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ORIGINAL ARTICLE
Year : 2006  |  Volume : 22  |  Issue : 2  |  Page : 122-124
 

Is shock wave lithotripsy safe in bleeding diathesis?


Department of Urology, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu, India

Correspondence Address:
G Gopalakrishnan
Professor & Head of Urology-II, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.26565

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   Abstract 

OBJECTIVE: To assess the safety of shock wave lithotripsy (SWL) in treatment of urinary calculi, in patients with bleeding diathesis. MATERIALS AND METHODS: From 1996 to 2004, seven patients with bleeding diathesis were treated by SWL for urolithiasis. Change of oral anticoagulants to heparin (low molecular heparin) and substitution of deficient coagulation factors was done on the day of treatment. RESULTS: Two out of seven patients had mild hematuria, which settled within 48 hours. None of them required transfusion. Six out of seven were stone-free at one month. None of them required any secondary procedure. CONCLUSION: SWL is a safe method for the treatment of urolithiasis in patients with bleeding diathesis, provided deficient coagulation factors are corrected.


Keywords: Bleeding diathesis, lithotripsy, urolithiasis


How to cite this article:
Adhikary S, Devasia A, Gnanaraj L, Chacko K N, Kekre N, Gopalakrishnan G. Is shock wave lithotripsy safe in bleeding diathesis?. Indian J Urol 2006;22:122-4

How to cite this URL:
Adhikary S, Devasia A, Gnanaraj L, Chacko K N, Kekre N, Gopalakrishnan G. Is shock wave lithotripsy safe in bleeding diathesis?. Indian J Urol [serial online] 2006 [cited 2019 Jun 18];22:122-4. Available from: http://www.indianjurol.com/text.asp?2006/22/2/122/26565



   Introduction Top


Since its introduction by Chaussy and associates in 1980, SWL has been proven to be a safe, effective, non-invasive and preferred method of treatment for patients with upper tract urolithiasis.[1] Though the risks of this procedure are relatively less, the potential for perirenal or intrarenal hemorrhage is well known.[2],[3],[4] Routine post-SWL imaging by CT and MRI has revealed perirenal or intrarenal hemorrhage in 20-25% of cases.[5],[6],[7] Hence, in the setting of deranged bleeding parameters, SWL has been considered to be a relative contraindication. We review our experience with SWL, in the treatment of 6 patients with altered coagulation profile.


   Materials and Methods Top


A total of 5 men and 2 women with history of bleeding diathesis or on oral anticoagulants underwent SWL for upper urinary tract calculi. All patients were symptomatic, with stone sizes between 8 mm to 35 mm in diameter. SWL was accomplished with the patient under intravenous sedation, using Dornier Compact S lithotripter. All patients were treated as inpatients and observed clinically as well as with serial hematocrit. Post- treatment imaging was not performed routinely, but for our first patient. It was decided to keep the patient hospitalized and to decide if imaging would be needed. Details of the individual patients are furnished below.

Case 1: A 25-year-old lady with von Willebrand's disease was found on evaluation, to have a 7 x 5 mm calculus in right lower calyx. Her bleeding parameters were deranged (APTT Patient 70/ Control 44, BT 13, VIII 12%). This was corrected with 10 units of cryoprecipitate before lithotripsy and 5 units twice a day for 5 days after SWL. She was given 1750 shocks at 14 KV in one session. She passed all the fragments spontaneously. Postoperative MRI did not show any perinephric hematoma.

Case 2: A 39-year-old lady with diagnosis of idiopathic thrombocytopenic purpura and solitary right kidney, presented with a 17 x 12 mm calculus in the renal pelvis. She underwent splenectomy and was put on prednisolone 40 mg OD and azathioprine 100 mg, once daily. After platelet counts had normalized (>60000), she underwent SWL after stenting. She was given 7000 shocks at 14 KV in 3 sessions. She passed all fragments without any complication.

Case 3: A 53 year old male had mitral valve replacement and was on warfarin. He was found to have 30 x 25 mm and 35 x 30 mm calculi in right upper and lower calyx, respectively. Warfarin was stopped 48 hours prior to SWL. He was put on Heparin 5000 units, 6 hourly. At the INR of 1.5, 15000 shocks in 5 sessions to the upper calyceal calculus and 17,500 shocks in 6 sessions to the lower calyceal calculus, were given over a period of 6 months with infective endocarditis prophylaxis. No hemorrhagic complications were noticed. One residual fragment of 6 x 5 mm was left. He did not require any secondary procedures.

Case 4: A 42 year old male on warfarin following mitral valve replacement, was found to have 15 x 12 mm and 8 mm calculi in left middle and lower calyces, respectively. Warfarin was stopped 48 hours before SWL; he was heparinised. At an INR of 1.5, 12000 shocks at 14 KV were given in 3 sessions, with infective endocarditis prophylaxis. No hemorrhagic complications observed. Total stone clearance was achieved.

Case 5: A 70-year-old male with ischemic heart disease on aspirin, had a 12 x 8 mm right upper ureteric calculus [Figure - 1]. He was put on low molecular weight heparin. At the INR of 1.16, 12000 shocks at 14 KV were given over 4 sessions. He had mild hematuria after the first session. He passed all the fragments spontaneously without any complications and total stone clearance was achieved.

Case 6: A 57 years old male with cirrhosis and portal hypertension, had bilateral ureteric calculus (right 10 x 8 mm, left 18 x 10 mm) [Figure - 2]. Bleeding parameters were deranged with prothrombin time: Patient 15.2 Control: 10.5, APTT: Patient 88; Control 28, INR 1.46 and a platelet count of 58,000. Vit.K was given 10 mg once daily for 3 days and SWL was covered with 4 units of fresh frozen plasma. 3500 shocks were given at 15 KV to the right upper ureteric calculus, with no untoward effect. It was decided to treat the left ureteric calculi with ureteroscopy, as it was 18 mm in size. He did have persistent hematuria following the ureteroscopy, which was managed with platelet transfusion and fresh frozen plasma.

Case 7: A 39 year old male with hemophilia A was found to have 2 calculi (16 mm and 11 mm) in right renal pelvis and lower pole calyx, respectively [Figure - 3]. His bleeding parameters were deranged (Factor VIII < 1%, APTT patient 54/ control 28). Factor VIII was corrected by giving 50 units / kg to achieve a factor level of 80-100%. On the day of SWL, the levels achieved were > 100%. Postprocedure factors were given to maintain a level between 60-80%. 6000 shocks were given in 4 sessions. He passed all the fragments spontaneously without any problem. Post SWL, CT scan did not reveal any perinephric or intrarenal hematoma [Figure - 4].


   Results Top


We performed a total of 27 SWL sessions in 7 patients. Deficient coagulation factors were substituted. Two out of seven patients developed mild hematuria, which settled within 48 hours. None of them required blood transfusion. All, but one patient (case 3) was stone free at one month. None of them required a secondary procedure. Case no. 1 had post procedure MRI. That didn't show any collection or perinephric hematoma. Other patients were observed clinically and did not warrant post- procedure imaging.


   Discussion Top


Development of perirenal or intrarenal hemorrhage following SWL, is a frequent observation in those with normal bleeding parameters.[3] The incidence of clinically significant bleeding is less than 1%.[2],[3],[4] Routine imaging with ultrasound, CT scan and MRI has confirmed perirenal and intrarenal hemorrhage in 20-25% of patients.[5],[6],[7] The presence of bleeding diathesis has therefore been considered as a relative contraindication to SWL. There have been reports of nephrectomy following SWL.[8] Alvarez and associates reported hypovolemic shock resulting from an extensive perirenal hematoma.[9] These reports taken together, support the concept that SWL is potentially risky in the setting of bleeding diathesis. On the contrary, there are reports of successful use of SWL in known hemophiliacs after specific therapy with infusion of anti-hemophiliac factor.[9],[10],[11] Ruiz Marcellan et al have reported successful use of SWL in 17 patients with coagulation disorders, after instituting hemotherapy for blood factor deficiencies.[12] We believe that these later case reports coupled with the data presented in this series, support the use of SWL in selected patients with correctable bleeding diathesis. All cases are managed conjointly with the hematology department. Since the cases presented are a mixed bag, it is difficult to suggest guidelines. However, depending on the nature of the disorder, we suggest the following line of treatment. In patients with von Willebrand's disease, one should aim to maintain a factor VIII level of > 70%; in those with hemophilia A, the Factor VIII level 80-100%, in ITP, a platelet count of 60000 should be safe. Fore those on oral anticoagulants, we aim to achieve an INR of < 1.5.


   Conclusion Top


SWL is a safe method of treatment of urolithiasis in patients with bleeding diathesis, provided the deficient coagulation factors are substituted. These procedures should be undertaken in the setting of a tertiary care institution, with an active hematological service and support of various blood products.

 
   References Top

1.Chaussy C, Schmiedt E. Extracorporeal Shock Wave Lithotripsy (ESWL) for kidney stones. An alternative to surgery? Urol Radiol 1984;6:80-7.  Back to cited text no. 1  [PUBMED]  
2.Drach GW. Dretler S, Fair W, Finlayson B, Gillenwater J, Griffith D, et al . Report of the United States cooperative study of extracorporeal shock wave Lithotripsy. J Urol 1986;135:1127-33.  Back to cited text no. 2    
3.Knapp PM, Kulb TB, Lingeman JE, Newman DM, Mertz JH, Mosbaugh PG, et al . Extracorporeal shock wave Lithotripsy-induced perirenal hematomas. J Urol 1988;39:700-3.  Back to cited text no. 3    
4.Coptcoat MJ, Webb DR, Kellett MJ, Fletcher MS, McNicholas TA, Dickinson IK, et al . The complications of extracorporeal shockwave Lithotripsy: Management and prevention. Br J Urol 1986;58:578-80.  Back to cited text no. 4    
5.Rubin JI, Arger PH, Pollack HM, Banner MP, Coleman BG, Mintz MC, et al . Kidney changes after extracorporeal shock wave Lithotripsy: CT evaluation. Radiology 1987;162:21-4.  Back to cited text no. 5    
6.Baumgartner BR, Dickey KW, Ambrose SS, Walton KN, Nelson RC, Bernardino ME. Kidney changes after extracorporeal shock wave Lithotripsy: Appearance on MR imaging. Radiology 1987;163:531-4.   Back to cited text no. 6  [PUBMED]  
7.Kaude JV, Williams CM, Millner MR, Scott KN, Finlayson B. Renal morphology and function immediately after extracorporeal shock wave Lithotripsy. Am J Roentgenol 1985;145:305-13.  Back to cited text no. 7  [PUBMED]  
8.Donahue LA, Linke CA, Rowe JM. Renal loss following extracorporeal shock wave Lithotripsy. J Urol 1989;142:809-11.  Back to cited text no. 8  [PUBMED]  
9.Alvarez JA, Gandia VM, Alted EJ, Cantalapiedra JA, Blasco MA, Nunnez A. Extracorporeal shock wave Lithotripsy in a patient with mild hemophilia. Letter to the Editor. New Eng J Med 1986;315:648-9.  Back to cited text no. 9    
10.Partney KL, Hollingsworth RL, Jordan WR, Beckham D, May CR. Hemophilia and extracorporeal shock wave Lithotripsy: A case report. J Urol 1987;138:393-4.  Back to cited text no. 10  [PUBMED]  
11.Czapilcki M, Jakubezyk T, Judycki J, Borkowski A, Misiae A, Szalecki P. ESWL in hemophiliac patients. Eur Urol 2000;38:302-5.  Back to cited text no. 11    
12.Ruiz Marcellan FJ, Mauri Cunill A, Cabre Fabre P, Argentino Gancedo Rodriguez V, Guell Oliva JA, Ibarz Servio L, et al . Extracorporeal shockwave lithotripsy in patients with coagulation disorders: Rev Arch Esp Urol 1992;45:135-7.  Back to cited text no. 12    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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    Abstract
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    Materials and Me...
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