Extracorporeal Shock Wave Lithotripsy

Erin M. Burns, PGY-2Medical University of South Carolina

Department of Urology

Grand Rounds9/28/10

Erin BurnsResident, MUSC

ESWLObjectives of Presentation:

History, Present, and Future UsesIn accordance with the ACCME Essentials & Standards, anyone involved in

planning or presenting this educational activity will be required to disclose any relevant financial relationships with commercial interests in the

healthcare industry. Speakers who incorporate information about off-label or investigational use of drugs or devices will be asked to disclose that

information at the beginning of their presentation.I have no financial relationships to disclose.

The Medical University of South Carolina designates this educational activity for a maximum of _1___

AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the

extent of their participation in the activity.

ESWL

•

History of ESWL•

How does ESWL work?

•

Indications•

Complications

•

Optimizing ESWL•

New Applications

•

Conclusions

History of ESWL

•

Focusing sound waves-Ancient Greece•

Sonic Boom-High energy shock waves

•

February 1980-Dornier lithotripter first used on human subject

History of ESWL

•

1983: Distribution and Production of the Dornier HM3

•

1984: ESWL approved by the USFDA1

How Does ESWL Work?

•

Shock waves-

a special form of sound waves that have a sharp peak in positive pressure followed by a trailing negative wave

•

The change in density and acoustic impedance when traveling from water to stone results in fragmentation

How ESWL Works

•

Energy Source

•

Device to focus the shock wave

•

Coupling Medium

•

Stone Localization System

How ESWL Works

•

Energy and Focus-two main types-point source-high voltage spark is

discharged and produces rapid evaporation of water

-extended source-sudden expansion of ceramic elements excited by a high frequency, high voltage pulse generates a shock wave

How ESWL works

•

Energy Source

•

Device to focus the shock wave

•

Coupling Medium: water

•

Stone localization system: flouroscopy

or sonography, or combination of both2

Indications for ESWL

•

Grasso et al, 1995 reviewed 121 ESWL failures3

ESWL

•

Ideal patient should be non-obese, and have total stone burden <2.2cm

•

Stone should not be located within dependent or obstructed portions of the collecting system

•

ESWL of infectious calculi can lead to overwhelming postoperative sepsis3

ESWL in Elderly Patients

•

Sighinolfi

et al: ESWL in 130 patients over 70. 52% were stone free after one treatment, 35% required an additional session, no complications were noted

•

They concluded that ESWL is safe in elderly with appropriate preoperative evaluations4, 5

ESWL in Pediatrics

•

Lu et al: 115 children, mean age 7.2 years, stone free rate 96.2% with retreatment rate of 13.2%6

•

Landeau

et at: 157 children, mean age 6.6 years, stone free rate 80% with retreatment rate of 19.7%7

•

Conclusions: ESWL is safe in children with low complication rate, more effective in stones <11mm

Complications of ESWL

HEMATOMA•

Navarro et al 2009 review 4819 ESWL cases performed at their institution in mexico

and

had 6 cases of perirenal and subcapsular hematoma (<1%)8

•

Serra et al 1999: performed ESWL on 10953 patients between 1987-1996. Renal hematomas developed in 31 patients, an incidence of 0.28%9

•

Usual presentation was low back pain, and risk factors included HTN, clotting disorders and history of previous ESWL treatments

Complications of ESWL

Diabetes Mellitus, Hypertension•

Krambeck

et al 2006: chart review of 630 pts

treated with ESWL, showed an increased rate in development of diabetes and hypertension, compared to controls managed nonoperatively10

•

Sato et al 2008: Compared new onset HTN and DM in pts with renal and ureteral

stones treated with

ESWL and found no difference in the rates of new onset11

•

Makhlouf

et al 2009: 1947 pts treated fm 1999-2002,

matched with controls, followed for 6 years. No difference was found in incidence of new onset diabetes12

Complications of ESWL

Steinstrasse•

Sayed

et al 2001: 885 pts from 1997-1999 with renal

and ureteral

stones treated with ESWL, 52 (6%)

developed Steinstrasse

•

48% were managed conservatively, 23% had repeated ESWL, 19% PCNL, 6% ureteroscopy, 4% open surgery13

•

Madbouly

et al 2002 concluded that risk of

Steinstrasse

was greater in stone size >2cm, more

likely with renal stones, dilated systems, and when using higher power (>22kV)14

Optimizing ESWL

•

Stent

•

Tamsulozin

(Flomax)

•

ESWL shock rate

Optimizing ESWL

To stent or not to stent??•

Argyropoulos

and Tolley

2008 evaluated 45

patients who were stented

at time of ESWL and compared them with pts with matched characteristics including stone size (mean 8.5mm) who were not stented

•

Overall success (defined as stone-free or fragments <4mm) was 16% higher for the stent free group (77 vs

93%)15

Optimizing ESWL

To stent or not to stent??•

Mohayuddin

et al 2009: 40 matched pairs with mean

stone size 2cm were compared for LUTS, ER visits, renal colic, steinstrasse, stone clearance, need for other procedures, and cost

•

The stented

group experienced less renal colic (7.5

vs

32.5%), less steinstrasse

(7.5 vs

10%), fewer ER

visits (mean 0.7 vs

2.1)

•

Stone clearance rates were 77.5% stented

and

82.5% unstented•

The stenting

was not significant in terms of

steinstrasse

or clearance rates, but was

statistically significant for decreasing renal colic.16

Optimizing ESWL: Flomax

•

Gravina

et al 2005: 130 pts undergoing ESWL for solitary stone size 4-20mm were randomized to receive flomax

daily

•

Stone free rates were higher in the flomax group (78.5 vs

60% stone free at 3 mos), this

difference became even more apparent when looking specifically at stones ≥1cm

•

They also noted less renal colic and less frequent use of pain meds/NSAIDs

in the

Flomax

group17

Optimizing ESWL: Flomax

•

Naja

et al 2008: prospective randomized study of 139 pts with 5-20mm stones undergoing ESWL every 3 weeks until stone free, were randomly assigned to receive flomax

or to the control group

•

The Flomax

group required fewer ESWL sessions, had less pain, and developed less steinstrass

(2patients in flomax

group vs

9 in

the control group)18

Optimizing ESWL-Rate

•

Options for ESWL frequencies range on most machines from 60-120 shocks/min, with a maximum threshold of 3000 shocks for renal stones.

•

Kato et al 2009: 134 pts treated between 2002-2004 were treated with either 60SW/min or 120SW/min

•

Effective fragmentation was noted more often after just one ESWL session in the 60SW/sec group (65.2% vs

47.1%), no

significant difference was noted at 3 months however19

Optimizing ESWL-Rate

•

Koo et al 2009: compared 102 pts receiving 70SW/min vs

100SW/min

•

Overall shocks to stone free status or fragments <3mm were fewer in the slower group (3045 vs

4414). They also

had a lower retreatment rate (22% vs 45%), and the associated costs were

less20

New Applications for ESWL

•

Chronic Calcific

Pancreatitis

•

Gallstones

•

Peyronie’s

Disease

•

Erectile Dysfunction

ESWL-Pancreatic Stones

•

Lawrence et al 2010: Of 30 pts from 2005- 2009, 58.6% either had fraction of stones so

they could be extracted with ERCP or absence of stones on follow up imaging, 60% had clinical improvement on the patient Global Impression of Improvement Scale

•

Use of narcotics did not significantly decrease, however pancreatic surgery was avoided in 64% at time of follow up21

ESWL-Applications

•

Gallstones-Can be useful in patients with large gallstones refractory to basket removal after sphincterotomy22

•

Peyronie’s

Disease-ESWL may be able to prevent further curvature and plaque growth

•

Erectile Dysfunction-low intensity ESWL may promote neovascularization

and improve

erectile function23

ESWL-Conclusions

•

ESWL is a noninvasive therapy for renal and ureteral

calculi that may achieve success in

particular conditions

•

Other therapies should be considered if the overal

stone burden is high (>2cm), in the

presence of infection, with calcium oxalate monohydrate stones, impacted or lower pole stones, in obese patients

ESWL-Conclusions

•

Complications of ESWL include renal hematoma and steinstrasse

•

The debate is still out regarding increases in diabetes and hypertension after ESWL but the more recent literature seems to show no increased risk

ESWL-Conclusions

•

Stenting

patients for ESWL typically does not improve stone free rates or cost, although it may decrease renal colic and pain med use

•

Flomax

is a useful adjunct in ESWL•

ESWL should be performed at 60-90 shocks/minute to achieve optimal stone fragmentation

ESWL-Conclusions

•

There are many new applications for ESWL technology, and several of them involve other management of other urological conditions….stay alert!

THE END

ESWL-References1.

Campbell’s Urology 20102.

Weizer

AZ, Zhong

P, and Preminger GM: New Concepts in Shock Wave Lithotripsy. Urol

Clin

N Am 2007; 34: 375-82.3.

Grasso M, Loisides

P, Beaghler

M, and Bagley D: The Case for Primary Endoscopic Management of Upper Urinary Tract Calculi: A Critical Review of 121 Extracorporeal Shock-Wave Lithotripsy Failures. Urology 1995; 45: 363-370.

4.

Sighinolfi

MC, Micali

S, Grande M, et al: Extracorporeal Shock Wave Lithotripsy in an Elderly Population: How to Prevent Complications and Make the Treatment Safe and Effective. J Endourol

2008; 22: 2223-2225.5.

Ng C, Wong A, and Tolley

D: Is Extracorporeal Shock Wave Lithotripsy the Preferred Treatment Option for Elderly Patients with Urinary Stone? A Multivariate Analysis of the Effect of Patient Age on Treatment Outcome. BJU Int

2007; 100: 392-395.6.

Lu J, Sun X, He L, and Wang Y: Efficacy of Extracorporeal Shock Wave Lithotripsy for Ureteral

Stones in Children. Ped

Surg

Int

2009; 25: 1109-1112

ESWL-References7.

Landau EH, Shenfield

OZ, Pode

D, et al: Extracorporeal Shock Wave Lithotripsy in Prepubertal

Children: 22-Year Experience at a Single Institution with a Single Lithotripter. J Urol

2009; 182: 1835-

1840.

8.

Navarro HP, Lopez PC, Ruiz JM, et al: Renal Hematoma after Extracorporeal Shock Wave Lithotripsy (ESWL). Actas

Urol

2009; 33: 296-303.

9.

Serra CA, Huguet

PJ, Monreal

GV, et al: Renal Hematoma as a Complication of Extracorporeal Shock Wave Lithotripsy. Scan J Urol

Nephrol

1999; 33: 171-175.10.

Krambeck

AE, Gettman

MT, Rohlinger

AL, et al: Diabetes Mellitus and Hypertension Associated with Shock Wave Lithotripsy of Renal

and Proximal Ureteral

Stones at 19 Years of Followup. J Urol

2006; 175: 1742-1747.

11.

Sato Y, Tanda

H, Kato S, et al: Shock Wave Lithotripsy for Renal Stones is not Associated with Hypertension and Diabetes Mellitus. Urology 2008; 71: 586-592.

ESWL-References12.

Makhlouf

AA, Thorner

D, Ugarte

R, and Monga

M: Shock Wave Lithotripsy not Associated with Development of Diabetes Mellitus at 6 Years of Follow-

up. Urology 2009; 73: 4-8.

13.

Sayed

MAB, El-Taher

HA, Aboul-Ella HA, and Shaker SE: Steinstrasse

after Extracorporeal Shockwave Lithotripsy: Aetiology, Prevention and Management. BJU Int

2001; 88: 675-678.14.

Madbouly

K, Sheir

KZ, Elsobky

E, et al: Risk Factors for the Formation of Steinstrasse

After Extracorporeal Shock Wave Lithotripsy: A Statistical Model. J Urol

2002; 167: 1239-1242.15.

Argyropoulos

AN and Tolley

DA: Ureteric

Stents Compromise Stone Clearance after Shock Wave Lithotripsy for Ureteric

Stones: Results of a Matched Pair Analysis. BJU Int

2008; 103: 76-80.16.

Mohayuddin

N, Malik

HA, Hussain

M, et al: The Outcome of Extracorporeal Shock Wave Lithotripsy for Renal Pelvic Stone With and Without JJ Stent-a Comparative Study. J Pak Med Assoc 2009; 59: 143-146.

17.

Gravina

GL, Costa AM, Ronchi

P, et al: Tamsulosin

Treatment Increases Clinical Success Rate of Extracorporeal Shock Wave Lithotripsy of Renal Stones. Urology 2005; 66: 24-28.

18.

Naja

V, Agarwal

MM, Mandal

AK, et al: Tamsulosin

Facilitates Earlier Clearance of Stone Fragments and Reduces Pain After Shockwave Lithotripsy for Renal Calculi: Results from an Open-Label Randomized Study. Urology 2008; 72: 1006-1011.

ESWL-References19.

Kato Y, Yamaguchi S, Hori J, et al: Improvement of Stone Comminution

by Slow Delivery of Shock Waves in Extracorporeal Lithotripsy. Int

J Urol

2006; 13: 1461-1465.

20.

Koo V, Beattie I, and Young M: Improved Cost-Effectiveness and Efficiency With a Slower Shockwave Delivery Rate. BJU Int

2009; 105: 692-69.21.

Lawrence C, Siddiqi

MF, Hamilton JM, et al: Chronic Calcific

Pancreatitis: Combination ERCP and Extracorporeal Shock Wave Lithotripsy for Pancreatic Duct Stones. So Med J 2010; 103: 505-508.

22.

Amplatz

S, Piazzi L, Felder M, et al: Extracorporeal Shock Wave Lithotripsy for Clearance of Refractory Bile Duct Stones. Dig and Liver Disease 2007; 39: 267-272.

23.

Vardi Y, Appel B, Jacob G, et al: Can Low Intensity Extracorporeal Shockwave Therapy Improve Erectile Function? A 6-Month Follow-up Pilot Study in Patients with Organic Erectile Dysfunction. Euro Urol

2010; 58: 243-248.

24.

http://www.ismst.com/bilder/histor_03.jpg25.

http://www.urolog.nl/urolog/images/features/stone38.jpg