International Urology and Nephrology 24 (4), pp, 369--373 (1992)
In Situ Prone ESWL for the Treatment of Lower Ureteral Stones: Experience with 28 Patients ]. BA,SAR, T. GURPINAR, A. ERKAN The ESWL Unit, Urology Clinic, Cagda~ Health Center, Samsun, Turkey (Accepted September 8, 1991) Twenty-eight patients with lower ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) in the prone position over the period of 7 months between March 1990 and September 1990. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. Satisfactory disintegration was achieved in 93 per cent of patients. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent had residual fragments less than or equal to 4 mm in diameter. Twenty-one per cent of patients required repeat treatments. For only 2 patients general anaesthesia was required (7 per cent). There were no remarkable complications except for haemospermia which resolved spontaneously 15 days after treatment. It was concluded that in situ prone ESWL is an effective and safe procedure for the treatment of lower ureteral stones.
Introduction The advent o f transurethral ureteroscopy and E S W L have replaced the traditional open surgical m a n a g e m e n t o f ureteral stones. It is generally accepted that E S W L is the m e t h o d o f choice for the treatment o f upper ureteral calculi [1 ]. Transurethral ureteroscopy has been the preferred method o f treatment for lower ureteral stones since 1982 [2]. Recently, with the use o f second-generation lithotripters and new techniques o f E S W L , the indications for E S W L have been extended to include lower and mid-ureteral stones. It was suggested in several studies that E S W L should be the primary method o f treatment in patients with lower ureteral stones [3, 4, 5, 6, 7]. However, the treatment o f lower and mid-ureteral stones is still controversial and there are only limited data reported on in situ E S W L for lower ureteral stones. We report our experience with in situ prone E S W L in 28 patients with lower ureteral stones.
Patients and methods The medical records o f 28 patients with lower ureteral stones who underwent in situ prone E S W L between M a r c h 1990 and September 1990 were evaluated retrospectively. Patients with stone streets after previous E S W L , patients with VSP, Utrecht Akaddmiai Kiad6, Budapest
370
Ba~/ar et aL : E S W L f o r lower ureteral stones
additional stones in the ipsilateral upper ureter or kidney, as well as those who underwent retrograde stone manipulation prior to ESWL were not included in the study group. There were 21 males and 7 females, aged between 21 and 68 years (mean age 40). Stone sizes were measured by using a millimetric graph paper. Average stone size was 0,9 cm z (range 0.25-1.9 cm2). According to the kidney-ureter-bladder film (KUB) all stones were located between the ureterovesical junction and the lower border of the sacroiliac joint. Patients under the age of 18 were not subjected to prone ESWL because of the possible harmful effects of shock waves to growing bone tissue [8]. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. The number of shock waves delivered with each treatment ranged between 2200 and 3000 (average 2850) at an average maximum k.v. of 19.2 (range 16 to 20 k.v.). Stone localization was accomplished by moving the treatment table under hi-planed fluoroscopic guidance with a portable C-arm unit. Stone destruction was monitored fluoroscopically at every 100 shock waves. Patient position was prone in all treatments where in some cases the ipsilateral leg was elevated by using additional support and cushioning in order to achieve a better exposure of the body surface onto the rubber membrane. The procedure was carried out under premedication with 1 mg/kg intramuscular pethidine chloride and/or under intravenous sedation with 5 nag diazepam. In case of intolerance to pain the procedure was continued under general anaesthesia. A KUB film and renal ultrasound were obtained one day after treatment in order to assess the degree of disintegration (Fig. 1). In case of inadequate disintegration repeat treatment was performed 7 days after the first treatment session,
Fig. 1. K U B series demonstrating the treatment of a lower ureteral stone in a 28-year-old patient. (A) Prior to treatment 2800 shocks were given at 18 k.v. (B) One day after treatment satisfactory disintegration was achieved. (C) One week after treatment the patient was stone-free International Urology and Nephrology 24, 1992
Basar et al. : E S W L f o r lower ureteral stor.es
371
Patients with fragments equal to or less than 4 mm in diameter were followed up weekly. A repeat KUB film and renal ultrasound were obtained 12 weeks after the last treatment. Results Twenty-eight patients underwent a total of 35 treatments (average 1.25, range 1 to 3). Of them, 79 per cent showed adequate disintegration at first treatment and 14 per cent at repeat treatments. There were 2 failures. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent of patients had residual fragments less than or equal to 4 mm in diameter. General anaesthesia was needed in 2 patients (7 per cent). Two patients who failed disintegration were subjected to stone basketing. Dormia extraction was successful in both of these patients. All patients had gross haematuria which resolved 2 to 24 hours after treatment. The majority of patients (89 per cent) had cutaneous ecchymosis at the shock wave entrance. An interesting complication was haemospermia in a 33-yearold patient with a stone in the intramural ureter who received a total of 5400 shocks at 20 k.v. in 2 treatment sessions. Repeat sperm analysis 15 days after the last treatment revealed that haemospermia was resolved. All treatments were performed as an outpatient procedure except for 2 patients who underwent stone basketing, l-hese 2 patients were discharged from the clinic after 24 hours of hospitalization.
Discussion The first available lithotripter, Dornier HM3, was not constructed for the treatment of lower and mid-ureteral stones and initial attempts for stone disintegration in the standard supine position by using the blast path technique had been discouraging [3]. Several investigators introduced various modifications in patient positioning and achieved success rates between 27 and 95 per cent by using the Dornier HM3 lithotripter [4, 5, 7, 9, 10]. In 1988 Jenkins and Gillenwater introduced prone ESWL for distal ureteral calculi and obtained good results but this position required special arrangements on the Dornier HM3 lithotripter [11]. With the advent of second-generation lithotripters, which do not require more than the patient turning on the abdomen for prone positioning, prone ESWL has become a more practical procedure. However, only limited data on in situ prone ESWL with second-generation lithotripters have been reported up to now [6]. In our study we have modified the prone position by elevating the leg of patients with additional support and cushioning so that the bony pelvis was situated at an angle of 45 degrees to the horizontal plane. We have observed that this manoeuvre was useful especially for focussing stones in the intramural part o f the ureter. International Urology and Nephrology 24, 1992
372
Basar et al. : E S W L for lower ureteral stones
Transurethral ureteroscopy is a considerably effective procedure for the treatment o f lower ureteral stones. In a n u m b e r o f studies success rates ranging f r o m 86 to 97 per cent were reported [4, 12, 13]. A l t h o u g h successful, ureteroscopy carries the risk o f serious major complications such as ureteral perforation and subsequent ureteral stricture [14]. The high success rate and low morbidity achieved in our study make us conclude that E S W L should be the treatment o f choice for lower ureteral stones and the use o f ureteroscopy should be more restricted. There is a theoretical possibility that shock waves can either have a teratogenie effect or damage to the ovary by haemorrhage and subsequent scarring. Some authors preferred to exclude w o m e n o f child-bearing age f r o m their series o f lower and mid-ureteral stones while others did n o t [5, 7]. In fact, these considerations have never been observed in practice and in experimental studies [15]. In the light o f these data w o m e n less than 40 years old were also subjected to p r o n e E S W L in our study. One o f our patients experienced haemospermia which resolved 15 days after treatment. This could possibly be explained by the close proximity o f the seminal vesicle to the intramural ureter. We do not k n o w the significance o f this complication. Further studies investigating the effects o f shock waves on the male reproductive tract and subsequent fertility are needed.
Acknowledgement We are grateful to Mrs. Hfilya Ko~ for typing the manuscript.
References 1. Jenkins, A. D.: Dornier extracorporeal shock-wave lithotripsy for ureteral stones. UroL Clin. North Am., 15, 377 (1988). 2. Prez-Castro Ellendt, E., Martinez-Pinerio, J. A.: Ureteral and renal endoscopy. A new approach. Eur. UroL, 8, 117 (1982). 3. Dretler, S. P. : Ureteral stone disease. Options for management. UroL Clin. North Am., 17, 217 (1990). 4. EI-Faqih, S. R., Husain, I., Ekrnan, P. E., Sharma, N. D., Chakrabarty, A., Talic, R.: Primary choice of intervention for distal ureteric stone: Ureteroscopy or ESWL? Br. J. UroL, 62, 13 (1988). 5. Cole, R. S., Shuttleworth, K. E. D.: Is extracorporeal shock wave lithotripsy a suitable treatment for lower ureteric stones? Br. J. Urol., 62, 525 (1988). 6. Netto, N. R., Lemos, G. S., Claro, J. F. A. : In situ extracorporeal shock wave lithotripsy for ureteral calculi. J. UroL, 144, 253 (1990). 7. Becht, E., Moll, V., Neisius, D., Ziegler, M. : Treatment of prevesical ureteral calculi by extracorporeal shock wave lithotripsy. J. UroL, 139, 916 (1988). 8. Yeaman, L. D., Jerome, J. P., Mc Cullough, D. L. : Effects of shock waves on the structure and growth of the immature rat epiphysis. J. UroL, 141, 670 (1989). 9. Miller, K., Bubeck, J. R., Hautmann, R. : Extracorporeal shock wave lithotripsy of distal ureteral calculi. Eur. grol., 12, 305 (1986). 10. Chaussy, C. G., Fuchs, G. J.: Extracorporeal shock wave lithotripsy of distal-ureteral calculi: Is it worthwhile? J. Endow.ol., 1, 1 (1987). International Urology and Nephrology 24, 1992
Basal* et aL : E S W L ./'or lower ureteral stones
373
11. Jenkins, A. D., Gillenwater, J. Y.: Extracorporeal shock wave lithotripsy in the prone position: Treatment of stones in the distal ureter or anomalous kidney. J. UroL, 139, 911 (1988). 12. Schultz, A., Kristensen, J. K., Bilde, T., Eldrup, J. : Ureteroscopy: Results and complications. J. UroL, 137, 865 (1987). 13. Kostakopoulos, A., Sofras, F., Karayiannis, A., Kranidis, A., Dimopoulos, C.: Ureterolithotripsy: Report of 1000 cases. Br. J. UroL, 63, 243 (1989). 14. Daniels, G. F., Garnett, J. E., Carter, M. F.: Ureteroscopic results and complications: Experience with 130 cases. J. Urol., 139, 710 (1988). 15. Mc Cullough, D. L., Yeaman, L. D., Bo, W. J., Assimos, D. G., Kroovand, R. L., Griffin, A. S., Furr, E. G. : Effects of shock waves on the rat ovary. J. Urol., 141, 666 (1989)
International Urology and Nephrology 24, 1992
In Situ Prone ESWL for the Treatment of Lower Ureteral Stones: Experience with 28 Patients ]. BA,SAR, T. GURPINAR, A. ERKAN The ESWL Unit, Urology Clinic, Cagda~ Health Center, Samsun, Turkey (Accepted September 8, 1991) Twenty-eight patients with lower ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) in the prone position over the period of 7 months between March 1990 and September 1990. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. Satisfactory disintegration was achieved in 93 per cent of patients. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent had residual fragments less than or equal to 4 mm in diameter. Twenty-one per cent of patients required repeat treatments. For only 2 patients general anaesthesia was required (7 per cent). There were no remarkable complications except for haemospermia which resolved spontaneously 15 days after treatment. It was concluded that in situ prone ESWL is an effective and safe procedure for the treatment of lower ureteral stones.
Introduction The advent o f transurethral ureteroscopy and E S W L have replaced the traditional open surgical m a n a g e m e n t o f ureteral stones. It is generally accepted that E S W L is the m e t h o d o f choice for the treatment o f upper ureteral calculi [1 ]. Transurethral ureteroscopy has been the preferred method o f treatment for lower ureteral stones since 1982 [2]. Recently, with the use o f second-generation lithotripters and new techniques o f E S W L , the indications for E S W L have been extended to include lower and mid-ureteral stones. It was suggested in several studies that E S W L should be the primary method o f treatment in patients with lower ureteral stones [3, 4, 5, 6, 7]. However, the treatment o f lower and mid-ureteral stones is still controversial and there are only limited data reported on in situ E S W L for lower ureteral stones. We report our experience with in situ prone E S W L in 28 patients with lower ureteral stones.
Patients and methods The medical records o f 28 patients with lower ureteral stones who underwent in situ prone E S W L between M a r c h 1990 and September 1990 were evaluated retrospectively. Patients with stone streets after previous E S W L , patients with VSP, Utrecht Akaddmiai Kiad6, Budapest
370
Ba~/ar et aL : E S W L f o r lower ureteral stones
additional stones in the ipsilateral upper ureter or kidney, as well as those who underwent retrograde stone manipulation prior to ESWL were not included in the study group. There were 21 males and 7 females, aged between 21 and 68 years (mean age 40). Stone sizes were measured by using a millimetric graph paper. Average stone size was 0,9 cm z (range 0.25-1.9 cm2). According to the kidney-ureter-bladder film (KUB) all stones were located between the ureterovesical junction and the lower border of the sacroiliac joint. Patients under the age of 18 were not subjected to prone ESWL because of the possible harmful effects of shock waves to growing bone tissue [8]. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. The number of shock waves delivered with each treatment ranged between 2200 and 3000 (average 2850) at an average maximum k.v. of 19.2 (range 16 to 20 k.v.). Stone localization was accomplished by moving the treatment table under hi-planed fluoroscopic guidance with a portable C-arm unit. Stone destruction was monitored fluoroscopically at every 100 shock waves. Patient position was prone in all treatments where in some cases the ipsilateral leg was elevated by using additional support and cushioning in order to achieve a better exposure of the body surface onto the rubber membrane. The procedure was carried out under premedication with 1 mg/kg intramuscular pethidine chloride and/or under intravenous sedation with 5 nag diazepam. In case of intolerance to pain the procedure was continued under general anaesthesia. A KUB film and renal ultrasound were obtained one day after treatment in order to assess the degree of disintegration (Fig. 1). In case of inadequate disintegration repeat treatment was performed 7 days after the first treatment session,
Fig. 1. K U B series demonstrating the treatment of a lower ureteral stone in a 28-year-old patient. (A) Prior to treatment 2800 shocks were given at 18 k.v. (B) One day after treatment satisfactory disintegration was achieved. (C) One week after treatment the patient was stone-free International Urology and Nephrology 24, 1992
Basar et al. : E S W L f o r lower ureteral stor.es
371
Patients with fragments equal to or less than 4 mm in diameter were followed up weekly. A repeat KUB film and renal ultrasound were obtained 12 weeks after the last treatment. Results Twenty-eight patients underwent a total of 35 treatments (average 1.25, range 1 to 3). Of them, 79 per cent showed adequate disintegration at first treatment and 14 per cent at repeat treatments. There were 2 failures. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent of patients had residual fragments less than or equal to 4 mm in diameter. General anaesthesia was needed in 2 patients (7 per cent). Two patients who failed disintegration were subjected to stone basketing. Dormia extraction was successful in both of these patients. All patients had gross haematuria which resolved 2 to 24 hours after treatment. The majority of patients (89 per cent) had cutaneous ecchymosis at the shock wave entrance. An interesting complication was haemospermia in a 33-yearold patient with a stone in the intramural ureter who received a total of 5400 shocks at 20 k.v. in 2 treatment sessions. Repeat sperm analysis 15 days after the last treatment revealed that haemospermia was resolved. All treatments were performed as an outpatient procedure except for 2 patients who underwent stone basketing, l-hese 2 patients were discharged from the clinic after 24 hours of hospitalization.
Discussion The first available lithotripter, Dornier HM3, was not constructed for the treatment of lower and mid-ureteral stones and initial attempts for stone disintegration in the standard supine position by using the blast path technique had been discouraging [3]. Several investigators introduced various modifications in patient positioning and achieved success rates between 27 and 95 per cent by using the Dornier HM3 lithotripter [4, 5, 7, 9, 10]. In 1988 Jenkins and Gillenwater introduced prone ESWL for distal ureteral calculi and obtained good results but this position required special arrangements on the Dornier HM3 lithotripter [11]. With the advent of second-generation lithotripters, which do not require more than the patient turning on the abdomen for prone positioning, prone ESWL has become a more practical procedure. However, only limited data on in situ prone ESWL with second-generation lithotripters have been reported up to now [6]. In our study we have modified the prone position by elevating the leg of patients with additional support and cushioning so that the bony pelvis was situated at an angle of 45 degrees to the horizontal plane. We have observed that this manoeuvre was useful especially for focussing stones in the intramural part o f the ureter. International Urology and Nephrology 24, 1992
372
Basar et al. : E S W L for lower ureteral stones
Transurethral ureteroscopy is a considerably effective procedure for the treatment o f lower ureteral stones. In a n u m b e r o f studies success rates ranging f r o m 86 to 97 per cent were reported [4, 12, 13]. A l t h o u g h successful, ureteroscopy carries the risk o f serious major complications such as ureteral perforation and subsequent ureteral stricture [14]. The high success rate and low morbidity achieved in our study make us conclude that E S W L should be the treatment o f choice for lower ureteral stones and the use o f ureteroscopy should be more restricted. There is a theoretical possibility that shock waves can either have a teratogenie effect or damage to the ovary by haemorrhage and subsequent scarring. Some authors preferred to exclude w o m e n o f child-bearing age f r o m their series o f lower and mid-ureteral stones while others did n o t [5, 7]. In fact, these considerations have never been observed in practice and in experimental studies [15]. In the light o f these data w o m e n less than 40 years old were also subjected to p r o n e E S W L in our study. One o f our patients experienced haemospermia which resolved 15 days after treatment. This could possibly be explained by the close proximity o f the seminal vesicle to the intramural ureter. We do not k n o w the significance o f this complication. Further studies investigating the effects o f shock waves on the male reproductive tract and subsequent fertility are needed.
Acknowledgement We are grateful to Mrs. Hfilya Ko~ for typing the manuscript.
References 1. Jenkins, A. D.: Dornier extracorporeal shock-wave lithotripsy for ureteral stones. UroL Clin. North Am., 15, 377 (1988). 2. Prez-Castro Ellendt, E., Martinez-Pinerio, J. A.: Ureteral and renal endoscopy. A new approach. Eur. UroL, 8, 117 (1982). 3. Dretler, S. P. : Ureteral stone disease. Options for management. UroL Clin. North Am., 17, 217 (1990). 4. EI-Faqih, S. R., Husain, I., Ekrnan, P. E., Sharma, N. D., Chakrabarty, A., Talic, R.: Primary choice of intervention for distal ureteric stone: Ureteroscopy or ESWL? Br. J. UroL, 62, 13 (1988). 5. Cole, R. S., Shuttleworth, K. E. D.: Is extracorporeal shock wave lithotripsy a suitable treatment for lower ureteric stones? Br. J. Urol., 62, 525 (1988). 6. Netto, N. R., Lemos, G. S., Claro, J. F. A. : In situ extracorporeal shock wave lithotripsy for ureteral calculi. J. UroL, 144, 253 (1990). 7. Becht, E., Moll, V., Neisius, D., Ziegler, M. : Treatment of prevesical ureteral calculi by extracorporeal shock wave lithotripsy. J. UroL, 139, 916 (1988). 8. Yeaman, L. D., Jerome, J. P., Mc Cullough, D. L. : Effects of shock waves on the structure and growth of the immature rat epiphysis. J. UroL, 141, 670 (1989). 9. Miller, K., Bubeck, J. R., Hautmann, R. : Extracorporeal shock wave lithotripsy of distal ureteral calculi. Eur. grol., 12, 305 (1986). 10. Chaussy, C. G., Fuchs, G. J.: Extracorporeal shock wave lithotripsy of distal-ureteral calculi: Is it worthwhile? J. Endow.ol., 1, 1 (1987). International Urology and Nephrology 24, 1992
Basal* et aL : E S W L ./'or lower ureteral stones
373
11. Jenkins, A. D., Gillenwater, J. Y.: Extracorporeal shock wave lithotripsy in the prone position: Treatment of stones in the distal ureter or anomalous kidney. J. UroL, 139, 911 (1988). 12. Schultz, A., Kristensen, J. K., Bilde, T., Eldrup, J. : Ureteroscopy: Results and complications. J. UroL, 137, 865 (1987). 13. Kostakopoulos, A., Sofras, F., Karayiannis, A., Kranidis, A., Dimopoulos, C.: Ureterolithotripsy: Report of 1000 cases. Br. J. UroL, 63, 243 (1989). 14. Daniels, G. F., Garnett, J. E., Carter, M. F.: Ureteroscopic results and complications: Experience with 130 cases. J. Urol., 139, 710 (1988). 15. Mc Cullough, D. L., Yeaman, L. D., Bo, W. J., Assimos, D. G., Kroovand, R. L., Griffin, A. S., Furr, E. G. : Effects of shock waves on the rat ovary. J. Urol., 141, 666 (1989)
International Urology and Nephrology 24, 1992
