Shuai Yuan et al., 2024: Comparative analysis of renal calculi treatment via different extracorporeal shock wave lithotripsy (ESWL) pathways

Monday, 02 December 2024

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Shuai Yuan 1 2, Ramaiyan Velmurugan 3, S Prasanna Bharathi 3
1Department of Urology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
2Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
Pharmacology, Saveetha College of Pharmacy, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, 601205, India.

Abstract

Objective: To compare the efficacy and safety of Extracorporeal Shock Wave Lithotripsy (ESWL) for treating renal calculi under different shock wave pathways.

Methods: This study involved a prospective analysis of clinical data obtained from 264 eligible patients with renal stones treated at the Urology Department of Shanxi Bethune Hospital between January 2021 and June 2023. Among these patients, 125 underwent ESWL via the dorsal shock wave pathway (Group A), while 139 patients underwent ESWL via the ipsilateral clavicular midline shock wave pathway (Group B). Preoperatively, all patients underwent non-contrast abdominal CT (NCCT) scans to assess stone count, diameter, CT values, and Skin-to-Stone Distance (SSD). Intraoperatively, ultrasonography was utilized to remeasure SSD and monitor stone fragmentation continuously. The ESWL procedure employed a standardized intermittent stepwise energy escalation technique until treatment completion. Various metrics, including intraoperative Visual Analog Scale (VAS) pain scores, number of shocks, total shock wave energy, stone-free rate (SFR) at 4 weeks post-operation, and postoperative complication rates, were recorded and subjected to statistical analysis.

Results: There were no statistically significant differences between the two groups regarding gender, age, BMI, stone count, stone diameter, stone CT values, intraoperative VAS pain scores, and postoperative complication rates (P>0.05). Preoperative SSD was significantly higher in Group B than in Group A (P<0.05), but there were no significant differences in intraoperative SSD between the groups (P>0.05). Group B showed significantly lower total shock wave energy and number of shocks compared to Group A (P<0.05). The stone-free rate (SFR) after 4 weeks did not exhibit significant differences between the groups (P>0.05). However, when the stone diameter was ≥1.3 cm, the SFR at 4 weeks post-operation in Group B was significantly higher than in Group A (P<0.05).

Conclusion: ESWL emerges as a safe and efficacious approach for treating renal calculi. Our findings suggest that utilizing the ipsilateral clavicular midline shock wave pathway in ESWL necessitates less shock wave energy and enhances efficiency, particularly in cases with larger stone burdens.

Int Urol Nephrol. 2024 Sep;56(9):2887-2895. doi: 10.1007/s11255-024-04025-5. Epub 2024 Apr 6.
PMID: 38581588

Comments 1

Hans-Göran Tiselius on Monday, 02 December 2024 10:00

One important prerequisite for optimal SWL is that the shock wave path is without or with only limited loss of energy during its passage from the source to the stone. Accordingly, it is necessary to have control of any interference that might occur between the shock wave and transverse processes, ribs and other bone structures, when shock waves are delivered from the back of the patient. For transabdominal administration it is necessary to avoid intestinal gas. The distance from the skin to the stone (SSD) also is considered of great importance.
With a lithotripter enabling positioning of the shock wave source both above and below the patient in supine position, the authors carried out a randomized comparison between dorsal (A) and frontal (B) administration of shock waves. For A two alternatives were used (scapular and posterior axillary entrance. But it is not mentioned in the article how the choice was made between the two A positions.
The comparison between the various shock wave paths was facilitated by excluding caliceal stones.
Stone-free rates were expressed in terms of residual fragments (26% in A and 23% in B). but it is unknown if that meant that 74% and 78% were absolutely stone free or had residual fragments.
It is indeed surprising that none of the patients required some kind of analgesic or sedative. One can wonder what the outcome would have been with such support.
Table 1 is difficult to read because the authors presented data with an excessive number of decimals. Moreover, the data in Table 1 and Figure 5 differ.
In the reviewer’s experience there is no standard position for optimal stone disintegration, but rather to place the patient individually according to the anatomical and geometrical conditions.

Hans-Göran Tiselius

One important prerequisite for optimal SWL is that the shock wave path is without or with only limited loss of energy during its passage from the source to the stone. Accordingly, it is necessary to have control of any interference that might occur between the shock wave and transverse processes, ribs and other bone structures, when shock waves are delivered from the back of the patient. For transabdominal administration it is necessary to avoid intestinal gas. The distance from the skin to the stone (SSD) also is considered of great importance. 
With a lithotripter enabling positioning of the shock wave source both above and below the patient in supine position, the authors carried out a randomized comparison between dorsal (A) and frontal (B) administration of shock waves. For A two alternatives were used (scapular and posterior axillary entrance. But it is not mentioned in the article how the choice was made between the two A positions.
The comparison between the various shock wave paths was facilitated by excluding caliceal stones.
Stone-free rates were expressed in terms of residual fragments (26% in A and 23% in B). but it is unknown if that meant that 74% and 78% were absolutely stone free or had residual fragments.
It is indeed surprising that none of the patients required some kind of analgesic or sedative. One can wonder what the outcome would have been with such support.
Table 1 is difficult to read because the authors presented data with an excessive number of decimals. Moreover, the data in Table 1 and Figure 5 differ.
In the reviewer’s experience there is no standard position for optimal stone disintegration, but rather to place the patient individually according to the anatomical and geometrical conditions.

Hans-Göran Tiselius

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