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DECREASING PERINEPHRIC HEMATOMAS INCIDENCE BY INCREMENTAL ENERGY SHOCKWAVE LITHOTRIPSY STRATEGY
584
THE JOURNAL OF UROLOGY®
We analyzed stone size and localization before and after treatment, disintegration rate, retreatment rate, stone free rates after 3 months, auxiliary procedures and complications. RESULTS: The mean age was 48.6 years (1.3- 81.4), including 11 children with a mean age of 8.4 years (1.3-16.7). 75% of the patients were male, 45% of the calculi were localized in the kidney and 55% in the ureter. Renal stones were localized in the upper, middle, lower calyx, and renal pelvis in 10%, 30%, 30% and 30 %, respectively. As for ureteral stones, 50%, 20%, and 30% were localized in the lower, middle and upper portion. The mean stone size before ESWL was 10.6 mm (4 - 25) in kidney and 8.2 mm (3 - 28) in ureteral calculi. Mean treatment time was 37 minutes (range). Overall fragmentation rate was 93%. Complete disintegration (stone fragment size < 4 mm) was achieved in 58% of patients, the overall retreatment rate was 21%, implying 1.3 treatments per patient. In 6.6% of the patients auxiliary procedures were necessary, including ureterorenoscopy and percutaneous nephrolithotripsy. The stone free rate after 3 months was 57.7%. We observed two complications (perirenal hematoma) which were treated conservatively and did not require blood transfusions. CONCLUSIONS: Clinical success rates with the Lithoskop ESWL machine are high and at least as good as with other available systems. Retreatment and complication rates are low. However, larger patients numbers with longer follow-up are still necessary. Source of Funding: None
1623 COMPUTED TOMOGRAPHY MAGNIFIED BONE WINDOWS ARE SUPERIOR TO STANDARD SOFT-TISSUE WINDOWS FOR ACCURATE MEASUREMENT OF STONE SIZE Brian H Eisner*, Avinash Kambadakone, Boston, MA; Manoj Monga, James K Anderson, Andrew Thoreson, Minneapolis, MN; Stephen P Dretler, Dushyant V Sahani, Boston, MA INTRODUCTION AND OBJECTIVES: To determine the most accurate method of measuring urinary stones on computed tomography (CT). METHODS: Twenty-four (24) calculi (12 calcium oxalate monohydrate, 12 uric acid) which had been previously collected in our clinic were measured manually with hand-calipers in vitro. The calculi were then embedded into potatoes and scanned using MDCT. CT measurements were performed at four different settings: standard soft-tissue windows (W-320 AND L-50), standard bone windows (WW1120 and WL-300), 5.13x magnified soft-tissue windows, and 5.13x magnified bone windows. The maximum dimensions of the stones were recorded. For the in vivo portion of the study, 41 patients with distal ureteral stones who underwent non-contrast computed tomography (CT) and subsequently spontaneously passed their stones were analyzed. All analyzed stones were calcium-based - none contained uric acid. Maximun stone diameter was measured with digital calipers as the goldstandard. This was compared to CT measurements using 4.0x magnified soft-tissue windows and 4.0x magnified bone windows. Statistical comparisons (Pearson’s correlation and paired t-test) were performed. RESULTS: In vitro, the most accurate measurements were obtained 5.13x magnified bone windows (mean difference from caliper measurement = 0.13 mm, p=0.6). Measurements performed in the soft-tissue window with and without magnification (mean difference 1.2 mm, p=0.003 and mean difference 1.9 mm, p<0.001) and bone window without magnification (mean difference 1.4 mm, p=0.0002) were significantly different from hand-caliper measurements. When stratified by stone composition, measurement error for calcium oxalate calculi was significantly different from gold-standard for all methods except magnified bone windows. For uric acid calculi, significant measurement error was observed only in the standard soft-tissue windows. In vivo, 4.0x magnified bone windows was superior to 4.0x magnified softtissue windows in measurement accuracy. Magnified bone windows measurements were not statistically different from digital calipers (mean difference from digital caliper was overestimate of 0.3 mm, p= 0.4), while magnified soft-tissue windows were statistically distinct (mean difference from digital caliper was underestimate of 1.4 mm, p=0.001).
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
CONCLUSIONS: Magnified bone windows was the most accurate method of stone measurements, in vitro and in vivo. We recommend routine use of magnified bone windows for CT measurement of stones. Source of Funding: None
1624 DECREASING PERINEPHRIC HEMATOMAS INCIDENCE BY INCREMENTAL ENERGY SHOCKWAVE LITHOTRIPSY STRATEGY. Amir Cooper*, Avram Tzachiashvili, Itay M Sevler, Erez Lang, Yoram Siegel, Zerifin, Israel INTRODUCTION AND OBJECTIVES: We report a strategy implemented to reduce the incidence of post shockwave lithotripsy (SWL) perinephric/subcapsular hematomas. METHODS: During 01.2004-06.2008 we treated 1818 patients with SWL for kidney and ureteral stones. All treatments were provided with the Siemens modularis lithostar , under sedation. We recorded prospectively all patients with perinephric hematomas. From 01.2004 till 12.2004 we employed an initial SWL Protocol-A: 2000 shocks at a frequency of 90Hz and energy level of 4 (Siemens scale) after 100 shockwaves. We then embarked on a prospective randomized study to evaluate if an increment energy strategy would decrease perinephric hematomas incidence. The protocol studied From 01.2005 - 07.2005 (Protocol B) was constructed as follows: first set of 600 shockwaves at energy of 1.7, the next set of 600 shocks at 2.2 and the last 800 at maximal energy of 2.7. From there on till 06.2008 Protocol B was adopted. RESULTS: Between 01.2004 - 07.2005 (Period a) 458 patients (including prospective study patients-(N=45) were treated with Protocol A and 11 perinephric hematomas cases occurred , of which, 2 within the study population (incidence: overall - 2%, Study population - 4.4%), Non of protocol B patients (N=46) suffered from perinephric hematomas. The study was discontinued and protocol B was implemented from then onwards. During 08.2005 - 06.2008 (Period b), 1314 patients were treated and 6 patients suffered from perinephric hematomas, incidence of 0.45% (P=0.006). CONCLUSIONS: The SWL protocol at our center had been altered as a result of our experience. The rate of perinephric hematomas was reduced significantly by lowering energy level and applying incremental intensity. Source of Funding: None
1625 COMPLICATIONS FOLLOWING THE USE OF THE DORNIER COMPACT DELTA ELECTROMAGNETIC LITHOTRIPTOR: CLAVIEN CLASSIFICATIONS Joe D Mobley, III*, Adam F Stewart, Frederick A. Klein, Wesley M White, Knoxville, TN INTRODUCTION AND OBJECTIVES: Extracorporeal shockwave lithotripsy (ESWL) is a common modality of treatment for renal and upper ureteral calculi. Urologists have developed a high level of confidence with this therapy as a result of its efficacy and excellent safety profile. While adverse events from this procedure have been reported, the majority are limited in severity and pose no long term morbidity for the patient. Reports of severe adverse event are rare, especially using third generation equipment. This paper reports the complications by Clavien classification from a large cohort of patients treated on the Dornier compact delta lithotripter. METHODS: Data was obtained by a retrospective review of all after care reports in the database of all patients treated on a Dornier Compact Delta Lithotriptor. Complications were stratified and reported by Clavien classification 1-5. RESULTS: Between 1/1/1999 and 6/30/2008, 12,552 patients in our database underwent 17,946 treatments for renal or ureteral calculi by ESWL. 15,443 (86.1%) cases had complete after care reports and were included for analysis. Clavien 1 included 46 hematomas (0.30%) and 77 fevers (0.50%). Clavien 2 complications included 76 urinary tract infections
THE JOURNAL OF UROLOGY®
We analyzed stone size and localization before and after treatment, disintegration rate, retreatment rate, stone free rates after 3 months, auxiliary procedures and complications. RESULTS: The mean age was 48.6 years (1.3- 81.4), including 11 children with a mean age of 8.4 years (1.3-16.7). 75% of the patients were male, 45% of the calculi were localized in the kidney and 55% in the ureter. Renal stones were localized in the upper, middle, lower calyx, and renal pelvis in 10%, 30%, 30% and 30 %, respectively. As for ureteral stones, 50%, 20%, and 30% were localized in the lower, middle and upper portion. The mean stone size before ESWL was 10.6 mm (4 - 25) in kidney and 8.2 mm (3 - 28) in ureteral calculi. Mean treatment time was 37 minutes (range). Overall fragmentation rate was 93%. Complete disintegration (stone fragment size < 4 mm) was achieved in 58% of patients, the overall retreatment rate was 21%, implying 1.3 treatments per patient. In 6.6% of the patients auxiliary procedures were necessary, including ureterorenoscopy and percutaneous nephrolithotripsy. The stone free rate after 3 months was 57.7%. We observed two complications (perirenal hematoma) which were treated conservatively and did not require blood transfusions. CONCLUSIONS: Clinical success rates with the Lithoskop ESWL machine are high and at least as good as with other available systems. Retreatment and complication rates are low. However, larger patients numbers with longer follow-up are still necessary. Source of Funding: None
1623 COMPUTED TOMOGRAPHY MAGNIFIED BONE WINDOWS ARE SUPERIOR TO STANDARD SOFT-TISSUE WINDOWS FOR ACCURATE MEASUREMENT OF STONE SIZE Brian H Eisner*, Avinash Kambadakone, Boston, MA; Manoj Monga, James K Anderson, Andrew Thoreson, Minneapolis, MN; Stephen P Dretler, Dushyant V Sahani, Boston, MA INTRODUCTION AND OBJECTIVES: To determine the most accurate method of measuring urinary stones on computed tomography (CT). METHODS: Twenty-four (24) calculi (12 calcium oxalate monohydrate, 12 uric acid) which had been previously collected in our clinic were measured manually with hand-calipers in vitro. The calculi were then embedded into potatoes and scanned using MDCT. CT measurements were performed at four different settings: standard soft-tissue windows (W-320 AND L-50), standard bone windows (WW1120 and WL-300), 5.13x magnified soft-tissue windows, and 5.13x magnified bone windows. The maximum dimensions of the stones were recorded. For the in vivo portion of the study, 41 patients with distal ureteral stones who underwent non-contrast computed tomography (CT) and subsequently spontaneously passed their stones were analyzed. All analyzed stones were calcium-based - none contained uric acid. Maximun stone diameter was measured with digital calipers as the goldstandard. This was compared to CT measurements using 4.0x magnified soft-tissue windows and 4.0x magnified bone windows. Statistical comparisons (Pearson’s correlation and paired t-test) were performed. RESULTS: In vitro, the most accurate measurements were obtained 5.13x magnified bone windows (mean difference from caliper measurement = 0.13 mm, p=0.6). Measurements performed in the soft-tissue window with and without magnification (mean difference 1.2 mm, p=0.003 and mean difference 1.9 mm, p<0.001) and bone window without magnification (mean difference 1.4 mm, p=0.0002) were significantly different from hand-caliper measurements. When stratified by stone composition, measurement error for calcium oxalate calculi was significantly different from gold-standard for all methods except magnified bone windows. For uric acid calculi, significant measurement error was observed only in the standard soft-tissue windows. In vivo, 4.0x magnified bone windows was superior to 4.0x magnified softtissue windows in measurement accuracy. Magnified bone windows measurements were not statistically different from digital calipers (mean difference from digital caliper was overestimate of 0.3 mm, p= 0.4), while magnified soft-tissue windows were statistically distinct (mean difference from digital caliper was underestimate of 1.4 mm, p=0.001).
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
CONCLUSIONS: Magnified bone windows was the most accurate method of stone measurements, in vitro and in vivo. We recommend routine use of magnified bone windows for CT measurement of stones. Source of Funding: None
1624 DECREASING PERINEPHRIC HEMATOMAS INCIDENCE BY INCREMENTAL ENERGY SHOCKWAVE LITHOTRIPSY STRATEGY. Amir Cooper*, Avram Tzachiashvili, Itay M Sevler, Erez Lang, Yoram Siegel, Zerifin, Israel INTRODUCTION AND OBJECTIVES: We report a strategy implemented to reduce the incidence of post shockwave lithotripsy (SWL) perinephric/subcapsular hematomas. METHODS: During 01.2004-06.2008 we treated 1818 patients with SWL for kidney and ureteral stones. All treatments were provided with the Siemens modularis lithostar , under sedation. We recorded prospectively all patients with perinephric hematomas. From 01.2004 till 12.2004 we employed an initial SWL Protocol-A: 2000 shocks at a frequency of 90Hz and energy level of 4 (Siemens scale) after 100 shockwaves. We then embarked on a prospective randomized study to evaluate if an increment energy strategy would decrease perinephric hematomas incidence. The protocol studied From 01.2005 - 07.2005 (Protocol B) was constructed as follows: first set of 600 shockwaves at energy of 1.7, the next set of 600 shocks at 2.2 and the last 800 at maximal energy of 2.7. From there on till 06.2008 Protocol B was adopted. RESULTS: Between 01.2004 - 07.2005 (Period a) 458 patients (including prospective study patients-(N=45) were treated with Protocol A and 11 perinephric hematomas cases occurred , of which, 2 within the study population (incidence: overall - 2%, Study population - 4.4%), Non of protocol B patients (N=46) suffered from perinephric hematomas. The study was discontinued and protocol B was implemented from then onwards. During 08.2005 - 06.2008 (Period b), 1314 patients were treated and 6 patients suffered from perinephric hematomas, incidence of 0.45% (P=0.006). CONCLUSIONS: The SWL protocol at our center had been altered as a result of our experience. The rate of perinephric hematomas was reduced significantly by lowering energy level and applying incremental intensity. Source of Funding: None
1625 COMPLICATIONS FOLLOWING THE USE OF THE DORNIER COMPACT DELTA ELECTROMAGNETIC LITHOTRIPTOR: CLAVIEN CLASSIFICATIONS Joe D Mobley, III*, Adam F Stewart, Frederick A. Klein, Wesley M White, Knoxville, TN INTRODUCTION AND OBJECTIVES: Extracorporeal shockwave lithotripsy (ESWL) is a common modality of treatment for renal and upper ureteral calculi. Urologists have developed a high level of confidence with this therapy as a result of its efficacy and excellent safety profile. While adverse events from this procedure have been reported, the majority are limited in severity and pose no long term morbidity for the patient. Reports of severe adverse event are rare, especially using third generation equipment. This paper reports the complications by Clavien classification from a large cohort of patients treated on the Dornier compact delta lithotripter. METHODS: Data was obtained by a retrospective review of all after care reports in the database of all patients treated on a Dornier Compact Delta Lithotriptor. Complications were stratified and reported by Clavien classification 1-5. RESULTS: Between 1/1/1999 and 6/30/2008, 12,552 patients in our database underwent 17,946 treatments for renal or ureteral calculi by ESWL. 15,443 (86.1%) cases had complete after care reports and were included for analysis. Clavien 1 included 46 hematomas (0.30%) and 77 fevers (0.50%). Clavien 2 complications included 76 urinary tract infections