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Elawdy MM et al, 2018: Extracorporeal shock wave lithotripsy for bilateral renal stones: A case report with serious complications that could be avoided.

Elawdy MM, El-Halwagy S, Al-Khanbashi S, Aga AA, Razek YA.
Department of Radiology, Ministry of Health, Sohar Hospital, Sohar, Sultanate of Oman.
Oman Medical College, Sohar, Sultanate of Oman.

Abstract

22-year-old male patient with irrelevant medical history presented with bilateral renal stones; multiple stones in right renal pelvis measured 10, 11, and 11mm and another one on the left side measured 12mm. Extra corporeal shock wave lithotripsy (ESWL) was done first on the left side, but after 400 shocks and total energy of 20 Storez Medical Lithotripsy Index only, the stone wasn't visible. Then, the operator switched to the right side and a he completed the session. A day after, the patient presented with bilateral renal colic, gradual rising of renal function and imaging showed bilateral steinstrasse with bilateral hydroureteronephrosis. Patient was managed with insertion of bilateral ureteric stents and had another session of ESWL on the right side. We concluded that bilateral simultaneous ESWL for bilateral renal stones doesn't affect the renal function on the long-term outcome, but still carries the risk of bilateral obstruction and acute renal injury.

Urol Ann. 2018 Oct-Dec;10(4):409-412. doi: 10.4103/UA.UA_69_18.

 

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Comentarios 1

Hans-Göran Tiselius en Miércoles, 13 Febrero 2019 08:45

The message delivered by the authors of this report is that obstruction caused by bilateral steinstrasse following SWL did not result in long-term reduced renal function. In this regard this specific patient was fortunate because a successful outcome cannot be taken for granted. There is no guarantee that stent insertion will be successful.

In my mind this is an example of SWL carried out in a suboptimal and careless way.

Firstly, when the operator after a small number of shock waves to the stone in the left kidney concluded that the stone had escaped to another location, the natural step would have been to search for the stone in a new position rather than starting treatment on the other side. If it was impossible to find the stone in the left kidney disintegration should have been suspected and SWL of stones in the right kidney planned at another occasion.

Secondly, the total stone surface area on the right side was approximately 165 mm2. Although such a stone burden can be treated without stenting, the uncertainty of what had happened on the left side should have called for insertion of a stent before proceeding with right-sided SWL.

I once treated a pilot with bilateral 3-4 mm papillary stones attached to papillae with the assumption that dislodged stones easily would pass. The patient returned the following day with bilateral obstruction and anuria. Insertion of stents was extremely difficult and a real challenge. If stenting fails the alternative is either percutaneous nephrostomy catheters or anaesthesia requiring endoscopy. Moreover, with nephrostomy catheters, non-infection stones can be converted to infection stones.

Recommendation: SWL of bilateral stones ideally should be carried out on separate occasions. If such a plan is less desirable one or two internal stents should be used as safety measure.

The message delivered by the authors of this report is that obstruction caused by bilateral steinstrasse following SWL did not result in long-term reduced renal function. In this regard this specific patient was fortunate because a successful outcome cannot be taken for granted. There is no guarantee that stent insertion will be successful. In my mind this is an example of SWL carried out in a suboptimal and careless way. Firstly, when the operator after a small number of shock waves to the stone in the left kidney concluded that the stone had escaped to another location, the natural step would have been to search for the stone in a new position rather than starting treatment on the other side. If it was impossible to find the stone in the left kidney disintegration should have been suspected and SWL of stones in the right kidney planned at another occasion. Secondly, the total stone surface area on the right side was approximately 165 mm2. Although such a stone burden can be treated without stenting, the uncertainty of what had happened on the left side should have called for insertion of a stent before proceeding with right-sided SWL. I once treated a pilot with bilateral 3-4 mm papillary stones attached to papillae with the assumption that dislodged stones easily would pass. The patient returned the following day with bilateral obstruction and anuria. Insertion of stents was extremely difficult and a real challenge. If stenting fails the alternative is either percutaneous nephrostomy catheters or anaesthesia requiring endoscopy. Moreover, with nephrostomy catheters, non-infection stones can be converted to infection stones. Recommendation: SWL of bilateral stones ideally should be carried out on separate occasions. If such a plan is less desirable one or two internal stents should be used as safety measure.
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