Extracorporeal Shock Wave Lithotripsy

Erin M. Burns, PGY-2

Medical University of South Carolina
Department of Urology
Grand Rounds
9/28/10
Erin Burns
Resident, MUSC
ESWL
Objectives of Presentation:
History, Present, and Future Uses
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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___
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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 USFDA
1
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 both
2
Indications for ESWL

Grasso et al, 1995 reviewed 121 ESWL
failures
3
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 sepsis
3
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
evaluations
4, 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 nonoperatively
10

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
onset
11

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
diabetes
12
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 surgery
13

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

group
17
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
however
19
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
less
20
New Applications for ESWL

Chronic Calcific

Pancreatitis

Gallstones

Peyronies

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 up
21
ESWL-Applications

Gallstones-Can be useful in patients with
large gallstones refractory to basket
removal after sphincterotomy
22

Peyronies

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

Erectile Dysfunction-low intensity ESWL may
promote neovascularization

and improve
erectile function
23
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-References
1.

Campbells Urology 2010
2.

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-References
7.

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-References
12.

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-References
19.

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.jpg
25.

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