Lu CH et al, 2017: Clinical analysis of 48-h emergency department visit post outpatient extracorporeal shock wave lithotripsy for urolithiasis.
Lu CH, Kuo JY, Lin TP, Huang YH, Chung HJ, Huang WJS, Wu HHH, Chang YH, Lin ATL, Chen KK.
Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Urology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Shu-Tien Urological Institute, National Yang-Ming University, Taipei, Taiwan, ROC.
BACKGROUND: Patients suffering from renal or ureteral stones can undergo significant discomfort, even when timely diagnosed and treated. The aim of this study was to assess the risk factors and safety of outpatient Extracorporeal Shock Wave Lithotripsy (ESWL) in the management of patients with renal or ureteral stones.
METHODS: In this study, our cohort consisted of 844 outpatients who underwent outpatient ESWL treated between February 2012 and November 2014 at Taipei Veterans General Hospital. Patients who visited the emergency room (ER) within 48 h after Outpatient ESWL were included in this article. This article analyzes the stone size, stone shape (long to short axis ratio), stone location, previous medical management, urinalysis data, complications and treatment received in the emergency department.
RESULTS: Among the 844 initial consecutive patients who underwent outpatient ESWL a total of 1095 times, there were 22 (2%) patients who sought help at our emergency room within 48 h after the outpatient ESWL. Of those 22 patients, the mean age was 54.3 ± 12.6 years, and the BMI was 25.9 ± 3.2. The most common complication complaint was flank pain (55.2%). Other complications included hematuria (13.8%), fever (17.2%), nausea with vomiting (6.9%), acute urinary retention (3.4%) and chest tightness with cold sweating (3.4%). In 22 patients who went back to the ER, 7 patients were admitted to the ward and 1 patient again returned to the ER. All patients received medical treatment without ESWL or surgical management. The meaningful risk factor of ER-visiting rate following outpatient ESWL within 48 h was stone location, and the renal stones showed statistic significant (p = 0.047) when compared to ureteral stones.
CONCLUSION: Our study indicated that renal stone contributed to a significantly higher risk of ER-visiting rate to patients than did ureteral stone, following outpatient ESWL within 48 h. This study confirmed that Outpatient ESWL is a safe treatment for renal or ureteral stones, while inpatient ESWL is not absolutely necessary.
J Chin Med Assoc. 2017 Sep;80(9):551-557. doi: 10.1016/j.jcma.2016.11.010. Epub 2017 Aug 9
It is of great clinical relevance to know to which extent patients treated with SWL return to the emergency unit within 48h. This of particular interest inasmuch as a majority of SWL-treatments today probably is carried out on an out-patient basis. I have personally applied an out-patient treatment concept without regional or general anaesthesia during approximately 20 years. Unfortunately we lack exact details about how many patients that returns to the hospital because of some kind of complication, usually pain.
In the present study 2% of the patients found it necessary to take such a step; that is a relatively small proportion of treated patients. It is interesting to note that more than half of the patients returned because of pain problems. Routine administration of diclofenac during a 5-7 day period after SWL has been my own routine and such a regimen might probably have reduced the number of patients who returned to the hospital because of pain.
Despite the large number of patients included in the report, serious complications such as septicaemia and subcapsular hematoma were not observed and the infection problems that occurred in less than 1% of the cases obviously were mild.
It is not mentioned how long after the SWL that the patients stayed in the hospital, but it is my own experience that a majority of patients who developed hematoma presented with exceptional pain already within the first few hours and a reasonable observation period after SWL is recommended.
In the attempts to predict the need of re-visits it was surprisingly concluded that patients who were treated for stones in the kidney were more prone to re-visits than patients treated for ureteral stones.
The discussion related to the importance of stone size, unfortunately, is hampered by the erroneous comparison of “mm” and “cm” in Table 1. And that difference is not statistically significant.