International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy.

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Optical coupling control: an important step toward better shockwave lithotripsy.

BACKGROUND: In modern "dry" lithotripters, shockwaves are generated in a membrane-covered water cushion that is then coupled to the patient.To limit energy loss, a coupling agent, usually ultrasound gel, is used in this acoustic interface. During the coupling process, air pockets are inevitably trapped in the coupling area, which subsequently remains invisible to the operator. These air pockets dramatically decrease stone fragmentation efficiency up to 40%. MATERIALS AND METHODS: To check for air bubbles in the coupling interface, a video camera was installed in the therapy head of our Dornier Gemini lithotripter: all air bubbles observed in the coupling zone could then be removed under visual control. We evaluated the effect of this optically controlled coupling (OCC) on treatment results (10/1/12-9/30/13) and compared these to the results obtained in a "blind" coupling mode (4/1/11-4/30/12). RESULTS: Optically controlled removal of air bubbles from the coupling area reduced the required number of shockwaves with 25.4% for renal stones and 25.5% for ureteral stones. Energy level was reduced by 23.1% for renal stones and by 22.5% for ureteral stones. For renal stones, total applied energy was thus reduced by 42.9%. Effectiveness quotients were comparable. CONCLUSIONS: Optical control with a video camera proved pivotal in the realization of bubble-free coupling. Bubble-free coupling significantly reduced the total energy needed to obtain comparable treatment results. Theoretically, this should also lead to a reduced incidence and severity of shockwave-induced adverse effects. We consider this an important step toward better and safer shockwave lithotripsy and would therefore advocate the standard incorporation of an OCC system in all new lithotripters.

Extracorporeal shock wave lithotripsy today.

Even 32 years after its first introduction shockwave lithotripsy (SWL) remains a matter of discussion and controversy. Since the first SWL in 1980, millions of treatments have been performed worldwide. To this day SWL remains the least invasive of all stone treatments and is considered the treatment modality of first choice for the majority of urinary stones. Despite the massive scale on which SWL is performed in a wide range of indications, complication rate has always remained very low and usually limited to minor side effects and complications. The introduction of affordable multifunctional lithotripters has made SWL available to more and more departments of urology worldwide. Still many centers are disappointed with the treatment results and concerned about the adverse tissue effects. In this SWL proves to be the victim of its uninvasiveness and its apparent ease of practice. Urologists need proper skill and experience; however, to adequately administer shockwaves in order to improve outcome. This aspect is too often minimized and neglected. Apart from this the power of shockwaves often is underestimated by operators of shockwave machines. Basic knowledge of the physics of shockwaves could further reduce the already minimal adverse tissue effects. Good training and coaching in the administration of shockwaves would no doubt lead to a renaissance of SWL with better treatment results and minimal adverse tissue effects.

Twenty years of single center experience in ESWL 1987-2007: an evaluation of 3079 patients.

INTRODUCTION: Since 1987 we have consecutively operated five different Dornier lithotriptors in the management of lithiasis at all levels of the urinary tract. At the time of usage of each machine we periodically evaluated the treatment results in order to eventually adapt treatment strategies to improve results. None of these evaluations comprised the totality of patients treated on a certain machine during the entire period it was in use. This overview retrospectively compares the results over the entire period in order to gauge the impact of the different machines and SW-sources on clinical results. MATERIAL AND METHODS: A total of 3079 patients, treated from september 1987 till september 2006 with two electrohydraulic machines, HM4 (1987-1988) and MPL9000 (1988-1994), and three electromagnetic machines, Compact (1991-1999), DoLi U/50 (1996-1999) and DoLi S (1999-2006) were thus evaluated. Parameters reviewed were stone location and size, retreatment rate, auxiliary procedures, stone free rate and Effectiveness Quotient (EQ). RESULTS: There is no significant difference in stone size or stone free rate (p=0.4715) for the different groups. There is a significant difference for auxiliary procedure rate and retreatment rate for the different machines. The DoLiS with EMSE 220F-XXP scores significantly better than any of the other systems for auxiliary procedure rate pre-ESWL (p<0.05) and total auxiliary procedure rate (p<0.05), and retreatment rate (p=0.0024). There is a gradual increase in EQ with the consecutive machines. CONCLUSION: Although stone free rates (85%-88.8%) remained constant, Effectiveness Quotients improved. This is largely due to reduced auxiliary procedure rates and reduced retreatment rates. The first effect is a consequence of improvement in treatment strategies and experience, the latter no doubt also of improvement in SW-sources.

Use of tramadol drip in controlling renal colic pain.

BACKGROUND AND PURPOSE: Although the continuous perfusion of antispasmodic drugs has been the traditional mainstay in the treatment of renal colic, the results more often than not are unsatisfactory. Our hypothesis was that a continuous intravenous (IV) drip of tramadol would be an effective and safe alternative. PATIENTS AND METHODS: In this prospective study, 300 patients with renal colic were randomized into four treatment groups, single blind for the patients. At the start, all received an anti-inflammatory drug intramuscularly and an antiemetic and antispasmodic IV. Group A was given the classical IV antispasmodic perfusion combined with a sham drip. Group B received the classical antispasmodic perfusion in combination with a tramadol drip. Group C had a sham perfusion and drip. Group D received a sham perfusion and tramadol drip. There was no significant difference in the degree of pain between the groups on a visual analog scale (VAS) at the start. The pain was scored again on the VAS at 30 minutes, 1 hour, and 4 hours after the start of the treatment and at IV urography. Side effects, as well as the need for rescue medication, were registered. RESULTS: Both tramadol groups scored significantly better after 60 and 240 minutes and during IV urography (P < 0.005). There was a significant decrease in VAS in group B after 30 minutes. The tramadol groups needed significantly less rescue medication (P = 0.001). There was no significant difference in the reported side effects. The combination spasmolytic-tramadol drip scored the best, although the difference was not statistically significant. CONCLUSION: We consider our hypothesis proved that a continuous tramadol drip is a safe and valuable analgesic regimen in renal colic.

Modern approach to ureteral stones.

Urolithiasis is a very common affliction of mankind. In western countries incidence is increasing steadily. An increasing proportion of patients are presenting with ureteral stones, of which renal colic most often is the first complaint and the most common reason for an emergency visit to a urologist. Proper imaging strategy is of paramount importance in the diagnosis of acute flank pain and in the subsequent therapy planning once a ureteral stone is diagnosed. Renal colic during pregnancy poses specific problems, both in imaging and therapy. Apart from the adequate treatment of renal colic, modern therapy of those ureteral calculi that will not pass spontaneously will consist of a judicious combination of ESWL (extracorporeal shock wave lithotripsy), endourology, and laparoscopy. Open surgery should only be reserved for limited and very specific indications. Although beyond the scope of this article, metaphylaxis should take an important role in the follow-up of stone patients in general.

In situ SWL of ureteral stones: comparison between an electrohydraulic and an electromagnetic shockwave source.

PURPOSE: To compare the influence of different shockwave emitters on treatment efficacy for SWL of ureteral stones in situ. PATIENTS AND METHODS: From January 1, 1990, until August 31, 1998, we treated 175 ureteral stones in situ 9 to 252 mm(2) (mean 55.2 mm(2)) using X-ray targeting on a Dornier MPL 9000 X lithotripter, a spark gap machine. From February 1996 through December 1997, we operated a Dornier Lithotripter S equipped with a conventional electromagnetic shockwave source, the EMSE 220. The size of the 71 treated ureteral stones at all levels ranged from 6 to 276 mm(2) (mean 47.4 mm(2)). After the introduction of an upgraded electromagnetic shockwave source, the EMSE F150, 33 ureteral stones of 9 to 150 mm(2) (mean 40.1 mm(2)) were treated in situ. After a second upgrade, to the more powerful EMSE F150-P, 50 ureteral stones ranging in size from 16 to 345 mm(2) (mean 62.3 mm(2)) were treated in situ. In all series, treatment strategies were identical. RESULTS: In the first series, auxiliary procedures were performed in 2.3% pre-SWL and 25.1% post-SWL (total 27.4%). The retreatment rate was 23.4%, bringing the effectiveness quotient (EQ) to 67.3. In the second series, the auxiliary procedure rate was 2.8% pre-SWL and 22.5% post-SWL (total 25.3%). The retreatment rate was 19.7%, and the EQ was 70.3. In the third series, auxiliary procedures were performed in 3.0% pre-SWL and 24.2% post-SWL (total 27.2%). The retreatment rate was 18.2% and the EQ 70.2. In the most recent series, no auxiliary procedures were needed before SWL, the post-SWL auxiliary procedure rate was 22%, and the retreatment rate was 10.0%, for an EQ of 75.8. CONCLUSION: The significant improvement in EQ with the EMSE F150-P must be attributed to an improved shockwave source, contradicting the myth that a spark gap source is by definition superior to an electromagnetic one.