Shuai Yuan et al., 2024: Shuai Yuan 1 2 , Ramaiyan Velmurugan 3 , S Prasanna Bharathi 3
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.
3Department of 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 Apr 6. doi: 10.1007/s11255-024-04025-5. Online ahead of print.
PMID: 38581588
Comments 1
Optimal patient positioning in SWL is fundamental for successful stone disintegration. In this report the authors compared administration of shockwaves from the back in supine position (A) and transabdominal shockwaves in supine position (B). The latter approach can only be achieved with a lithotripter in which it is possible to place the therapy head above the patient.
The reviewer’s opinion is that there is no standard position for SWL, and that successful treatment requires individual patient positioning. Thereby it is necessary to consider any interference between the SW-path and skeletal structures, distance to the stone and intestinal gas. The latter problem is not mentioned apart from information that laxative was given to patients before SWL.
It is not understood why the authors excluded patients with caliceal stones because most patients have stones in that position. Possibly the authors mean calyx diverticular stones.
It is notable that the treatment was carried out without analgesics, and that might indicate that the shockwave power applied was lower than optimal.
The advantage of this report was that ultrasound was used for localization of stones and to follow the disintegration.
There were no differences in terms of residuals with the two approaches: 33/125 in A and 31/139 in B.
Reviewer’s major comment: Although the authors came to the conclusion that ipsilateral clavicular midline path-wave in several aspects was superior, individual patient positioning still needs to be considered before proceeding to treatment.
Hans-Göran Tiselius