Baba D. et al., 2025: Which localization method is optimal in ESWL: fluoroscopy or ultrasonography?
Dursun Baba, Necati Ekici, Arda Taşkın Taşkıran, Yusuf Şenoğlu, Alpaslan Yüksel, Ekrem Başaran, Mehmet Ali Özel, Ahmet Yıldırım Balık
BMC Urol. 2025 Feb 20;25(1):35. doi: 10.1186/s12894-025-01716-8 FREE PMC ARTICLE
Abstract
Background: Urinary stone disease is a common urological disorder, particularly among middle-aged individuals. Extracorporeal Shock Wave Lithotripsy (ESWL) is often the first-line treatment for kidney and ureteral stones. Traditionally, fluoroscopy is used for stone targeting in ESWL, but it exposes patients and clinicians to radiation and cannot visualize non-opaque stones. Ultrasonographic targeting eliminates these issues. This study compares the advantages and disadvantages of fluoroscopy and ultrasound-targeted ESWL.
Methods: At Düzce University Hospital, 100 patients with radio-opaque stones indicated for ESWL between February 2023 and February 2024 were divided into two groups. Group A underwent ESWL with fluoroscopic targeting, while Group B used ultrasonographic targeting. Patient demographics, stone size (measured by CT), and stone locations were recorded. The number of shocks per session, energy intensity (kV), and fluoroscopy time were noted for Group A. One week after each ESWL session, patients were evaluated by ultrasound or direct radiography. Success was defined as being stone-free or having ≤ 4 mm asymptomatic residual stones after up to four sessions. Failure was defined as no results after two sessions or the need for additional treatment.
Results: The procedure success rate was 66% for men and 78% for women, with no statistically significant gender difference (p > 0.05). Stone locations were similar in both groups. Success rates were 66% in Group A and 74% in Group B, with no significant difference (p > 0.05). Successful procedures were associated with an average patient weight of 76.6 kg, stone size of 8.9 mm, and total energy of 12.2 kV, with significant differences compared to unsuccessful procedures (p < 0.04, p < 0.04, p < 0.001, respectively). No significant differences were found between Group A and Group B in terms of age, height, BMI, stone density (HU), and number of sessions (p > 0.05).
Conclusion: Ultrasonography is as effective as fluoroscopy for imaging and focusing during ESWL treatment. It enhances the success of ESWL for non-opaque stones and reduces radiation exposure disadvantages.
In this report the author compared the outcome of SWL carried out with fluoroscopy and ultrasound imaging. There were two groups, each comprising 50 patients included in the comparison. It is not clear, however, how the patients were selected for the two imaging procedures.
There is no doubt that the most important role of ultrasound is to reduce the exposure to radiation. That is of fundamental importance. The reason that most SWL centers use fluoroscopy is its ease to use and there is no doubt that ultrasound imaging requires special skill and appropriate education.
The disadvantage of fluoroscopy for identification of radiolucent stones is of less importance, because most of those stones can be identified by comparing plain KUB and NCCT. Moreover, uric acid stones advantageously can be treated medically.
One advantage emphasized by the operators is that with ultrasound the stone can be maintained in focus continuously. Whether it is good or not for the operator to stay close to the shock wave source during the whole procedure is a matter that needs further considerations.
The bottom-line of this report is that there were no differences in results related to the imaging technique. Although such an outcome is desirable for every SWL-center, it might require extensive efforts to get there. Nevertheless, I think it is highly important to move from fluoroscopy to ultrasound as much as possible.
Hans-Göran Tiselius