Extracorporeal Shock Wave Lithotripsy 25 Years Later: Complications and Their Prevention

doi:10.1016/j.eururo.2006.01.045

European Urology

Volume 50, Issue 5, November 2006, Pages 981-990

https://doi.org/10.1016/j.eururo.2006.01.045 Get rights and content

Abstract

Objective

We review the pathophysiology and possible prevention measures of complications after extracorporeal shock wave lithotripsy (ESWL).

Methods

A literature search was performed with the Medline database on ESWL between 1980 and 2004.

Results

ESWL application has been intuitively connected to complications. These are related mostly to residual stone fragments, infections, and effects on tissues such as urinary, gastrointestinal, cardiovascular, genital, and reproductive systems. Recognition of ESWL limitations, use of alternative therapies, correction of pre-existing renal or systemic disease, treatment of urinary tract infection, use of prophylactic antibiotics, and improvement of ESWL efficacy are the most important measures of prevention. Decrease of shock wave number, rate and energy, use of two shock-wave tubes simultaneously, and delivery of two shock waves at carefully timed close intervals improve ESWL efficacy and safety.

Conclusion

ESWL is a safe method to treat stones when proper indications are followed. The need for well-designed prospective randomised trials on aetiology and prevention of its complications arises through the literature review.

Introduction

Since its first presentation in West Germany in the early1980s [1], extracorporeal shock wave lithotripsy (ESWL) has revolutionized the treatment of urinary lithiasis. ESWL has gained rapid acceptance worldwide because of its ease of use, noninvasive nature, high efficacy in treating kidney and ureteral stones, and wide availability of lithotriptors. ESWL acts via a number of mechanical and dynamic forces on stones such as cavitation, shear, and spalling [2]. The most important force is thought to be cavitation [2]. The destructive forces generated when the cavitation bubbles collapse are responsible for the ultimate stone fragmentation. However, they can also cause trauma to thin-walled vessels in the kidneys and adjacent tissues [3], which result in haemorrhage, release of cytokines/inflammatory cellular mediators, and infiltration of tissue by inflammatory response cells. These may lead to short-term complications and to formation of scar and possible chronic loss of tissue function (Table 1).

In this review we present an overview of the post-ESWL complications, their potential mechanisms and predisposing factors, and various ways to prevent them. A thorough Medline search was performed to review various types of papers such as clinical trials, randomised controlled trials, reviews, meta-analysis, editorials, and letters to the editor. Combinations of the following keywords were used: ESWL; complications; stone fragmentation; failure; residual stones; obstruction; steinstrasse; infection; renal anatomy; renal function; hypertension; vascular; cardiac; gastrointestinal; children; fertility; and pregnancy. We reviewed 3,937 abstracts and read 220 papers in full. Ninety-three of these are sited in the reference list.

Section snippets

Complications related to stone fragments

Incomplete fragmentation, residual stone fragments, steinstrasse, and obstruction are among the problems urologists confront when ESWL fails to completely fragment the stone treated (Table 2).

Growth of residual fragments <4 mm has been documented in 21%–59% of patients who underwent ESWL [4], [5]. Streem et al demonstrated a 43% risk of having a symptomatic episode or needing an intervention, or both, after a mean 26-month follow-up in patients with residual calculi ≤4 mm [6]. With increasing

Incidence and severity

The renal trauma and vascular disruption associated with ESWL may allow bacteria in urine to enter the bloodstream. Moreover, when infected calculi are destroyed, bacteria are released from the stone into the urine and may be absorbed systemically [2]. As a consequence, bacteriuria, bacteraemia, clinical urinary tract infection (UTI), urosepsis, perinephric abscess formation, endocarditis, candidal and Klebsiella endophthalmitis, candidal septicaemia, tuberculosis, and (rarely) death have been

Renal complications

Renal complications can be subdivided into early effects on kidney anatomy that lead to haematuria and haematoma formation, and late complications that affect kidney function and cause systemic hypertension (Table 4).

Histopathological examination of human and animal kidneys showed endothelial cell damage to midsized arteries, veins, and glomerular capillaries immediately after ESWL [40], [41]. Thin-walled arcuate veins in the corticomedullary junction are especially vulnerable to shock wave

Effects of ESWL on fertility and pregnancy

There is enough evidence from experimental and clinical studies that ESWL does not have severe permanent effects on testicular and ovarian function [89], [90]. Consequently, male and female fertility are not affected by ESWL [89], [90]. Pregnancy is the only absolute contraindication to ESWL because of the potential disruptive effects of the shock wave energy on the foetus that are found in numerous experimental studies [91]. These animal studies are supported by clinical reports of spontaneous

Conclusions

ESWL is a safe method to treat stones in the urinary tract when proper indications are followed. Today, 25 years after its implementation, various side effects have been reported and studied, but most are rare and do not hamper the effectiveness of this technique. Preventive measures can be taken to minimize the frequency of these side effects.

Editorial Comment

Patras, Greece

The authors present an interesting review article summing up the experience of the

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Is extracorporeal lithotripsy a first-line treatment for urinary stones today?
2024, Actas Urologicas Espanolas
Evaluar la eficacia y complicaciones de la litotricia extracorpórea por ondas de choque (LEOCh) como tratamiento de primera línea de la litiasis renal y ureteral.
Estudio observacional retrospectivo de todos los pacientes tratados con litotricia en un centro de tercer nivel entre enero de 2014 y enero de 2021. Se recogieron las características de los pacientes, de la litiasis, y las complicaciones y resultados de la LEOCh. Se realizó una regresión logística multivariante de los factores asociados a la reducción del tamaño litiásico. También se llevó a cabo un análisis estadístico de los factores asociados a la necesidad de tratamiento adicional tras la LEOCh y de los factores asociados a las complicaciones.
Se incluyeron 1.727 pacientes. El tamaño litiásico medio fue de 9,5 mm. En 1.540 (89,4%) pacientes se observó la reducción del tamaño litiásico. En el análisis multivariante, el tamaño (OR = 1,13; p = 0,00), la localización de la litiasis en el uréter (OR = 1,15; p = 0,052) y el número de ondas (p = 0,002; OR = 1,00) utilizadas en la LEOCh son los factores asociados a la reducción del tamaño litiásico. Un total de 665 pacientes (38,5%) precisaron tratamiento adicional tras la litotricia. Los factores asociados a la necesidad de retratamiento fueron el tamaño litiásico (OR = 1.131; p = 0,000), el número de ondas (OR = 1.000; p = 0,000) y la energía administrada (OR = 1.005; p = 0,000). En 153 pacientes (8,8%) se produjeron complicaciones tras la LEOCh. Se encontró una asociación estadísticamente significativa entre el tamaño de la litiasis (p = 0,024; OR = 1.054) y la derivación urinaria previa (p = 0,004; OR = 0,571).
La litotricia sigue siendo eficaz como tratamiento de primera línea para la litiasis reno-ureteral, con un bajo porcentaje de complicaciones.
To evaluate the efficacy and complications of extracorporeal lithotripsy (SWL) as a first-line treatment for renal and ureteral stones.
Retrospective and observational study of all the patients treated with lithotripsy in a third level center between January 2014 and January 2021; characteristics of the patients, the stones, complications and results of SWL is recollected. Multivariate logistic regression of the factors associated with stone size reduction was performed. A statistical analysis of the factors associated with additional treatment after SWL and factors associated with complications is also executed.
1727 patients are included. Stone mean size was 9,5 mm. 1540 (89.4%) patients presented reduction in stone size. In multivariate analysis, stone size (OR = 1.13; P = 0.00), ureteral location of the lithiasis (OR = 1.15; P = 0.052) and number of waves (P = 0.002; OR = 1.00) used in SWL are the factors associated with reduction of stone size. Additional treatment after lithotripsy was needed in 665 patients (38.5%). The factors associated with the need for retreatment were stone size (OR = 1.131; P = 0.000), number of waves (OR = 1.000; P = 0.000), energy (OR = 1.005; P = 0.000). 153 patients (8.8%) suffered complications after SWL. A statistically significant association was found between the size of the lithiasis (P = 0.024, OR = 1.054) and the previous urinary diversion (P = 0.004, OR = 0.571).
Lithotripsy remains an effective treatment as the first line of therapy for reno-ureteral lithiasis with a low percentage of complications.
Extracorporeal shock wave lithotripsy for lower calyx stones: Predicting treatment success
2023, Actas Urologicas Espanolas
El uso de la litotricia extracorpórea por ondas de choque (LEOCh) en litiasis de grupo calicial inferior (GCI) se asocia con una alta tasa de fragmentos residuales. Nuestro objetivo es analizar la efectividad y complicaciones del tratamiento con LEOCh en litiasis de GCI.
Revisión retrospectiva de pacientes con litiasis en GCI tratadas con LEOCh entre enero 2014 y diciembre del 2020. Se determina anatomía favorable del GCI mediante longitud infundibular, ancho infundibular y ángulo infundibulopélvico. Se considera fracaso de LEOCh la presencia de fragmentos > 3 mm en radiografía simple, TC o ecografía a los 3 meses del procedimiento.
Análisis de complicaciones, procedimientos auxiliares y factores de riesgo asociados con hematoma perirrenal. Análisis estadístico mediante software SPSS.
En total, 512 pacientes con litiasis en GCI fueron tratados con LEOCh. El 80,3% de los pacientes tenía anatomía GCI favorable. La tasa libre de litiasis (TLL) fue 70,5%. Las principales complicaciones fueron: calle litiásica (5 pacientes) e infección del tracto urinario (3 casos). Se describen 10 hematomas perirrenales (2%). La toma de antiagregantes mostró asociación estadística con el riesgo de hematoma perirrenal (p = 0,004). Mediante regresión logística binaria se demuestra asociación entre anatomía desfavorable del GCI (p = 0,000), tamaño de litiasis (p = 0,001), número de ondas de choque (p = 0,003), energía aplicada (p = 0,038) y necesidad de tratamiento adicional tras LEOCh.
El tratamiento con LEOCh puede ser considerado de primera elección en litiasis de GCI. El tamaño de la litiasis, anatomía calicial desfavorable, número de ondas de choque y energía utilizadas pueden predecir la necesidad de retratamiento.
The use of extracorporeal shock wave lithotripsy (ESWL) for lower calyx stones is associated with a high rate of residual fragments. Our aim is to analyse the effectiveness and complications of ESWL for lower calyx stones.
Retrospective review of patients with lower renal calyx stones treated with ESWL between January-2014 and December-2020. Measurement of infundibular length, infundibular width and infundibulopelvic angle in lower renal pole to determine favourable anatomy. ESWL failure: fragments > 3 mm detected in plain abdominal film, CT scan and/or renal ultrasound 3 months after treatment.
Complications after ESWL, auxiliary procedures along with risk factors associated with perirenal haematoma were analysed. SPSS statistical software was used.
512 patients with lower calyx stones were treated with ESWL. 80.3% of patients had a favourable anatomy. Overall stone-free rate was 70.5%. Regarding main complications after ESWL, stainstrasse was described in 5 patients and urinary tract infection in 3 patients. 10 perirenal haematomas (2%) were reported. Statistical association was found between antiplatelet treatment and the risk of perirenal haematoma (p = 0.004). Logistic binary regression proved the association between unfavourable anatomy of the lower renal pole (p = 0.000), size of the stone (p = 0.001), number of shock waves (p = 0.003), energy applied (p = 0.038) and the need for additional treatment after ESWL.
ESWL can still be considered as the initial treatment option for lower renal pole stones. The size of the stone, an unfavourable anatomy of the lower renal calyx, number of shock waves and energy applied can help predict the need for additional treatment.
2022 Recommendations of the AFU Lithiasis Committee: Extracorporeal shock wave lithotripsy (ESWL)
2023, Progres en Urologie
Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive technique for the fragmentation of urinary tract stones using shock waves under fluoroscopic and/or ultrasound guidance. ESWL results depend on the indication (stone size/composition, clinical context) and also on how it is performed. The stone structure, nature and density (Hounsfield units; evaluated by CT without contrast agent) influence the fragmentation achieved by ESWL. The upper size limit of kidney stones has been lowered to 15 mm (1.68 cm³) due to the increased risk of steinstrasse with larger sizes and the potential need of anesthesia and ureteral stenting. Conversely, the development of endourological technologies allows a finer stone fragmentation and/or better elimination, thus reducing the risk of steinstrasse and decreasing the potential number of sessions or additional interventions.
These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.
La lithotripsie extracorporelle (LEC) est une technique mini-invasive de fragmentation des calculs urinaires par ondes de choc sous contrôle d’imagerie radioscopique et/ou échographique. Les résultats de la LEC dépendent de l’indication (calcul, contexte clinique) mais aussi des modalités de réalisation. La structure, la nature et la densité à la TDM IV− (UH) des calculs influencent la fragmentation obtenue par la LEC. La limite supérieure de taille des calculs rénaux a été abaissée à 15 mm (1,68 cm³) en raison du risque majoré d’empierrement au-delà et de nécessité potentielle d’anesthésie ainsi que d’implantation d’endoprothèse urétérale alors que le développement des technologies endourologiques permet une fragmentation plus fine des calcul s et/ou une meilleure élimination, réduisant ainsi le risque d’empierrement et diminuant ainsi le nombre potentiel de séances ou de réinterventions.
Ces recommandations ont été élaborées selon deux méthodes : la méthode RPC (Recommandation pour la Pratique Clinique) et la méthode ADAPTE, en fonction de la considération ou non de la question dans les recommandations de l’EAU https://uroweb.org/guidelines/urolithiasis [EAU 2022] et de leur adaptabilité au contexte français.
International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy
2023, European Urology Focus
Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL.
For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.
Coronary lithotripsy – a state of the art review
2023, Trends in Cardiovascular Medicine
Lesion calcification is frequently encountered during percutaneous coronary intervention and has been directly linked to procedural complications and future cardiac events. Intravascular lithotripsy is a novel balloon-based modality that does not rely on barotrauma or debulking, but converts electrical energy into mechanical energy creating sonic pressure waves that selectively disrupt calcium. The present review provides an overview of its mechanism of action, the available evidence on its safety and efficacy and indications for use.
Are the current nomograms sufficient to predict shockwave lithotripsy outcomes?
2022, Actas Urologicas Espanolas
Investigar los factores que afectan los resultados del tratamiento con LEOCH, validar tres nomogramas actuales (Kim JK, Triple D y S3HoCKwave) y comparar la capacidad predictiva de los nomogramas para los resultados de la LEOCH en los cálculos del tracto urinario superior.
Se revisaron retrospectivamente las historias clínicas de los pacientes con cálculos renales y ureterales proximales tratados con LEOCH entre marzo de 2013 y octubre de 2020. Se analizaron los factores que afectan al éxito de LEOCH con un análisis de regresión logística multivariante y se compararon los tres sistemas de puntuación con el área bajo la curva (AUC).
Nuestro estudio incluyó un total de 580 pacientes. La tasa global de eliminación de cálculos fue del 61% y 144/580 pacientes (24,8%) estaban libres de cálculos tras una sesión. En el análisis de regresión logística multivariante, la ubicación del cálculo en el cáliz superior (OR: 2,988; IC 95%: 1,350-6,612; p = 0,007), en el cáliz medio (OR: 3,036; IC 95%: 1,472-6,258; p = 0,003) y en el cáliz inferior (OR: 2,131; IC 95%: 1,182-3,839; p = 0,012), así como el número de cálculos (OR: 1,663; IC 95%: 1,140-2,425; p = 0,008), el diámetro máximo del cálculo (OR: 1,156; IC 95%: 1,098-1,217; p < 0,001) y el valor máximo de unidades Hounsfield (OR: 1,001; IC 95%: 1,001-1,002; p < 0,001) fueron factores de riesgo independientes del fracaso de LEOCH. Las AUC de las puntuaciones Kim JK, Triple D y S2HoCKwave para predecir el éxito de la LEOCH fueron de 0,678, 0,548 y 0,626, respectivamente.
La localización del cálculo, el número, el diámetro mayor y el valor máximo de UH fueron factores predictivos independientes del resultado de LEOCH en el tratamiento de los cálculos del tracto urinario superior. Los nomogramas actuales, el nomograma de Kim JK, la puntuación triple D y la puntuación de S3HoCKwave pueden predecir el éxito del tratamiento con LEOCH, pero todos ellos tienen una mala discriminación según el análisis AUC.
To investigate factors affecting SWL outcomes, validate three current nomograms (Kim JK, Triple D and S3HoCKwave) and compare the predictive ability of the nomograms for SWL outcomes in upper urinary tract stones.
Medical records of patients with renal and proximal ureteral stones treated with SWL between March 2013 and October 2020 were retrospectively reviewed. Factors affecting SWL success were analyzed with multivariate logistic regression analysis and the three predictive scoring systems compared with the area under the curve (AUC).
A total of 580 patients were included in our study. The overall stone free rate was 61% and 144/580 patients (24.8%) were stone free after one session. In multivariate logistic regression analysis, stone location at upper calyx (OR:2.988; 95%Cl: 1.350–6.612; p = 0.007), middle calyx (OR:3.036; 95%Cl: 1.472–6.258; p = 0.003), and lower calyx (OR:2.131; 95%Cl: 1.182–3.839; p = 0.012), as well as number of stones (OR:1.663; 95%Cl: 1.140–2.425; p = 0.008), maximum diameter of stone (OR:1.156; 95%Cl: 1.098–1.217; p < 0.001) and maximum Hounsfield Unit (OR:1.001; 95%Cl: 1.001–1.002; p < 0.001) were independent risk factors of SWL failure. The AUCs of the Kim JK, Triple D and S2HoCKwave scores for predicting SWL success were 0.678, 0.548, and 0.626 respectively.
Stone location, number, maximal diameter, and maximum HU were independent predictive factors for SWL outcome in the treatment of upper urinary tract stones. Current nomograms, Kim JK nomogram, Triple D score and S3HoCKwave score can predict treatment success after SWL, but all of them have poor discrimination according to AUC analysis.

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ESUT Special PaperExtracorporeal Shock Wave Lithotripsy 25 Years Later: Complications and Their Prevention

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Complications related to stone fragments

Incidence and severity

Renal complications

Effects of ESWL on fertility and pregnancy

Conclusions

Editorial Comment

Urology

J Urol

Scand J Urol Nephrol

J Endourol

Urology

J Endourol

J Urol

J Urol

J Urol

J Urol

Eur Urol

J Urol

J Urol

J Urol

Urol Int

J Urol

Urol Int

Urology

J Urol

J Urol

J Urol

Eur Urol

Eur Urol

Urol Res

J Urol

J Urol

Urology

J Urol

J Urol

Arch Esp Urol

AJR Am J Roentgenol

Nephron

Arch Pediatr

J Urol

Curr Opin Urol

Urology

J Urol

JAMA

J Urol

J Urol

J Urol.

Eur Urol

J Endourol

BJU Int

J Endourol

ESUT Special Paper
Extracorporeal Shock Wave Lithotripsy 25 Years Later: Complications and Their Prevention