Nafie S et al, 2014: Efficacy of a mobile lithotripsy service: A one-year review of 222 patients
Nafie S, Dyer JE, Minhas JS, Mills JA, Khan MA
Department of Urology, University Hospitals of Leicester NHS Trust , Leicester , UK
OBJECTIVE: Extracorporeal shockwave lithotripsy (ESWL) is the management of choice for ureteric and renal stones 20 mm or smaller, with a stone clearance rate of up to 89%. This study determined whether such a high success rate could apply to centres using mobile ESWL, by reviewing the performance at one centre that provides such a service.
MATERIAL AND METHODS: Between July 2011 and July 2012, 222 patients (median age 51 years, range 18-90 years) underwent one to five sessions of ESWL for ureteric and renal stones (mean size 15 mm, range 4-22 mm). Stone clearance was regarded as residual fragments 2 mm or smaller after completion of sessions.
RESULTS: In total, 110 out of 222 patients (49%) were clear of stones. Stones were radiopaque in 198 (89%) and radiolucent in 24 patients (11%), with clearance rates of 48% and 63%, respectively. Regarding size, 36 (16%) were 1-5 mm, 144 (65%) 5-10 mm, 28 (12%) 10-15 mm, eight (4%) 15-20 mm and six (3%) larger than 20 mm, with clearance rates of 61%, 55%, 18%, 13% and 50%, respectively. In total, 173 (78%) were renal stones and 49 (22%) ureteric, with respective clearance rates of 49% and 51%. For kidney stones, 15 (9%) were in the upper, 32 (18%) in the mid, 75 (43%) in the lower pole and 51 (30%) in the pelvis, with clearance rates of 52%, 59%, 49% and 41%; for ureteric stones, 32 (65%) were in the upper, 10 (20%) in the mid and seven (15%) in the lower ureter, with clearance rates of 47%, 70% and 43%, respectively.
CONCLUSION: The performance of mobile ESWL was significantly poorer than expected, and this may be related to a lack of clinical ownership. The authors believe that such a service should be permanently placed on site.
Scand J Urol. 2014 Feb 12. [Epub ahead of print]
PMID:24521183[PubMed - as supplied by publisher]
This is an article that is of great interest by showing that operator experience and a solid organisation play important roles for successful lithotripsy. With a mobile lithotripter shared by several departments (?), the stone-free rates of 49% for stones in the kidney and 51% for stones in the ureter are much lower than expected. Also if this device was only used in one department each operator treated in average less than 40 patients per year, thus less than one patient per week.
Despite the statement that the operators were qualified technicians the number of treatments for each operator is too small for optimal results. It is difficult to understand how a middle-grade urologist was able to assess the treatment if not actively participating in the SWL.
I cannot but agree with the authors that lithotripter service should be stationary. It is also necessary to concentrate the treatment efforts to fewer operators in order to improve the results. It seems much more relevant to transport patients to a specialised centre than by doing the reverse.