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Reviewer's Choice

Young MJ. et al., 2022: Acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones - 7-years' experience from a busy district general hospital.

Young MJ, Pang KH, Elmussarah M, Hughes PF, Browning AJ, Symons SJ.
Pinderfields General Hospital, Wakefield - Mid-Yorkshire Hospitals Trust, Wakefield, UK.

Abstract

Objectives: To demonstrate the efficacy and cost-effectiveness of acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones we present our experience of ESWL in 530 ureteric stone cases, in the largest UK series we are aware of to date. ESWL is underutilised in ureteric stone management. The Getting It Right First Time (GIRFT) report showed just four units nationally treated >10% of acute ureteric stones with ESWL. Despite guideline recommendations as a first-line treatment option, few large volume studies have been published.

Patients and methods: Retrospective review of prospectively collected data between December 2012 and February 2020 was performed. Data relating to patient demographics, stone characteristics, skin-to-stone distance, and treatment failure were collected. Cost analysis was conducted by the Trust's surgical financial manager. Multivariable analyses were performed to assess for predictors of ESWL success.

Results: A success rate of 68% (95% confidence interval 64%-72%) at 6 weeks was observed (n = 530). The median (interquartile range) number of treatment sessions was 2 (1, 2). Stone diameter was observed to be a predictor of ESWL success. The small number of stones treated of >13 mm or >1250 HU had an ~50% chance of successful treatment. Acute ureteric ESWL was less costly than acute ureterorenoscopy, consistent with findings from previous NHS studies.

Conclusion: Acute ESWL is a safe, reliable, and financially viable treatment option for a wider spectrum of patients than reflected in international guidelines based on our large, heterogenous series. In the coronavirus disease 2019 (COVID-19) era, with theatre access reduced and concerns over aerosol generating procedures, acute ESWL remains an attractive first-line treatment option.
BJU Int. 2022 Jun 10. doi: 10.1111/bju.15820. Online ahead of print. PMID: 35689415

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Comments 1

Hans-Göran Tiselius on Thursday, 08 September 2022 10:45

This is a highly interesting article in which the authors report their experience of acute SWL of ureteral stones. The message is clear, and I recommend this article for reading by all urologists and other colleagues who in one way or another are involved in the treatment of patients with urolithiasis.
I completely agree with the view that SWL is not sufficiently used in treatment of patients with ureteral stones. It is surprising that URS so generally is recommended for removal of ureteral stones.
All 530 patients were treated with the Storz Modulith SLX lithotripter. The patients studied had presented with acute stone colic and were treated with SWL within 48 hours.
The authors state that the treatments were carried out by two “experienced sonographers” without input from a urological surgeon. That organisation certainly lays the ground for the low cost, but it might be unfortunate that urologists in this way stay away from the SWL technique and accordingly will have only vague ideas about what SWL can bring for their patients.
The stone-free rate of 68% is lower than expected which the authors also noted. One can speculate if a lower shockwave frequency or more powerful analgetic regimen had resulted in improved stone-free rate. But details of the SWL treatment strategy are not given.
The mean number of sessions was 2.12, also slightly higher than I expected.
That the treatment was cost effective is highlighted and of great health economic relevance.
The conclusion is that SWL should be the first line treatment for ureteral stones with diameter ≤ 10 mm, with SSD ≤ 14 cm and stone density ≤ 1250 HU.
I cannot but support this recommendation of a conventional method without need of specific preparations, without general or regional anaesthesia, without need of an operating theatre and perfectly well suited for out-patient treatment. With attention paid to the details of SWL the outcome will be at least as good as reported in this article.

Hans-Göran Tiselius

This is a highly interesting article in which the authors report their experience of acute SWL of ureteral stones. The message is clear, and I recommend this article for reading by all urologists and other colleagues who in one way or another are involved in the treatment of patients with urolithiasis. I completely agree with the view that SWL is not sufficiently used in treatment of patients with ureteral stones. It is surprising that URS so generally is recommended for removal of ureteral stones. All 530 patients were treated with the Storz Modulith SLX lithotripter. The patients studied had presented with acute stone colic and were treated with SWL within 48 hours. The authors state that the treatments were carried out by two “experienced sonographers” without input from a urological surgeon. That organisation certainly lays the ground for the low cost, but it might be unfortunate that urologists in this way stay away from the SWL technique and accordingly will have only vague ideas about what SWL can bring for their patients. The stone-free rate of 68% is lower than expected which the authors also noted. One can speculate if a lower shockwave frequency or more powerful analgetic regimen had resulted in improved stone-free rate. But details of the SWL treatment strategy are not given. The mean number of sessions was 2.12, also slightly higher than I expected. That the treatment was cost effective is highlighted and of great health economic relevance. The conclusion is that SWL should be the first line treatment for ureteral stones with diameter ≤ 10 mm, with SSD ≤ 14 cm and stone density ≤ 1250 HU. I cannot but support this recommendation of a conventional method without need of specific preparations, without general or regional anaesthesia, without need of an operating theatre and perfectly well suited for out-patient treatment. With attention paid to the details of SWL the outcome will be at least as good as reported in this article. Hans-Göran Tiselius
Monday, 20 May 2024