.
In situ ESWL for ureteric stones, being the least invasive procedure and which can be carried out with no need for anesthesia, is an attractive proposition. In association with stone disintegration, it can simultaneously relieve obstruction. Even when disintegration is partial after the session of ESWL, the obstruction is often relieved. In situ ESWL has been shown to be effective upto 81% for stones in all parts of the ureter., In the present series, the overall stone free rate of in situ ESWL for ureteric stones was 84.2%, no fragmentation in 5.26%, 2 cases lost to followup after one session (10.5% partial clearance) and there were no cases of sepsis or other significant complications afterward. Joshi et al showed 81 % sucess rate after in situ ESWL with no complications: almost equal with the present study.
Many complications have been reported after ESWL, including flank pain, urosepsis, slight hematuria and steinstrasse. These complications are less common after treatment using new generation lithotripters. In the present series, complications rate was 12.9%, including urosepsis (0.9%), gross hematuria (1.8%), ureteric colic (4.6%) and steinstrasse (5.55%). Most of the patients were managed conservatively except one patient who underwent JJ stenting and one who underwent URSL. As the newer generation of lithotripers have small focal areas, possible lung damage is minimized in case of children. In the present study, like that of Van Horn et al, no lung shielding was used and no haemoptysis was reported after treatment in children and adolescents. However, some authors still advocate lung shielding in small children (< 135 cms tall or < 30 kgs) with upper pole calculi.
In conclusion, ESWL is a safe option for treating adults and children with stone disease up to 2 cms. Irrespective of the make of lithotripter, the clearance rate was 75-97%. The stone free rate is influenced significantly by stone size, site, number and radiological features. JJ stents are not required routinely at the time of ESWL but if complication arise in form of infection JJ stenting may be required. Steinstrasse usually responds to conservative therapy but occasionally may require URSL or ESWL itself for big obstructing fragments. We recommend thorough radiological evaluation before management of urinary stones and in situ ESWL for ureteric stones.
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[Table - 1], [Table - 2], [Table - 3]