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Year : 2001  |  Volume : 18  |  Issue : 1  |  Page : 31-35

Augmentation of the success of extracorporeal shock wave lithotripsy for upper ureteral calculi after manipulation

KCP Nephro-Urology Center and Research Foundation, Pinnamaneni Poly Clinic and Department of Biochemistry, Siddhartha Medical College, University of Health Sciences, Vijayawada., India

Correspondence Address:
C Nageswara Rao
KCP Nephro-Urological Center and Research Foundation, Pinnamaneni Poly Clinic, Siddhartha Nagar, Vijayawada - 520 010
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Source of Support: None, Conflict of Interest: None

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Objective: To assess the efficacy of in situ ESWL in the treatment of neglected, long-standing upper ureteral calculi and to study whether or not manipulation and stenting followed by ESWL augments the success rate.
Patients and Methods: The study involves 54 solitar t upper ureteral stones, first treated in situ. Unresponsive stones were pushed back into the renal pelvis and the collecting system was stented, catheterized before subjecting the patients to ESWL again. Plain X-ray was done not earlier than 10 days after treatment to assess the stone status.
Results: Of the 54 stones, 36 (66.6 %) could be fragmented successfully with in situ ESWL. The remaining 18 were manipulated before another session of ESWL. Success for treatment of upper ureteral calculi was augmented from 66.6% after in situ ESWL to 96.2% after manipulating those 33.4% stones unresponsive to in situ ESWL. Although larger calculi (>1.6 cm) required manipulation, they were fragmented with exposure to lesser number of shock waves.
Conclusion: In situ ESWL is effective in stones < 1 crn. As the stone size increases, successful stone clearance demands manipulation prior to ESWL. As evident from our results, stones > 1.6 cm are better treated by ESWL after manipulation and stenting catheterization, as these are less likely to fragment in situ.

Keywords: Extracorporeal Shock Wave Lithotripsy; Upper Ureteral Calculi; Manipulated Calculi.

How to cite this article:
Rao C N, Khan S, Nadar D, Rao C S, Satyanarayana U. Augmentation of the success of extracorporeal shock wave lithotripsy for upper ureteral calculi after manipulation. Indian J Urol 2001;18:31-5

How to cite this URL:
Rao C N, Khan S, Nadar D, Rao C S, Satyanarayana U. Augmentation of the success of extracorporeal shock wave lithotripsy for upper ureteral calculi after manipulation. Indian J Urol [serial online] 2001 [cited 2023 Jan 30];18:31-5. Available from:

   Introduction Top

Extracorporeal shock wave lithotripsy (ESWL) is the treatment of choice for the majority of urinary tract stone.[1],[2],[3]he upper ureteral calculi is more difficult than for the stones situated in the renal pelvis or calyces. Urologists, therefore, prefer to treat these calculi by manipulation and stenting followed by ESWL.[4],[5],[6]

Recently, some workers have concluded that ESWL after manipulation has not significantly increased the stone free rate compared to in situ ESWL.[7],[8],[9],[10],[11],[12],[13] studies the stone size was around 1 cm or greater number of shock waves/treatment sessions and additional procedures were required.

Urologists in India and other developing countries encounter a different situation with regard to stone patients. Due to lack of financial resources, non-availability of medical facilities coupled with negligence, the calculi of patients in the developing countries, in general. are longstanding and therefore larger in size. In this communication, we report our experience in treating upper ureteral stones by ESWL and augmentation of the success rate after manipulation.

   Patients and Methods Top

We reviewed 54 solitary upper ureteral calculi treated on Medispec's Econolith 2000 Lithotripter at voltage ranging from 18-22 kV. There were 42 males and 12 females between 17 and 62 years of age. Upper ureter was considered as extending between the pelvi-ureteric junction and upper border of sacrum. The largest diameter (in cm) as seen on a plain X-ray was taken as the size of the stone in the study. Residual fragments < 4mm were considered insignificant and successfully fragmented.

Pretreatment evaluation of the urolithiasis patients revealed that majority of them (70.3%) had an obstructed renal collecting system. All the patients were treated under antibiotic cover.

The flow diagram [Figure] elaborates our study. Initially. all the 54 patients were subjected to in situ ESWL. Stone status was assessed after a period of 10 days by a plain X-ray. Stones that were fragmented either partially[7] or completely(29) constituted the in situ group. The partially fragmented 7 calculi were retreated in situ.

The remaining 18 calculi that did not respond to in situ ESWL were manipulated into the renal pelvis by flushing with saline mixed with lidocaine through a ureteral catheter under regional anaesthesia. These manipulated stones were dealt with as follows:

  • In 14 successful relocation in renal pelvis was followed by double-J stenting.
  • In 2, double-J stent bypass was possible, even though the pushback attempt failed.
  • In the remaining 2 pushback failures, a ureteral catheter was left upto the level of the stone through which saline irrigation was performed during ESWL.

All these 18 stones were again subjected to ESWL, and the stone status was assessed by plain X-ray, not earlier than 10 days after treatment.

There were 2 stones refractory to ESWL, one required percutaneous nephrostolithotomy and the other ureteroscopic extraction.

Student's `t' test was performed to evaluate the statistical significance between the two groups.

   Results Top

In situ ESWL group

At the end of 3 months, a success rate of 66.6% (36/54) was achieved after in situ ESWL for the upper ureteral calculi. Of these 36 calculi, 29 (80.5%) were fragmented in a single session [Table - 1], while 7 required retreatment. In 4 of these 36, insignificant residual fragments (4 mm) were observed.

Manipulated - ESWL group

In our study, 33.4% (18/54) cases needed manipulation before ESWL. 14 calculi could be successfully pushed back into the renal pelvis and all but one could be fragmented completely [Figure]. The exception was a result of lodging of the relocated stone in the lower calyx, and it had to be retrieved by percutaneous nephrostolithotomy.

The 2 calculi that were subjected to ESWL after ureteral catheterization and one among those bypassed, were successfully cleared. The remaining stone among the bypassed group, required ureteroscopic extraction as a big fragment failed to clear after retreatment and stent removal. The success achieved in manipulated group was 88.9% (16/18).

The total success achieved by ESWL for the upper ureteral calculi treated in situ and after manipulation put together was 96.2% (52/54).

The mean size of the calculi encountered and the number of shock waves required are given in [Table - 2]. The manipulated stones were significantly larger (P < 0.001) than those treated in situ, while the number of shock waves required for their fragmentation was significantly fewer (P < 0.01).

The stones < 1 can could be fragmented in a single session of in situ ESWL (i.e. 100% success). Out of the 28 calculi sized between 1.1 cm to 1.5 cm, 15 could be fragmented in a single session, 7 needed retreatment and 6 were manipulated before retreatment. Majority of the calculi > 1.6 cm (10/12) could be successfully fragmented, but after manipulation. Those refractory to ESWL even after manipulation were 2.0 cm and 2.1 cm in size [Table - 1].

   Discussion Top

The choice of treatment for urinary calculi depends upon the location, size and the chemical composition. along with efficacy of the modality employed and the associated morbidity, availability of equipment and expertise of the surgeon, days of hospitalization, patient's health, his preference and finally the cost.

ESWL is the treatment of choice for 80% of urinary calculi.[3] For the treatment of upper ureteral calculi success with in situ ESWL has been reported to be between 57-96% whereas that for manipulated stones is between 81-97%.[4],[8],[13],[14],[15],[16],[17] In our study, we could achieve a success of 66.6% by in situ ESWL. We must admit that if in situ retreatment were continued for the unresponsive calculi, the success achieved could have been a little higher.

Application of in situ ESWL for upper ureteral calculi results in attenuation of shock waves as they pass through the body tissue and bowel gas.[18],[19] Further, localization of stones in the ureter is difficult and impacted stones fragment poorly as the external mucosal contact keeps the fragments in place and creates multiple interfaces where the greater part of shock wave energy gets absorbed .[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] Therefore, the initial consensus on the treatment modality of the upper ureteral calculi was in favour of manipulation.

Mueller et al reported 62% success with in situ ESWL compared to 97% for the stones that were pushed back into the renal pelvis.[5] Some other reports also suggest better success with ESWL after manipulation.[3],[4],[5],[14],[15],[16] However, some workers did not find any significant difference in the stone free rate after manipulation compared to in situ ESWL.[7],[8],[9],[10],[11],[12],[13],[20]

We observed that with an increase in the size of the stone (≥ 1.1 cm), definite fragmentation may not be achieved in a single session of ESWL, some require a retreatment in situ, and a few after manipulation. Larger calculi (> 1.6 cm) if subjected to prior manipulation (followed by stenting / catherization of ureter), could be effectively fragmented by ESWL almost in a single session. In addition to the stone size, the hardness (calcium oxalate monohydrate, uric acid and cystine) of the calculi affects the success of fragmentation.[19] Due to incomplete data, we have not analysed the relation between chemical composition and success rate of ESWL. In any case, there was a substantial improvement in the success of ESWL for upper ureteral calculi from 66.6% with in situ to 96.2% after manipulation. There might exist a possibility that initial in situ ESWL (prior to manipulation) would have disimpacted the stones, which facilitated manipulation and fragmentation later. It must however be borne in mind that manipulation was performed only for those stones which were almost unresponsive to initial in situ ESWL.

We have observed the complete absence of residual fragments among the manipulated calculi, in contrast to 4 cases with residual fragments in the in situ group. Similar findings were reported by Kumar et al." It has been suggested 1that residual fragments show a regrowth of in between 20-70% in 1.5 to 3 years.[21]

   Conclusion Top

We have reported here that the upper ureteral calculi, particularly larger stones (≥1.6 cm) which were resistant to in situ ESWL could be manipulated and successfully fragmented. Since multiple sessions of in situ ESWL may not necessarily be successful and performing a more invasive procedure like percutaneous nephrostolithotomy or ureteroscopy is fraught with morbidity, the larger calculi could be conveniently dealt with by manipulation prior to ESWL. Our observations are very important and relevant in dealing with urolithiasis patients with larger upper ureteral calculi, frequently encountered in the developing countries.

   Acknowledgement Top

We are grateful to Dr. C. Sudha. Director, Pinnamaneni Poly Clinic, for her support during the study. We also wish to thank Mr. V.L. Dutt, Chairman, KCP Industries.

   References Top

1.SeguraJW, Preminger GM. Assimos DG et al. Ureteral stones: clinical guidelines panel summary report on the management of ureteral calculi. J Urol 1997: 158: 1915-1921.  Back to cited text no. 1    
2.Sin-al RK. Denstedt JD. Contemporary management of ureteral stones. Urol Clin North Am 1997; 24: 59-70.  Back to cited text no. 2    
3.Segura JW. The role of percutaneous surgery in renal and ureteral stone removal. J Urol 1989; 141: 780-781.  Back to cited text no. 3    
4.Riehle Jr RA, Nausland EB. Treatment of calculi in the upper ureter with extracorporeal shock wave lithotripsy. Surg Gynae Obstet 1987: 164:171.  Back to cited text no. 4    
5.Mueller SC, Willbert D, Thueroff JW Alken P. Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings. J Urol 1986; 135: 831-834.  Back to cited text no. 5    
6.Fetner CD. Preminger GM. Seger J. Lea TA. Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use centre. J Urol 1988: 139: 1192-1194.  Back to cited text no. 6    
7.Dawson C. Whitfield HN. The long-term results of treatment of urinary stones. Br J Urol 1994: 74: 397-404.  Back to cited text no. 7    
8.Danuser H, Ackerman DK. Marth DC, Studer UE. Zingg EJ. Extracorporeal shock wave lithotripsy in situ or after push-up for upper ureteral calculi: a prospective randomized trial. J Urol 1993: 150: 824-826.  Back to cited text no. 8    
9.Frabboni R, Santi V. Ronchi M et al. In situ echoguided extracotporeal shock wave lithotripsy of ureteric stones with the Dormer MPL 9000: a multicentric study group. Br J Urol 1994; 73: 487-493.  Back to cited text no. 9    
10.Cass AS. Do upper ureteral stones need to be manipulated (pushback) into the kidneys before extracorporeal shock wave lithotripsy? J Urol 1992; 147: 349-351.  Back to cited text no. 10    
11.Holden D, Rao PN. Ureteral stones: the results of primary in situ extracorporeal shock wave lithotripsy. J Urol 1989; 142: 37-39.  Back to cited text no. 11    
12.Kumar A. Kumar RV. Mishra VK et al. Should upper ureteral calculi be manipulated before extracorporeal shock wave lithotripsy? A prospective controlled trial. J Urol 1994; 152: 320-323.  Back to cited text no. 12    
13.Mobley TB, Myers DA. Jenkins J Mck, Grine WB, Jordan WR. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18,825 calculi using the lithostar lithotriptor. J Urol 1994: 152: 53-56.  Back to cited text no. 13    
14.Liong ML. Clayman RV, Gittes RF et al. Treatment options for proximal ureteral urolithiasis: review and recommendations. J Urol 1989; 141: 504-509.  Back to cited text no. 14    
15.Parr NJ, Pye SD. Ritchie AWS, Tolley DA. Mechanisms responsible for diminished fragmentation of ureteral calculi: an experimental and clinical study. J Urol 1992; 148: 1079-1083.  Back to cited text no. 15    
16.Rasweiler J, Lutz K. Gumpinger R, Eisenberger F. Efficacy of in situ extracorporeal shock wave lithotripsy for upper ureteral calculi. Fur Urol 1986: 12: 377.  Back to cited text no. 16    
17.GraffJ. PastorJ. Funke PJ. Mach P, Senee TH. Extracorporeal shock wave lithotripsy for ureteral stones: a retrospective analysis of 417 cases. J Urol 1988; 139: 513-516.  Back to cited text no. 17    
18.Eisenberger F. Schmidt AS. Extracorporeal shock wave lithotripsy. Curr Opin Urol 1993; 3: 309-312.  Back to cited text no. 18    
19.Vallancien G, Aviles J. Munoz R et al. Piezoelectric extracorporeal lithotripsy by ultra-short waves with EDAP LT 01 device. J Urol 1988: 139: 689-694.  Back to cited text no. 19    
20.Tiselius HG. Anaesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones. J Urol 1991: 146: 8-12.  Back to cited text no. 20    
21.Kohrmann KU, Raasweiler J, Alken P. The recurrence rate of stones following ESWL. World J Urol 1993; 11: 26-30.  Back to cited text no. 21    


  [Figure - 1]

  [Table - 1], [Table - 2]


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