SWL literature
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Hashem A. et al., 2019: Efficacy of pethidine, ketorolac, and lidocaine gel as analgesics for pain control in shockwave lithotripsy: A single-blinded randomized controlled trial.

Hashem A, Ghobrial FK, Elbaset MA, Atwa AM, Fadallah M, Laymon M, El-Assmy A, Sheir KZ, Abol-Enein H.
Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.

Abstract

Purpose: To compare the safety and efficacy of xylocaine gel and ketorolac as opioid-sparing analgesia compared with pethidine for shock wave lithotripsy (SWL) pain.Materials and Methods: A single-blinded randomized controlled trial (RCT) was performed in 132 patients with renal and upper ureteral stones amenable to treatment with SWL. The first patient group received intravenous (IV) pethidine and placebo gel; the second group received IV ketorolac plus placebo gel; the third group received lidocaine gel locally plus normal saline IV. Stone disintegration was classified as none (no change from basal by kidney, ureter, bladder X-ray or ultrasound [US] imaging), partial (fragmented and >4-mm residual fragments), and complete (≤4-mm residual fragments). Stone disintegration was assessed by kidney-ureter-bladder X-ray and US imaging. Pain was evaluated by use of the Numeric Pain Rating Scale (NPRS).Results: The NPRS scores were highest in the xylocaine group at 10, 20, and 30 minutes (p=0.0001) with no significant difference between the ketorolac and pethidine groups, except at 10 minutes (p=0.03) and a near significant difference at 30 minutes (p=0.054) in favor of ketorolac. Results for stone disintegration (none, partial, and complete, respectively) were as follows: 25 (50.0%), 23 (46.0%), and 2 (4.0%) for pethidine; 19 (35.8%), 23 (43.4%), and 11 (20.8%) for ketorolac; and 26 (89.7%), 3 (10.3%), and 0 (0.0%) for lidocaine (p=0.008).Conclusions: Ketorolac is a safe and more effective alternative to morphine derivatives for SWL analgesia. Lidocaine gel should not be used as mono-analgesia for SWL.

Investig Clin Urol. 2019 Jul;60(4):251-257. doi: 10.4111/icu.2019.60.4.251. Epub 2019 May 29.

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Comments 1

Hans-Göran Tiselius on Tuesday, January 14 2020 08:05

It is well recognized ever since SWL was introduced that effective pain treatment is a pre-requisite for successful outcome. Early results with EMLA-cream showed that this form of pain treatment was insufficient at least when electro-hydraulic shock waves were applied [1].

Although it is stated in the article text that disintegration was not considered, such data are given in the Abstract.

https://www.storzmedical.com/images/blog/Hashem_Tabelle.PNG

These results are difficult to interpret because patients in Group C were obviously insufficiently treated and the stone volumes were surprisingly small (but probably erroneously reported?). The outcome is, however, generously poor also with Ketorolac and Pethidin, but of the three alternatives only group B had the best disintegration.

It is clear that local anaesthetic cream is insufficient for pain treatment during efficient SWL.

Reference
1. Tiselius HG Cutaneous anesthesia with lidocaine-prilocaine cream: a useful adjunct during shock wave lithotripsy with analgesic sedation. J Urol. 1993 149(1):8-11.

It is well recognized ever since SWL was introduced that effective pain treatment is a pre-requisite for successful outcome. Early results with EMLA-cream showed that this form of pain treatment was insufficient at least when electro-hydraulic shock waves were applied [1]. Although it is stated in the article text that disintegration was not considered, such data are given in the Abstract. [img]https://www.storzmedical.com/images/blog/Hashem_Tabelle.PNG[/img] These results are difficult to interpret because patients in Group C were obviously insufficiently treated and the stone volumes were surprisingly small (but probably erroneously reported?). The outcome is, however, generously poor also with Ketorolac and Pethidin, but of the three alternatives only group B had the best disintegration. It is clear that local anaesthetic cream is insufficient for pain treatment during efficient SWL. Reference 1. Tiselius HG Cutaneous anesthesia with lidocaine-prilocaine cream: a useful adjunct during shock wave lithotripsy with analgesic sedation. J Urol. 1993 149(1):8-11.
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