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1.  Usefulness of Early Extracorporeal Shock Wave Lithotripsy in Colic Patients with Ureteral Stones 
Korean Journal of Urology  2012;53(12):853-859.
To compare efficacy and safety between early extracorporeal shock wave lithotripsy (eESWL) and deferred ESWL (dESWL) in colic patients with ureteral stones and to investigate whether eESWL can play a critical role in improving treatment outcomes.
Materials and Methods
A total of 279 patients who underwent ESWL for single radio-opaque ureteral stones of 5 to 20 mm in size were included in this retrospective study. The patients were categorized into two groups according to the time between the onset of colic and ESWL: eESWL (<48 hours, n=153) and dESWL (≥48 hours, n=126). Success was defined as stone-free status as shown on a plain radiograph within 1 month of the first session.
For all patients, the success rate in the eESWL group was significantly higher than that in the dESWL group. The eESWL group required significantly fewer ESWL sessions and less time to achieve stone-free status than did the dESWL group. For 241 patients with stones <10 mm, all treatment outcomes in the former group were superior to those in the latter group, but not for 38 patients with stones sized 10 to 20 mm. The superiority of eESWL over dESWL in the treatment outcomes was more pronounced for proximal ureteral stones than for mid-to-distal ureteral stones. Post-ESWL complication rates were comparable between the two groups. In the multivariate analysis, smaller stone size and a time to ESWL of <48 hours were independent predictors of success.
Our data suggest that eESWL in colic patients with ureteral stones is an effective and safe treatment with accelerated stone clearance.
PMCID: PMC3531639  PMID: 23301130
Colic; Lithotripsy; Ureteral calculi
2.  Efficacy of extracorporeal shockwave lithotripsy using Dornier SII in different levels of ureteral stones 
Urology Annals  2014;6(4):346-351.
The objective of this study was to evaluate the efficacy and safety of the Dornier lithotripter S II system in the treatment of ureteral calculi.
Patients and Methods:
A total of 97 cases which consists of 54 males and 43 females with ureteral stones were treated by extracorporeal shock wave lithotripsy (ESWL). Mean age was 42.6 years. Inclusion criteria were solitary radiopaque ureteral stones of radiological stone size of ≤1 cm. The stones were not impacted, with normal kidney functions. Procedure time, number of shocks, energy used, number of sessions and complications were reported. The outcome of ESWL was also recorded.
Stones were in the abdominal (upper ureter) in 50% of patients, in pelvic (middle ureter) in 47% of patients. All patients had unilateral stones and the mean stone size in maximum length was) 10 mm). Good dye excretion passing the stone was noted in all patients. Mild hydronephrosis was found in 85% of cases. A total of 49 cases were treated by a single session, while in 35% of cases two sessions were enough and 16% received three sessions. The average number of shocks per session was 3125. The average number of shocks per patient was 5962.5 shocks and average energy was 204.3 Joules. The overall stone-free rate 3 months after lithotripsy was 94%. After a single session of lithotripsy, 49 patients (49%) became stone-free. Stone free rates after ESWL for upper, middle ureteral stones were 94%, 95.7% respectively. Additional procedures were needed in only 6 cases (6%) to render patients stone-free after lithotripsy. No serious complications occurred.
The Dornier lithotripter S II is very effective in the treatment of ureteral calculi with no major complications.
PMCID: PMC4216543  PMID: 25371614
Dornier; extracorporeal shock wave lithotripsy; lithotripter; ureteral stones
3.  Kidney stones 
Clinical Evidence  2011;2011:2003.
The age of peak incidence for stone disease is 20 to 40 years, although stones are seen in all age groups. There is a male to female ratio of 3:2.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions for stone removal in people with asymptomatic kidney stones? What are the effects of interventions for the removal of symptomatic renal stones? What are the effects of interventions to remove symptomatic ureteric stones? What are the effects of interventions for the management of acute renal colic? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: antispasmodic drugs, extracorporeal shockwave lithotripsy, intravenous fluids, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral fluids, percutaneous nephrolithotomy, and ureteroscopy.
Key Points
Kidney stones develop when crystals separate from the urine and aggregate within the kidney papillae, renal pelvis, or ureter. The age of peak incidence for stone disease is 20 to 40 years, although stones are seen in all age groups. There is a male to female ratio of 3:2.
The RCT evidence is somewhat sparse regarding the best treatments for people with asymptomatic kidney stones. Both percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) may reduce the need for further invasive surgery. However, they are not without risk, and the risks and benefits should be weighed carefully in asymptomatic people.We found no RCT evidence assessing ureteroscopy in people with asymptomatic kidney stones.
For symptomatic kidney stones, PCNL, ureteroscopy, and ESWL are all options for treatment. PCNL seems more effective than ESWL in removing symptomatic kidney stones, but it is associated with more complications.In very highly selected, uncomplicated cases, tubeless (no nephrostomy but stented) and totally tubeless (no nephrostomy or stent) PCNL seems to give an improved recovery profile.Ureteroscopy seems as effective as ESWL in removing symptomatic kidney stones, but it is associated with more complications.With ESWL, a slower shock rate of 60 per minute may result in greater treatment success.People with larger stones are likely to take longer to pass stone fragments after ESWL; in these cases PCNL may be a more suitable option. Open nephrolithotomy has been largely superseded by PCNL in developed countries.
For symptomatic ureteric stones, ureteroscopy seems to increase overall stone-free rates and decrease time to becoming stone free compared with ESWL.
Medical expulsive therapy with alpha-blockers seems to increase stone-free rates and decrease time to stone passage compared with standard treatment. We found no RCT evidence examining ureterolithotomy (either open or laparoscopic) in people with symptomatic ureteric stones.
PMCID: PMC3275105  PMID: 22075544
4.  Flexible Ureterorenoscopy versus Extracorporeal Shock Wave Lithotripsy for the treatment of upper/middle calyx kidney stones of 10–20 mm: a retrospective analysis of 174 patients 
SpringerPlus  2014;3:557.
To compare the outcomes of flexible ureterorenoscopy (F-URS) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper or mid calyx kidney stones of 10 to 20 mm.
A total of 174 patients with radioopaque solitary upper or mid calyx stones who underwent ESWL or F-URS with holmium:YAG laser were enrolled in this study. Each group treated with ESWL and F-URS for upper or mid calyx kidney stones were retrospectively compared in terms of retreatment and stone free rates, and complications.
87% (n = 94) of patients who underwent ESWL therapy was stone free at the end of 3rd month. This rate was 92% (n = 61) for patients of F-URS group (p = 0.270 p > 0.05). Retreatment was required in 12.9% of patients (n = 14) who underwent ESWL and these patients were referred to F-URS procedure after 3rd month radiologic investigations. The retreatment rate of cases who were operated with F-URS was 7.5% (n = 5) (p = 0.270 p > 0.05). Ureteral perforation (Clavien grade 3B) was occured in 3 patients (4.5%) who underwent F-URS. Fever (Clavien grade 1) was noted in 7 and 5 patients from ESWL and F-URS group, respectively (6.4% vs 7.5%) (p = 0.78 p > 0.05).
F-URS and ESWL have similar outcomes for the treatment of upper or mid calyx renal stones of 10–20 mm. ESWL has the superiority of minimal invasiveness and avoiding of general anethesia. F-URS should be kept as the second teratment alternative for patients with upper or mid caliceal stones of 10–20 mm and reserved for cases with failure in ESWL.
PMCID: PMC4190185  PMID: 25332859
Flexible ureterorenoscopy; Shock wave lithotripsy; Upper calyx stones; Mid calyx stones
5.  Factors Affecting the Outcome of Extracorporeal Shock Wave Lithotripsy for Unilateral Urinary Stones in Children: A 17-Year Single-Institute Experience 
Korean Journal of Urology  2013;54(7):460-466.
Extracorporeal shock wave lithotripsy (ESWL) is a first-line treatment for pediatric urinary stone disease. We aimed to determine the factors affecting the outcome of ESWL for unilateral urinary stones in children.
Materials and Methods
A total of 81 pediatric patients aged 0 to 16 years with urinary stones treated by ESWL from January 1995 through May 2012 were retrospectively reviewed. All patients were required to have unilateral urinary stone disease. Children who underwent other surgical procedures before ESWL were excluded. Outcomes evaluated after ESWL were the stone-free rate at 3 months after ESWL, success within a single session, and success within three sessions. Factors affecting the success within three sessions were also analyzed.
The final analysis was for 42 boys and 22 girls (mean age, 9.2±5.2 years). Of these 64 patients, 58 (90.6%) were treated by ESWL without other surgical procedures and 54 (84.4%) were successfully treated within three ESWL sessions. In the multivariate analysis, multiplicity (odds ratio [OR], 0.080; 95% confidence interval [CI], 0.012 to 0.534; p=0.009) and large stone size (>10 mm; OR, 0.112; 95% CI, 0.018 to 0.707; p=0.020) were significant factors that decreased the success rate within three ESWL sessions.
Most of the pediatric urinary stone patients in our study (90.6%) were successfully treated by ESWL alone without additional procedures. If a child has a large urinary stone (>10 mm) or multiplicity, clinicians should consider that several ESWL sessions might be needed for successful stone fragmentation.
PMCID: PMC3715710  PMID: 23878689
Lithotripsy; Pediatrics; Treatment outcome; Urinary calculi
6.  Usefulness of adjunctive alpha1-adrenergic antagonists after single extracorporeal shock wave lithotripsy session in ureteral stone expulsion 
We evaluate the efficiency of α-adrenergic antagonists on stone clearance after extracorporeal shock wave lithotripsy (ESWL) in patients with lower ureteral stones.
A total of 356 patients with solitary lower ureteral stones who underwent single ESWL sessions were divided into 2 groups. Group 1 received our standard medical therapy, and Group 2 was treated with 0.4 mg/day tamsulosin for a maximum of 2 weeks. All patients were re-evaluated with plain film radiography and ultrasound each week during the treatment period. A computed tomography scan was systematically performed 3 months after ESWL.
In total, 82 of the 170 patients in Group 1 (48.2%) and 144 of the 186 patients in Group 2 (77.4%) (p = 0.002) were stone-free. Among the patients with stones 10 to 15 mm in diameter, the stone-free rate was 38.4% in Group 1 and 77.1% in Group 2 (p = 0.003). Average stone expulsion time was 10.6 days and 8.4 days in Groups 1 and 2, respectively. Ureteral colic occurred in 40 patients (23.5%) in Group 1, but only in 10 patients (5.3%) in Group 2 (p = 0.043). The only side effect of tamsulosin was slight dizziness in 5 of the 186 patients in Group 2 (2.6%).
Adjunctive therapy with α1-adrenergic antagonists after ESWL is more efficient than, and equally as safe as, lithotripsy alone to manage patients with lower ureteral stones. The adding of α-blockers is more reliable and helpful for stones with a large dimension, and can also decrease stone elimination time and episodes of ureteral colic.
PMCID: PMC3896566  PMID: 24454608
7.  Management of ureteric stone in pediatric patients 
The management of ureteral stones in children is becoming more similar to that in adults. A number of factors must be taken into account when selecting one's choice of therapy for ureteral stone in children such as the size of the stone, its location, its composition, and urinary tract anatomy. Endoscopic lithotripsy in children has gradually become a major technique for the treatment of ureteral stones. The stone-free rate following urteroscopic lithotripsy for ureteral stones has been reported in as high as 98.5-100%. The safety and efficacy of Holmium:YAG laser lithotripsy make it the intracorporeal lithotriptor of choice. Given its minimally invasive features, extracorporeal shock wave lithotripsy (ESWL) has become a primary mode of treatment for the pediatric patients with reno-ureteral stones. Stone-free rates have been reported from 59% to 91% although some patients will require more than one treatment session for stone clearance. It appears that the first-line of therapy in the child with distal and mid-ureteral stones should be ureteroscopic lithotripsy. While ESWL is still widely considered the first-line therapy for proximal ureteral calculi, there is an increasing body of evidence that shows that endoscopic or ESWL are equally safe and efficacious in those clinical scenarios. Familiarity with the full spectrum of endourological techniques facilitates a minimally invasive approach to pediatric ureteral stones.
PMCID: PMC3034067  PMID: 21369391
ESWL; pediatric urolithiasis; ureteroscopy
8.  Effects of hydrochlorothiazide on kidney stone therapy with extracorporeal shock wave lithotripsy 
Urology Annals  2014;6(3):208-211.
The aim of this investigation was to assess the efficacy of hydrochlorothiazide as a hypocalciuric diuretic on stone-free rate of renal pelvic calculi after extracorporeal shock wave lithotripsy (ESWL).
Materials and Methods:
A double-blind, placebo-controlled randomized clinical trial was conducted and 52 patients with renal pelvic calculi (diameter ≤2 cm) were enrolled from February 2010 to September 2010. ESWL protocol was performed by 2,500 shocks per session. The patients were randomized into two groups: (1) 26 patients who were given 25 mg hydrochlorothiazide twice daily; and (2) 26 patients who received placebo. The stone-free rate was defined as residual calculus size ≤4 mm in controlled ultrasound on 2nd week, 1 month and 3 months after ESWL.
19 (78%) of the first group and 9 (42.9%) of the second group were stone-free after one session of ESWL (P = 0.02). 88% of the group 1 and 47.8% of the group 2 were stone-free on 1 month after ESWL (P = 0.003); however, this effect of hydrochlorothiazide was not related to the patients' body mass index, age and gender. The accessory treatment procedures were applied in 24% of the group 1 compared with 19% of the group 2 during 3 months (P = 0.68). All patients in both groups were stone-free on 3 months following lithotripsy.
Hydrochlorothiazide did not impact on the stone-free rate and using accessory procedure within 3 months; however, it decreased duration of stone-free status and number of ESWL sessions.
PMCID: PMC4127856  PMID: 25125892
Hydrochlorothiazide; kidney calculi; lithotripsy
9.  Extracorporeal Shock-wave Lithotripsy Success Rate and Complications: Initial Experience at Sultan Qaboos University Hospital 
Oman Medical Journal  2013;28(4):255-259.
To assess the efficacy and safety of extracorporeal shock wave lithotripsy with Modularis Vario Siemens in the management of patients with renal and ureteral stones.
Between 2007 and 2009, 225 outpatients were treated with Siemens Modularis Vario lithotripter at Sultan Qaboos University Hospital. Stone size, location, total number of shockwaves, stone-free rate, complications and adjunctive interventions were investigated. Chi-Square and Logistic Regression analyses were used, with p<0.05 set as the level of significance.
Of the 225 initial consecutive patients who underwent extracorporeal shock wave lithotripsy, 192 (85%) had renal stones and 33 (15%) had ureteric stones. The mean±SD stone size was 11.3±4.5 mm, while the mean age of the patients was 39.9±12.8 years with 68.5% males. The mean renal stone size was 11.6±4.7 mm; a mean of 1.3 sessions was required. The mean ureteric stone size was 9.9±3 mm; and a mean of 1.3 sessions was required. Treatment success (defined as complete clearance of ureteric stones, stone-free or clinically insignificant residual fragments of <4 mm for renal stones) was 74% for renal stones and 88% for ureteric stones. Additional extracorporeal shock wave lithotripsy and ureteroscopy were the most adjunctive procedures used for stone clearance. Complications occurred in 74 patients (38.5%) with renal stones and 13 patients (39.4%) with uretetric stones. The most common complication was loin pain (experienced by 16.7% with renal stones and 21% with ureteric stones). Severe renal colic mandating admission occurred in 2% of patients with renal stones and 6% of patients with ureteric stones. In patients with renal stone, steinstrasse occurred in 3.6% and infection post extracorporeal shock wave lithotripsy in 0.5%. Using Multivariate Logistic Regression analysis, factors found to have significant effect on complete stone clearance were serum creatinine (p=0.004) and the number of shockwaves (p=0.021).
Siemens Modularis Vario lithotripter is a safe and effective tool for treating renal and ureteric stones.
PMCID: PMC3725239  PMID: 23904918
Extracorporeal shock-wave lithotripsy (ESWL); Kidney; Ureter; Stones
10.  Analyzing the Effect of Distance from Skin to Stone by Computed Tomography Scan on the Extracorporeal Shock Wave Lithotripsy Stone-Free Rate of Renal Stones 
Korean Journal of Urology  2012;53(1):40-43.
To determine whether the distance from skin to stone, as measured by computed tomography (CT) scans, could affect the stone-free rate achieved via extracorporeal shock wave lithotripsy (ESWL) in renal stone patients.
Materials and Methods
We retrospectively reviewed the records 573 patients who had undergone ESWL at our institution between January 2006 and January 2010 for urinary stones sized from about 5 mm to 20 mm and who had no evidence of stone movement. We excluded patients with ureteral catheters and percutaneous nephrostomy patients; ultimately, only 43 patients fulfilled our inclusion criteria. We classified the success group as those patients whose stones had disappeared on a CT scan or simple X-ray within 6 weeks after ESWL and the failure group as those patients in whom residual stone fragments remained on a CT scan or simple X-ray after 6 weeks. We analyzed the differences between the two groups in age, sex, size of stone, skin-to-stone distance (SSD), stone location, density (Hounsfield unit: HU), voltage (kV), and the number of shocks delivered.
The success group included 33 patients and the failure group included 10. In the univariate and multivariate analysis, age, sex, size of stone, stone location, HU, kV and the number of shocks delivered did not differ significantly between the two groups. Only SSD was a factor influencing success: the success group clearly had a shorter SSD (78.25±12.15 mm) than did the failure group (92.03±14.51 mm). The results of the multivariate logistic regression analysis showed SSD to be the only significant independent predictor of the ESWL stone-free rate.
SSD can be readily measured by CT scan; the ESWL stone-free rate was inversely proportional to SSD in renal stone patients. SSD may therefore be a useful clinical predictive factor of the success of ESWL on renal stones.
PMCID: PMC3272555  PMID: 22323973
ESWL; Lithotripsy; Tomography; spiral computed
11.  Treatment of Kidney Stones Using Extracorporeal Shock Wave Lithotripsy (ESWL) and Double-J Stent in Infants 
Advances in Urology  2012;2012:589038.
Background. Extracorporeal shock wave lithotripsy (ESWL) has progressively acquired popularity as being the gold standard treatment for upper urinary tract lithiasis in infants since 1980. Our aim was to evaluate the outcome of ESWL for kidney stones and the use of double-J stent in infants. Material and Methods. A prospective clinical trial study performed on 50 infants with renal calculi at pelvic admitted in the Urology ward of Shafa Hospital, Sari, Iran, between 2001 and 2010. Main outcome measure of our study was clearing stones after one or more consecutive sessions of ESWL. Results. The study included 50 patients with renal calculi at pelvic. Among them, there were 35 (70%) boys and 15 (30%) girls with the age ranging from 1 to 13 months (mean of 7 month ± 3 days). All of them were treated by standard ESWL using Simons Lithostor plus machine. The stone sizes ranged from 6 mm to 22 mm. Double-J stents were placed in 11 infants (22%) with stones larger than 13 mm. Most of the patients required only one ESWL session. Conclusion. Since there were no complications following ESWL treatment, we can conclude that, in short term, ESWL is an effective and safe treatment modality for renal lithiasis in infants. In addition, we recommend double-J stent in infants with stones larger than 13 mm.
PMCID: PMC3329132  PMID: 22550483
12.  Double J stent reduces the efficacy of extracorporeal shock wave lithotripsy in the treatment of lumbar ureteral stones 
We evaluated the effect of the presence of a double J stent on the efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of lumbar ureteral stones.
Material and methods
Between January 2007 and February 2012, we performed a retrospective cohort study. Forty–four patients were treated by ESWL for lumbar ureteral stones and included into two groups for the analysis: group 1, non–stented (n = 27) and group 2, stented patients (n = 17). Treatment efficacy was evaluated by abdominal X–ray or CT–scan at 1 month. Stone–free patients and those with a residual stone ≤4 mm were considered to be cured.
Mean stone size and density in groups 1 and 2 were 8.2mm/831HU, and 9.7 mm/986HU respectively. Both groups were comparable for age, BMI, stone size and density, number, and power of ESWL shots given. The success rates in groups 1 and 2 where 81.5% and 47.1%, respectively (p = 0.017). There was no difference between the groups for stones measuring 8 mm or less (p = 0.574). For stones >8 mm, the success rates were respectively 76% and 22.2% for groups 1 and 2 (p = 0.030). Logistic regression analysis revealed a higher failure rate when a double J stent was associated with a stone >8 mm (p = 0.033).
The presence of a double J stent affects the efficacy of ESWL in the treatment of lumbar ureteral stones. This effect is significant for stones >8 mm. Ureteroscopy should be considered as the first–line treatment in such patients.
PMCID: PMC3974482  PMID: 24707370
shock wave lithotripsy; double J stent; ureteral stone; lumbar
13.  The usefulness of stone density and patient stoutness in predicting extracorporeal shock wave efficiency: Results in a North African ethnic group 
We determine the role of stone density and skin-to-stone distance (SSD) by non-contrast computed tomography of the kidneys, ureters and bladder (CT-KUB) in predicting the success of extracorporeal shock wave lithotripsy (ESWL).
We evaluated 89 patients who received ESWL for renal and upper ureteric calculi measuring 5 to 20 mm, over a 12-month period. The mean stone density in Hounsfield units (HU) and mean SSD in mm was determined on pre-treatment CT-KUB at the CT workstation. ESWL was successful if post-treatment residual stone fragments were ≤3 mm.
ESWL success was observed in 68.5% of patients. Mean stone densities were 505 ± 153 and 803 ± 93 HU in the ESWL successful and failure groups, respectively (p < 0.001, student’s t-test). The mean SSD were 10.6 ± 2.0 and 11.2 ± 2.6 cm in ESWL successful and failure groups, respectively; this was not statistically significant.
This study shows that stone density can help to predict the outcome of ESWL. We propose that stone density <500 HU are highly likely to result in successful ESWL. Conversely, stone densities >800 HU are less likely to be successful.
PMCID: PMC4137029  PMID: 25210567
14.  Efficacy of Alfuzosin After Shock Wave Lithotripsy for the Treatment of Ureteral Calculi 
Korean Journal of Urology  2013;54(2):106-110.
We evaluated the efficacy of alfuzosin for the treatment of ureteral calculi less than 10 mm in diameter after extracorporeal shock wave lithotripsy (ESWL).
Materials and Methods
A randomized, single-blind clinical trial was performed prospectively by one physician between June 2010 and August 2011. A total of 84 patients with ureteral calculi 5 to 10 mm in diameter were divided into two groups. Alfuzosin 10 mg (once daily) and loxoprofen sodium 68.1 mg (as needed) were prescribed to group 1 (n=41), and loxoprofen sodium 68.1 mg (as needed) only was prescribed to group 2 (n=44). The drug administration began immediately after ESWL and continued until stone expulsion was confirmed up to a maximum of 42 days after the procedure.
Thirty-nine of 41 (95.1%) patients in group 1 and 40 of 43 (93.0%) patients in group 2 ultimately passed stones (p=0.96). The number of ESWL sessions was 1.34±0.65 and 1.41±0.85 in groups 1 and 2, respectively (p=0.33). The patients who required analgesics after ESWL were 8 (19.5%) in group 1 and 13 (30.2%) in group 2 (p=0.31). Visual analogue scale pain severity scores were 5.33±1.22 and 6.43±1.36 in groups 1 and 2, respectively (p=0.056). The time to stone expulsion in groups 1 and 2 was 9.5±4.8 days and 14.7±9.8 days, respectively (p=0.005). No significant adverse effects occurred.
The use of alfuzosin in combination with ESWL seems to facilitate stone passage and to reduce the time of stone expulsion but does not affect the stone-free rate.
PMCID: PMC3580299  PMID: 23550174
Alfuzosin; Lithortripsy; Urolithiasis
15.  How has extracorporeal shock-wave lithotripsy changed the treatment of urinary stones in Quebec? 
OBJECTIVES: To determine the number of people who underwent treatment of urinary stones in Quebec before and after the introduction of extracorporeal shock-wave lithotripsy (ESWL) and to determine how the introduction of ESWL influenced resource utilization. DESIGN: Before-after study; data were obtained from administrative databases and hospital-based cost estimates. SETTING: The 68 acute care hospitals in Quebec in which treatment of urinary stones is undertaken. PATIENTS: Quebec residents admitted to hospital for treatment of urinary stones between the fiscal years 1984 and 1992. OUTCOME MEASURES: Number of people treated for urinary stones per year, total number of procedures per year (including open surgery, percutaneous procedures, retrograde procedures and ESWL), and annual resources (including number of hospital bed-days and direct costs) for treatment of urinary stones used overall and in hospitals with and without ESWL services. RESULTS: Over the study period the number of people treated for urinary stones increased by 59%. As well, the combined frequency of ESWL and surgery (the two main treatment methods) increased by 107%. These increases were largely due to rates of treatment that grew by 52% among women and by 34% among men. The total number of hospital bed-days decreased by 28%, which reflected shorter hospital stays for ESWL. However, despite this decrease, the total direct annual costs were 7% higher in 1992 than in 1984 because of the increased numbers of people treated and procedures performed. In the three hospitals that offered ESWL the number of hospital bed-days and the direct costs of treating urinary stones increased by 49% and $2.5 million respectively. In the 65 other hospitals these figures decreased by 41% and about $2.9 million respectively. CONCLUSIONS: Because of increased intervention rates the total cost of treating urinary stones has risen since the introduction of ESWL. The introduction of ESWL has also been associated with a shift in the use of resources for treating urinary stones to hospitals with a lithotriptor. The reasons for the increased intervention rates are unknown. However, given the possibility of negative health effects and the increased costs, studies to determine whether the increased rates improve health outcomes are warranted.
PMCID: PMC1488166  PMID: 8529187
16.  Management of lower ureteric stones: a prospective study 
To discuss the current concepts in lower ureteric stone management.
Material and methods
Between October 2008 and November 2010, 190 patients of both sexes and of different age groups with lower ureteric stones, underwent in situ extracorporeal shock wave lithotripsy (ESWL) (48 cases), ureterorenoscopy (URS) (120 cases) and open stone surgery (OSS) (22 cases).
The patients’ clinical and radiological findings, as well as stone characteristics, were reviewed and correlated with the stone–free status.
In the ESWL group, the operative time was 43.13 +22.5 min; the average number of sessions/patients was 1.5 sessions; the average number of SW/patients was 4500 SW/patients; the average energy was 16.5 kV; the average stone burden was 7.8/mm; the overall stone–free rate was 75% (36/48); and the average radiation exposure time was 3.5 min.
In the URS group, the operative time was 49.21 +16.09 min; the average stone burden was 10.81mm; the overall stone–free rate was 97.5% (117/120); the average hospital stay was 3.99 days; and the average radiation exposure time was 0.75 min.
In the OSS group, the operative time was 112.38 +37.1 min; the overall stone–free rate was 100% (22/22); and the average hospital stay was 9.74 days.
In the management of patients with lower ureteral stones, URS, SWL and OSS were considered acceptable treatment options.
This recommendation was based on the stone–free results, morbidity and retreatment rates for each therapy.
PMCID: PMC3992439  PMID: 24757544
management; stones; SWL; URS; OSS; ureter
17.  Management of symptomatic ureteral calculi during pregnancy: Experience of 23 cases 
Urology Annals  2013;5(4):241-244.
To present our experience in the management of symptomatic ureteral calculi during pregnancy.
Materials and Methods:
Twenty-three pregnant women, aged between 19 and 28 years presented to the obstetric and urology departments with renal colic (17 cases, 73.9%) and fever and renal pain (6 cases, 26.1%); suggesting ureteric stones. The diagnosis was established by ultrasonography (abdominal and transvaginal). Outpatient follow-up consisted of clinical assessment and abdominal ultrasonography. Follow-up by X-ray of the kidneys, ureter, and bladder (KUB), or intravenous urography (IVU) was done in the postpartum period.
Double J (DJ) stent was inserted in six women (26%) with persistent fever followed by extracorporeal shock wave lithotripsy (ESWL) one month post-partum. Ureteroscopic procedure and pneumatic lithotripsy were performed for 17 women (distal ureteric stone in 10, middle ureter in 5, and upper ureteric stone in 2). Stone-free rate was 100%. No urologic, anesthetic, or obstetric complications were encountered.
Ureteroscopy, pneumatic lithotripsy, and DJ insertion could be a definitive and safe option for the treatment of obstructive ureteric stones during pregnancy.
PMCID: PMC3835980  PMID: 24311902
Pregnancy; ureteral calculi; ureteroscopy
18.  Predictive Factors of the Outcome of Extracorporeal Shockwave Lithotripsy for Ureteral Stones 
Korean Journal of Urology  2012;53(6):424-430.
Extracorporeal Shock Wave Lithotripsy (ESWL) has shown successful outcomes for ureteral stones. We investigated predictive factors for failure of ESWL for treating ureteral stones.
Materials and Methods
A total of 153 patients who underwent ESWL between July 2006 and July 2009 for ureteral stones diagnosed by non-enhanced spiral computed tomography were divided into two groups: (group A, stone size ≤10 mm; and group B, stone size >10 mm). The failure was defined as remnant stones >4 mm. We assessed age, sex, body mass index, stone size, laterality, location, skin-to-stone distance (SSD), Hounsfield unit, and the presence of secondary signs (hydronephrosis, renal enlargement, perinephric fat stranding, and tissue rim sign). We analyzed predictive factors by using logistic regression in each group.
The success rates were 90.2% and 68.6% in group A and B, respectively. In the univariate analysis of each group, stone size, SSD, and all secondary signs showed statistically significant differences in terms of the outcome of ESWL (p<0.05). In the multivariate logistic regression, stone size (odds ratio [OR], 50.005; 95% confidence interval [CI], 6.207 to 402.852) was an independent predictive factor in group A. The presence of perinephric fat standing (OR, 77.634; 95% CI, 1.349 to 446.558) and stone size (OR, 19.718; 95% CI, 1.600 to 243.005) were independent predictive factors in group B.
Stone size is an independent predictive factor influencing failure of ESWL for treating ureteral stones. In larger ureteral stones (>10 mm), the presence of perinephric fat stranding is also an independent predictive factor.
PMCID: PMC3382694  PMID: 22741053
Lithotripsy; Treatment outcome; Ureteral calculi
19.  Is an excretory urogram mandatory in patients with small to medium-sized renal and ureteric stones treated by extra corporeal shock wave lithotripsy? 
BMC Medicine  2004;2:15.
An intravenous urogram (IVU) has traditionally been considered mandatory before treating renal and ureteric stones by extracorporeal shock wave lithotripsy (ESWL). This study was designed to see whether there is a difference in complications and the need for ancillary procedures in patients managed by ESWL for renal and ureteric calculi, according to preoperative imaging technique.
This retrospective study compared 133 patients undergoing ESWL from January 2001 to July 2002. Patients were divided into three groups according to the preoperative imaging technique used: i) IVU; ii) non-contrast enhanced helical computed tomography (UHCT); and iii) ultrasound (US) + X-ray kidney, ureter and bladder (KUB). The groups were matched in terms of age and gender, as well as location, side and size of stones.
There was no statistically significantly difference for number of ESWL sessions, number of shock waves and use of ancillary procedures between the three groups. The stone-free rate was 98% for the IVU and UHCT groups, and 97% for the US + X-ray KUB group.
The complication rate and need for ancillary procedures was comparable across the three groups. Patients imaged by UHCT or US + X-ray KUB prior to ESWL for uncomplicated renal and ureteric stones do not require IVU.
PMCID: PMC411063  PMID: 15115545
20.  Variables influencing the likelihood of cardiac dysrhythmias during extracorporeal shock wave lithotripsy 
Extracorporeal shock wave lithotripsy (ESWL) is a safe and effective treatment of upper urinary tract calculi. While serious side effects are rare, transient cardiac dysrhythmias (CD) may be associated with ESWL. The exact etiology of these events, which are often unpredictable, is poorly understood. Awareness of CD during ESWL and identification of risk factors for developing them could help clinicians predict and manage them safely and effectively. The current study examines selected variables to determine whether they may predispose individuals to developing CD during ESWL.
We compared 16 patients who experienced CD during ESWL to 56 control patients. Cases and controls were compared with respect to several continuous and discrete variables, including age, pre-treatment heart rate, number of shocks received during treatment, energy setting of the lithotripter, gender, presence of a ureteric stent, previous ESWL and side being treated.
Cardiac dysrhythmias occurred more frequently in younger patients and in those being treated for right-sided stones. The other variables did not influence the likelihood of CD. All CD resolved promptly following conversion to electrocardiogram (ECG)-gating.
Younger age and right-sided treatment predisposed individuals to developing CD during ESWL. Careful ECG monitoring should be performed during treatment.
PMCID: PMC3328549  PMID: 21740856
21.  Comparison of ESWL and Ureteroscopic Holmium Laser lithotripsy in Management of Ureteral Stones 
PLoS ONE  2014;9(2):e87634.
There are many options for urologists to treat ureteral stones that range from 8 mm to 15 mm, including ESWL and ureteroscopic holmium laser lithotripsy. While both ESWL and ureteroscopy are effective and minimally invasive procedures, there is still controversy over which one is more suitable for ureteral stones.
To perform a retrospective study to compare the efficiency, safety and complications using ESWL vs. ureteroscopic holmium laser lithotripsy in management of ureteral stones.
Between October 2010 and October 2012, 160 patients who underwent ESWL or ureteroscopic holmium laser lithotripsy at Suzhou municipal hospital for a single radiopaque ureteral stone (the size 8–15 mm) were evaluated. All patients were followed up with ultrasonography for six months. Stone clearance rate, costs and complications were compared.
Similarity in stone clearance rate and treatment time between the two procedures; overall procedural time, analgesia requirement and total cost were significantly different. Renal colic and gross hematuria were more frequent with ESWL while voiding symptoms were more frequent with ureteroscopy. Both procedures used for ureteral stones ranging from 8 to 15 mm were safe and minimally invasive.
ESWL remains first line therapy for proximal ureteral stones while ureteroscopic holmium laser lithotripsy costs more. To determining which one is preferable depends on not only stone characteristics but also patient acceptance and cost-effectiveness ratio.
PMCID: PMC3912003  PMID: 24498344
22.  Fluoroscopically guided laser lithotripsy versus extracorporeal shock wave lithotripsy for retained bile duct stones: a prospective randomised study. 
Gut  1997;40(5):678-682.
BACKGROUND AND AIMS: To compare extracorporeal shock wave lithotripsy (ESWL) and laser induced shock wave lithotripsy (LISL) of retained bile duct stones to stone free rate, number of therapeutic sessions, and costs. PATIENTS: Thirty four patients were randomly assigned to either ESWL or LISL therapy. The main reasons for failure of standard endoscopy were due to stone impaction (n = 12), biliary stricture (n = 8), or large stone diameter (n = 14). METHODS: An extracorporeal piezoelectic lithotripter with ultrasonic guidance and a rhodamine 6G laser with an integrated stone tissue detection system were used. LISL was performed exclusively under radiological control. RESULTS: Using the initial methods complete stone fragmentation was achieved in nine of 17 patients (52.4%) of the ESWL group and in 14 of 17 patients (82.4%) in the LISL group, or combined with additional fragmentation techniques 31 of the 34 patients (91.2%) were stone free at the end of treatment. In comparison LISL tended to be more efficient in clearing the bile ducts (p = 0.07, NS). Significantly less fragmentation sessions (1.29 v 2.82; p = 0.0001) and less additional endoscopic sessions (0.65 v 1.6; p = 0.002) were necessary in the LISL group. There were no major complications in either procedure. CONCLUSIONS: Compared with ESWL, fluoroscopically guided LISL achieves stone disintegration more rapidly and with significantly less treatment sessions, which leads to a significant reduction in cost.
PMCID: PMC1027174  PMID: 9203950
23.  A Prospective Randomized Controlled Trial of the Efficacy of Tamsulosin After Extracorporeal Shock Wave Lithotripsy for a Single Proximal Ureteral Stone 
Korean Journal of Urology  2013;54(8):527-530.
The objective of this study was to evaluate the efficacy of tamsulosin on stone clearance after extracorporeal shock wave lithotripsy (ESWL) in patients with a single proximal ureteral stone.
Materials and Methods
This prospective randomized controlled trial was performed on 88 patients with a single proximal ureteral stone. After consenting with a doctor, the patients were allocated to the treatment (tamsulosin 0.2 mg once a day) or control (no medication) group, and the efficacy of tamsulosin was evaluated. The primary outcome of this study was the stone-free rate, and the secondary outcomes were the period until clearance, pain intensity, analgesic requirement, and incidence of complications.
A stone-free state was reported in 37 patients (84.1%) in the treatment group and 29 (65.9%) in the control group (p=0.049). The mean expulsion period of the stone fragments was 10.0 days in the treatment group and 13.2 days in the control group (p=0.012). There were no statistically significant differences in aceclofenac requirement or pain score between the two groups. Only one patient in the treatment group experienced transient dizziness associated with medical expulsive therapy, and this adverse event disappeared spontaneously.
The results of this prospective randomized controlled trial of the efficacy of tamsulosin after ESWL for a single proximal ureteral stone suggest that tamsulosin helps in the earlier clearance of stone fragments and reduces the expulsion period of stone fragments after ESWL.
PMCID: PMC3742905  PMID: 23956828
Lithotripsy; Tamsulosin; Urolithiasis
24.  Extracorporeal shockwave lithotripsy for lower pole calculi smaller than one centimeter 
Extracorporeal shockwave lithotripsy (ESWL) has revolutionized the treatment of urinary calculi and became the accepted standard therapy for the majority of stone patients. Only for stones located in the lower calix, ESWL displayed a limited efficacy. Since the stone-free rate seemed to be preferential, endoscopic maneuvers like percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) have been proposed as the primary approach for this stone localization.
Stone size seems to be the most important parameter in regard to the stone-free rate, whereas anatomical characteristics of the lower pole collecting system are discussed controversial. Various studies show a good stone clearance between 70-84% for stones up to 1 cm in diameter. Additional physical and medical measures are suitable to improve treatment results. Stone remnants after ESWL, defined as clinical insignificant residual fragments (CIRF) will not cause problems in every case and will pass until up to 24 months after treatment; in total 80-90% of all patients will become stone-free or at least symptom-free.
When complete stone-free status is the primary goal, follow-up examinations with new radiological technologies like spiral CT show that the stone-free rate of ESWL and endoscopically treated patients (RIRS) does not differ significantly. However, in comparison to endoscopic stone removal, shockwave therapy is noninvasive, anesthesia-free and can be performed in an outpatient setup. Therefore, ESWL remains the first choice option for the treatment of lower caliceal stones up to 1 cm. The patient will definitely favour this procedure.
PMCID: PMC2684396  PMID: 19468510
Extracorporeal shockwave lithotripsy; lower pole; nephrolithiasis
25.  Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones 
AIM: The usual bile duct stone may be removed by means of Dormia basket or balloon catheter, and results are quite good. However, the degree of difficulty is increased when stones are larger. Studies on the subject reported many cases where mechanical lithotripsy is combined with a second technique, e.g., electrohydraulic lithotripsy (EHL), where stones are crushed using baby-mother scope electric shock. The extracorporeal shock-wave lithotripsy (ESWL) or laser lithotripsy also yields an excellent success rate of greater than 90%. However, the equipment for these techniques are very expensive; hence we opted for the simple mechanical lithotripsy and evaluated its performance.
METHODS: During the period from August 1996 to December 2002, Mackay Memorial Hospital treated 304 patients suffering from difficult bile duct stones (stone >1.5 cm or stones that could not be removed by the ordinary Dormia basket or balloon catheter). These patients underwent endoscopic papillotomy (EPT) procedure, and stones were removed by means of the Olympus BML-4Q lithotripsy. A follow-up was conducted on the post-treatment conditions and complications of the patients.
RESULTS: Out of the 304 patients, bile duct stones were successfully removed from 272 patients, a success rate of about 90%. The procedure failed in 32 patients, for whom surgery was needed. Out of the 272 successfully treated patients, 8 developed cholangitis, 21 developed pancreatitis, and 10 patients had delayed bleeding, and no patient died. Among these 272 successful removal cases, successful bile duct stone removal was achieved after the first lithotripsy in 211 patients, whereas 61 patients underwent multiple sessions of lithotripsy. As for the 61 patients that underwent multiple sessions of mechanical lithotripsy, 6 (9.8%) had post-procedure cholangitis, 12 (19.6%) had pancreatitis, and 9 patients (14.7%) had delayed bleeding. Compared with the 211 patients undergoing a single session of mechanical lithotripsy, 3 (1.4%) had cholangitis, 1 (0.4%) had delayed bleeding, and 7 patients (3.3%) had pancreatitis. Statistical deviation was present in post-procedure cholangitis, delayed bleeding, and pancreatitis of both groups.
CONCLUSION: Mechanical bile stone lithotripsy on difficult bile duct stones could produce around 90% successful rate. Moreover, complications are minimal. This finding further confirms the significance of mechanical lithotripsy in the treatment of patients with difficult bile duct stones.
PMCID: PMC4250818  PMID: 15641153
Common bile duct stones; Mechanical lithotripsy

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