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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.
Purpose
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.
Results
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.
Conclusions
Our data suggest that eESWL in colic patients with ureteral stones is an effective and safe treatment with accelerated stone clearance.
doi:10.4111/kju.2012.53.12.853
PMCID: PMC3531639  PMID: 23301130
Colic; Lithotripsy; Ureteral calculi
2.  Kidney stones 
Clinical Evidence  2011;2011:2003.
Introduction
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).
Results
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.
Conclusions
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
3.  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.
Purpose
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.
Results
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.
Conclusions
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.
doi:10.4111/kju.2013.54.7.460
PMCID: PMC3715710  PMID: 23878689
Lithotripsy; Pediatrics; Treatment outcome; Urinary calculi
4.  Usefulness of adjunctive alpha1-adrenergic antagonists after single extracorporeal shock wave lithotripsy session in ureteral stone expulsion 
Introduction:
We evaluate the efficiency of α-adrenergic antagonists on stone clearance after extracorporeal shock wave lithotripsy (ESWL) in patients with lower ureteral stones.
Methods:
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.
Results:
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%).
Conclusion:
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.
doi:10.5489/cuaj.1261
PMCID: PMC3896566  PMID: 24454608
5.  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.
doi:10.4103/0970-1591.74462
PMCID: PMC3034067  PMID: 21369391
ESWL; pediatric urolithiasis; ureteroscopy
6.  Extracorporeal Shock-wave Lithotripsy Success Rate and Complications: Initial Experience at Sultan Qaboos University Hospital 
Oman Medical Journal  2013;28(4):255-259.
Objective
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.
Methods
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.
Results
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).
Conclusion
Siemens Modularis Vario lithotripter is a safe and effective tool for treating renal and ureteric stones.
doi:10.5001/omj.2013.72
PMCID: PMC3725239  PMID: 23904918
Extracorporeal shock-wave lithotripsy (ESWL); Kidney; Ureter; Stones
7.  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.
Purpose
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.
Results
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.
Conclusions
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.
doi:10.4111/kju.2012.53.1.40
PMCID: PMC3272555  PMID: 22323973
ESWL; Lithotripsy; Tomography; spiral computed
8.  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.
doi:10.1155/2012/589038
PMCID: PMC3329132  PMID: 22550483
9.  Double J stent reduces the efficacy of extracorporeal shock wave lithotripsy in the treatment of lumbar ureteral stones 
Introduction
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.
Results
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).
Conclusions
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.
doi:10.5173/ceju.2013.03.art14
PMCID: PMC3974482  PMID: 24707370
shock wave lithotripsy; double J stent; ureteral stone; lumbar
10.  Efficacy of Alfuzosin After Shock Wave Lithotripsy for the Treatment of Ureteral Calculi 
Korean Journal of Urology  2013;54(2):106-110.
Purpose
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.
Results
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.
Conclusions
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.
doi:10.4111/kju.2013.54.2.106
PMCID: PMC3580299  PMID: 23550174
Alfuzosin; Lithortripsy; Urolithiasis
11.  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
12.  Management of lower ureteric stones: a prospective study 
Objective
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.
Results
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.
Conclusion
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.
doi:10.5173/ceju.2013.04.art19
PMCID: PMC3992439  PMID: 24757544
management; stones; SWL; URS; OSS; ureter
13.  Management of symptomatic ureteral calculi during pregnancy: Experience of 23 cases 
Urology Annals  2013;5(4):241-244.
Purpose:
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.
Results:
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.
Conclusions:
Ureteroscopy, pneumatic lithotripsy, and DJ insertion could be a definitive and safe option for the treatment of obstructive ureteric stones during pregnancy.
doi:10.4103/0974-7796.120294
PMCID: PMC3835980  PMID: 24311902
Pregnancy; ureteral calculi; ureteroscopy
14.  Predictive Factors of the Outcome of Extracorporeal Shockwave Lithotripsy for Ureteral Stones 
Korean Journal of Urology  2012;53(6):424-430.
Purpose
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.
Results
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.
Conclusions
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.
doi:10.4111/kju.2012.53.6.424
PMCID: PMC3382694  PMID: 22741053
Lithotripsy; Treatment outcome; Ureteral calculi
15.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1741-7015-2-15
PMCID: PMC411063  PMID: 15115545
16.  Variables influencing the likelihood of cardiac dysrhythmias during extracorporeal shock wave lithotripsy 
Introduction:
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.
Methods:
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.
Results:
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.
Conclusion:
Younger age and right-sided treatment predisposed individuals to developing CD during ESWL. Careful ECG monitoring should be performed during treatment.
doi:10.5489/cuaj.10122
PMCID: PMC3328549  PMID: 21740856
17.  Comparison of ESWL and Ureteroscopic Holmium Laser lithotripsy in Management of Ureteral Stones 
PLoS ONE  2014;9(2):e87634.
Background
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.
Objective
To perform a retrospective study to compare the efficiency, safety and complications using ESWL vs. ureteroscopic holmium laser lithotripsy in management of ureteral stones.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1371/journal.pone.0087634
PMCID: PMC3912003  PMID: 24498344
18.  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
19.  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.
doi:10.4103/0970-1591.44260
PMCID: PMC2684396  PMID: 19468510
Extracorporeal shockwave lithotripsy; lower pole; nephrolithiasis
20.  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.
Purpose
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.
Results
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.
Conclusions
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.
doi:10.4111/kju.2013.54.8.527
PMCID: PMC3742905  PMID: 23956828
Lithotripsy; Tamsulosin; Urolithiasis
21.  Pulverisation of calcified and non-calcified gall bladder stones: extracorporeal shock wave lithotripsy used alone. 
Gut  1994;35(3):417-422.
Using a modified electromagnetic lithotripter (Siemens), extracorporeal shock wave lithotripsy (ESWL) was performed in 260 patients with gall bladder stones. Exclusion criteria for treatment were a non-functioning gall bladder, subcostal gall bladder location, and multiple stones occupying more than three quarters of the gall bladder volume. Stone pulverisation was the end point of ESWL. The number of shock wave discharges and sessions was not limited. Pulverisation was achieved in 250 patients (96.1%) after a median of three ESWL sessions (range 1-21). The number of sessions required depended upon stone composition and burden. More than three sessions were required in 60.2% of patients with calcified stones compared with 35.9% of patients with non-calcified stones (p < 0.001). 65.8% of patients with stones measuring more than 30 mm in total diameter required more than three sessions compared with 42.9% of patients with a stone burden less than 30 mm (p < 0.01). At 18-24 (8-12) months follow up, stone clearance was achieved in 94.3% (80.4%) of patients with non-calcified stones, compared with 89.5% (76.8%) in patients with calcified stones and in 75% (71.4%) of patients with a total stone diameter more than 30 mm compared with 95.7% (80.4%) for patients with a total stone diameter less than 30 mm (p < 0.05). ESWL related complications (gross haematuria) occurred in three patients. Thirty six (13.8%) patients experienced biliary colic; four had cholecystectomy, and five endoscopic papillotomy because of common bile duct obstruction. Stone recurrence was seen in 5.3% of patients over a follow up period of up to two years (median 16.6 months).
PMCID: PMC1374602  PMID: 8150358
22.  Managing caliceal stones 
The natural course of untreated asymptomatic caliceal calculi has not been clearly defined, especially in terms of disease progression, and the indications for and outcomes of surgical intervention are not precise. Caliceal stones may remain asymptomatic but, in case of migration, ureteral calculi can cause acute ureteric colic with severe complications. The decision for an active treatment of caliceal calculi is based on stone composition, stone size and symptoms. Extracorporal shock-wave lithotripsy (ESWL) has a low complication rate and is recommended by the current guidelines of the European Association of Urology as a first-line therapy for the treatment of caliceal stones <2 cm in diameter. However, immediate stone removal is not achieved with ESWL. The primary stone-free rates (SFR) after ESWL depend on stone site and composition and, especially for lower pole calculi, the SFR differ widely from other caliceal stones. Minimally-invasive procedures including percutaneous nephrolithotomy and ureteroscopy are alternatives for the treatment of caliceal stones, associated with low morbidity and high primary SFR when performed in centers of excellence.
doi:10.4103/0970-1591.124214
PMCID: PMC3897062  PMID: 24497690
Caliceal stones; extracorporeal shock-wave lithotripsy; percutaneous nephrolithotomy; ureteroscopy
23.  Clinical effectiveness of the PolyScope™ endoscope system combined with holmium laser lithotripsy in the treatment of upper urinary calculi with a diameter of less than 2 cm 
The aim of this study was to evaluate the clinical value of the PolyScope™ endoscope system in the treatment of upper urinary calculi with a diameter of <2 cm. A total of 86 patients hospitalized with upper urinary tract calculi were included. The patients were placed under general or spinal anesthesia and in a lithotomy position. Following the dilation of the ureter, a guide wire was inserted under the direct vision of an F8/9.8 rigid ureteroscope, and an F12/14 flexible ureteral access sheath was positioned along the guide wire. Holmium laser lithotripsy was subsequently performed, using an F8.0 ‘PolyScope’ modular flexible ureteroscope. Plain film of the kidney-ureter-bladder (KUB) was performed 1 day subsequent to the surgery, in order to determine the result of the lithotripsy and the position of the double-J stent which was inserted after after holmium laser lithotripsy. In addition, in certain patients, KUB radiography was performed 2–4 weeks subsequent to the surgery, and extracorporeal shockwave lithotripsy (ESWL) was performed if the diameter of the residual stones was >6 mm. Lithotripsy was successful in 77 patients and the duration of the surgery ranged between 25 and 80 min (mean duration, 42 min). Little bleeding was observed. Three patients presented with a slight fever following the surgery; however, no ureteral perforation, high fever or septicemia was observed among the patients following anti-inflammatory treatment. The stone-free rate (SFR) of the single-pass lithotripsy was 89.5% (77/86) and the SFR with ESWL was 96.5% (83/86). The study demonstrated that the F8 modular flexible ureteroscope was safe, convenient and effective for the lithotripsy of upper-tract calculi.
doi:10.3892/etm.2013.1184
PMCID: PMC3786953  PMID: 24137232
modular; flexible ureteroscope; Holmium laser; lithotripsy; urinary calculi
24.  Extracorporeal shockwave lithotripsy, endourology and open surgery: the management and follow-up of 200 patients with urinary calculi. 
The management and follow up of 200 consecutive patients with renal and ureteric calculi are presented. The primary treatment of 185 (92.5%) was by extracorporeal shockwave lithotripsy (ESWL), of whom three (1.6)%) with large calculi underwent percutaneous nephrolithotripsy (PCNL) prior to ESWL as a planned combined procedure. Twelve (6%) were treated by PCNL or ureterorenoscopy (URS) as their definitive treatment and three (1.5%) by conventional open renal and ureteric surgery. The average in-patient stay was 3.8 days and most returned to normal activity within one day of discharge. Of the 185 patients 102 (55%) required no analgesia after treatment by ESWL, 29 (15.6%) required parenteral analgesia and the rest were comfortable with oral non-narcotic medication. Thirty (16%) required auxillary treatment by percutaneous nephrostomy (PCN), PCNL and URS following ESWL for obstructive complications from stone particles. Two required further ESWL and one PCNL at three months for large fragments. Overall, open surgery was required for only 1% of renal calculi and 13% of ureteric stones. These results are consistant with the extensive West German experience confirming that most urinary calculi are now best managed by ESWL and endoscopic techniques. Where these facilities are available open surgery should only be necessary for less than 5% of upper urinary tract stones.
PMCID: PMC2498105  PMID: 4073760
25.  Outcome of bilateral ureteroscopic retrieval of stones in a single session 
Urology Annals  2012;4(3):158-161.
Aim:
Evaluation of bilateral ureteroscopic retrieval of stones as a single-stage procedure in terms of clearance of the stones, complications of the procedure and duration of hospital stay. A successful outcome was considered when both ureters were free of stones without any major complications.
Materials and Methods:
A total of 60 patients with bilateral ureteric stones were treated ureteroscopically from March 2006 to September 2009 in the department of Surgery (Urology unit). Majority of the patients were in their third and fourth decade of life with 38 males and 22 females. A single session bilateral ureteroscopic retrieval of stones was done using a 7.8 Fr semirigid ureteroscope. A 0.038-inch guide wire was used and advanced under direct vision, and monitored by C-arm X-ray image intensifier. Balloon dilatation of the intramural ureters was required in 82 renal units. The stones were either extracted directly or disintegrated into small pieces by lithotripsy (pneumatic) before extraction. Ureteric stenting was required in 39 patients. Patients were followed for a period of 3-12 months.
Results:
A total of 60 patients (120 renal units) with bilateral ureteric stones were treated ureteroscopically. The stone size in the treated patients was in the range 6-20 mm. The stones were radio-opaque in 47 patients and radiolucent in 13 patients. Single stone was present in all except two patients. Operative time ranged between 40 and 120 minutes. Stones were completely removed in 51 (85%) patients following single-session procedure of which 39 (76.4%) were stonefree intraoperatively and another 12 (23.5%) were cleared of the stones in 4 weeks follow-up. Six patients were stonefree unilaterally. Failed procedures were managed with repeated ureteroscopy, DJ stenting and ESWL or open ureterolithotomy. Intraoperatively false passage or minor ureteric perforations were seen in six patients. Postoperative complications included abdominal pain in 10, persistent fever in 4 and hematuria in 2 patients. No long-term complications were observed. Most of the patients were discharged in 2 days.
Conclusion:
Bilateral same-session ureteroscopy is a safe and effective procedure in the management of bilateral ureteral stones. The results are comparable to unilateral or staged bilateral procedures.
doi:10.4103/0974-7796.102662
PMCID: PMC3519107  PMID: 23248522
Bilateral ureteroscopy; bilateral ureteric stones; single session

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