Rassweiler J et al, 2014: Extracorporeal shock wave lithotripsy: An opinion on its future

Monday, 24 February 2014

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Rassweiler J, Rassweiler MC, Frede T, Alken P
Department of Urology, SLK Kliniken Heilbronn, Germany
Department of Urology, Medical School of Mannheim, University of Heidelberg, Germany
Department of Urology, Helios Kliniken Müllheim, Germany

Abstract

The development of miniaturized nephroscopes which allow one-stage stone clearance with minimal morbidity has brought the role of shock wave lithotripsy (SWL) in stone management into question. Design innovations in SWL machines over the last decade have attempted to address this problem. We reviewed the recent literature on SWL using a MEDLINE/PUBMED research. For commenting on the future of SWL, we took the subjective opinion of two senior urologists, one mid-level expert, and an upcoming junior fellow. There have been a number of recent changes in lithotripter design and techniques. This includes the use of multiple focus machines and improved coupling designs. Additional changes involve better localization real-time monitoring. The main goal of stone treatment today seems to be to get rid of the stone in one session rather than being treated multiple times non-invasively. Stone treatment in the future will be individualized by genetic screening of stone formers, using improved SWL devices for small stones only. However, there is still no consensus about the design of the ideal lithotripter. Innovative concepts such as emergency SWL for ureteric stones may be implemented in clinical routine.

Indian J Urol. 2014 Jan;30(1):73-9. doi: 10.4103/0970-1591.124211.
PMID:24497687[PubMed]
PMCID:PMC3897058

Comments 1

Hans-Göran Tiselius on Monday, 24 February 2014 14:52

This is an interesting and considerate report of the present trends in stone removal as well the future perspective of SWL. Shortcomings of our present lithotripters are summarized and some new concepts presented and discussed, in view of the general opinion that the development of lithotripter technology has been minimal. This is the conclusion drawn when compared with the corresponding technical achievements for endoscopic devices. Although technical improvements of the lithotripters certainly might result in slightly better results, it is important to emphasize that in many centres improved results should be anticipated with an optimized use of the lithotripter. Development of the lithotripter technology is thus not entirely in the hands of engineers and manufacturers, but also the responsibility of operators. But without an interest in SWL such progress cannot be expected.

It is correctly stated that an ideal lithotripter is not available and that one important factor in explanation of that is the need of producing multifunctional units.

The present trend is that young urologists obviously favour endo-urological methods before SWL. That attitude is interesting and partly explains why the use of SWL presently is decreasing. The commonly presented arguments for preferring an invasive approach are that SWL often requires re-treatment and is associated with occurrence of residual fragments. I fear, however, that the non-invasive character of SWL poorly satisfies the surgical mentality of many urologists. It therefore appears more attractive with endoscopy than SWL. Unfortunately, it can be assumed that the attraction by endoscopy will remain even if there was no need of re-treatments and no residuals. It can for instance be mentioned that with an appropriate technique the majority of patients with ureteral stones can be satisfactorily treated with one session and without residuals. Despite this obvious advantage with a non-anaesthesia requiring out-patient procedure, the frequency of URS is increasing.

Hans-Göran Tiselius

It is correctly stated that an ideal lithotripter is not available and that one important factor in explanation of that is the need of producing multifunctional units.

The present trend is that young urologists obviously favour endo-urological methods before SWL. That attitude is interesting and partly explains why the use of SWL presently is decreasing. The commonly presented arguments for preferring an invasive approach are that SWL often requires re-treatment and is associated with occurrence of residual fragments. I fear, however, that the non-invasive character of SWL poorly satisfies the surgical mentality of many urologists. It therefore appears more attractive with endoscopy than SWL. Unfortunately, it can be assumed that the attraction by endoscopy will remain even if there was no need of re-treatments and no residuals. It can for instance be mentioned that with an appropriate technique the majority of patients with ureteral stones can be satisfactorily treated with one session and without residuals. Despite this obvious advantage with a non-anaesthesia requiring out-patient procedure, the frequency of URS is increasing.

Hans-Göran Tiselius

This is an interesting and considerate report of the present trends in stone removal as well the future perspective of SWL. Shortcomings of our present lithotripters are summarized and some new concepts presented and discussed, in view of the general opinion that the development of lithotripter technology has been minimal. This is the conclusion drawn when compared with the corresponding technical achievements for endoscopic devices. Although technical improvements of the lithotripters certainly might result in slightly better results, it is important to emphasize that in many centres improved results should be anticipated with an optimized use of the lithotripter. Development of the lithotripter technology is thus not entirely in the hands of engineers and manufacturers, but also the responsibility of operators. But without an interest in SWL such progress cannot be expected. It is correctly stated that an ideal lithotripter is not available and that one important factor in explanation of that is the need of producing multifunctional units. The present trend is that young urologists obviously favour endo-urological methods before SWL. That attitude is interesting and partly explains why the use of SWL presently is decreasing. The commonly presented arguments for preferring an invasive approach are that SWL often requires re-treatment and is associated with occurrence of residual fragments. I fear, however, that the non-invasive character of SWL poorly satisfies the surgical mentality of many urologists. It therefore appears more attractive with endoscopy than SWL. Unfortunately, it can be assumed that the attraction by endoscopy will remain even if there was no need of re-treatments and no residuals. It can for instance be mentioned that with an appropriate technique the majority of patients with ureteral stones can be satisfactorily treated with one session and without residuals. Despite this obvious advantage with a non-anaesthesia requiring out-patient procedure, the frequency of URS is increasing. Hans-Göran Tiselius

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