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Kamel M et al, 2015: Supine Transgluteal vs Prone Position in Extracorporeal Shock Wave Lithotripsy of Distal Ureteric Stones.

Kamel M, Salem EA, Maarouf A, Abdalla M, Ragab A, Shahin AM
Department of Urology, Faculty of Medicine, Zagazig University, Zagazig, Sharkia, Egypt

Abstract

OBJECTIVE: To evaluate of efficacy of transgluteal (supine) approach for shock wave lithotripsy (SWL) in treatment of distal ureteric stones. PATIENTS AND METHODS: This prospective, randomized, comparative study was conducted on 98 patients. Patients were randomly assigned into 2 groups: group A (n = 49; prone position) and group B (n = 49; supine position, transgluteal). Inclusion criteria included patients with radiopaque lower ureteric stones ≤10 mm. Exclusion criteria included radiolucent stones, stones >10 mm, the need for any auxiliary procedure, and any contraindication for SWL. Post-SWL evaluation included plain x-ray of kidney, ureter, and bladder at 2 weeks after treatment and then at monthly intervals after treatment for 3 months. Stone-free status was defined as no residual stone fragments visible on plain x-ray. Treatment failure was defined as persistence of stone fragments at 3 months or the need for ureteroscopy. RESULTS: Stone-free rate after 1 treatment session was achieved in 44.9% and 75.5% for prone and supine positions, respectively. Proceeding to ureteroscopy, after failure of the second SWL session to clear the stones, was done in 34.7% and 8.2% for prone and supine positions, respectively. The overall success rate for SWL treatment in prone and supine groups was 65.3% and 91.8%, respectively (P <.001). CONCLUSION: Transgluteal SWL while patient in supine position proved efficacy for treatment of distal ureteric stones. Larger group studies comparing the results of SWL in supine position with those of prone position and also with those of ureteroscopy may enrich our
data to reach a consensus for the ideal management of distal ureteric stones. 

Urology. 2015 Jan;85(1):51-4. doi: 10.1016/j.urology.2014.08.033. Epub 2014 Oct 28.

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Comments 1

Hans-Göran Tiselius on Friday, 13 February 2015 08:56

It is of interest to note that SWL in patients treated for stones in prone position (that is with shockwaves administered from the abdominal side) did not result in a better stone-free rate than 65%. In contrast 92% of patients treaded in supine position (shockwaves administered from the gluteal side) were stone-free.

When treating stones in the distal ureter it is necessary to make sure that the shockwave path does not interfere with skeletal structures (supine position) or intestinal gas (prone position). In my own experience patient position in the lithotripter needs to be determined individually with close attention also to the features of the patient and properties of the lithotripter used. Therefore for most lithotripters and patients it does not make sense to randomize the patients in this way.

No explanation was provided by the authors why stone-free rate was as low as 65% for patients treated with two SWL sessions from the abdominal side.

In a previously published study of ureteral stone treatments with Storz Modulith SLX classic or SLX-F2 supine position was used in 91% of the cases whereas 9% were treated prone [1]. Successful SWL requires that in every patient obstacles to the free path of the shockwave must be discovered and avoided. For the patients with distal uerteral stones referred to above (n=236), 97.8 % became stone free after 1.2 sessions and as many as 83.2% only required one SWL session.

Reference
1. Tiselius HG.How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones?
J Endourol. 2008 ;22:249-255.

It is of interest to note that SWL in patients treated for stones in prone position (that is with shockwaves administered from the abdominal side) did not result in a better stone-free rate than 65%. In contrast 92% of patients treaded in supine position (shockwaves administered from the gluteal side) were stone-free. When treating stones in the distal ureter it is necessary to make sure that the shockwave path does not interfere with skeletal structures (supine position) or intestinal gas (prone position). In my own experience patient position in the lithotripter needs to be determined individually with close attention also to the features of the patient and properties of the lithotripter used. Therefore for most lithotripters and patients it does not make sense to randomize the patients in this way. No explanation was provided by the authors why stone-free rate was as low as 65% for patients treated with two SWL sessions from the abdominal side. In a previously published study of ureteral stone treatments with Storz Modulith SLX classic or SLX-F2 supine position was used in 91% of the cases whereas 9% were treated prone [1]. Successful SWL requires that in every patient obstacles to the free path of the shockwave must be discovered and avoided. For the patients with distal uerteral stones referred to above (n=236), 97.8 % became stone free after 1.2 sessions and as many as 83.2% only required one SWL session. Reference 1. Tiselius HG.How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones? J Endourol. 2008 ;22:249-255.
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