Chiang YT. et al., 2023: Ultrasound-guided extracorporeal shock wave lithotripsy with minimal x-ray exposure prevented genitourinary tract injury patients with urolithiasis in Taiwan.

Wednesday, 03 April 2024

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Chiang YT, Chen SM, Tsui HM, Juang HH, Lin CW, Chiang MH, Liu CH, Hu SW, Kao WT, Chen KC, Tzou KY, Wu CC, Wu WL, Tsui KH.
Department of Urology, Shuang Ho Hospital, School of Medicine, College of Medical, Taipei Medical University, Taipei, Taiwan.
Department of Urology, Heping Campus, Taipei City Hospital, Taipei, Taiwan.
Department of Anatomy, School of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
Clinical Metabolomics Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Department of Urology, Shuang Ho Hospital, Shuang Ho Cancer Center, Taipei Cancer Center, School of Medicine, College of Medical, Taipei Medical University, Taipei, Taiwan.

Abstract

Background: This study investigated the use of ultrasound-guided extracorporeal shock wave lithotripsy (ESWL) to break stones in the genitourinary tract and prevent genitourinary injury. Our goals were to achieve accurate focusing and minimal X-ray exposure for the benefit of the patients.

Methods: The LiteMed LM-9200 lithotripter with ultrasonography and fluoroscopy was used for two different procedures: autoaimed and autoperiodical. These procedures enabled dual focusing on stone localization and tracking.

Results: Out of 108 patients who underwent autoperiodical procedures, 29 had no gross hematuria. Among the 335 patients who received autoaimed procedures, 194 had no gross hematuria. The average duration of X-ray exposure during autoperiodical and autoaimed procedures was 120 and 50 s, respectively.

Conclusion: The ultrasound-guided ESWL with minimal X-ray exposure was found to be useful in treating genitourinary upper-tract urolithiasis in the autoaimed procedure. Patients who underwent the autoaimed procedure experienced less gross hematuria compared to those who underwent the autoperiodical procedure.

Sci Prog. 2023 Oct-Dec;106(4):368504231220988. doi: 10.1177/00368504231220988. PMID: 38130182 FREE ARTICLE

Comments 1

Peter Alken on Wednesday, 03 April 2024 10:00

“The machine has an autofiring system; the shock waves are only fired when the stone is in the focal zone.”
There is a long story behind the autofiring system using continuous ultrasound control for ESWL treatment. I found the idea of firing exclusively to the stone always attractive. I had previously selected two papers on that topic as reviewers’ choice (1,2). One of them(1) referred to previous studies published between 2001 and 2009 (2-4) on automated stone tracking. However, I had my doubts.
In the present paper (5) two series are compared: “The autoaimed [or autofiring] procedure is a technique that mainly utilizes the ultrasound-based real time system to track the stone. The autoperiodical procedure is a technique that mainly utilizes fluoroscopy to target the stone.” In the “autofiring system the shock waves are only fired when the stone is in the focal zone.”
There are two previous publications on the clinical application (6,7). Even though the type of machine used, the has the same name in all publications, technical details of the machine may have been changed during the time periods 2004-2007 (6), 2013-2019 (7) and 2020-2022 (5). At least the present paper states: “With the newly developed computer software, the important feature of the real-time tracking system is the real-time analysis of ultrasound images.” If any changes were made; than most probably to improve the performance. Better results should be the effect. What could be nice, practical effects of the autoaimed or autofiring system would be a reduced number of shots, and possibly a shorter treatment time and /or a better disintegration. Unfortunately, the publications (5-7) do not provide enough data to make them comparable.
The details on the number of shots are variable and show an increase up to what is known of other lithotripters:
2009 (6): “1716 (range 864-2500)”
2020 (7): “Maximum 3000 shots per session”
2023 (5): “The average number of shock waves delivered per session was 3650.5:
(range 3500 - 5000).”
The average treatment time was:
2009 (6): “23.8 minutes (range 11.0–35.0 minutes)”
2020 (7): no data
2023 (5): The average treatment time, including the initial localization … was 39.7 min (range:
–45 min)” It was identical with the time evaluated in the group 2nd with a conventional system.
The stone free rate was:
2009 (6): 80 % at 3 months
2020 (7): 43.5% at 6 months
2023 (5): 83,7%. at 2 weeks. This is fantastic but also not different from the 81,7 % in the conventional group. Both hard to believe if not misunderstood by me.

What is identical in all three studies is that they only treated renal stones with a slight exception in (5) where 3 % ureteral stones were treated. Obviously, the authors found it difficult to localise ureter stones sonographically what confirms my experience but contradicts some other papers on the easy feasibility to treat ureteral stones with sonographic localisation only.

1 Chang CC, et al. In vitro study of the revised ultrasound based real-time tracking of renal stones for shock wave lithotripsy: Part 1. J Urol. 2013 Jun;189(6):2357-63. doi: 10.1016/j.juro.2012.11.111.
2 Sorensen MD, et al. Quantitative assessment of shockwave lithotripsy accuracy and the effect of respiratory motion. J Endourol. 2012 Aug;26(8):1070-4. doi: 10.1089/end.2012.0042. Free PMC article
3 Chang CC, Liang SM, Pu YR, Chen CH, Manousakas I, Chen TS, Kuo CL, Yu FM, Chu ZF. In vitro study of ultrasound based real-time tracking of renal stones for shock wave lithotripsy: part 1. J Urol. 2001 Jul;166(1):28-32. PMID: 11435816.
4 (present paper) Chiang YT, et al. Ultrasound-guided extracorporeal shock wave lithotripsy with minimal x-ray exposure prevented genitourinary tract injury patients with urolithiasis in Taiwan.
Sci Prog. 2023 Oct-Dec;106(4):368504231220988. doi: 10.1177/00368504231220988
5 Chen CJS et al: Clinical experience with ultrasound-based real-time tracking lithotripsy in the single renal stone treatment. J Endourol 2009; 23: 1811)
6 Chang TH, et al. Comparison of ultrasound-assisted and pure fluoroscopy-guided extracorporeal shockwave lithotripsy for renal stones. BMC Urol. 2020 Nov 10;20(1):183. doi: 10.1186/s12894-020-00756-6. Free PMC article

Peter Alken

What is identical in all three studies is that they only treated renal stones with a slight exception in (5) where 3 % ureteral stones were treated. Obviously, the authors found it difficult to localise ureter stones sonographically what confirms my experience but contradicts some other papers on the easy feasibility to treat ureteral stones with sonographic localisation only. 
 
1	Chang CC, et al. In vitro study of the revised ultrasound based real-time tracking of renal stones for shock wave lithotripsy: Part 1. J Urol. 2013 Jun;189(6):2357-63. doi: 10.1016/j.juro.2012.11.111. 
2	Sorensen MD, et al. Quantitative assessment of shockwave lithotripsy accuracy and the effect of respiratory motion. J Endourol. 2012 Aug;26(8):1070-4. doi: 10.1089/end.2012.0042.  Free PMC article
3	Chang CC, Liang SM, Pu YR, Chen CH, Manousakas I, Chen TS, Kuo CL, Yu FM, Chu ZF. In vitro study of ultrasound based real-time tracking of renal stones for shock wave lithotripsy: part 1. J Urol. 2001 Jul;166(1):28-32. PMID: 11435816.
4	 (present paper) Chiang YT, et al. Ultrasound-guided extracorporeal shock wave lithotripsy with minimal x-ray exposure prevented genitourinary tract injury patients with urolithiasis in Taiwan.
Sci Prog. 2023 Oct-Dec;106(4):368504231220988. doi: 10.1177/00368504231220988
5	Chen CJS et al: Clinical experience with ultrasound-based real-time tracking lithotripsy in the single renal stone treatment. J Endourol 2009; 23: 1811)
6	Chang TH, et al. Comparison of ultrasound-assisted and pure fluoroscopy-guided extracorporeal shockwave lithotripsy for renal stones. BMC Urol. 2020 Nov 10;20(1):183. doi: 10.1186/s12894-020-00756-6.  Free PMC article

Peter Alken

“The machine has an autofiring system; the shock waves are only fired when the stone is in the focal zone.” There is a long story behind the autofiring system using continuous ultrasound control for ESWL treatment. I found the idea of firing exclusively to the stone always attractive. I had previously selected two papers on that topic as reviewers’ choice (1,2). One of them(1) referred to previous studies published between 2001 and 2009 (2-4) on automated stone tracking. However, I had my doubts. In the present paper (5) two series are compared: “The autoaimed [or autofiring] procedure is a technique that mainly utilizes the ultrasound-based real time system to track the stone. The autoperiodical procedure is a technique that mainly utilizes fluoroscopy to target the stone.” In the “autofiring system the shock waves are only fired when the stone is in the focal zone.” There are two previous publications on the clinical application (6,7). Even though the type of machine used, the has the same name in all publications, technical details of the machine may have been changed during the time periods 2004-2007 (6), 2013-2019 (7) and 2020-2022 (5). At least the present paper states: “With the newly developed computer software, the important feature of the real-time tracking system is the real-time analysis of ultrasound images.” If any changes were made; than most probably to improve the performance. Better results should be the effect. What could be nice, practical effects of the autoaimed or autofiring system would be a reduced number of shots, and possibly a shorter treatment time and /or a better disintegration. Unfortunately, the publications (5-7) do not provide enough data to make them comparable. The details on the number of shots are variable and show an increase up to what is known of other lithotripters: 2009 (6): “1716 (range 864-2500)” 2020 (7): “Maximum 3000 shots per session” 2023 (5): “The average number of shock waves delivered per session was 3650.5: (range 3500 - 5000).” The average treatment time was: 2009 (6): “23.8 minutes (range 11.0–35.0 minutes)” 2020 (7): no data 2023 (5): The average treatment time, including the initial localization … was 39.7 min (range: –45 min)” It was identical with the time evaluated in the group 2nd with a conventional system. The stone free rate was: 2009 (6): 80 % at 3 months 2020 (7): 43.5% at 6 months 2023 (5): 83,7%. at 2 weeks. This is fantastic but also not different from the 81,7 % in the conventional group. Both hard to believe if not misunderstood by me. What is identical in all three studies is that they only treated renal stones with a slight exception in (5) where 3 % ureteral stones were treated. Obviously, the authors found it difficult to localise ureter stones sonographically what confirms my experience but contradicts some other papers on the easy feasibility to treat ureteral stones with sonographic localisation only. 1 Chang CC, et al. In vitro study of the revised ultrasound based real-time tracking of renal stones for shock wave lithotripsy: Part 1. J Urol. 2013 Jun;189(6):2357-63. doi: 10.1016/j.juro.2012.11.111. 2 Sorensen MD, et al. Quantitative assessment of shockwave lithotripsy accuracy and the effect of respiratory motion. J Endourol. 2012 Aug;26(8):1070-4. doi: 10.1089/end.2012.0042. Free PMC article 3 Chang CC, Liang SM, Pu YR, Chen CH, Manousakas I, Chen TS, Kuo CL, Yu FM, Chu ZF. In vitro study of ultrasound based real-time tracking of renal stones for shock wave lithotripsy: part 1. J Urol. 2001 Jul;166(1):28-32. PMID: 11435816. 4 (present paper) Chiang YT, et al. Ultrasound-guided extracorporeal shock wave lithotripsy with minimal x-ray exposure prevented genitourinary tract injury patients with urolithiasis in Taiwan. Sci Prog. 2023 Oct-Dec;106(4):368504231220988. doi: 10.1177/00368504231220988 5 Chen CJS et al: Clinical experience with ultrasound-based real-time tracking lithotripsy in the single renal stone treatment. J Endourol 2009; 23: 1811) 6 Chang TH, et al. Comparison of ultrasound-assisted and pure fluoroscopy-guided extracorporeal shockwave lithotripsy for renal stones. BMC Urol. 2020 Nov 10;20(1):183. doi: 10.1186/s12894-020-00756-6. Free PMC article Peter Alken

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