Lithotripsy Patient Reviews: Kidney Stone Symptoms, Treatment, Causes & Prevention

07.09.197901.12.2021 by alexxlab

What are the first signs of kidney stones? How are kidney stones treated and prevented? Patients share their medical experiences with kidney stones and lithotripsy.

Содержание

Kidney Stone Symptoms and Causes

Kidney stones can cause severe pain, with one patient describing the experience as “much worse pain than either appendicitis or gall bladder removal.” The first signs of kidney stones often include sharp, cramping pain in the back, abdomen or groin as the stones try to pass through the urinary tract. Other common symptoms include blood in the urine, difficulty urinating, and nausea or vomiting.

Kidney stones can form for a variety of reasons, including dehydration, high-sodium diets, obesity, and certain medical conditions. One patient noted that a kidney stone had been growing during her pregnancy, but the fetus kept it from causing too much pain at the time.

Lithotripsy Treatment for Kidney Stones

For many kidney stones, the recommended treatment is a procedure called lithotripsy. During lithotripsy, a machine called a lithotripter uses shock waves to break the kidney stone into smaller pieces that can then be more easily passed through the urinary tract.

Lithotripsy is typically performed while the patient is under some form of anesthesia to manage the pain and ensure they do not move during the procedure. The shock waves can be quite powerful and uncomfortable. After lithotripsy, patients may experience soreness, discomfort, and the need for pain medication as the stone fragments pass.

Patient Experiences with Lithotripsy

Many patients have shared their experiences with lithotripsy for kidney stones. One patient described passing out at work from the pain and waking up in the emergency room, where they were scheduled for a lithotripsy. While the lithotripsy itself went well, the patient found the pain unbearable after the procedure and ended up removing the stent themselves, against their doctor’s advice.

Another patient had multiple episodes of kidney stones, including one shortly after giving birth. They too had repeated lithotripsy procedures, but found the pain after the surgery nearly intolerable, requiring an emergency room visit with extremely low blood pressure.

Passing Kidney Stones After Lithotripsy

After lithotripsy, the goal is for the patient to be able to pass the smaller stone fragments through their urine. Some patients find that it is less painful to pass the stones after the lithotripsy procedure. However, this is not guaranteed, and some patients may still experience significant discomfort and pain as the stones are passed.

Patients are advised to drink plenty of water to help flush out the stone fragments. If pain persists or the stones do not pass as expected, further medical intervention may be necessary.

Preventing Kidney Stones

While lithotripsy can be an effective treatment for kidney stones, prevention is ideal. Staying hydrated, limiting sodium intake, and making dietary changes to reduce oxalate or uric acid levels can all help prevent kidney stone formation. Patients with recurrent kidney stones may also be prescribed medications to inhibit stone growth.

By understanding the causes of kidney stones and taking proactive steps to prevent them, many people can avoid the painful experience of passing a kidney stone or undergoing lithotripsy treatment.

Factors Affecting Lithotripsy Outcomes

The success of lithotripsy can depend on several factors, including the size and location of the kidney stone. Stones in the upper urinary tract generally respond better to lithotripsy than those in the lower tract. The number of shock waves used and the power settings of the lithotripter machine can also impact the outcome.

Patients’ individual anatomy and stone composition can also play a role. In some cases, lithotripsy may not be effective, and other treatment options like ureteroscopy or percutaneous nephrolithotomy may be necessary.

Conclusion

Kidney stones can be a painful and disruptive medical condition, but treatments like lithotripsy can help manage the problem. By understanding the symptoms, causes, and treatment options, patients can work with their healthcare providers to develop a plan to address kidney stones and prevent future occurrences.

The First Signs of Kidney Stones: Pain, Causes, Treatment & Passing Patient Comments: Kidney Stones – Treatment – Viewers Share Their Medical Experiences

I am 33 and have had two kidney stones removed so far and currently have a small one waiting to be passed/blown to bits. I had already had appendicitis and gall bladder removal prior to my first kidney stone episode but the kidney stone was much worse pain than either of those. I remember passing out at work from the pain and then waking up in the emergency room (ER) where they told me it was kidney stones and scheduled a lithotripsy after doping me up a bit. The lithotripsy went well and they put a stent in but a day later, it hurt even worse. I tried for a few days to take the pain but I could barely breathe and it was making me almost delirious. So (brace yourself), I went in the bathroom and pulled out my stent. Much better! Doctor wasn’t happy when I told him what I did; better than contemplating suicide over the pain. The next episode was after I had my first child, literally, about a week postpartum. Apparently, it had been in there the whole time growing but the fetus kept it from causing too much pain somehow. Again, I had another lithotripsy and another stent, although I warned the doctor about what happened the last time. Sure enough, the same night after surgery, I was rolling around in bed and no position brought any amount of relief. Finally, I told my husband to call an ambulance (which I need to be dying to ask for) and he said he would just take me in the car to the ER. I waited in the ER in a wheelchair for about an hour, trying not to pass out. When I finally got back to triage, my blood pressure was 70/20! Well, that got things moving. In about 5 minutes, I was in a bed with Dilaudid through an IV which was amazing for the pain although my husband says it made me say lots of funny things. That was almost 2 years ago and here we are again for the 3rd go round. Urologist says current one is not big enough to be causing pain quite yet but my back does hurt same place it always does when I have a stone, so we’ll see.

What’s it like: To get lithotripsy

Why get lithotripsy?

Extracorporeal shock wave lithotripsy is a procedure used to treat some kidney stones. During the procedure, a lithotripter machine uses shock waves to break a kidney stone into smaller passable pieces. Typically, people will have lithotripsy performed when the stone is in the upper third of the urinary tract and a size that can be seen by fluoroscopy, similar to an X-ray “movie.” If your doctor can see the stone through fluoroscopy, then it can generally be treated through lithotripsy.

Not all kidney stones can be treated effectively using lithotripsy. You will need to talk with your doctor about what is appropriate for your case.

What happens during the procedure?

The shock waves generate enough power and force that it hurts. Because of this, you’ll generally be placed under some form of anesthesia and fall asleep.

This is also to ensure that you don’t move. It’s important that you don’t move because the shock waves are focused on your kidney stone. Medical professionals will use X-ray to refine the focal point of where they’re targeting the shock waves.

It’s up to the patient to pass the stone once it’s broken. If your anatomy is correct and you drink enough water, hopefully the passage occurs without any problem. Some patients find that, after lithotripsy, it doesn’t hurt as much to pass the stone.

Lithotripsy machines can send up to 2,500 shock waves to the kidney. It’s not generally recommended to go higher, for risk of damaging the kidney. If the stone is in the kidney, the procedure works in the majority of patients. In this scenario, you’ll discharge the fragments in about a month. If the stone is the ureter, the tube leading from the kidney to the bladder, it will be discharged about 80 percent of the time.

Lithotripsy for Kidney Stones: Procedure, Risks, What to Expect

Knowing what to expect after a lithotripsy can help you get back to your everyday life as soon as possible.

How will I feel after the lithotripsy?

You may have soreness and discomfort in your abdomen or back after lithotripsy. To reduce discomfort, take slow deep breaths. You will likely have pain medication to control your pain. You might feel a little drowsy from the sedative and pain medications you were given. Tell your doctor if your pain is not well controlled by your medication because it can be a sign of a complication.

When can I go home?

You will stay in the recovery room or radiology department for a short period of time after your lithotripsy. You will be discharged home when you are fully alert, breathing effectively, and your vital signs are stable. This generally takes a couple of hours, depending on the type of sedation you receive.

You may still be a bit drowsy and will need a ride home from your procedure. You will not be able to drive for about 24 hours, and someone should stay with you during that time. Most people can resume normal activities within a day or two.

It is important to drink plenty of water to help pass the stone fragments after lithotripsy. You may feel pain and nausea when you pass a stone fragment. Your doctor may give you pain medication, antibiotics, and anti-inflammatory medications to make you more comfortable. Certain medications can increase the risk of bleeding, so only take those recommended by your doctor.

You may continue to pass stone fragments for up to eight weeks after your lithotripsy. Your doctor may ask you to strain your urine in order to recover the stone fragments, which are sent to a laboratory for analysis. This may help guide preventive strategies in the future.

When should I call my doctor?

After a lithotripsy you should keep your follow-up appointments and call your doctor if you have concerns between appointments. Call your doctor if you have:

Bloody urine that does not go away after a few days
Burning with urination or an urgent or frequent need to urinate
Fever or chills
Pain that is not controlled by your pain medication
Severe abdominal, pelvic, or low back pain

Efficacy of commercialised extracorporeal shock wave lithotripsy service: a review of 589 renal stones | BMC Urology

The overall rate of stone clearance in this study was found to be in line with the reported stone free rate of centres with static machines. The overall stone free rate of 93% found in this study is significantly different from what was described in a recent study by Nafie et al., reporting a stone clearance rate of 49% [7]. In the study by Nafie it was speculated whether the low rate of stone clearance was due to a relative high proportion of patient with stones in the lower pole (43.3%). This is in significant contrast to a stone clearance of 93% for lower pole stones found in the present study, were 44% of the stones were located in the lower pole.

With regard to patient selection, information on the lower pole anatomy was not available and might have favoured stone clearance rates in this study but is unlikely to account for such large differences. Furthermore, the efficacy of ESWL is very dependent on the skills of the technician performing the treatment and in the present study treatments were carried out by a small team of very skilled and dedicated technicians [8]. In a previous multicentre study it was demonstrated that a transportable ESWL system had a high margin of safety with low complications rates and no apparent sacrifice of efficacy with regard to non-transportable systems [9].

Management of stones in the lower calyx using ESWL remains somewhat controversial. It has been reported that lower pole stones carry a lower success rate after ESWL monotherapy compared to stones in upper and middle calyx [1, 10]. However, a study with 246 cases of lower pole stones treated with EWSL concluded that stone size rather than lower pole anatomy was predictive of the efficacy [11]. Another study with nearly 600 renal stones fund no significant difference in stone clearance rate between stones located in the lower, middle and upper pole [12]. In the present study, no significant difference in ESWL success rate was observed between intra renal stone locations. Stones in the lower calyx were just as sensitive to ESWL as stones in other intra renal locations.

With a retreatment rate of 31%, the majority of stones required only a single treatment. However, the slightly higher retreatment rate found in this study compared to other series is consistent with the department’s liberal policy towards ESWL. By performing a second treatment of the stones that was initially unsuccessfully treated, the overall stone free rate increased from 69% to 87%. Performing three or more ESWL attempts only increases the overall success rate slightly from 87% to 93%. Based on the finding in the present study, it seems reasonable to offer a patient who was initially unsuccessful treated with ESWL at least one other attempt before considering invasive procedures.

The literature contains only little information on JJ-usage in relation to ESWL treatments and indications remains unclear and without consensus. The intention of a JJ is to prevent complications associated with ureteral obstruction as stone fragments is cleared trough the ureter. Conversely, the main drawbacks of JJ are bladder and kidney discomfort, risk of infections and calcification of the JJ. A survey among American urologists reported the JJ usage prior to ESWL to be 28% for 10 mm stones, 57% for 15 mm stones and 87% for 20 mm stones [13]. The results in the present study indicate a similar correlation between stone size and treatment with JJ prior to ESWL, though the results did not reach statistically significance. With respect to intra renal stone location, we found that significantly more patients with stones in the renal pelvis than elsewhere in the kidney were treated with JJ prior to ESWL. As expected, stones in the renal pelvis did give rise to to JJ-demanding obstruction more frequently than other intra renal locations. Previously, only a few studies have reported on JJ usage in relation to ESWL and concludes that treatment with a JJ prior to ESWL does not significantly influence stone free rates but generally results in more discomfort [14,15,16,17]. In the group of patients not treated with JJ prior to ESWL, we found that only 17 patients (3%) subsequently required treatment with an acute JJ because of complications associated with ureteral obstruction. Furthermore, we found association between stone size or intra renal stone location and the risk of needing treatment with JJ after the ESWL procedure.

The present study highlights the discrepancy in the efficacy of ESWL being reported in the literature, especially regarding mobile lithotripsy service. Although this study presents a large number of stones treated with EWSL the study is limited to being a single-centre design. Also, the retrospective design raises the issue of potential selection bias which are likely to have influenced the results of the present study. Further studies are warranted into the efficacy of mobile lithotripsy service, learning curve for ESWL technicians and commercialised health care services in general.

The Influence of Pain on the Outcome of Extracorporeal Shockwave Lithotripsy – FullText – Current Urology 2018, Vol. 12, No. 2

Abstract

Introduction: The aim of this study was to determine the predictive value of pain scores on the efficacy of extracor-poreal shockwave lithotripsy (ESWL) and to identify other predictive risk factors for treatment success. Materials and Methods: A total of 476 patients who underwent ESWL (piezoelectric lithotripsy) for urolithiasis between September 2011 and December 2015 were identified. The primary end-point of this study was success rate, which was evaluated 4 months after ESWL. The secondary outcome was the occurrence of complications as a result of ESWL. Results: The average pain perception was reported at 5 on a scale from 0 to 10. The overall success rate of ESWL was found to be 43.9% and the success rate after the first ESWL was 35.1%. Univari-ate analysis showed no significant correlation between pain score and success of ESWL (p = 0.135). The level of intensity was correlated with pain scores (Pearson correlation -0.423, p Conclusion: No correlation was found between the pain scores and efficacy of ESWL. Despite this absence, pain scores during ESWL sessions remain high and additional analgesia would improve patient satisfaction.

Introduction

Since the introduction of extracorporeal shockwave lithotripsy (ESWL) in the early 1980s, it has been recommended as a first-line treatment for renal and ureteral calculi less than 20 mm in diameter. Contrary to percutaneous nephrolithotomy (PCNL) and ureteroscopy, the procedure can be performed without the use of general anesthesia and in an outpatient setting. Success rates of ESWL range from 33 to 91%, depending on the efficacy of the lithotriptor, stone factors, patient habitus and the competence of the operator [1]. Predicting the efficacy of ESWL is key in reducing repetitive treatment, hospital costs and patient burden [2].

After the introduction of ESWL, the procedure was performed under general anesthesia. Technical improvement of lithotripters has enabled the treatment to be performed without the use of general anesthesia, although a lower level of intensity was generally being used. However, ESWL is still generally considered to be a painful procedure. This could be caused by shockwaves reaching superficial (skin and muscle) and deeper structures (ribs, nerves and the kidney capsule) [3,4].

It has commonly been assumed that pain effects the outcome of ESWL due to involuntary pain-induced movements and excessive respiratory excursions during the procedure, which impedes the operator’s efforts to maintain focus on the stone. High pain perception might also limit opportunities to apply an adequate dose of energy [5]. However, little evidence is available to confirm the direct effect of pain on success rates of ESWL [4,5,6].

The aim of this study is to evaluate the correlation between pain perception during treatment as well as other potential predictive risk factors and the stone-free rate (i.e. rate of success) after ESWL.

Materials and Methods

Cohort Selection Criteria

We included patients diagnosed with urolithiasis who were referred to a urology outpatients’ clinic for ESWL between September 2011 and December 2015. They were identified from a prospectively collected database. These patients were adults (> 18 years) receiving their first ESWL for a solitary stone located in the kidney or the ureter or those who had not received an ESWL within the previous 2 years. We excluded patients whose essential variable “pain-score” was missing (n = 19), those whose diagnosis was uncertain (n = 16), along with those who had been lost to follow-up (n = 46). This study was approved by the local institutional review board (METC Zuidwest Holland) and is in compliance with the Helsinki Declaration.

Review of Patient Data

Patient characteristics (age and sex), urologic presentation (previous ESWL, antibiotics, hydronephrosis, double-J catheter, nephrostomy catheter, use of tamsulosin, use of butylscopolamine and number of reinterventions), stone characteristics (side, size and location) and treatment parameters (level of intensity, applied amount of shocks, operator and fluoroscopy time) were obtained from the database. Use of tamsulosin was defined as use of 0.4 mg once daily at the moment of ESWL or for several days prior to the first follow-up. Stone size was measured using the largest measured diameter.

The primary endpoint of this study was the success rate defined as completely stone-free or with fragments smaller than 4 mm. Since all patients received an appointment at 3 weeks after treatment and if necessary followed by another appointment at 3 months, success rate was evaluated within 4 months of follow-up.

The need for additional treatment or reintervention (ESWL, ure-teroscopy or PCNL) within 6 months was evaluated by urologist, in case of persisting stone or patients with recurrent urolithiasis. The secondary outcome was the complication rate due to ESWL, measured using the Clavien-Dindo classification [7].

Extracorporeal Shockwave Lithotripsy

Shockwave lithotripsy was performed using the PiezoLith 3000 (Wolf®), a third generation piezoelectric shockwave litho-triptor. All patients received 1,000 mg oral paracetamol and 100 mg diclofenac per rectum half an hour prior to their procedure. Anticoagulants were stopped 1 week before treatment. Fluoros-copy or ultrasound was used to locate the stone. The target was to deliver 3,000 shocks for renal stones and 4,000 shocks for ureteral stones with a frequency of 2 Hz. Depending on the patients’ pain tolerance, the intensity level was gradually increased to a maximum of 17 for renal stones and 20 for ureteral stones (Supplementary table, metric scale of power as indicated by Wolf). No ramping was performed. Patients were asked to indicate their degree of pain on a scale from 0 to 10 (0, describing “no pain” and 10, describing “maximal possible pain”) multiple times during ESWL.

The highest pain score was reported. A pain score less than 4 was considered as acceptable. Three weeks after treatment, their stone status was evaluated by kidney-ureter-bladder radiography and, in case of radiolucent stones, ultrasonography or an abdominal computerized tomography (CT) scan. The procedure was carried out by urologists or specially trained nurses.

Statistical Analysis

SPSS-version 23.0 was used to perform statistical analyses. The Pearson correlation coefficient was used to evaluate the correlation between intensity levels and pain scores. Univariate and multivariate logistic regression analyses (stepwise backward method) were used to determine the predictive value of pain and other variables for the efficacy of ESWL. The Hosmer-Lemeshow test was used to evaluate the quality of the prediction model. A p-value < 0.05 was considered statistically significant.

Results

Patient, Stone and Procedure Characteristics

The patient and demographic characteristics are summarized in Table 1. A total number of 476 patients with urolithiasis is analyzed in this study. The median age is 52 years and sex ratio (M/F) is 3:1. A double-J catheter was in situ in 11 patients (2.3%) and a nephrostomy catheter in 21 patients (4.4%). For renal stones, a median of 3,000 shockwaves was applied with a median intensity level of 12.9, while ureteral stones were treated on with 3,500 shockwaves and an intensity level of 13.9. The level of intensity was correlated with the pain scores (Pearson correlation -0.423, p < 0.001). The higher the pain scores, the lower the level of intensity.

Table 1

Baseline patient and stone characteristics

Primary Outcome

The median pain score is reported as 5. Two patients (0.4%) experienced no pain (pain score 0), 104 patients (21.8%) mild pain (pain score 1-3), 224 patients (47.1%) moderate pain (pain score 4-6) and 146 patients (30.7%) severe pain (pain score 7-10). The pain score was significantly higher among patients younger than 60 years old (5.4 vs. 4.7, p = 0.001). A total of 46 patients (9.7%) required extra use of opiates (oxycodon, tramadol, pirit-ramide or morphine), resulting in a mean pain score of 4.96. There was no significant difference in pain score between the group with and without use of extra opiates (4. 96 vs. 5.20, p = 0.432). The use of butylscopolamine as analgesic was reported in 30 patients (6.3%). There was no significant difference between pain scores for renal and ureteral stones (5.4 vs. 5.1, p = 0.113).

The success rate of the first ESWL in our department was recorded as 35.1%. One hundred thirty-seven patients received a second or third ESWL session, resulting in an overall success rate of 43.9% with a mean of 1.37 sessions. Most of those patients (93.4%) received re-ESWL within 6 months. Univariate analysis showed no significant correlation between the pain score and the success of ESWL (p = 0.135). Univariate analysis identified sex, stone location, stone size, hydronephrosis and the use of tamsulosin as potentially predictive factors (Table 2). Multivariate logistic regression analysis showed that sex, stone location and size independently influenced the success of ESWL (Table 3). The Hosmer-Lemeshow test indicates a good quality of the prediction model (p = 0.177). An additional operation after ESWL was required to 115 patients (24.2%) who were not stone-free after ESWL. Ureteroscopy was performed in 106 patients (22.3%) and PCNL in 9 patients (1.9%).

Table 2

Table 3

Secondary Outcome

Complications were reported in 12.4% of patients (Table 4). The majority of complications reported during the study period were minor and without the need for an intervention, such as hematuria and pain. In 1 case, a transient ischemic attack occurred due to a temporary stop of anticoagulants. One patient developed an acute renal insufficiency, but spontaneously recovered after several days.

Table 4

Complication rates of ESWL

Discussion

The introduction of ESWL has been revolutionary for the treatment of urolithiasis. However, ESWL causes shockwave-induced pain during the treatment. The correct dosage of analgesics is mandatory to maintain patient comfort and may improve treatment outcomes [8]. The hypothesis is that adequate treatment of pain during ESWL would result in higher success rates due to less involuntary movements and better stone focus. We designed this study in order to evaluate this assumption.

Parameters for Stone Fragmentation and Clearance

Stone fragmentation and clearance are multifactorial events. The success of ESWL depends on many factors, including stone factors, patient habitus, competence of the operator, and the efficacy of the lithotriptor. The size of stone is inversely correlated with higher success rates. High-density stones and lower pole renal stones are associated with worse results [1]. The use of alpha-blockers to improve elimination rates by relaxing smooth muscle cells in the urinary tract, remains controversial [9]. Elec-trohydraulic, electromagnetic, and piezoelectric are three different types of shockwave generators which are being used in practice [10]. These generators seem to produce different rates of success and complications [3,10].

Our Data and the Literature

The wide variation in success rates in the current literature might be due to differing definitions of success and stone-free status [1]. Success is determined after one or multiple sessions and after several weeks or months. It is defined as completely stone-free or as the fragmentation of stones into smaller concrements using different types of imaging.

A few studies have been published concerning our study hypothesis. Cleveland et al. [11] observed that movement of calculi in vitro during ESWL caused a significant reduction in fragmentation rates due to the stone being out of focus. Furthermore, a prospective study of 222 patients from Vergnolles et al. [5] describes a significantly higher fragmentation rate in patients with a visual analog scale of lower than 3, compared to patients needing additional analgesia. However, this correlation could be due to the fact that the session was interrupted in 16.9% of treatments, when visual analog scale remained at 3 or higher, despite the use of additional analgesia. In addition, Sorensen et al. [12] reported a significantly higher stone-free rate in patients treated with general anesthesia, compared to patients receiving intravenous sedation using a second-generation lithotripter.

Our study reveals that the outcome of ESWL is not affected by pain during the treatment, according to the numeric pain scale. The level of intensity correlates with pain scores (Pearson correlation -0.423, p < 0.001), but does not seem to influence the success of ESWL (t-test, p = 0.88). The negative results of our study concerning the correlation between pain perception and success rates contradict the aforementioned literature. In contrast to our study, Vergnolles et al. [5] and Sorensen et al. [12] compared success rates in groups, with or without additional analgesia, or compared different forms of anesthesia instead of using pain scores. In addition, other types of shockwave generators were used. These factors make it difficult to compare the results of these studies with our own results. In general, pain scores are widely used due to their simplicity and adaptability to a broad range of populations and settings. However, using a pain score is very subjective when evaluating pain perception. Pain itself is multifactorial and affected by many factors such as age, gender, ethnicity, social status, education, personality and degree of understanding about the intervention. Individual variation is difficult to establish.

In our cohort, the success rate was 35.1% after the first treatment and 43.9% after subsequent ESWL sessions. No additional intervention was needed in 62.6% of treated patients within 6 months after ESWL, since complaints and hydronephrosis were absent while some small residual fragments persisted. An additional operation (ureteroscopy or PCNL) was required in only 24.2% of cases, which would suggest that ESWL is a viable option to prevent operative procedures.

Multivariate logistic regression analysis revealed male gender, stone size and location as predictive factors for success. Stone size was inversely associated with the success of the treatment. In our study, the success rate for renal lower pole stones was found to be 18.6%. ESWL on stones located in the lower renal pole is less likely to be successful compared with the treatment on stones in the renal upper pole (OR 0. 450, p = 0.05). Our findings on the predictive value of stone size and its location are supported by various studies. The predictive value of male gender is not found in other studies and might be an incidental finding [2,3,13].

Study Limitations

A potential limitation of our study is the lack of use of non-contrast spiral CT-scan as assessment prior to treatment, since that is the investigation of choice for urolith-iasis. Contrary to X-ray, Hounsfield unit, stone volume, inflammation of ureter, and skin-to-stone distance could be easily assessed [1]. In our department it is not used as first choice due to its potentially higher dose of radiation and associated costs.

Recommendations

The median pain score in our study was described as “5”, which is a relatively high level of pain sensation, considering that analgesics are given. In addition one third of the patients experienced severe pain (pain score 7-10) and our data show that high pain score are correlated with a lower level of intensity during ESWL. This suggests that our current pain prevention protocol is not sufficient and should be revised. Additional analgesia (a combination of paracetamol, NSAID and opioid) might lower the mean pain score and improve patient comfort. In our study no significant difference in pain score could be found between the patients who did (n = 46) and did not (n = 430) receive extra opiates. This is probably due to the small group of patients who received opiates. A study of Tokgöz et al. [3] analyzing pain perception during ESWL, supports our findings by describing a mean pain score for a first ESWL session as being 4.67. Since anxiety could also be an influencing factor on pain perception, patient education regarding the procedure and potentially a low dose of sedation might also help in lowering the pain score [4,5,6]. More random controlled trials are required to determine the best possible management of pain medication during ESWL.

Conclusion

Contrary to the general view that pain influences the treatment outcomes of ESWL, our results suggest that high pain perception does not correlate with the effect of ESWL. Despite the absence of a correlation with the outcome, pain scores during ESWL sessions remain high. Therefore, additional analgesia is recommended to improve patient comfort. Finally, our results support previous studies where stone size and stone location are predictive factors on the outcome of ESWL.

Acknowledgement

We thank Peter Warner for his help in reviewing this manuscript.

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Author Contacts

Elke Bovelander

Haga Ziekenhuis, Department of Urology

Els Borst-Eilersplein 275

2545 AA’s-Gravenhage (Netherlands)

E-Mail elke. [email protected]

Article / Publication Details

First-Page Preview

Received: November 29, 2017
Accepted: March 06, 2018
Published online: March 08, 2019

Issue release date: March 2019

Number of Print Pages: 7

Number of Figures: 0

Number of Tables: 4

ISSN: 1661-7649 (Print)
eISSN: 1661-7657 (Online)

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Transgluteal versus prone approach to extracorporeal shockwave lithotripsy for patients with distal ureteral stones: A systematic review and meta-analysis

https://doi.org/10.1016/j.asjsur.2021.02.021Get rights and content

Abstract

To explore the effectiveness of transgluteal approach during extracorporeal shockwave lithotripsy (ESWL) for patients with distal ureteral stones compared to the prone approach. A systematic literature search was carried out by two reviewers independently on the basis of three electronic databases up to Aug. 2020. Three randomized controlled trials (RCT) and one cohort studies (CS), with a total of 516 patients, comparing transgluteal approach with prone approach during ESWL for distal ureteral stones were included. The methodological quality of RCT was evaluated by Cochrane collaboration’s tools, and the quality of CS and CCS was evaluated by modified Newcatle-Ottawa scale. The weighted mean difference (WMD) and odds ratio (OR) was respectively used to describe results of continuous and dichotomous variables. Pooled data showed that transgluteal approach could significantly improve the rate of stone free after the first treatment [OR = 3.18, 95% confidence interval (CI) 2.19–4.63, p < 0.00001] and the rate of overall stone free (OR = 4.03, 95% CI 2.43–6.69, p < 0.00001). In addition, compared with the prone approach, the transgluteal one could also significantly reduce the rate of ureteroscopy (OR = 0.21, 95% CI 0.12–0.36, p < 0.00001). What’s more, complications were rarely reported, which demonstrated a similar safety for two approaches. Our study suggested that, during ESWL for patients with distal ureteral stones, transgluteal approach was a safe and more effective choice than the prone position.

Keywords

ESWL

Transgluteal approach

Distal ureteral stones

Meta-analysis

Citing articles

Shock Wave Lithotripsy (Kidney Stone Treatment): Procedure Details & Recovery

Overview

Shock Wave Lithotripsy.

What is shock wave lithotripsy?

Shock wave lithotripsy is a common treatment for kidney stones. Providers sometimes call this procedure extracorporeal shock wave lithotripsy (ESWL).

Shock wave lithotripsy uses high-energy shock (pressure) waves to break up stones. Tiny pieces of kidney stones can then move through the urinary tract more easily.

Shock wave lithotripsy may help reduce your symptoms (such as pain) and allow you to pass the kidney stones on your own. It may help you avoid more invasive surgery to remove kidney stones.

What are kidney stones?

Kidney stones are composed of substances (like calcium) that are present in the urine. A kidney stone forms when high levels of these substances crystallize into a mass.

Most kidney stones form inside the kidney but may move into the ureter (the tube that carries urine to the bladder).

When does a kidney stone need to be treated?

Most kidney stones pass on their own. But sometimes, a kidney stone becomes too big to move through (or gets stuck inside) the urinary tract. Pain during a ‘kidney stone attack’ is typically due to a stone getting stuck in the ureter and blocking drainage of urine from the kidney. Kidney stones may cause health issues, such as kidney damage, blood in the urine or a severe infection. In these cases, treatment can help you safely get rid of kidney stones and feel better.

When is shock wave lithotripsy needed?

Shock wave lithotripsy usually works best to treat smaller stones inside the kidney or upper part of the ureter (urine tube). Your provider will consider a stone’s size, your medical problems (including medications) and your body structure before deciding what’s best for you.

Providers often use shock wave lithotripsy to treat kidney stones that:

Are too large to pass on their own (larger than 5 millimeters in diameter — about the size of a pencil eraser).
Block urine flow.
Are very painful.

When is shock wave lithotripsy not recommended to treat kidney stones?

Your provider needs to know a stone’s exact location. Typically a CT scan is performed to identify your stone location and size. Sometimes an X-ray and/or ultrasound can be used as well.

You may not be a candidate for shock wave lithotripsy if you have:

Hard stones: Kidney stones made up of certain substances (like cystine or certain types of calcium stones) may be more difficult to break up with shock wave lithotripsy.
Pregnancy: Women who are or could be pregnant should not have lithotripsy. The shockwaves may harm an unborn child.
Infected kidney stone: An infected kidney stone that is stuck in the ureter and causing fevers or chills is a medical emergency and should not be treated with shockwave lithotripsy.
Special medical needs: Shockwave lithotripsy should not be used in medical conditions that result in increased risk of bleeding, such as use of blood thinners, due to increased risk of severe bleeding from the kidney.
Very large kidney stones: Shock wave lithotripsy works best on small kidney stones. Your provider may recommend another treatment for kidney stones over 1-2 centimeters in diameter.

How common is shock wave lithotripsy?

Shock wave lithotripsy is very common. It is the second most common way in which kidney stones are surgically treated in the US.

Procedure Details

What can I expect before a shock wave lithotripsy procedure?

Your healthcare provider will explain how to prepare for your procedure. You may need to:

Complete lab work: You may have blood tests to check your kidney function and blood counts, as well as urine tests to check for infection in your urine.
Review your medications with your provider: Keep taking all medications unless your provider tells you otherwise. You may need to stop taking warfarin or other blood-thinning medications. These medications could increase the risk of bleeding related to the procedure.
Follow a specific diet: You will need to stop eating and drinking for a few hours before your procedure.

Who performs shock wave lithotripsy?

Urologists usually perform shock wave lithotripsy. Urologists are highly trained doctors who specialize in treating complex problems of the kidney and other urinary organs.

What can I expect during a shock wave lithotripsy procedure?

Your provider will not need to make any incisions during a shock wave lithotripsy procedure. But you’ll still need some form of anesthesia (pain relief) to keep you comfortable. You may be awake but drowsy or asleep during the procedure.

During a shock wave lithotripsy procedure:

You lie on a padded table on top of a water-filled cushion. Less commonly, you may sit in a large tub of water.
Providers use X-rays or ultrasound to pinpoint a kidney stone’s location. These images help providers aim shock waves precisely to make treatment more effective.
Your care team may move you slightly to line up your body with the energy beams.
A shock wave lithotripsy machine sends powerful energy waves through the water and into your body. If you’re awake for the procedure, you may hear a popping sound or feel a tapping sensation along your side.
Thousands of shock waves are aimed at the kidney stone, breaking the stone into many pieces. Smaller pieces can then pass more easily through the urinary tract.

How long does a shock wave lithotripsy procedure take?

Shock wave lithotripsy typically takes about one hour. Your procedure may take more or less time, depending on the size and number of kidney stones you have and your overall health.

What can I expect right after a shock wave lithotripsy procedure?

Shock wave lithotripsy is typically an outpatient procedure. While you should go home the same day, expect to spend a few hours in the recovery room. Because you’ll receive sedation, someone will need to drive you home.

How long does it take to pass stones after shock wave lithotripsy?

You can expect to pass kidney stone fragments in your urine for several days to weeks after the procedure. Stone pieces may look like sand, gravel or dust.

Passing stone fragments (even tiny ones) can still hurt. Over-the-counter pain medication can keep you comfortable until you’ve passed all the stone fragments.

Risks / Benefits

How effective is shock wave lithotripsy at treating kidney stones?

The success rate of shock wave lithotripsy varies. It depends on the size, location, and type of kidney stone and your body type.

Overall, 70% to 90% of people who are good candidates for shock wave lithotripsy are stone-free (as seen on follow-up X-rays) three months after treatment. You have a higher chance of success if the kidney stone is inside certain parts of the kidney or in the upper part of the ureter.

What if shock wave lithotripsy doesn’t work?

In some cases, shock wave lithotripsy doesn’t break up a stone enough for all pieces to pass on their own. If that happens, you may need another procedure.

Depending on your situation, your provider may recommend a second shock wave lithotripsy. Or your provider may suggest clearing any remaining stones through a minimally invasive procedure called ureteroscopy. Talk to your healthcare provider about the different types of kidney stone treatments.

What are the potential risks or complications after shock wave lithotripsy?

Potential risks of shock wave lithotripsy include, but are not limited to:

Blockage in the ureter.
Blood in the urine or bleeding around the kidney.
Infection.
Mild discomfort or bruising on the back (near the treated area).
Painful urination.

Who is ineligible for shock wave lithotripsy?

Certain medical conditions could make shock wave lithotripsy less effective or riskier. For that reason, your healthcare provider may recommend against shock wave lithotripsy if you have:

Recovery and Outlook

What does recovery after shock wave lithotripsy look like?

As you recover from shock wave lithotripsy, you can expect to:

Feel sore for a day or two: Right after shock wave lithotripsy, you may feel sore or stiff near the treatment area. Some people notice slight bruising along their side.
See blood in your urine: It’s common to see small amounts of blood in your urine. (Your pee may look pink.) It may hurt to urinate. These symptoms usually go away after a few days.
Collect stone pieces that you pass: Testing the stone may tell your provider what caused your kidney stones (and how to prevent new stones). Your provider may give you a urine strainer. It looks like a funnel with mesh at the bottom. It collects stone fragments when you pee.
Drop off the stone sample for testing: You can store the stone fragments you collect in a specimen cup your provider gives you or a plastic bag. Follow your provider’s instructions. You may need to take it to your next follow-up visit or drop the sample off at a lab.
Drink plenty of water: Staying hydrated helps stone fragments move through your body. Drinking water may also help you avoid constipation (a common side effect of certain pain medications).

How long does it take to recover from shock wave lithotripsy?

Most people get back to their usual routines within a few days. But you may have lingering side effects until your body has passed the last of the stone fragments.

When to Call the Doctor

When should I call my healthcare provider?

Call your doctor if you have sudden, severe belly or back pain that doesn’t go away, or persistent nausea or vomiting. If you have these symptoms, go straight to the emergency room.

These symptoms are signs that a kidney stone may be blocking urine flow. Rarely, a blockage can lead to a serious infection (that causes fevers or chills) that may pose a danger to your health.

Call your provider anytime you have concerns, especially if you have:

Blood clots in your urine.
Fever.
Pain that gets worse, even after taking pain medication.
Problems peeing (you feel the urge to pee but can’t).
Nausea or vomiting.
Dizziness or light-headedness.

A note from Cleveland Clinic

Shock wave lithotripsy is a safe treatment to get rid of kidney stones. Passing even tiny kidney stone fragments can hurt — sometimes a lot. If you have shock wave lithotripsy, expect to feel some discomfort as stone fragments pass in the days and weeks after treatment. Pain may come and go until all the kidney stone pieces have worked their way out of your body. If you have other health issues, such as uncontrolled high blood pressure, shock wave lithotripsy may pose extra risks to you. Talk with your doctor about what to expect and whether shock wave lithotripsy is the right kidney stone treatment for your needs.

90,000 Lithotripsy of kidney stones, crushing of stones in the kidneys and ureter, price in St. Petersburg

Lithotripsy is the destruction of stones in various parts of the urinary tract (kidneys, ureters, bladder, urethra) using various types of energy impact.

There are the following types of lithotripsy (stone crushing):

extracorporeal lithotripsy,
transurethral contact,
percutaneous (or percutaneous).

The possibilities of using this or that method depend on the location, size, and density of the calculus (stone). In many cases, the wishes of the patient are also taken into account.

Extracorporeal lithotripsy (DLT)

A method in which crushing of a kidney (or ureter) stone is achieved by focusing a shock wave on it from the outside. By the types of energy used, the following types of lithotripters are distinguished: piezoelectric, electro-hydraulic, electro-magnetic.Focusing the shock wave on the stone is carried out using ultrasound or under X-ray. In most cases, operations are performed under general anesthesia (anesthesia).

SWL can destroy small kidney stones (up to 2 cm), as well as ureteral stones.

Being the least invasive method, SWL has a number of significant limitations:

Density of stone (stones of high density – more than 1000 units on the Hounsfield scale – often cannot be effectively destroyed. We have to resort to repeated sessions of lithotripsy or use other methods).
Stone size (crushing of kidney stones larger than 2 centimeters is often associated with impaired discharge of stone fragments along the ureter, which is manifested by repeated renal colic, as well as the most formidable complication – a “stone path”, when many small stone fragments get stuck and accumulate in the ureter In addition, so-called residual stones often remain in the kidney, which further lead to a relapse of stone formation).
When performing extracorporeal lithotripsy, shock wave damage to healthy tissues around the stone – renal parenchyma, ureter wall, is always noted. In this case, hematuria (visual impurity of blood in the urine) occurs, which is observed in more than 90% of cases after SWL.

Transurethral contact lithotripsy – laser stone crushing

A method of surgical treatment in which stones are crushed with the help of special thin instruments – ureteroscopes, which deliver a destructive impulse directly to the stone. These operations are always performed under general anesthesia (anesthesia).

According to the types of energy used contact lithotripsy is distinguished by:

pneumatic,
laser,
ultrasonic,
transurethral.

Endoscopic visual control allows you to crush a stone in any part of the urinary tract and completely remove the stone fragments outside. For crushing stones in the cups and pelvis, special flexible instruments are used.

For this method, there are much fewer restrictions than for extracorporeal lithotripsy:

The density of the stone does not matter: even very dense stones can be destroyed with the help of a powerful laser.
There is no damage to healthy tissue around the stone.

In the vast majority of cases, contact lithotripsy can completely crush a bladder, ureter or kidney stone in one operation. The use of endoscopic techniques also ensures a quick return to daily activities: the period of stay in the urology department of the clinic is usually 1-2 days.

Percutaneous (percutaneous) lithotripsy

Surgical endoscopic method for the treatment of large and coral kidney stones, in which access to the stone is made through a puncture in the lumbar region.Operations are performed under general anesthesia (anesthesia). This method is more invasive than distance and contact lithotripsy, however, it allows you to completely destroy and evacuate large (more than 2 cm) and even coral-shaped stones (performing the entire renal calyceal system).

This method of treatment in our clinic is available free of charge under the High-Tech Medical Assistance (HMP) program.

In the urology department, the method of endoscopic transurethral laser lithotripsy (crushing of urinary stones) was introduced into practice using the unique flexible Olympus and Karl Storz endoscopes.

Such operations allow completely (“into dust”) to crush multiple, large (up to 2-3 cm) and super-dense stones in any part of the ureter and kidney. This intervention is carried out completely endoscopically, without disturbing the skin and is one of the most high-tech and minimally invasive methods of treating urolithiasis.

The use of flexible small-diameter endoscopes minimizes the risk of damage to the urinary tract and promotes a speedy recovery – discharge for outpatient treatment is possible as early as the second day after the operation with full preservation of working capacity.

In difficult clinical cases, when large stones (more than 2.5 cm) and coral calculi are detected, percutaneous nephrolithotripsy (PNL) is used. Access to the kidney during this operation is made through a puncture in the lumbar region. This method is currently the “gold standard” in the world of surgical treatment of coral nephrolithiasis and successfully replaces open surgery.

Performing PNL at the urology department of the N.N.NI Pirogov is possible under the program of high-tech medical care (free of charge).

Operations are carried out using the latest equipment from the world’s best manufacturers: Olympus, Karl Storz, Richard Wolf.

Along with high-tech operations – transurethral laser lithotripsy and percutaneous lithotripsy, the urology department also performs traditional endoscopic operations for ureteral stones of any localization.These minimally invasive surgeries are also performed within the framework of the compulsory medical insurance (free of charge).

You can learn more about all the indications and contraindications during a consultation with the specialists of the urology department of the Clinic of High Medical Technologies named after N.I. Pirogova.

Contact lithotripsy (crushing) stones of the kidneys, ureter and urinary bladder

Our department of urology specializes in the surgical treatment of ICD, and has all the endourological technologies existing in the world that allow us to perform such high-tech operations as:

ureteral stenting (installation of a ureteral stent, allowing to regulate the outflow of urine from the kidney)
percutaneous nephrolithotripsy (percutaneous crushing of large and coral kidney stones) – through punctures in the skin no larger than 10 mm
mini-percutaneous nephrolithotripsy (percutaneous crushing of large and coral kidney stones) – through punctures in the skin no larger than 5 mm
transurethral ureterolithotripsy and nephrolithotripsy (crushing stones of the ureter and kidney) using semi-rigid and flexible, nephroscopes and ureteropyeloscopes

Most urological diseases today are amenable to minimally invasive (non-traumatic) treatment without compromising effectiveness and safety.But this is achievable only in specialized multidisciplinary clinics that have not only equipment, consumables and medicines, but also qualified personnel undergoing regular training according to the best international standards.

Today, in our clinic, you can count on high rates of quality of treatment and at the same time get help free of charge – within the framework of the compulsory medical insurance.

Removal of kidney stones can only be done by surgery.The only type of stone that undergoes conservative drug dissolution are uric acid calculi. There are several types of kidney stone interventions, each with specific advantages and disadvantages. L lithotripsy – crushing a kidney or ureteric stone using various types of energy (ultrasonic, laser, pneumatic, electro-hydraulic, piezo-electric, etc.) There are the following types of lithotripsy:

Please note that the uroportal.ru is for informational purposes only. Do not try to engage in self-diagnosis and treatment, if you have symptoms of the disease, we strongly recommend that you seek the advice of a specialist.

Make an appointment with a urologist

Extracorporeal extracorporeal lithotripsy

The method of crushing a stone under the influence of shock waves supplied from the outside by a special device – a lithotripter, which generates and focuses shock wave impulses on the stone from the outside.In this case, the stone is destroyed inside the kidney or ureter into fragments, which independently pass through the ureter, bladder and go out with the urine stream. Introduced into clinical practice in the 1970s. As a rule, extracorporeal lithotripsy is performed without anesthesia. To improve the discharge of stone fragments, the so-called “forced diuresis” is used – taking a large amount of liquid and diuretic drugs. DLT is effective for single stones of a relatively small size – up to 15-20 mm in the largest dimension with an average or low densitometric density – no more than 900-1000 HU.

Insufficient efficacy of SWL is also observed when the stone is located in the lower group of bowls – from this segment of the pelvic-pelvic system, stone fragments are difficult to leave, there is a likelihood of incomplete discharge of all fragments and, as a result, recurrence of stone formation. It should be noted that the amount of energy and frequency of impulses for one EBRT procedure are limited and regulated. Exceeding these values in order to enhance the effect on the stone leads to severe trauma to the kidney tissue and can cause an exacerbation of the chronic inflammatory process, the formation of hematomas, and pain syndrome.Therefore, several sessions of ESWL are often required (from 2 to 5), the interval between which, as a rule, is 14-21 days. Thus, the treatment process can be quite lengthy. Due to the greater shock wave load on the kidney than with ureteral calculi, SWL is almost always performed under general anesthesia. Another limitation for SWL is the patient’s weight. With severe obesity (2-3 degrees), precise focusing of the wave on the stone is difficult, therefore, the effectiveness is significantly reduced.

Extracorporeal lithotripsy indications:

X-ray-positive ureteral stones more than 0.5 cm,
stones of the pelvis and calyx of the kidney less than 2 cm

Despite the obvious advantages, this type of treatment is the least invasive, but it has a number of limitations and side effects:

the shock wave always damages healthy tissues surrounding the calculus, including kidney tissue
fragments of destroyed calculus, coming out with urine, often cause renal colic.Therefore, it is impractical, and sometimes dangerous, to crush large kidney stones by the method of distance lithotripsy;
high-density kidney stones are not affected by the shock waves of the lithotripter, i.e. extracorporeal lithotripsy may be simply ineffective;
For complete crushing of the stone and its removal from the kidneys and ureter, several operations of extracorporeal lithotripsy may be required.

Transurethral contact lithotripsy

The minimally invasive method of crushing stones of the kidneys and ureter is retrograde (transurethral) endoscopic interventions (Fig.1). The essence of this technique is to conduct thin optical instruments (endoscopes) under anesthesia through the urethra, bladder, ureter, reaching the renal pelvis and stone. Thus, the entire procedure takes place under continuous visual control. The optimal stone sizes for these manipulations are from 15 to 25 mm. Upon reaching the stone, it is subsequently fragmented using various types of energies.

Fig.1 Retrograde endoscopic interventions

There are the following types of contact lithotripsy: ultrasonic, pneumatic, laser.

ultrasonic – most effective at low stone density (less than 800 HU). The working probe is designed as a titanium alloy tube. High-frequency vibration allows the stone to be destroyed into very small fragments resembling dust in consistency, and the built-in aspiration system instantly removes them through the lumen of the probe into a special container.Leaving stone fragments for this method is practically impossible. Unfortunately, kidney stones of such a low density are quite rare in our region.

pneumatic – the probe works on the principle of a jackhammer, making rapid translational movements. For this type of energy, the density of the stone is of less importance: stones of very high density, as a rule, cannot be crushed – 1500 HU and higher. The main disadvantage of the method is the formation of large stone fragments, which are rather difficult to extract.In this case, there is a risk of migration of a stone fragment to other parts of the calyx-pelvic system.

The above types of energies for lithotripsy are used with so-called semi-rigid (rigid) endoscopes (Fig. 2). This type of instrument is characterized by good visualization and controllability, however, many parts of the pelvic-pelvic system (for example, the middle and lower cups – and this is where stones are most often localized and fragments are displaced here) for such instruments are not available.In such cases, special thin flexible endoscopes are used, capable of reaching any part of the PCS. The disadvantages of such tools are their small working life, high cost of repairs, quick breakdown if mishandled and processed.

Fig. 2 Semi-rigid ureteroscope

With flexible instruments (Fig. 3), only laser or electrohydraulic energy can be used – the working probes of these lithotripters are capable of bending.However, these types of energy exposure are also used with rigid endoscopes.

Fig. 3 Flexible ureteroscope

laser – a high-energy laser beam is brought to the stone through an optical probe. The destruction of the stone is carried out from the periphery to the center. The density of the stone does not matter: even the densest are subject to destruction! With the correct action of the laser, the formed fragments of 1-3 mm in size are fully self-contained in the early postoperative period.This method is preferred for breaking up kidney stones.

electro-hydraulic – works on the principle of a piezo-element. An electric arc is created between the two electrodes, which has a destructive force. Of course, taking into account the small size of the fiber (diameter of about 1 mm), the effect is carried out only on the stone. The density of the stone also does not matter much. The disadvantage of this energy, in contrast to laser energy, is the unpredictability of the size of the resulting fragments.Therefore, this type of lithotripsy is advisable to use with relatively small stones – 10-15 mm.

Transurethral interventions are characterized by a low incidence of complications: the most frequent exacerbation of chronic pyelonephritis occurs in the postoperative period, the incidence of such a complication is about 10 percent. Damage to the kidney during such interventions is excluded. At the end of each operation, a special thin inner tube is inserted into the ureter – a stent, which facilitates rapid and almost painless removal of stone fragments.Removal of the stent is performed 7-10 days after the operation and is performed on an outpatient basis. The duration of transurethral interventions does not exceed 2 hours. This is quite enough to completely fragment the stone, however, occasionally, with large stone sizes, repeated interventions may be required. The patient’s weight and the presence of clinically significant obesity do not affect the effectiveness of the operation.

Contact lithotripsy allows you to crush stones of the ureter and kidney in all departments.The density of the stone does not matter. In this case, there is no damage to the healthy tissues surrounding the stone.

At the same time, a fairly quick recovery and return to daily activities is ensured: patients, as a rule, are discharged as early as 1-2 days after the operation.

Percutaneous (percutaneous) lithotripsy

Percutaneous lithotripsy (PNL) Fig. 4 – also refers to endoscopic operations and is a minimally invasive and technically complex intervention, but at the same time, the most effective, especially for stones of significant size 2 cm or more, as well as for coral and multiple stones.The operation is performed under general anesthesia, most often in the prone position. Under the control of an ultrasound device or fluoroscopy, a directed puncture is performed with a special thin needle of the skin, subcutaneous tissue, lumbar muscles – up to the calyx-pelvic system with a stone. Further, a special conductor is installed into the kidney, along which a passage is formed up to the kidney. An optical instrument, a nephroscope, is held along the formed path to the stone, and a phased crushing of the stone, aspiration of fragments or their removal using endoscopic forceps is carried out.At the end of the procedure, the pelvis and cups are revised with a special flexible endoscope, which allows complete collection of stone fragments or, in the presence of multiple stones, completely eliminate them from the kidney. This technique is the “method of choice” for large, multiple and coral stones. The duration of the intervention depends on the size and number of stones, but rarely exceeds 2 hours. At the end of the operation, a special thin (3-4 mm in diameter) tube, a nephrostomy tube, is installed from the kidney outside, which facilitates the discharge of small fragments of a stone and blood clots.The nephrostomy is usually removed 2-3 days after the operation.

The main complications of percutaneous interventions are exacerbation of chronic pilonephritis (due to the use of modern antibacterial drugs, this only prolongs the hospital stay by 3-4 days). The likelihood of developing pyelonephritis is about 10%. Bleeding can be another serious complication. In our experience, this happens quite rarely. The frequency of the need for blood transfusion after PNL was less than 1% in our clinic.

With the development of technologies, instruments of a smaller diameter have appeared – mini-nephroscopes, which can reduce surgical trauma to the kidney, and somewhat reduce the risk of complications. The principles of operation of such tools are similar to the standard ones.

Fig. 4 Percutaneous nephrolithotripsy

Open operations for the treatment of urolithiasis (removal of stones from the kidneys and ureter) are currently used quite rarely, in difficult cases or when it is technically impossible to perform minimally invasive endoscopic intervention.Thus, having the entire arsenal of treatment methods, you can crush and remove any stone in any part of the urinary tract (kidney stone, ureteral stone, etc.). After any operations for KSD, all patients are recommended to undergo a metabolic study aimed at finding the causes of calculus formation, as well as dynamic observation.

In the Northwest Center for Endourology and Lithotripsy, all types of endoscopic operations are performed using modern equipment from leading world manufacturers: Olympus, KarlStorz, RichardWolf.