Effect of low-energy shock wave therapy on intravesical epirubicin delivery in a rat model of bladder cancer.

OBJECTIVES: To study the efficacy of low-energy shock wave therapy (LESW) on enhancing intravesical epirubicin (EPI) delivery in a rat model of bladder cancer (BCa). MATERIALS AND METHODS: A total of 100 female Fischer rats were randomly allocated into five groups: control; BCa; LESW; EPI; and EPI plus LESW. After BCa induction by N-butyl-N-(4-hydroxybutyl)nitrosamine, EPI (0.6 mg/0.3 mL of EPI diluted in 0.3 mL saline) or saline (0.6 mL) was administered and retained in the bladders for 1 h with or without LESW treatment (300 pulses at 0.12 mJ/mm2 ). This was repeated weekly for 6 weeks. Survival was then calculated, rats were weighed and their bladders were harvested for bladder/body ratio estimation, histopathological examination, p53 immunostaining, miR-210, hypoxia-inducible factor (HIF)-1α, tumour necrosis factor (TNF)-α and interleukin (IL)-6 relative gene expression and fluorescence spectrophotometric drug quantification. Heart and blood samples were also collected for assessment of the safety profile and toxicity. RESULTS: The EPI plus LESW group had significantly lower mortality rates, loss of body weight and bladder/body ratio. Histopathological results in terms of grossly visible bladder lesions, mucosal thickness, dysplasia formation and tumour invasion were significantly better in the combined treatment group. The EPI plus LESW group also had statistically significant lower expression levels of p53 , miR-210, HIF-1α, TNF-α and IL-6. LESW increased urothelial concentration of EPI by 5.7-fold (P < 0.001). No laboratory variable exceeded the reference ranges in any of the groups. There was an improvement of the indicators of EPI-induced cardiomyopathy in terms of congestion, hyalinization and microvesicular steatosis of cardiomyocytes (P = 0.068, 0.003 and 0.046, respectively) in the EPI plus LESW group. CONCLUSIONS: The combined use of intravesical EPI and LESW results in less BCa invasion and less dysplasia formation, as LESW increases urothelial permeability of EPI and enhances its delivery into tumour tissues, without subsequent toxicity.

The alternating bidirectional versus the standard approach during shock wave lithotripsy for upper lumbar ureteric stones: a randomized controlled trial.

PURPOSE: To compare the outcome of shock wave lithotripsy (SWL) for upper lumbar ureteric stones using the alternating bidirectional approach versus the standard approach during the first session. METHODS: Our study was a randomized controlled trial including patients with single radio-opaque stone < 1 cm located in the upper lumbar ureter (from the ureteropelvic junction till the level medial to the lower margin of the kidney). SWL was conducted using electromagnetic Dornier Gemini Lithotripter. In group 1, patients were treated with the alternating under and over-table approach during the first session only and if other sessions were needed, the standard under-table approach was used. In group 2, patients were treated with the standard under-table approach during all sessions. Stone disintegration after the first session was assessed by kidney-ureter-bladder X-ray, renal ultrasonography and noncontrast computed tomography. Moreover, the incidence and severity of postoperative complications were evaluated. RESULTS: Forty-eight patients in each group completed the study. Patient demographics and stone characteristics were comparable in both groups. Complete disintegration was achieved in 41.7% of patients in group 1 versus 18.8% in group 2 (P = 0.021). Stone-free rate (SFR) was 58.3% and 20.8% in group 1 and 2 respectively (P = 0.001). The mean session time was 56.42 min in group 1 versus 46.35 min in group 2 (P < 0.001). There was no significant difference in postoperative complications. CONCLUSION: Stone disintegration and SFR after the first SWL session are higher when using the alternating bidirectional approach for upper lumbar ureteric stones at the expense of longer procedural duration. TRIAL REGISTRATION: ClinicalTrials identifier (ID: NCT03243682), clinicaltrials.gov.

Optimal non-invasive treatment of 1-2.5 cm radiolucent renal stones: oral dissolution therapy, shock wave lithotripsy or combined treatment-a randomized controlled trial.

PURPOSE: To evaluate the efficacy of oral dissolution therapy (ODT), shock wave lithotripsy (SWL), and combined SWL and ODT for medium-sized radiolucent renal stone (RLS). METHODS: A randomized controlled trial for patients with medium-sized RLS, 1-2.5 cm, ≤ 500 Hounsfield unit (HU). The ODT patients were counseled for oral potassiumsodium-hydrogen citrate (Uralyt-U®). The 2nd group underwent SWL and the last group had combined SWL and ODT. The primary outcome, stone-free rate (SFR) at 3 months, was assessed by non-contrast computed tomography (NCCT). We defined complete response (success) if no residual fragment were detected by NCCT; partial response (failure) if there was a decrease in stone size, but presence of residual stones; no response if there was no change or increase in stone size (failure). RESULTS: 150 patients completed follow-up. The SFR at 1st month and 3rd month were, respectively; 16% and 50% in the ODT group, 10% and 46% in the SWL group, and 35% and 72% patients in combined group with (p = 0.03 and 0.003, respectively. The overall SFR for all groups was 66%. Combined treatment and initial response in first month follow-up were independent factors predicting SFR. In addition, combined treatment significantly decreased the overall stone volume (p = 0.03) and the need for additional stone management procedures after 3 months (p = 0.01). CONCLUSION: Combined ODT and SWL treatment constitutes the most rapid and effective therapeutic approach for medium-sized RLS, decreasing overall stone volume as well as the number of SWL sessions needed in comparison to SWL therapy, alone.

Shock wave lithotripsy versus endoscopic cystolitholapaxy in the management of patients presenting with calcular acute urinary retention: a randomised controlled trial.

PURPOSE: Shock wave lithotripsy (SWL) in treatment of bladder and urethral stones was not precisely determined. The objective of this study is to compare the efficacy and safety of SWL versus visual cystolitholapaxy in the management of calcular acute urine retention. METHODS: From March 2015 to February 2017, a randomised controlled study was conducted on 100 patients for whom urethral catheter fixed for acute retention of urine due to urethral or vesical radio-opaque stone(s) ≤ 2 cm. Patients were randomised to either SWL group (n = 50) or visual cystolitholapaxy (endoscopy group) (n = 50). RESULTS: No statistically significant differences between the pre-operative parameters of both groups were found. The mean stone diameter was 12.2 ± 3 mm and 12.2 ± 3.2 mm in SWL and endoscopy groups, respectively (p value = 0.4). The overall success rates of SWL group were 94% (47 of 50 patients) and endoscopy group were 98% (49 of 50 patients). SWL failed in 3 patients (6%); these 3 patients underwent cystolitholapaxy and were rendered free of stones. Intra-operative and post-operative complications were comparable between both groups (p value = 0.5 and 1, respectively). One patient had bladder perforation in the endoscopy group and was managed conservatively. CONCLUSIONS: SWL mono-therapy is safe, non-invasive and as effective as visual cystolitholapaxy in management of patients presenting with acute urine retention by vesical or urethral stones 2 cm or less and could be useful for patients unwilling/unfit for general anaesthesia.

A randomised controlled trial evaluating renal protective effects of selenium with vitamins A, C, E, verapamil, and losartan against extracorporeal shockwave lithotripsy-induced renal injury.

OBJECTIVE: To evaluate the protective effects of selenium with vitamins A, C and E (selenium ACE, i.e. antioxidants), verapamil (calcium channel blocker), and losartan (angiotensin receptor blocker) against extracorporeal shockwave lithotripsy (ESWL)-induced renal injury. PATIENTS AND METHODS: A randomised controlled trial was conducted between August 2012 and February 2015. Inclusion criteria were adult patients with a single renal stone (<2 cm) suitable for ESWL. Patients with diabetes, hypertension, congenital renal anomalies, moderate or marked hydronephrosis, or preoperative albuminuria (>300 mg/L) were excluded. ESWL was performed using the electromagnetic DoLiS lithotripter. Eligible patients were randomised into one of four groups using sealed closed envelopes: Group1, control; Group 2, selenium ACE; Group 3, losartan; and Group 4, verapamil. Albuminuria and urinary neutrophil gelatinase-associated lipocalin (uNGAL) were estimated after 2-4 h and 1 week after ESWL. The primary outcome was differences between albuminuria and uNGAL. Dynamic contrast-enhanced magnetic resonance imaging was performed before ESWL, and at 2-4 h and 1 week after ESWL to compare changes in renal perfusion. RESULTS: Of 329 patients assessed for eligibility, the final analysis comprised 160 patients (40 in each group). Losartan was the only medication that showed significantly lower levels of albuminuria after 1 week (P < 0.001). For perfusion changes, there was a statistically significant decrease in the renal perfusion in patients with obstructed kidneys in comparison to before ESWL (P = 0.003). These significant changes were present in the control or antioxidant group, whilst in the losartan and verapamil groups renal perfusion was not significantly decreased. CONCLUSIONS: Losartan was found to protect the kidney against ESWL-induced renal injury by significantly decreasing post-ESWL albuminuria. Verapamil and losartan maintained renal perfusion in patients with post-ESWL renal obstruction.

Evaluation of acute post-shock wave lithotripsy renal changes by dynamic magnetic resonance imaging: a prospective clinical study.

PURPOSE: We studied acute renal morphological and hemodynamic changes after shock wave lithotripsy of renal stones. MATERIALS AND METHODS: A total of 60 adult patients with a single renal stone 25 mm or less in a radiologically normal urinary tract were eligible for shock wave lithotripsy and included in analysis. Study exclusion criteria were hypertension, diabetes mellitus, previous recent stone management and other contraindications to shock wave lithotripsy. Renal perfusion and morphological changes were evaluated by dynamic magnetic resonance imaging before, and 2 to 4 hours and 1 week after lithotripsy. RESULTS: In all cases there was a statistically significant decrease in renal perfusion 1 week after shock wave lithotripsy compared to before and 2 to 4 hours after lithotripsy (66% vs 71% and 72% of the aortic blood flow, respectively, p <0.05). At 1-week followup 39 unobstructed renal units (65%) showed no significant difference in renal perfusion at any time while 21 (35%) obstructed renal units showed a significant decrease in renal perfusion compared to before and 2 to 4 hours after lithotripsy (63% vs 76% and 75%, p = 0.003 and 0.005, respectively). Hematomas were observed in 7 cases (12%) 2 to 4 hours after lithotripsy, of which 5 were subcapsular and 2 were intrarenal. Three subcapsular hematomas resolved after 1 week. Localized loss of corticomedullary differentiation was observed in 2 patients (3.3%) with intrarenal hematoma 2 to 4 hours after treatment. Generalized loss of corticomedullary differentiation was observed 1 week after lithotripsy in 5 cases (8.3%). CONCLUSIONS: Shock wave lithotripsy alone induces minimal, reversible acute renal morphological changes and does not induce significant changes in renal perfusion. Posttreatment obstruction has a major effect on renal perfusion on the treated side and must be managed urgently.

A randomized controlled trial evaluating low-intensity shockwave therapy for treatment of persistent storage symptoms following transurethral surgery for benign prostatic obstruction.

BACKGROUND: Low-intensity shockwave therapy (Li-SWT) can improve bladder function through enhancement of angiogenesis and nerve regeneration and suppression of inflammation and overactivity. In this trial, we aimed to evaluate the efficacy of Li-SWT on persistent storage symptoms after transurethral surgery (TUS) for benign prostatic obstruction (BPO). METHODS: Between July 2020 and July 2022, 137 patients with persistent storage symptoms; urgency episodes/24 h ≥ 1 and daytime frequency ≥8, for at least three months after TUS for BPO were randomly allocated to Li-SWT versus sham versus solifenacin 10 mg/day in 3:1:1 ratio. The primary end point was the percent reduction from baseline in overactive bladder symptom score (OABSS) at 3-month follow-up. The changes in 3-day voiding diary parameters, quality of life (QoL) score, peak flow rate and residual urine at 3 and 6-month follow-up were compared. Treatment-related adverse effects were also evaluated. RESULTS: Baseline data were comparable between groups. The percent reduction from baseline in OABSS at 3-month follow-up was significantly higher in Li-SWT compared to sham (-55% versus -11%), and it was comparable between Li-SWT and solifenacin-10 (-55% versus -60%). Li-SWT achieved significant improvement like solifenacin-10 in 3-day voiding diary parameters and QoL score at 3-month follow-up. This improvement remained comparable between Li-SWT and solifenacin-10 at 6-month follow-up. No adverse effects related to Li-SWT were noted apart from tolerable pain during the procedure. Solifenacin-10 was associated with bothersome adverse effects in 73% of the patients with 11.5% discontinuation rate. CONCLUSIONS: Li-SWT ameliorates persistent storage symptoms and promotes QoL after TUS for BPO, with comparable efficacy and better tolerance compared to solifenacin.

Are there long-term effects of extracorporeal shockwave lithotripsy in paediatric patients?

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Extracorporeal shockwave lithotripsy is effective for the treatment of paediatric renal stones with favourable short-term safety. Extracorporeal shockwave lithotripsy for treatment of paediatric renal stones is also safe for the kidney and the child on long-term follow-up. OBJECTIVE: To evaluate the long-term effects of extracoporeal shockwave lithotripsy (SWL) for treatment of renal stones in paediatric patients. PATIENTS AND METHODS: A database of paediatric patients who underwent SWL monotherapy for treatment of renal stones from September 1990 through to January 2009 was compiled. This study included only patients with follow-up for more than 2 years. The long-term effects of SWL were evaluated at the last follow-up with measurement of patients' arterial blood pressure, estimation of random blood sugar and urine analysis. The results of diastolic blood pressure were plotted against a standardized age reference curve. The treated kidney was examined by ultrasonography for measurement of renal length and detection of stones. The measured renal lengths were plotted against age-calculated normal renal lengths in healthy individuals. RESULTS: The study included 70 patients (44 boys (63%) and 26 girls) with mean age at the time of SWL 6.5 ± 3.6 years (range 1-14). The mean follow-up period was 5.2 ± 3.6 years (range 2.1-17.5). The mean age at last follow-up was 11.7 ± 5.3 years (range 4.4-27.5). No patients developed hypertension or diabetes. Only one treated kidney was smaller than one standard deviation of the calculated length. The cause of this was obstruction by a stone in the pelvic ureter 3 years after SWL. CONCLUSION: The long-term follow-up after SWL for treatment of renal stones in paediatric patients showed no effect on renal growth and no development of hypertension or diabetes.

Extracorporeal shockwave lithotripsy for renal stones in pediatric patients: a multivariate analysis model for estimating the stone-free probability.

OBJECTIVES: To define factors affecting the stone-free rate of extracorporeal shockwave lithotripsy in the treatment of pediatric renal calculi, and to establish a regression model for pretreatment prediction of stone-free probability. METHODS: From January 1999 through February 2012, 207 children with mean age 6.4 ± 3.8 years underwent shockwave lithotripsy with Dornier Lithotripter S for treatment of renal stones. The stone-free rate was evaluated 3 months after the last shockwave lithotripsy session with non-contrast computed tomography. Treatment success was defined as complete clearance of the stones with no residual fragments. Multivariate logistic regression analysis was used to identify independent risk factors and to predict the probability of being stone free. RESULTS: The mean length of the stone was 11.6 ± 4 mm. The stone-free rate was 71%. Independent factors that adversely affect stone-free rate were increasing stone length and calyceal site of the stone. Relative risks for not being free of stones were 1.123 for stone length, 2.673 for stones in the upper or middle calyx and 4.208 for lower calyx stones. CONCLUSION: Stone length and location are prognostic factors determining stone-free rate after shockwave lithotripsy for renal calculi in pediatric patients. Based on our analysis, shockwave lithotripsy should be recommended for renal pelvis stones up to 24 mm, upper or middle calyceal stones up to 15 mm and lower calyceal stones up to 11 mm.

The Ideal Interval Between Repeated Shockwaves Lithotripsy Sessions for Renal Stones: A Randomized Controlled Trial.

Objectives: To assess the ideal interval between repeated extracorporeal shockwave lithotripsy (SWL) for renal stones. Patient and Methods: Eligible patients with a single renal stone ≤20 mm who required SWL were randomly assigned to one of three groups based on intervals between first and second sessions. Patients underwent the second session after 3, 7, and 14 days in Groups 1, 2, and 3, respectively. Tubular functions were assessed through comparisons of urinary execration of kidney injury molecule-1 (KIM-1), neutrophil gelatinase associated lipocalin (NGAL), and interleukin-18 (IL-18) with pre-SWL values, whereas glomerular function was assessed by comparisons of protein/creatinine ratio with pre-SWL and changes in ipsilateral renal function on isotope scans. Treatment success was assessed by noncontrast CT after 3 months. Results: All demographics of the 166 patients included in the study were comparable between the three groups. There were significant elevations of tubular biomarkers and protein/creatinine ratio after first and second SWL sessions compared with pre-SWL values (p < 0.0001). All tubular biomarkers returned to pre-SWL values at 7 and 14 days after second session, whereas they remained significantly elevated 3 days after second session (p = 0.027, < 0.001 and <0.001 for KIM-1, NGAL, and IL-18, respectively). SWL success was 73.6% in Group 1, 83.7% in Group 2, and 81% in Group 3. A significant decrease in ipsilateral renal split function was observed in Group 1 at the 3-month follow-up. Conclusions: An interval of 7 days is required between SWL sessions when treating renal stones to allow for complete recovery of kidney functions. Clinical Trial Registration: ID: NCT04575480.

Flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for treatment of lower pole stones of 10-20 mm.

UNLABELLED: What's known on the subject? and What does the study add? Shock wave lithotripsy and flexible ureterorenoscopy are acceptable treatment options for lower pole stones smaller than 10 mm, while percutaneous nephrolithotomy is the favoured treatment for stones larger than 20 mm. For treatment of lower pole stones of 10-20 mm, flexible ureterorenoscopy has a significantly higher stone-free rate and lower retreatment rate than shock wave lithotripsy. OBJECTIVE: To compare the outcomes of flexible ureterorenoscopy (F-URS) and extracorporeal shock wave lithotripsy (ESWL) for treatment of lower pole stones of 10-20 mm. PATIENTS AND METHODS: The database of patients with a single lower pole stone of 10-20 mm was examined to obtain two matched groups who were treated with F-URS or ESWL. Matching criteria were stone length, side and patient gender. Stone-free rates were evaluated 3 months after the last treatment session by non-contrast computed tomography. Both groups were compared for retreatment rate, complications and stone-free rate. RESULTS: The matched groups included 37 patients who underwent F-URS and 62 patients who underwent ESWL. Retreatment rate was significantly higher for ESWL (60% vs 8%, P < 0.001). Complications were more after F-URS (13.5% vs 4.8%), but the difference was not significant (P= 0.146). All complications were grade II or IIIa on modified Clavien classification. The stone-free rate was significantly better after F-URS (86.5% vs 67.7%, P= 0.038). One failure of F-URS (2.7%) and five failures (8%) of ESWL were treated with percutaneous nephrolithotomy. Significant residual fragments in three patients (8%) after F-URS were treated with ESWL, while significant residual fragments after ESWL in five patients (8%) were treated with F-URS. Residual fragments (<4 mm) were followed every 3 months in one patient (2.7%) after F-URS and in 10 patients (16%) after ESWL. CONCLUSIONS: For treatment of lower pole stones of 10-20 mm, F-URS provided significantly higher stone-free rate and lower retreatment rate compared with ESWL. The incidence of complications after F-URS was not significantly more than after ESWL.

Validation of the Arabic linguistic version of the Danish Prostatic Symptom Score for benign prostatic hyperplasia associated with lower urinary tract symptoms.

Objective: To validate an Arabic version of the Danish Prostatic Symptom Score (DAN-PSS), a self-administered quality-of-life questionnaire. Patients and methods: The reliability of the Arabic DAN-PSS was assessed by determining the internal consistency (Cronbach's α coefficient) and by assessing the test-retest reliability (Kappa [κ] test). Inter-domain associations were examined using Spearman's correlation coefficient (r). The discrimination validity was evaluated using receiver operating characteristic (ROC) curves. The sensitivity to change of the questionnaire and its individual items was assessed before and after intervention using a paired t-test. Results: In all, 106 men (55 patients with BPH and 51 without BPH symptoms) were included. A high level of internal consistency amongst the three domains of the answered Arabic DAN-PSS questionnaire was observed (Cronbach's α > 0.70). Also, there was a good correlation between storage and voiding (r = 0.75; P < 0.001) and post-micturition symptoms domains (r = 0.51; P < 0.001). Voiding and post-micturition symptoms domains also had a good correlation (r = 0.51; P < 0.001). The agreement between the test and retest scores had a κ value of 0.83 (P < 0.001). The ROC curve had an area under the curve of 0.98. The sensitivity to change comparing patients with BPH who received medical or surgical intervention revealed Arabic DAN-PSS mean (SD) scores of 34.7 (17.7) and 17 (8.7) before and after the intervention, respectively (P < 0.001). Conclusion: The Arabic DAN-PSS is a clear questionnaire, valid, reliable, and responsive that can be used for BPH associated with lower urinary tract symptoms assessment and follow-up in clinical practice and research in Arabic-speaking patients. Abbreviations: AUC: area under the curve; BPH: benign prostatic hyperplasia; CI: confidence interval; DAN-PSS: Danish Prostatic Symptom Score; DRE: digital rectal examination; ICIQ-MLUTS: International Consultation on Incontinence Male LUTS Questionnaire; ICS: international continence society; IPSS: international Prostatic Symptom Score; IPSS-Arb: Arabic version of the IPSS; LUTS: lower urinary tract symptoms; PSA: prostatic specific antigen; PSS: prostatic symptom score; QoL: quality of life; ROC: receiver operating characteristic; UTI: urinary tract infection.

Preoperative risk factors for complications of percutaneous nephrolithotomy.

This study was conducted to evaluate preoperative risk factors for development of complications of percutaneous nephrolithotomy (PCNL). All consecutive patients aged ≥ 16 years who underwent PCNL during 2015 were retrospectively reviewed. Non-contrast CT (NCCT) was performed for all patients to evaluate stone complexity. The technique of PCNL was the same for all patients. Intra-operative and postoperative complications were recorded and classified based on modified Clavien system. The differences in preoperative data (patients, renal and stone characteristics including Guy's and STONE scores) between complicated and uncomplicated cases were compared using univariate and multivariate statistical analyses for detection of independent risk factors. The study included 1178 patients (61% were males). Mean age was 50 ± 12 years, and mean BMI was 30.7 ± 5.7 kg/m2. Complicated group included 166 patients (14.1%). Independent risk factors on multivariate analysis were infected preoperative urine culture (RR: 2.098, P 0.001, 95%CI: 1.380-3.189), largest stones diameter 30 mm or more (RR: 2.481, P > 0.001, 95%CI: 1.697-3.627) and number of calyces affected by the stones (RR: 2.431, P 0.002, 95%CI: 1.400-4.222 for affection of two calyces and RR: 2.778, P 0.005, 95%CI: 1.357-5.684 for affection of three calyces). While two scoring systems (Guy's and STONE) were not predictive of complications after PCNL, preoperative risk factors were infected preoperative urine culture, distribution of the stones or stone branches in two or three calyceal groups and stone size 30 mm or more.

Delivery of intravesical botulinum toxin A using low-energy shockwaves in the treatment of overactive bladder: A preliminary clinical study.

Objective: To evaluate the efficacy and safety of botulinum toxin A (BoNT-A) instillation in the bladder under the effect of low-energy shockwaves (LESWs) for the treatment of refractory idiopathic overactive bladder (OAB). Patients and methods: A preliminary clinical study was conducted, including 15 patients with refractory OAB, between September 2016 and July 2017. Intravesical instillation of 100 IU of BoNT-A was done followed by LESWs (3000 shocks over 10 min) exposure to the supra-pubic area. Patients were followed-up by urine analysis, urine culture, post-void residual urine volume (PVR), and Overactive Bladder Symptom Score (OABSS) at 1, 2 and 3 months. Results: There were statistically significant improvements in all OABSS domains and the total score after 1 and 2 months of treatment (P < 0.05). Whereas, only the nocturia domain remained significantly improved after 3 months (P = 0.02). There was no significant increase in PVR throughout the study period (P > 0.05) and none of the patients required clean intermittent catheterisation. Two, two and three patients developed urinary tract infections after 1, 2 and 3 months, respectively. Conclusion: Intravesical instillation of BoNT-A and LESWs is safe and effective method for the treatment of refractory OAB with a durable response for 2 months. Abbreviations: BoNT-A: botulinum toxin A; CIC: clean intermittent catheterisation; DO: detrusor overactivity; LESWs: low-energy shockwaves; OAB: overactive bladder; OABSS: Overactive Bladder Symptom Score; Qmax: maximum urinary flow rate; QoL: quality of life; UUI: urgency urinary incontinence.

Efficacy of pethidine, ketorolac, and lidocaine gel as analgesics for pain control in shockwave lithotripsy: A single-blinded randomized controlled trial.

Purpose: To compare the safety and efficacy of xylocaine gel and ketorolac as opioid-sparing analgesia compared with pethidine for shock wave lithotripsy (SWL) pain. Materials and Methods: A single-blinded randomized controlled trial (RCT) was performed in 132 patients with renal and upper ureteral stones amenable to treatment with SWL. The first patient group received intravenous (IV) pethidine and placebo gel; the second group received IV ketorolac plus placebo gel; the third group received lidocaine gel locally plus normal saline IV. Stone disintegration was classified as none (no change from basal by kidney, ureter, bladder X-ray or ultrasound [US] imaging), partial (fragmented and >4-mm residual fragments), and complete (≤4-mm residual fragments). Stone disintegration was assessed by kidney-ureter-bladder X-ray and US imaging. Pain was evaluated by use of the Numeric Pain Rating Scale (NPRS). Results: The NPRS scores were highest in the xylocaine group at 10, 20, and 30 minutes (p=0.0001) with no significant difference between the ketorolac and pethidine groups, except at 10 minutes (p=0.03) and a near significant difference at 30 minutes (p=0.054) in favor of ketorolac. Results for stone disintegration (none, partial, and complete, respectively) were as follows: 25 (50.0%), 23 (46.0%), and 2 (4.0%) for pethidine; 19 (35.8%), 23 (43.4%), and 11 (20.8%) for ketorolac; and 26 (89.7%), 3 (10.3%), and 0 (0.0%) for lidocaine (p=0.008). Conclusions: Ketorolac is a safe and more effective alternative to morphine derivatives for SWL analgesia. Lidocaine gel should not be used as mono-analgesia for SWL.

Long-term effects of extracorporeal shock wave lithotripsy on renal function: our experience with 156 patients with solitary kidney.

PURPOSE: We studied the long-term impact of shock wave lithotripsy on renal function, stone recurrence and hypertension in patients with a solitary kidney. Patients with a solitary kidney provide a unique opportunity to evaluate any clinically significant change in renal function. MATERIALS AND METHODS: We retrospectively reviewed the records of 156 patients with stones in a solitary kidney treated with shock wave lithotripsy monotherapy. Treatment outcome was evaluated after 3 months. Long-term followup (more than 12 months) was available for 108 patients. Serum creatinine, systolic and diastolic blood pressure, new onset hypertension, calculated glomerular filtration rate, and kidney morphology were determined before and after treatment, and compared by chi-square, paired and unpaired t tests. RESULTS: After 3 months the overall stone-free rate was 80.8% (126 of 156). Renal obstruction caused by steinstrasse after shock wave lithotripsy occurred in 14 (8.9%) patients. Secondary procedures were required in 20 (12.8%) patients. Followup ranged from 1 to 16 years with a mean of 3.8 (SD +/- 3.5). After long-term followup the stone-free rate was 76.8% and real stone recurrence developed in 18.5% of patients. There was no significant difference in any evaluated pretreatment or posttreatment parameters. CONCLUSIONS: The demonstrated effectiveness, small number of complications at short-term followup, insignificant effect on renal function, blood pressure and relatively small number of recurrences at the long-term followup confirm that shock wave lithotripsy is not only effective but is also safe in the long run.

Prospective study of the long-term effects of shock wave lithotripsy on renal function and blood pressure.

PURPOSE: We clarified the long-term effects of extracorporeal shock wave lithotripsy on renal function and blood pressure, and its relation to body mass index and type of lithotriptor. MATERIALS AND METHODS: A total of 100 patients with a single radiopaque renal stone 2 cm or less in length were followed for 18 to 57 months (mean 43.6 +/- 13.8) after being stone-free by extracorporeal shock wave lithotripsy monotherapy using 2 lithotriptors. Mean patient age was 47.9 +/- 9.1 years (range 23 to 66). Nuclear scintigraphy using (99m)technetium-mercaptoacetyltriglycine was done for all patients before extracorporeal shock wave lithotripsy, as well as at the last followup visit to estimate glomerular filtration rate, clearance and split renal function. Blood pressure measurements were recorded at admission and at each followup visit. RESULTS: Before extracorporeal shock wave lithotripsy treated side mean (99m)technetium-mercaptoacetyltriglycine clearance, glomerular filtration rate and split function were 146.22 +/- 59.48, 52.66 +/- 13.69 and 49.7 +/- 7.31, respectively. At the last followup visit they were 145.1 +/- 58.82 (p = 0.842), 54.85 +/- 15.75 (p = 0.114) and 49.96 +/- 8.68 (p = 0.577), respectively. Of 100 patients 18 were hypertensive before extracorporeal shock wave lithotripsy and 21 were hypertensive at the last followup visit. Mean diastolic blood pressure before extracorporeal shock wave lithotripsy was 80.2 +/- 6.2 vs 80.6 +/- 7.8 mm Hg (p = 0.674) at the end of followup. Mean systolic blood pressure before extracorporeal shock wave lithotripsy was 121.2 +/- 9 vs 121.55 +/- 10.2 mm Hg by the end of the study (p = 0.748). There were no statistically significant differences among body mass index groups or lithotriptor groups. CONCLUSIONS: Extracorporeal shock wave lithotripsy is a safe procedure and has no significant long-term effects on renal function or blood pressure regardless of the type of machine used or body mass index.

Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: a prospective randomized study of effectiveness and safety in comparison to standard single-pulse technique.

OBJECTIVE: To asses the efficacy and safety of bidirectional synchronous twin-pulse extracorporeal shock wave lithotripsy (ESWL) compared with standard ESWL. PATIENTS AND METHODS: Between March 2003 and December 2006, 240 patients with a radio-opaque single renal stone of 10 mm the rate for the failure of disintegration was 13.3% for the DLS vs 1.4% for the TH (P = 0.009). For stones of 10 mm it was 78.1% and 66.7%, respectively (P = 0.14). The median (range) number of sessions in both groups was 2 (1-5). After ESWL urinary NAG levels were increased significantly in both groups; in the TH group it declined below the level before ESWL after 2 days, while in the DLS group it remained high after 7 days. In the DLS group four patients developed subcapsular or parenchymal haematoma after ESWL, vs none in the TH group. There was loss of corticomedullary differentiation after ESWL in three patients in the DLS group and only one in the TH group. In the DLS group there was a statistically significantly decrease in bilateral renal perfusion after ESWL, but no changes in the TH group. CONCLUSIONS: Synchronous twin-pulse ESWL has clinical advantages over standard ESWL in terms of safety and efficacy.

Hospital admission for treatment of complications after extracorporeal shock wave lithotripsy for renal stones: a study of risk factors.

The objective of this study was to determine risk factors of hospital admission for treatment of complications after extracorporeal shock wave lithotripsy (SWL). The electronic files and images of all patients who underwent SWL for treatment of renal stones between January 2011 and December 2015 were retrospectively reviewed. All patients underwent SWL with the same electromagnetic lithotripter (Dornier Lithotripot S). The data of those who needed hospital admission for treatment of complications within 30 days after SWL were compared with patients who did not require hospital admission. Compared data included patients' demographics (age, gender, BMI, ASA score, and pre-SWL stenting), renal characters (side, hydronephrosis, and solitary kidney), and stone characters (site, length, density, and previous treatment). Univariate and multivariate statistical analyses were used to identify risk factors. The study included 1179 patients. Complications that required hospital admission were observed in 108 patients (9.2%). They included obstructing steinstrasse in 91 (7.7%), peri-renal hematoma in 3 (0.25%), and fever (>38.0 °C) in 14 (1.2%). Independent risk factors on multivariate analysis were solitary kidney (OR 2.855, P = 0.017), pre-SWL stenting (RR 2.03, P = 0.044), ASA II (OR 1.965, P = 0.007), hydronephrosis (RR 1.639, P = 0.024), and stone length (RR 1.083, P < 0.001). Patients with medical co-morbidities, pre-SWL ureteral stents, large stones and those with obstructed and/or solitary renal unit are more liable to post-SWL complications that need hospital admission. The probability of hospital admission has to be explained to patients with these risk factors.

Predictors of clinical significance of residual fragments after extracorporeal shockwave lithotripsy for renal stones.

PURPOSE: To determine the predictors of the clinical outcome of residual fragments after extracorporeal shockwave lithotripsy (SWL). PATIENTS AND METHODS: During the last 10 years, residual fragments < or =5 mm were present in 99 male and 55 female patients (mean age 43.1 years) for >3 months after SWL for renal stones. Follow-up with history, urine examination, and non-contrast CT scanning was carried out every 6 months or when symptoms developed. Clinically insignificant residual fragments were diagnosed in patients who became stone free or had asymptomatic fragments of the same size during follow-up. A clinically significant outcome was considered to have occurred in patients requiring secondary intervention for regrowth of the fragments or medical treatment for frequent symptomatic episodes. Univariate (Kaplan-Meier) and multivariate (Cox-regression) analyses were performed to determine significant predictors of the outcome. The mean follow-up was 31 months (range 6-80 months). RESULTS: Stone-free status, regrowth of fragments, and persistence of fragments of the same size were present in 21 (13.6%), 52 (33.8%), and 81 (52.6%) patients, respectively. A clinically significant outcome was documented in 75 patients (48.7%) as percutaneous nephrolithotomy was needed in 2, repeat SWL in 50, and medical treatment for symptomatic episodes in 23 patients. Significant independent predictors of a clinically significant outcome were fragment size > or =4 mm and history of recurrent stone disease (P < 0.001). CONCLUSION: The term "clinically insignificant residual fragments" is not appropriate for all patients with post-SWL fragments, as 48.7% of patients had fragments that became clinically significant. Fragments of 4 to 5 mm and recurrent stone disease predicted clinical significance.