• Users Online: 221
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 383-387

Success factors of extracorporeal shock wave lithotripsy for renal and upper ureteric calculi in adults


1 From Faculty of Medicine for Girls, Al-Azhar University, Egypt
2 National Institute of Urology and Nephrology, Egypt

Date of Submission28-Apr-2020
Date of Decision14-May-2020
Date of Acceptance19-May-2020
Date of Web Publication2-Oct-2020

Correspondence Address:
MBBCH Mohammed K Khalifa
National Institute of Urology and Nephrology, Al-Azhar University, Cairo
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_49_20

Get Permissions

  Abstract 


Background Extracorporeal shock wave lithotripsy (ESWL) is considered the first-line treatment for most patients with renal and ureteric calculi, as it is safe and noninvasive.
Objective The present study was undertaken to evaluate the most significant factors that influence the success rate of ESWL for renal and upper ureteric calculi in adults.
Patients and methods This randomized prospective study for adult patients more than or equal to 18 years old included 50 patients with renal stone less than or equal to 2 cm and 50 patients with upper ureteric stone less than or equal to 2 cm. The included patients were treated with ESWL at Al-Zahraa University Hospital and National Institute of Urology and Nephrology between August 2018 and July 2019. Patients with multiple ipsilateral stones, bleeding disorders, impaired renal function, congenital abnormalities, untreated urinary tract infections, have BMI more than 30 kg/m2, pregnant women, and patients with radiolucent stones were excluded from the study. P value less than or equal to 0.05 was taken as the level of significance.
Results The overall success of ESWL was 86 (86%), including 81 (94.2%) patients who had total stone clearance. The other five patients had Steinstrasse after the first session. The success rate of ESWL in males was 92.6% compared with 78.3% in females (P=0.040). The success rate of ESWL in patients with stent was 66.77%, whereas the success rate of ESWL in patients without stent was 90.2%, with P value 0.009. The success rate of ESWL in stone density more than 1000 HU was 80.8%, whereas the success rate of ESWL in stone density less than or equal to 1000 HU was 96.97%, with P value of 0.027.
Conclusion ESWL should be considered a first-line therapy for treatment in patients with upper urinary tract calculi with density less than or equal to 1000 HU and size up to 20 mm. Stenting should be considered in certain cases when indicated.

Keywords: extracorporeal shock wave lithotripsy, factors, urinary tract calculi


How to cite this article:
Elmasry HA, Edris AM, Khalifa MK. Success factors of extracorporeal shock wave lithotripsy for renal and upper ureteric calculi in adults. Sci J Al-Azhar Med Fac Girls 2020;4:383-7

How to cite this URL:
Elmasry HA, Edris AM, Khalifa MK. Success factors of extracorporeal shock wave lithotripsy for renal and upper ureteric calculi in adults. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 28];4:383-7. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/383/296945




  Introduction Top


Urinary stone disease is a major health problem owing to its high prevalence and incidence. There are different therapeutic approaches for renal and ureteral stones depending on stone size, location, and anatomical variations of the urinary tract. Shock wave lithotripsy is the least invasive treatment for upper urinary tract calculi and is recommended as a first-line therapy [1].

Extracorporeal shock wave lithotripsy (ESWL) was first introduced in 1980 by Shinde et al. [2] and became a preferred treatment modality for renal and ureteral stone less than 20 mm.

There is a considerable variability in reported treatment results of SWL with success rates varying from 60 to 90% [3],[4],[5].

However, patients treated by ESWL are not immediately stone free. Some patients will require repeated sessions of ESWL, and others will have residual fragments that may require auxiliary interventions [6].

Many factors are thought to influence the final results of ESWL, including patient selection, stone size, stone location, stone composition, and type of lithotripter, in addition to experience level of the operator, total shock number, energy delivered, and shock frequency [3].

So, we evaluate the most significant factors that influence the success rate of ESWL for renal and upper ureteric calculi in adults.


  Patients and methods Top


This randomized prospective study for adult patients more than or equal to 18 years old included 50 patients with renal stone less than or equal to 2 cm and 50 patients with upper ureteric stone less than or equal to 2 cm. After took an ethical approvment from community department faculty of medicine for girls AlAzhar Universuty. Patients were selected from Al-Zahraa University Hospital and National Institute of Urology and Nephrology. The included patients were treated with ESWL between August 2018 and July 2019.

Patients with multiple ipsilateral stones, patients with size of the stone more than 2 cm, patients with bleeding disorders, patients with impaired renal function, patients with muscloskeletal malformations that make positioning impossible, patients with congenital abnormalities, patients with previous stone interventions on the same side, patients with untreated urinary tract infections, patients who have a BMI more than 30 kg/m2, pregnant women, and patients with radiolucent stones were excluded from the study. Informed consent form was signed by all patients regarding investigations and management.

All patients were subjected to the following:
  1. Clinical evaluation, which included the following:
    1. Full history taking and complete physical examination.
  2. Laboratory investigations:
    1. Urine analysis, and urine culture and sensitivity when indicated.
    2. Complete blood picture, fasting blood sugar, blood urea, serum creatinine, liver function tests, and coagulation profile.
  3. Imaging study included the following:
    1. Kidney, ureter, and bladder film.
    2. Noncontrast computed tomography.


Technique

The ESWL procedure was performed in ESWL unit using the Siemens lithostar lithotripter, which is a second-generation electromagnetic lithotripter at Al-Zahraa University Hospital or the Dornier Gemini at National Institute of Urology and Nephrology.

Follow-up of the patients consisted of plain radiograph urinary tract 2 weeks after the session. SWL was repeated until stone disintegration or reaching three sessions of SWL. Failure of disintegration of the stone after the third session was considered to be SWL failure.

Statistical analysis

The comparison between groups regarding qualitative data was done by using c2 test and/or Fisher exact test when the expected count in any cell was found less than 5. The comparison between two groups regarding quantitative data and parametric distribution was done by using independent t-test. P value less than 0.05 was considered significant.


  Results Top


Of the total number of the patients, ESWL was successful in 86 patients, including 81 (94.2%) patients who had total stone clearance [44 (51.2%) were stone free with one session, 28 (32.6%) patients required two sessions, and nine (10.5%) patients required three sessions], and the other five patients had Steinstrasse after the first session and had to be cleared by ureteroscopy. ESWL failed to disintegrate the stone in 14 (14%) patients after three sessions ([Table 1] and [Table 2]).
Table 1 Demographic data of all patients

Click here to view
Table 2 Stone-free rate after extracorporeal shock wave lithotripsy in all patients

Click here to view


The success rate of ESWL in males was 92.6% compared with 78.3% in females, and this result was statistically significant (P=0.040) ([Table 3], [Figure 1] and [Figure 2]).
Table 3 Success rate and factors affecting outcome of extracorporeal shock wave lithotripsy in all patients

Click here to view
Figure 1 Success and failure rate in all patients.

Click here to view
Figure 2 ESWL outcome according to sex. ESWL, extracorporeal shock wave lithotripsy.

Click here to view


The success rate of ESWL in stones more than 10 mm was 83.1%, whereas the success rate of ESWL in stones less than or equal to 10 mm was 95.7%, with P value of 0.128. The mean stone size in the success group was 12.04±2.98 mm, whereas it was 15.50±3.37 mm in the failure group, with P value less than 0.01 ([Table 3]).

The success rate of ESWL in patients with stent was 66.77%, whereas the success rate of ESWL in patients without stent was 90.2%, with P value 0.009, and this result was statistically significant ([Table 3] and [Figure 3]).
Figure 3 ESWL outcome with a double J stent. ESWL, extracorporeal shock wave lithotripsy.

Click here to view


Outcome of extracorporeal shock wave lithotripsy in all patients

The success rate of ESWL in stone density more than 1000 HU was 80.0%, whereas the success rate of ESWL in stone density less than or equal to 1000 HU was 96.97%, with P value=0.027, which is statistically significant ([Table 3] and [Figure 4]).
Figure 4 ESWL outcome according to stone density. ESWL, extracorporeal shock wave lithotripsy.

Click here to view


Complications were minor, including loin pain (16%), gross hematuria (2%), Steinstrasse (5%), low-grade fever (<38.5°C) (4%), and LUTS (18%).

No major complications occurred in any patient.


  Discussion Top


The success of ESWL in this study was 86% (86 patients). Similar to our study, Abdel-Khalek et al. [7] reported overall success rate of 86.7%.

Some of the previous studies have reported overall success rate of 82% [8], 80% [9], 79.1% [2], and 78% [10]. This difference in the stone-free rate among these studies and our study could be attributed to difference in the machines used, treatment of different stone sizes, different types of stents used, or difference in the number of cases.

In our study, the success rate of ESWL in males was 92.6% (50/54) compared with 78.3% (36/46) success in females, and this result was statistically significant (P=0.040). In contrast to our study, a study of 153 patients with ureteric stones treated with ESWL reported 83.33% (75/90) success in males compared with 82.54% (52/63) in females, which was also not statistically significant [11].

Similar to our study, Shinde et al. [2] found a significant sex difference, and the success rate was higher among men. The success rate of ESWL in males was 82.4% (155/188) compared with 66.0% (31/47) success in females, with P value of 0.017.

In our study regarding stone site, we found that calyceal stones have poor outcome with ESWL treatment compared with renal pelvic and ureteral stones (success rates of 80.9, 86.2, and 88.8%, respectively), whereas lower calyceal renal calculi have poorer results with ESWL compared with middle and upper calyceal calculi (success rates of 75, 77.8, and 100%, respectively). The success rate of ESWL for lower calyceal stones was 75% compared with 86.9% for stones at all other sites. Our present study results match with the study of Weld et al. [12], who found better success of ESWL for calculi in the pelvis and ureter than lower calyx.

In our study, ESWL success for lower calyceal calculi is slightly lower than the results of the study of Robert et al. [13], who achieved an overall stone clearance of ∼84% for lower calyceal stones. This difference may be because of the size of stones between 5 and 15 mm in their study as compared with stone size of less than or equal to 20 mm in our study.

The success rate of ESWL in patients with stones density more than 1000 HU was 80.0%, whereas the success rate of ESWL in patients with stones density less than or equal to 1000 was 96.9%, with P value of 0.027, which is statistically significant.

In our study, stone density less than or equal to 1000 HU required 1.4 mean sessions, whereas stones more than 1000 HU required 2.1 mean sessions. The mean total number of shocks in stone density less than or equal to 1000 was 4152.52±1767.93, range from 2450 to 8200, whereas the mean total number of shocks in stone density more than 1000 was 5286.9±2299.85, range from 2600 to 12 000, with P value of 0.014.Similar to our study, Pareek et al. [14] found density as a significant predictor factor in determining outcome of ESWL for ureteric as well as renal calculi (P<0.001).

In contrast to our study, Bandi et al. [15], found in a study that in patients with solitary upper urinary tract stones, stone volume measured by a noncontrast computed tomography was the strongest predictor of ESWL outcome.

The use of a double J stent before ESWL in renal and upper ureteric calculi is rather controversial. Musa [16] reported stone-free rate of 88% in the stented patients and 91% in the unstented patients.

In contrast to the previous studies, in our study, the success rate of ESWL in patients with stent was 66.77%, whereas the success rate of ESWL in patients without stent was 90.2%, with P value 0.009, and this result was statistically significant.

In another study, Shinde et al. [2] reported the success rate of ESWL in patients with stent was 47.9 versus 87.2% in patient without stent, with a P value less than 0.001.


  Conclusion Top


Any single predictive factor cannot determine outcome of ESWL treatment individually; therefore, all predictive factors of the outcome of ESWL for upper urinary tract calculi should be considered collectively.

ESWL is recommended as a first-line therapy for treatment of patients with upper urinary tract calculi of density less than or equal to 1000 HU and size up to 20 mm. Stenting should be considered in certain cases when indicated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Freeg MA, Ranade AV, Muttappallymyalil J, Ghaffar TF. Extracorporeal shockwave lithotripsy in the management of a large proximal ureteric stone: a case report. Nepal J Epidemiol 2011; 1:70–73.  Back to cited text no. 1
    
2.
Shinde S, Al Balush Y, Hossny M, Jose S, Al Busaidy S. Factors affecting the outcome of extracorporeal shockwave lithotripsy in urinary stone treatment. Oman Med J 2018; 33:209–217.  Back to cited text no. 2
    
3.
Abid AF. Success factors of extracorporeal shock wave lithotripsy (ESWL) for renal & ureteric calculi in adult. Open J Urol 2014; 4:26–32.  Back to cited text no. 3
    
4.
Elkoushy MA, Hassan JA, Morehouse DD, Anidjar M, Andonian S. Factors determining stone-free rate in shock wave lithotripsy using standard focus of storzmodulith SLX-F2 lithotripter. Urology 2011; 78:759–763.  Back to cited text no. 4
    
5.
Matlaga BR, Semins MJ. How to improve results with extracorporeal shock wave lithotripsy. Ther Adv Urol 2009; 1: 99–105.  Back to cited text no. 5
    
6.
Salman M, Al-Ansari AA, Talib RA, El-Malik el F, Al-Bozaom IA, Shokeir AA. Prediction of success of extracorporeal shock wave lithotripsy in the treatment of ureteric stones. Int Urol Nephrol 2007; 39:85.  Back to cited text no. 6
    
7.
Abdel-Khalek M, Sheir KZ, Mokhtar AA, Eraky I, Kenawy M, Bazeed M. Prediction of success rate after extracorporeal shock-wave lithotripsy of renal stones − a multivariate analysis model. Scand J Urol Nephrol 2004; 38:161–167.  Back to cited text no. 7
    
8.
Panchal PG, Mahesh K, Dhammdeep CD, Onkar CS. Study of factors predicting clinical outcomes of extracorporeal shock wave lithotripsy in Indian patients with upper urinary tract calculi. Int Surg J 2018; 5:1532–1537.  Back to cited text no. 8
    
9.
Joseph P, Mandal AK, Singh SK, Mandal P, Sankhwar SN, Sharma SK. Computerized tomography attenuation value of renal calculus: can it predict successful fragmentation of the calculus by extracorporeal shock wave lithotripsy? A preliminary study. J Urol 2002; 167:1968–1971.  Back to cited text no. 9
    
10.
Al-Ansari A, As-Sadiq K, Al-Said S, Younis N, Jaleel OA, Shokeir AA. Prognostic factors of success of extracorporeal shock wave lithotripsy (ESWL) in the treatment of renal stones. Int Urol Nephrol 2006; 38:63–67.  Back to cited text no. 10
    
11.
Choi JW, Song PH, Kim HT. Predictive factors of the outcome of extracorporeal shockwave lithotripsy for ureteral stones. Korean J Urol 2012; 53:424–430.  Back to cited text no. 11
    
12.
Weld KJ, Montiglio C, Morris MS, Bush AC, Cespedes RD. Shock wave lithotripsy success for renal stones based on patient and stone computed tomography characteristics. Urology 2007; 70:1043.  Back to cited text no. 12
    
13.
Robert M, Marotta J, Rakotomalala E, Muir G, Grasset D. Piezoelectric extracorporeal shock-wave lithotripsy of lower pole nephrolithiasis. Eur Urol 1997; 32:301–304.  Back to cited text no. 13
    
14.
Pareek G, Armenakas NA, Fracchia JA. Hounsfield units on computerized tomography predict stonefree rates after extracorporeal shock wave lithotripsy. J Urol 2003; 169:1679–1681.  Back to cited text no. 14
    
15.
Bandi G, Ryan J, Perry J, Stephen Y. Stone measurement by volumetric three-dimensional computed tomography for predicting the out come after extracorporeal shock wave lithotripsy. BJU Int 2009; 103:528.  Back to cited text no. 15
    
16.
Musa AA. Use of double-J stents prior to extracorporeal shock wave lithotripsy is not beneficial: results of a prospective randomized study. Int Urol Nephrol 2008; 40:19–22.  Back to cited text no. 16
    


    Figures

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

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed63    
    Printed4    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]