Basulto-Martínez M et al, 2018: The role of extracorporeal shock wave lithotripsy in the future of stone management.

Wednesday, 17 April 2019

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Basulto-Martínez M, Klein I, Gutiérrez-Aceves J.
Department of Urology, Hospital Regional de Alta Especialidad de la Península de Yucatán, Merida, Yucatán, Mexico.
Department of Urology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.

Abstract

PURPOSE: of review The most relevant recent findings on the use of extracorporeal shock wave lithotripsy (ESWL) in adult population to provide an insight of its role in the current and future of stone treatment. Comparing ESWL with other modalities is not in the scope of this review.
RECENT FINDINGS: We conducted a PubMed/Embase search and reviewed recent publications that include relevant information on the development of ESWL. Low-rate shock waves improve stone breakage, ramping energy modalities improve stone fragmentation and have lower incidence of hematoma and kidney injury. Transgluteal approach is suggested to improve stone-free rates for distal ureteral stones in a single session. Proper coupling is the most important technical aspect of the treatment and coupling improvement can be achieved by optical monitorization. Triple D score is a promising tool in proper patient selection, but external validation is needed. Predictive information arising from computed tomography scans has been refined by the variant coefficient of stone density and 3D texture analysis that might improve outcomes in the future.
SUMMARY: Recent evidence suggests that modifying techniques and protocols, and better patient selection are the current trends for improving ESWL outcomes. EWSL will keep its role as the single noninvasive treatment in stone management with room for outcome improvement in the future.

Curr Opin Urol. 2018 Dec 17. doi: 10.1097/MOU.0000000000000584. [Epub ahead of print]

Comments 1

Hans-Göran Tiselius on Wednesday, 17 April 2019 12:17

In view of the constantly increasing interest in and use of endoscopic procedures for stone removal this article provides insights in successful use of SWL. The conclusion worthwhile to cite is that “ESWL will maintain its stature as an excellent non-invasive treatment option for stones in years to come”.

The authors discuss a number of technical steps as well as the importance of appropriate patient selection with the aim of optimizing SFR. It is obvious that apart for optical coupling control and development of devices for mechanical percussion, there have been few technical improvements of lithotripsy during recent years. The article is recommended for reading and below follows some personal reflections.

It is emphasized that despite more than 30 years of clinical experience with SWL, there is no standardized principles for the treatment. My personal view is that this lack of standardization not necessarily is a shortcoming and that several years of experience indicate that individualized treatment has been a winning concept. The ongoing debate deals for instance with the question on whether distal ureteral stones are treated better in the prone or supine position. Different factors are of importance for this decision and whereas most stones are best treated with transgluteal shock wave approach (my own standard position since 1987) some stones might be treated more efficiently in prone position.

The optimal shock wave frequency remains another controversial issue as does the upper limit of number of shock waves during the same session. Personally I would hesitate to go as far as 7000 as suggested. At least with the lowest frequency of shock wave administration such an approach will cause a demanding duration of the treatment.

The authors claim that prediction of treatment outcome with the “triple D” method is useful: SSD ≤ 12 cm; Stone volume ≤ 150 mm3 and HU ≤ 600. The future use of AI is mentioned, but I think that this method cannot compete with decisions made by the experienced operator.

Two other points deserve a special comment:

Whereas SFR always is the standard end-point, the extent of disintegration is seldom discussed unless in terms of CIRF, which usually is a less well defined variable. The degree of disintegration might be important for understanding what can be achieved with mechanical percussion and how this technique can be developed further.

Nothing is mentioned about pain control; but when only analgesics and/or sedatives are used repeated SWL should not be considered a failure!

Contrary to the authors´ opinion that insufficient standardization of SWL is a disadvantage, I think that the specific flavour of this non-invasive therapy is just its low degree of standardization. This is the prerequisite that enables personalized treatment.

The authors discuss a number of technical steps as well as the importance of appropriate patient selection with the aim of optimizing SFR. It is obvious that apart for optical coupling control and development of devices for mechanical percussion, there have been few technical improvements of lithotripsy during recent years. The article is recommended for reading and below follows some personal reflections.

It is emphasized that despite more than 30 years of clinical experience with SWL, there is no standardized principles for the treatment. My personal view is that this lack of standardization not necessarily is a shortcoming and that several years of experience indicate that individualized treatment has been a winning concept. The ongoing debate deals for instance with the question on whether distal ureteral stones are treated better in the prone or supine position. Different factors are of importance for this decision and whereas most stones are best treated with transgluteal shock wave approach (my own standard position since 1987) some stones might be treated more efficiently in prone position.

The optimal shock wave frequency remains another controversial issue as does the upper limit of number of shock waves during the same session. Personally I would hesitate to go as far as 7000 as suggested. At least with the lowest frequency of shock wave administration such an approach will cause a demanding duration of the treatment.

The authors claim that prediction of treatment outcome with the “triple D” method is useful: SSD ≤ 12 cm; Stone volume ≤ 150 mm3 and HU ≤ 600. The future use of AI is mentioned, but I think that this method cannot compete with decisions made by the experienced operator.

Two other points deserve a special comment:

Whereas SFR always is the standard end-point, the extent of disintegration is seldom discussed unless in terms of CIRF, which usually is a less well defined variable. The degree of disintegration might be important for understanding what can be achieved with mechanical percussion and how this technique can be developed further.

Nothing is mentioned about pain control; but when only analgesics and/or sedatives are used repeated SWL should not be considered a failure!

Contrary to the authors´ opinion that insufficient standardization of SWL is a disadvantage, I think that the specific flavour of this non-invasive therapy is just its low degree of standardization. This is the prerequisite that enables personalized treatment.

In view of the constantly increasing interest in and use of endoscopic procedures for stone removal this article provides insights in successful use of SWL. The conclusion worthwhile to cite is that “ESWL will maintain its stature as an excellent non-invasive treatment option for stones in years to come”. The authors discuss a number of technical steps as well as the importance of appropriate patient selection with the aim of optimizing SFR. It is obvious that apart for optical coupling control and development of devices for mechanical percussion, there have been few technical improvements of lithotripsy during recent years. The article is recommended for reading and below follows some personal reflections. It is emphasized that despite more than 30 years of clinical experience with SWL, there is no standardized principles for the treatment. My personal view is that this lack of standardization not necessarily is a shortcoming and that several years of experience indicate that individualized treatment has been a winning concept. The ongoing debate deals for instance with the question on whether distal ureteral stones are treated better in the prone or supine position. Different factors are of importance for this decision and whereas most stones are best treated with transgluteal shock wave approach (my own standard position since 1987) some stones might be treated more efficiently in prone position. The optimal shock wave frequency remains another controversial issue as does the upper limit of number of shock waves during the same session. Personally I would hesitate to go as far as 7000 as suggested. At least with the lowest frequency of shock wave administration such an approach will cause a demanding duration of the treatment. The authors claim that prediction of treatment outcome with the “triple D” method is useful: SSD ≤ 12 cm; Stone volume ≤ 150 mm3 and HU ≤ 600. The future use of AI is mentioned, but I think that this method cannot compete with decisions made by the experienced operator. Two other points deserve a special comment: Whereas SFR always is the standard end-point, the extent of disintegration is seldom discussed unless in terms of CIRF, which usually is a less well defined variable. The degree of disintegration might be important for understanding what can be achieved with mechanical percussion and how this technique can be developed further. Nothing is mentioned about pain control; but when only analgesics and/or sedatives are used repeated SWL should not be considered a failure! Contrary to the authors´ opinion that insufficient standardization of SWL is a disadvantage, I think that the specific flavour of this non-invasive therapy is just its low degree of standardization. This is the prerequisite that enables personalized treatment.

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