Outcome of a session of extracorporeal shock wave lithotripsy before endoscopic retrograde cholangiopancreatography for problematic and large common bile duct stones

AIM To compare the efficacy of a session of extracorporeal shock wave lithotripsy(ESWL) before endoscopic retrograde cholangiopancreatography(ERCP) vs ERCP only for problematic and large common bile duct(CBD) stones.METHODS Adult patients with CBD stones for whom initial ERCP was unsuccessful because of the large size of CBD stones were identified. The patients were randomized into two groups,an "ESWL + ERCP group" and an "ERCP-only" group. For ESWL + ERCP cases,ESWL was performed prior to ERCP. Clearance of the CBD,complications related to the ESWL/ERCP procedure,frequency of mechanical lithotripsy use and duration of the ERCP procedure were evaluated in both groups.RESULTS There was no significant difference in baseline characteristics between the two groups. A session of ESWL before ERCP compared with ERCP only resulted in similar outcomes in terms of successful stone removal within the first treatment session(74.2% vs 71.0%,P = 0.135),but a higher clearance rate within the second treatment session(84.4% vs 51.6%,P = 0.018) and total stone clearance(96.0% vs 86.0%,P = 0.029). Moreover,ESWL prior to ERCP not only reduced ERCP procedure time(43 ± 21 min vs 59 ± 28 min,P = 0.034) and the rate of mechanical lithotripsy use(20% vs 30%,P = 0.025),but also raised the clearance rate of extremely large stones(80.0% vs 40.0%,P = 0.016). Post-ERCP complications were similar for the two groups.CONCLUSION Based on the higher rate of successful stone removal and minimal complications,ESWL prior to ERCP appears to be a safe and effective treatment for the endoscopic removal of problematic and large CBD stones.

Effect of tamsulosin versus tamsulosin plus tadalafil on renal calculus clearance after shock wave lithotripsy:An open-labelled,randomised,prospective study

Objectives:To compare the efficacy of tamsulosin versus tamsulosin plus tadalafil in achieving clearance of fragments after shock wave lithotripsy(SWL)to treat renal calculi.Methods:Between January 2016 to December 2017,140 patients with solitary,non-branched,non-lower calyceal renal calculus and measuring less than 20 mm and treated with SWL were randomized to tamsulosin(group A)or tamsulosin plus tadalafil(group B).Therapy was given for a period of 4 weeks.Stone clearance rate,analgesic requirement,occurrence of steinstrasse,need for auxiliary procedures(endoscopic treatment),and adverse effects of drugs were recorded.Results:The overall clearance rate was 72.5%(50/69)in the group A and 90.1%(64/71)in the group B(pZ0.007).For stones up to 12 mm,the difference in the clearance rate was significant(pZ0.039)while it was not so for stones larger than 12 mm(pZ0.151).There was no statistically significant difference between the two groups with regards to analgesic requirement(pZ0.94),occurrence of steinstrasse(pZ0.101),need for auxiliary procedures(pZ0.76),and adverse effects of the drugs(pZ0.148).Conclusion:Our study shows that adjunctive medical expulsive therapy with tamsulosin and tadalafil achieves better clearance rate than tadalafil alone in patients receiving SWL for renal stones.

Extracorporeal Shock Wave Lithotripsy Treatment for Renal and Ureteral Stones in Duhok City

The present study reports the results of extracorporeal shock-wave lithotripsy treatment for renal and ureteral stones in Duhok city. The data were collected from the center of breakdown kidney stones in Duhok hospital. There were a total of 40 patients (25 males and 15 females) aged from 20 to 60 years old. The patients harboring (23 renal and 17 ureteral) stones of size ranged from 7.5 to 20 mm. Almost stones are of average size 9 mm and composed of uric acid, calcium and cystine stones. The study has been carried out by taking into consideration the parameters (type, sizes, composition and location of stone as well as region and ages of patients, also power, number of shock wave and sessions). The results show that the stones size increases according to increasing ages of patients (male and female) for uric acid ureter stone and calcium (renal, ureter) stones. Also (renal, ureter) stone size for patients aged from 20 to 30 years old increases from the minimum value for phosphate to maximum value for cystine stones, while for patients aged from 40 to 60 years old, the minimum size is obtained for calcium oxalate and the maximum size for calcium only. On the other hand, for uric acid stones of average size 9 mm, number of shock wave and sessions as well as the power required to breakdown the stones decrease nearly exponentially according to enhancing patients’ ages. At the same time, it's found that for adult patients (20 - 30 years old), number of sessions and the power of shock wave decrease also according to increasing size of calcium and cystine stones. Contrary to that, for the same ages and renal, uretral cysteine stones number of shock wave needed to breakdown large stones will be increased.

Changes of serum β2-MG, Cys C and urine mAlb levels in patients with ureteral calculi before and after extracorporeal shock wave lithotripsy and their clinical significance

Objective:To investigate the changes of serumβ2 microglobulin(β2-MG),cystatin C(CysC)and urine microalbumin(mAlb)levels in patients with ureteral calculi before and after extracorporeal shock wave lithotripsy and their clinical significance.Methods Sixty-eight patients with ureteral calculi admitted to the hospital between June 2018 and June 2019 were selected as the observation group.35 volunteers who received physical elimination in the hospital during the same period were selected as the control group.Levels ofβ2-MG,Cys C and urine mAlb in the observation group were compared before and after treatment,and compared with those in the control group.Changes in serumβ2-MG,Cys C and urine mAlb levels and renal function indicators[blood urea nitrogen(BUN),serum creatinine(SCr)]in patients with different prognosis in the observation group after treatment were analyzed.The value of serumβ2-MG,Cys C and urine mAlb levels in the diagnosis and treatment of ureteral calculi was analyzed with ROC curve.The correlations between serumβ2-MG,Cys C and urine mAlb levels and renal function indexes were analyzed.Results Serumβ2-MG,Cys C and urine mAlb levels in the observation group before treatment were significantly higher than those in the same group after treatment or those in the control group(P<0.05).Serumβ2-MG,Cys C and urine mAlb levels,BUN and SCr in patients with residual stones were significantly higher than those in patients without(P<0.05).ROC curve analysis showed that the sensitivity and the area under the curve of combined detection of serumβ2-MG,Cys C and urine mAlb levels for evaluating the curative effect of extracorporeal shock wave lithotripsy on ureteral calculi were significantly higher/larger than those of single detection of the three(P<0.05).Partial correlation analysis showed that serumβ2-MG,Cys C and urine mAlb levels were positively correlated with BUN and SCr(P<0.05).Conclusion There are obvious changes of serumβ2-MG,Cys C and urine mAlb levels in patients with ureteral calculi before and after extracorporeal shock wave lithotripsy.The combined detection of the three indexes is helpful for the early diagnosis of ureteral calculi and the evaluation of renal function after lithotripsy.They can provide reference for protecting renal function in patients with ureteral calculi treated by extracorporeal shock wave lithotripsy.

A STUDY ON LIMITATION OF HIGH-ENERGY SHOCK WAVE-INDUCED RENAL DAMAGE BY SALVIA MILTIORRHIZAE INJECTION IN RABBIT MODEL

Objective To study the protective function of Salvia Miltiorrhizae on high-energy shockwaves (HESW) induced renal damage. Methods Thirty healthy New Zealand adult male white rabbits were randomly divided into Salvia Miltiorrhizae group and control group with 15 in each. Three days before extracorpeal shock wave lithotripsy (ESWL) the two groups were injected Salvia Miltiorrhizae and physiological saline respectively. Plasma endothelin-1 (ET-1), Superoxide dismutase (SOD) and malondialdehyde (MDA) were determined and renal morphology was observed. Results After ESWL, levels of ET-1 and MDA increased significantly, the activity of SOD decreased significantly compared with those before ESWL in control group (P< 0.05, respectively); the Salvia Miltiorrhizae treated group showed a much increase in ET-1 and MDA (P< 0.05, respectively), which kept no more than a week. And MDA in Salvia Miltiorrhizae group was not statistically significant as compared with the pre-shocking's (P> 0.05). After shocking, SOD, related to renal protection, in Salvia Miltiorrhizae group was significantly higher than that of controls (P< 0.05). Renal morphological injury was slight in Salvia Miltiorrhizae group. Conclusion Salvia Miltiorrhizae injection has protective function on renal toxicity induced by high-energy shock waves.

The Relationship Between the Energy Levels of Shock Waves and the Degree ofRenal Damage After ESWL：A Prospective Clinical Mat

In an attempt to understand the effects of high energy shock wave (HESW)on renal function, we studied prospectively 40 patients with nephrolithiasis in 4 groups,using same voltage with different numbers of shock wave therapy to identify the difference of effects on renal function. Stone burdens and posit ion were similar in these groups. Each group received 1500, 2000, 2500 or 3000 puises at 12. 5 KV on JT-3lithotripotor respectively. All the groups had significantly increased the levels of urinary NAG, β2MG, ALB and serum β2MG, which reached the highest values on 1-3days after ESWL (P<0. 001), and then decreased to the pre-ESWL levels except urinary NAG in group Cand D and serum β2MG which were still significantly higher (P<0.05) than those before-ESWL on the 7th day after ESWL. There was significant correlation between either urinary NAG (γ=0. 977, P<0. 05) or β2MG (γ=0. 933, P<0. 001) with the number of shock wave. In addition, urinary NAG and β2MG increased significantly when the number of shock waves was over 2500 shots.These above findings suggest that shock wave had induced acute changes in renal functions and transient renal tubular damages, although these functional changes recovered within one week, and the tubular damage might last longer than 7 days , In order to avoid serious renal damage, it’s necessary to limit the energy level of shock waves under 12. 5 KV×2500 shots by using JT-3 lithotriptor.

Sound field prediction of ultrasonic lithotripsy in water with spheroidal beam equations

With converged shock wave, extracorporeal shock wave lithotripsy（ESWL） has become a preferable way to crush human calculi because of its advantages of efficiency and non-intrusion. Nonlinear spheroidal beam equations（SBE） are employed to illustrate the acoustic wave propagation for transducers with a wide aperture angle. To predict the acoustic field distribution precisely, boundary conditions are obtained for the SBE model of the monochromatic wave when the source is located on the focus of an ESWL transducer. Numerical results of the monochromatic wave propagation in water are analyzed and the influences of half-angle, fundamental frequency, and initial pressure are investigated. According to our results, with optimization of these factors, the pressure focal gain of ESWL can be enhanced and the effectiveness of treatment can be improved.

Do available data support the widespread adoption of pancreatoscopy guided-lithotripsy?

Peroral pancreatoscopy(POPS)is a demanding endoscopic procedure that can be used to perform intracanal lithotripsy in obstructing pancreatic stones but the experience is limited.Most stones can be removed successfully by endoscopic retrograde cholangio-pancreatography but patients with large stones require advanced therapeutic approaches,such as extracorporeal shock wave lithotripsy(alone or followed by endoscopic retrograde cholangio-pancreatography),currently the mainstay of treatment.Unfortunately,in about 10%of cases,extracorporeal shock wave lithotripsy can fail;moreover,it is not be available in many institutions.For this subgroup of patients,POPS guided-lithotripsy can play a role and have benefits.The most consistent study concerns a retrospective multicenter analysis that enrolled few patients per center.Considering the epidemiological scenario and the scant volume of skilled endoscopists,POPS must be developed in very few high-volume referral centers with standardized pathways and capable of performing multi-modality treatment.In addition,we could reasonably assume that POPS-guided-lithotripsy should be used as rescue therapy in special situations,identifying the ideal candidate who can achieve the maximum clinical result,and carefully balancing risk/benefits ratio.

Contemporary minimal invasive surgical management of stones in children

Objective:Pediatric urolithiasis has been more common over the past 20 years,and urologists have unique challenges in managing it surgically because this particular demographic is recognized as one of the high-risk categories for stone recurrence.Given this reality,care focuses on maintaining renal function,achieving total stone-free status,and most importantly avoiding stone recurrences.In this presented article,we aimed to make a comprehensive review of the current minimally invasive treatment of pediatric kidney stone disease.Methods:We evaluated the results of 74 studies following a comprehensive PubMed search till February 2023.This article was written by making use of current urology guidelines.Results:Considering the reported occurrence of metabolic issues in up to 50%of cases in addition to the anatomic anomalies(about 30%of cases),the treatment of pediatric urolithiasis necessitates a full metabolic and urological examination on an individual basis.Timely management of metabolic imbalances and obstructive diseases is necessary.In addition to encouraging proper fluid consumption,it is advisable to improve urine volume and consider using medical therapeutics to raise urinary citrate levels.The location,content,and size of the stone(s),the morphology of the collecting system,the presence of urinary tract infection,as well as the presence of any obstruction,should all be taken into consideration while deciding on the best surgical procedure.Conclusion:All modern endourological methods are now used in the safe and efficient care of pediatric urolithiasis as a consequence of the obvious advancements in instrument technology and expanding expertise derived from adult patients.Other minimally invasive procedures,such as ureterorenoscopy and percutaneous nephrolithotomy,require more expertise and can be successfully applied with careful management for an excellent stone-free rate with minimal morbidity.Of these procedures,shock wave lithotripsy is still the first choice in the majority of cases with upper tract calculi.Open surgery will still be the therapy of choice for pediatric patients with complicated and big stones as well as anatomical anomalies.

ESWL for difficult bile duct stones:A 15-year single centre experience

AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus,SIEMENS)from October 1990 to April 2005 were evaluated.All patients were monitored during the procedure and antibiotics were administered in case of cholangitis.Theχ 2 test and logistic regression analysis were performed as appropriate.RESULTS:Two hundred and fourteen patients(102 males,112 females;mean age 74.8±0.84 years-single stone 97,multiple stones 117)underwent ESWL.The mean number of sessions and shock waves were 3.5 ±0.13 and 3477.06±66.17,respectively.The maximum stone size was 5 cm.Complete stone clearance was achieved in 192(89.7%)patients.Of the remain-ing patients 15 required surgery,2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance.Age,sex and stone characteristics were not related to treatment outcome.Major complications occurred in two patients(haemobilia and rectal bleeding) and minor complications in 25(3 vomiting,22 arrhythmias).No procedure-related deaths occurred.CONCLUSION:ESWL is a safe and effective technique for clearance of refractory bile duct stones.