Treatment Options

Extracorporeal Shockwave Lithotripsy (SWL)

SWL is a reliable and efficient outpatient treatment option for urinary calculi less than 2 cm in diameter. Currently, pregnancy is the only absolute contraindication to SWL. New generation lithotriptors require only intravenous sedation-analgesia. The use of EMLA cream (eutectic mixture of lidocaine and prilocaine), a topical agent, has been shown to reduce anesthetic requirements and to shorten the recovery time after SWL.

Patients with renal anomalies have a lower stone-free rate. In horseshoe kidneys prone positioning may be necessary to localize a stone. However, in this group, stone free rates are at best 50% due to poor passage of fragments. Lower pole calyceal stones of one cm or larger may fragment well but are not likely to pass. A new strategy of combining retrograde flexible endoscopy with SWL has helped to successfully localize and treat stones associated with intrarenal stenoses and concomitant renal and ureteral stones.

The effects of SWL on renal hemodynamics have been extensively reviewed in animal models and in the human kidney. Functional and enzymatic studies before and after treatment demonstrate most SWL induced effects are transient. The production of oxygen free radicals, heat shock proteins or other inflammatory processes has been identified.

Complications of SWL include macroscopic hematuria in all patients. Renal or perirenal hematomas occur in a small percentage of patients. Post-SWL morbidity most commonly relates to the passage of stone fragments.

Following ESWL, a patient developed RLQ pain. The KUB, below, shows the collection of stones in the distal right ureter (steinstrausse), noted by the red arrowheads. A stent was placed to unblock the kidney (yellow arrowheads).

Suggested readings
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Saxby MF, Sorahan T, Slaney P, Coppinger SWV. A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy. Br J Urol 1997, 79: 3: 317-323.

Streem SB. Contemporary clinical practice of shock wave lithotripsy: A reevaluation of contraindications. J Urol 1997, 157: 4: 1197-1203.

Cass AS. Comparison of first-generation (Dornier HM3) and second-generation (Medstone STS) lithotripters: Treatment results with 145 renal and ureteral calculi in children. J Endourol 1996, 10: 6: 493-499.

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Patel A, Fuchs GJ. Expanding the horizons of SWL through adjunctive use of retrograde intrarenal surgery: New techniques and indications. J Endourol 1997, 11:1:33-36.

Sarica K, Soygur T, Yaman O, Ozer G, Sayin N, Akbay C, Kupeli S, Yaman LS. Stone recurrence after shockwave lithotripsy: Possible enhanced crystal deposition in traumatized tissue in rabbit model. J Endourol 1996, 10: 6: 513-515.

Willis LR, Evan AP, Connors BA, Fineberg NS, Lingeman JE. Effects of SWL on glomerular filtration rate and renal plasma flow in uninephrectomized minipigs. J Endourol 1997, 11:1:27-32.

Kroovand RL. Pediatric urolithiasis. Urol Clin North Am 1997, 24:1:173-184.

Sarica K, Kosar A, Yaman O, Beduk Y, Durak I, Gogus O, Kavakeu M. Evaluation of ischemia after ESWL: Detection of free oxygen radical scavenger enzymes in renal parenchyma subjected to high-energy shock waves. Urol Int 1996, 57:4:221- 223.

Sarica K, Ozer G, Soygur T, Yaman O, Ozer E, Ustun H, Yaman LS, Gogus O. Preservation of shock-wave-induced renal histologic changes by dermatan sulfate. Urology 1997, 49:1:145-150.

Roessler W, Wieland WF, Stein bach P, Hofstaedter F, Thuroff S, Chaussy C. Side effects of high-energy shockwaves in the human kidney:First experience with model comparing two shockwave sources. J Endourol 1996, 10: 6: 507-511.

Baltaci S, Ozer G, Soygur T, Yaman O, Sarica K, Muftuoglu YZ, Gogus O. Effects of extracorporeal shockwave lithotripsy on urinary concentration of epidermal growth factor. J Endourol 1996,10:6:519-521.

Johansson M, Sorensen V, Jonsson O, Pettersson S, Volkmann R. Examination of intrarenal blood flow by Doppler ultrasound before and after extracorporeal shock wave lithotripsy for urolithiasis. Scand J Urol Nephrol 1997, 31:1:27-30.

Katz R, Admon D, Pode D. Life-threatening retroperitoneal hematoma caused by anticoagulant therapy for myocardial infarction after SWL. J Endourol 1997,11:1:23-25.

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