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In situ extracorporeal shock wave lithotripsy (ESWL) for the management of primary ureteric calculi in children
In Situ Extracorporeal Shock Wave Lithotripsy (ESWL) for the Management of Primary Ureteric Calculi in Children ByHasan
Mohammed Ali Farsi, Hisham Ahmed Mosli, Mohammed Ahmed A. Bahnesy, and Mohammed A. lbrahim
Alzemaity,
Jeddah, Saudi Arabia 0 Lithotripsy wa- used to treat 19 children (3 to 16 years of age) with primary ureteric calculi. No attempts were made to mobilize the stones to the kidney. Stones were located in the upper ureter in seven patients, middle ureter in three, and lower ureter in nine. Stone size ranged from 5 to 25 mm (average, 10.4 mm). All treatments were performed in the outpatient unit. Two children required general anesthesia, and 17 received intravenous sedation. The mean amount of energy used was 17.6 kV, and the average number of shock waves was 5,469. Before commencement of lithotripsy, two patients needed ureteric catheterization, and two had placement of double pigtail catheters. Of the 16 children who had adequate follow-up, 17 (94.4%) were completely stone-free, without any complication. The authors conclude that in situ extracorporeal shock wave lithotripsy is a safe and effective method for the treatment of primary ureteric calculi in children. Copyright o 1994 by W.B. Saunders Company INDEX WORDS: teric calculi.
Extracorporeal
shock wave lithotripsy;
ure-
E
XTRACORPOREAL shock wave lithotripsy (ESWL) was introduced by Chaussy et al as a noninvasive method for the treatment of renal calculi.’ It has gained great popularity and has been found to be safe and effective for the treatment of renal stones in children.2-5 Recently, in situ treatment of ureteric calculi in adults was found to have excellent results.6-s Herein we report our experience with ESWL in the management of 19 children with primary ureteric calculi. MATERIALS AND METHODS Nineteen children aged 4 to 16 years (mean, 12.8 years) with primary ureteric stones were treated with the Siemens Lithostar lithotriptor (Siemens AG, Medical Engineering Group, Erlangen, Germany). There were 12 boys and seven girls. Seven children had upper ureterlc, three had mtdureteric, and nine had lower ureteric calculi. Six patients had a history of stone disease. The stone size (expressed as the stone’s largest diameter) ranged from 5 to 25 mm and averaged 10.4 mm. Twelve patients had variable degrees of hydronephrosis. All children were treated in the day-care unit. Blood chemistry studies, prothrombin and partial thromboplastin measurements, urinalyses, and urine cultures were performed in the outpatient clinic. A plain abdominal radiograph was taken just before the procedure. Two patients were treated under general anesthesia, and 17 patients received intravenous sedation (pentazotine and promethazine, 0.25 mg and 0.5 mg per kg body weight, respectively). Patients with upper ureteric stones were treated in the supine position; those with mid or lower ureteric stones were treated in the prone position. Neither the lungs nor the gonads were shielded. Occasionally, with very thin patients, a 1-L plastic bag containing water was placed on the shock head to achieve proper contact. The ultrasound jelly was applied on the shock head JournalofPediatricSurgery,
Vol29,
No 10 (October),
1994:
pp 1315-1316
and on the bag. None of the children required a gel disk. No attempts were made to mobilize the stones to the kidney. Two patients needed ureteric catheterization, which was performed just before the lithotripsy treatment, and two had double pigtail catheters inserted a few days before the treatment. These ancillary measures were used for patients who had severe hydronephrosis or stones that were difficult to visualize on a plain radiograph. Thirteen patients required one treatment session. Five patients had two sessions, and one had four. The number of shocks delivered ranged from 2,000 to 16,000 and averaged 5,489. The average kilovoltage used was 17.8 (range, 16 to 19). The power index was calculated by multiplying the number of shocks received during all treatment sessions by the kilovoltage, then dividing by 100. This averaged 983.6 (range, 378 to 3,022). A plain abdominal radiograph was obtained upon completion of the treatment, and 1 week and 1 month afterward. An intravenous pyelogram was performed 3 months after the completion of treatment.
RESULTS
Skin ecchymoses were noted at the shock-wave entry site in all patients. Post-ESWL colic was relieved by oral analgesics. None of the patients had hemoptysis, arrhythmias, or bleeding in the rectum. On several occasions, the immediate posttreatment radiographs did not show any changes in the calculus. Patients were considered to be stone-free if there were no residual fragments 3 months after the last ESWL session. One patient did not have follow-up. Of the 18 patients with follow-up, 17 (94.4%) were stone-free. The treatment was not successful for one child, and he underwent ureterolithotomy. Not all the stones were analyzed; however, the majority of analyzed stones were calcium-oxalate. DISCUSSION
Several investigators have shown that children with renal calculi can be treated with ESWL. The results of treatment with the original HM3 Dornier9 (Dornier Medical Systems, Inc, Marietta, GA), the Siemens Lithostar,iO and the piezoelectric lithotriptorii were similar. Although the sequelae of ESWL on growing From the Departments of Urology and Communi@ Medicine, King Abdulaziz UniversityHospital, Jeddah, Saudi Arabia. Date accepted: July 22. 1993. Address reprint requests to Hasan Mohammed Ali Farsi, FACS, FRCS, Department of Urology, King Abdulaziz University Hospital, PO Box 6615. Jeddah. SaudiArabia 21452. CoDtight Q 1994 by W.B. Saunders Company 0022-3468194/2910-0005$03.0010 1315
1316
FARSI ET AL
kidneys remain open to speculation, previous experience with ESWL in an animal model or in children has not confirmed the theoretical risks.i*-l5 For the treatment of ureteric stones, the effect of the shock waves on the kidneys is eliminated, with the exception of upper ureteric stones. It was shown that the transmission of the shock wave energy through the bone would lead to energy attenuation of up to 90%.16 The treatment of midureteric or lower ureteric stones was performed with the patient in the prone position to avoid the passage of the shock waves through bones. Treatment in the prone position would expose the children’s gonads to the effects of the shock waves or radiation. However, a few preliminary experimental studies have not shown any mutagenic or carcinogenic effect of shock waves on the ovaries.i’Js Several investigators have studied the radiation exposure to patients during ESWL treatment of renal stones.i9-21 It was found that exposure from fluoros-
copy and video spot filming were within the range of expected patient exposures and comparable to routine radiological procedures. Similar work is probably required to evaluate the radiation dose to the gonads for patients with ureteric calculi treated in the prone position. It has been suggested that the confinement of the calculi in the ureter with the absence of the fluid interface between the wall of the ureter and the calculus make ureteric stones more difficult to treat.22,23 Initially, retrograde manipulation of ureteric stones was recommended for ESWL.24,2s However, more recent experience has shown that in situ treatment is effective and noninvasive.26J7 We conclude that ESWL is effective in the treatment of ureteral calculi in children. The long-term effect on the gonads of children with lower ureteric calculi treated in the prone position must be better determined before any definite conclusion can drawn as to its long-term safety.
REFERENCES 1. Chaussy C, Schmiedt E, Jocham D, et al: First clinical experience with extracorporeal induced destruction of kidney stones by shock waves. J Ural 127:417-420, 1982 2. Kramolowsky EV, Willoughby BL, Loening SA: Extracorporeal shock wave lithotripsy in children. J Ural 137:939-941,1987 3. Sigman M, Laudone VP, Jenkins AD, et al: Initial experience with extracorporeal shock wave lithotripsy in children. J Urol 138:839-841, 1987 4. Abara E, Merguerian PA, McLorie GA, et al: Lithostar extracorporeal shock wave lithotripsy in children. J Urol 144:489491,199o 5. Alzimaity MFA, Mosli HA, Farsi HMA: Second generation extracorporeal shock wave lithotripsy treatment for childhood urolithiasis. Saudi Med J 13:.54-56,1992 6. Rassweiler J, Lutz K, Gumpinger R, et al: Efficacy of in situ extracorporeal shock wave lithotripsy for upper ureteral calculi. Eur Ural 12:377-386,1986 7. Bowsher WG, Carter S, Philp T, et al: Clinical experience using the wolf piezolith device at 2 British stone centers. J Ural 142:679-682,1989 8. Tailly GG: In situ treatment of ureteral stones using fluoroscopic imaging on the Dornier MPL 9000 lithotripter. J Ural 145:225,1991 (abstr) 9. Kroovand RL, Harrison LH, McCullough DL: Extracorporeal shock wave lithotripsy in childhood. J Urol138:1106-1109,1987 10. Vandeursen H, Devos P, Baert L: Electromagnetic extracorporeal shock wave lithotripsy in children. J Ural 145:1229-1231,199l 11. Marberger M, Turk C, Steinkogler I: Piezoelectric extracorporeal shock wave lithotripsy in children. J Urol 142:349-352, 1989 12. Jones BJ, Connolly JA, Nowlan P, et al: Paediatric extracorporeal shock wave lithotripsy (ESWL): The effect of shockwave injury on growth and function of the developing kidney. J Ural 145:173,1991 (abstr) 13. Arsdalen KNV, Kurzweil S, Smith J, et al: Effect of lithotripsy on immature rabbit bone and kidney development. J Urol146:213-216, 1991 14. Kaji DM, Xie HW, Hardy BE, et al: The effect of extracorporeal shock wave lithotripsy on renal growth, function and arterial blood pressure in an animal model. J Ural 146:544-547, 1991
1.5. Nijman RJM, Ackaert K, Schltmeijer RJ, et al: Long term results of extracorporeal shock wave lithotripsy in children. J Ural 142609-611, 1989 16. Graff J, Berding Ch, Herne JP: Transmission of shock waves through bone-Treatment of iliac ureteral stones in a supine position. J Urol 143:170,1990 (abstr) 17. Carroll PR, Yang SR: Genetic toxicity of high energy shock waves: Assessment using the induction of mutations in Chinese hamster ovary cells. J Ural 135:749, 1986 (abstr) 18. McCullough DL, Yeaman LD, Bo WJ, et al: Do extracorporeal shock waves affect fertility and fetal development? A study of shock wave effects on the rat ovary and fetus. J Ural 139:650, 1988 (abstr) 19. Swearingen FLV, McCullough DL, Dyer R, et al: Radiation exposure to patients during extracorporeal shock wave lithotripsy. J Urol 138:18-20, 1987 20. Lin PJP, Hrejsa AF: Patient exposure and radiation environment of an extracorporeal shock wave lithotripsy system. J Urol 138:712-715,1987 21. Bush WH, Jones D, Gibbons RP: Radiation dose to patient and personnel during extracorporeal shock wave lithotripsy. J Urol 138:716-719,1987 22. Mueller SC, Wilbert D, Thueroff JW, et al: Extracorporeal shock wave lithotripsy of ureteral stones: Clinical experience and experimental findings. J Urol135:831-834,1986 23. Parr NJ, Pye SD, Ritchie AW, et al: Why are ureteral calculi more difficult to fragment in situ? J Ural 145:231,1991 (abstr) 24. Lingeman JE, Newman DM, Mertz HO, et al: Ureterat stone manipulation preceding extracorporeal shock wave lithotriosv. J Ural 135:197, 1986 (abstr) 25. Evans RJ, Wingfield DD, Morollo BA, et al: Ureteral stone manipulation before extracorporeal shock wave lithotripsy. J Ural 139:33-36,1988 26. Preminger GM, Ketteehut MC, Elkins SL, et al: Ureteral stenting during extracorporeal shock wave lithotripsy: Help or hindrance? J Urol 142:32-36,1989 27. Holden D, Rao PN: Ureteral stones: The results of primary in situ extracorpotreal shock wave lithotripsy. J Urol 142:37-39, 1989 I
,
Mohammed Ali Farsi, Hisham Ahmed Mosli, Mohammed Ahmed A. Bahnesy, and Mohammed A. lbrahim
Alzemaity,
Jeddah, Saudi Arabia 0 Lithotripsy wa- used to treat 19 children (3 to 16 years of age) with primary ureteric calculi. No attempts were made to mobilize the stones to the kidney. Stones were located in the upper ureter in seven patients, middle ureter in three, and lower ureter in nine. Stone size ranged from 5 to 25 mm (average, 10.4 mm). All treatments were performed in the outpatient unit. Two children required general anesthesia, and 17 received intravenous sedation. The mean amount of energy used was 17.6 kV, and the average number of shock waves was 5,469. Before commencement of lithotripsy, two patients needed ureteric catheterization, and two had placement of double pigtail catheters. Of the 16 children who had adequate follow-up, 17 (94.4%) were completely stone-free, without any complication. The authors conclude that in situ extracorporeal shock wave lithotripsy is a safe and effective method for the treatment of primary ureteric calculi in children. Copyright o 1994 by W.B. Saunders Company INDEX WORDS: teric calculi.
Extracorporeal
shock wave lithotripsy;
ure-
E
XTRACORPOREAL shock wave lithotripsy (ESWL) was introduced by Chaussy et al as a noninvasive method for the treatment of renal calculi.’ It has gained great popularity and has been found to be safe and effective for the treatment of renal stones in children.2-5 Recently, in situ treatment of ureteric calculi in adults was found to have excellent results.6-s Herein we report our experience with ESWL in the management of 19 children with primary ureteric calculi. MATERIALS AND METHODS Nineteen children aged 4 to 16 years (mean, 12.8 years) with primary ureteric stones were treated with the Siemens Lithostar lithotriptor (Siemens AG, Medical Engineering Group, Erlangen, Germany). There were 12 boys and seven girls. Seven children had upper ureterlc, three had mtdureteric, and nine had lower ureteric calculi. Six patients had a history of stone disease. The stone size (expressed as the stone’s largest diameter) ranged from 5 to 25 mm and averaged 10.4 mm. Twelve patients had variable degrees of hydronephrosis. All children were treated in the day-care unit. Blood chemistry studies, prothrombin and partial thromboplastin measurements, urinalyses, and urine cultures were performed in the outpatient clinic. A plain abdominal radiograph was taken just before the procedure. Two patients were treated under general anesthesia, and 17 patients received intravenous sedation (pentazotine and promethazine, 0.25 mg and 0.5 mg per kg body weight, respectively). Patients with upper ureteric stones were treated in the supine position; those with mid or lower ureteric stones were treated in the prone position. Neither the lungs nor the gonads were shielded. Occasionally, with very thin patients, a 1-L plastic bag containing water was placed on the shock head to achieve proper contact. The ultrasound jelly was applied on the shock head JournalofPediatricSurgery,
Vol29,
No 10 (October),
1994:
pp 1315-1316
and on the bag. None of the children required a gel disk. No attempts were made to mobilize the stones to the kidney. Two patients needed ureteric catheterization, which was performed just before the lithotripsy treatment, and two had double pigtail catheters inserted a few days before the treatment. These ancillary measures were used for patients who had severe hydronephrosis or stones that were difficult to visualize on a plain radiograph. Thirteen patients required one treatment session. Five patients had two sessions, and one had four. The number of shocks delivered ranged from 2,000 to 16,000 and averaged 5,489. The average kilovoltage used was 17.8 (range, 16 to 19). The power index was calculated by multiplying the number of shocks received during all treatment sessions by the kilovoltage, then dividing by 100. This averaged 983.6 (range, 378 to 3,022). A plain abdominal radiograph was obtained upon completion of the treatment, and 1 week and 1 month afterward. An intravenous pyelogram was performed 3 months after the completion of treatment.
RESULTS
Skin ecchymoses were noted at the shock-wave entry site in all patients. Post-ESWL colic was relieved by oral analgesics. None of the patients had hemoptysis, arrhythmias, or bleeding in the rectum. On several occasions, the immediate posttreatment radiographs did not show any changes in the calculus. Patients were considered to be stone-free if there were no residual fragments 3 months after the last ESWL session. One patient did not have follow-up. Of the 18 patients with follow-up, 17 (94.4%) were stone-free. The treatment was not successful for one child, and he underwent ureterolithotomy. Not all the stones were analyzed; however, the majority of analyzed stones were calcium-oxalate. DISCUSSION
Several investigators have shown that children with renal calculi can be treated with ESWL. The results of treatment with the original HM3 Dornier9 (Dornier Medical Systems, Inc, Marietta, GA), the Siemens Lithostar,iO and the piezoelectric lithotriptorii were similar. Although the sequelae of ESWL on growing From the Departments of Urology and Communi@ Medicine, King Abdulaziz UniversityHospital, Jeddah, Saudi Arabia. Date accepted: July 22. 1993. Address reprint requests to Hasan Mohammed Ali Farsi, FACS, FRCS, Department of Urology, King Abdulaziz University Hospital, PO Box 6615. Jeddah. SaudiArabia 21452. CoDtight Q 1994 by W.B. Saunders Company 0022-3468194/2910-0005$03.0010 1315
1316
FARSI ET AL
kidneys remain open to speculation, previous experience with ESWL in an animal model or in children has not confirmed the theoretical risks.i*-l5 For the treatment of ureteric stones, the effect of the shock waves on the kidneys is eliminated, with the exception of upper ureteric stones. It was shown that the transmission of the shock wave energy through the bone would lead to energy attenuation of up to 90%.16 The treatment of midureteric or lower ureteric stones was performed with the patient in the prone position to avoid the passage of the shock waves through bones. Treatment in the prone position would expose the children’s gonads to the effects of the shock waves or radiation. However, a few preliminary experimental studies have not shown any mutagenic or carcinogenic effect of shock waves on the ovaries.i’Js Several investigators have studied the radiation exposure to patients during ESWL treatment of renal stones.i9-21 It was found that exposure from fluoros-
copy and video spot filming were within the range of expected patient exposures and comparable to routine radiological procedures. Similar work is probably required to evaluate the radiation dose to the gonads for patients with ureteric calculi treated in the prone position. It has been suggested that the confinement of the calculi in the ureter with the absence of the fluid interface between the wall of the ureter and the calculus make ureteric stones more difficult to treat.22,23 Initially, retrograde manipulation of ureteric stones was recommended for ESWL.24,2s However, more recent experience has shown that in situ treatment is effective and noninvasive.26J7 We conclude that ESWL is effective in the treatment of ureteral calculi in children. The long-term effect on the gonads of children with lower ureteric calculi treated in the prone position must be better determined before any definite conclusion can drawn as to its long-term safety.
REFERENCES 1. Chaussy C, Schmiedt E, Jocham D, et al: First clinical experience with extracorporeal induced destruction of kidney stones by shock waves. J Ural 127:417-420, 1982 2. Kramolowsky EV, Willoughby BL, Loening SA: Extracorporeal shock wave lithotripsy in children. J Ural 137:939-941,1987 3. Sigman M, Laudone VP, Jenkins AD, et al: Initial experience with extracorporeal shock wave lithotripsy in children. J Urol 138:839-841, 1987 4. Abara E, Merguerian PA, McLorie GA, et al: Lithostar extracorporeal shock wave lithotripsy in children. J Urol 144:489491,199o 5. Alzimaity MFA, Mosli HA, Farsi HMA: Second generation extracorporeal shock wave lithotripsy treatment for childhood urolithiasis. Saudi Med J 13:.54-56,1992 6. Rassweiler J, Lutz K, Gumpinger R, et al: Efficacy of in situ extracorporeal shock wave lithotripsy for upper ureteral calculi. Eur Ural 12:377-386,1986 7. Bowsher WG, Carter S, Philp T, et al: Clinical experience using the wolf piezolith device at 2 British stone centers. J Ural 142:679-682,1989 8. Tailly GG: In situ treatment of ureteral stones using fluoroscopic imaging on the Dornier MPL 9000 lithotripter. J Ural 145:225,1991 (abstr) 9. Kroovand RL, Harrison LH, McCullough DL: Extracorporeal shock wave lithotripsy in childhood. J Urol138:1106-1109,1987 10. Vandeursen H, Devos P, Baert L: Electromagnetic extracorporeal shock wave lithotripsy in children. J Ural 145:1229-1231,199l 11. Marberger M, Turk C, Steinkogler I: Piezoelectric extracorporeal shock wave lithotripsy in children. J Urol 142:349-352, 1989 12. Jones BJ, Connolly JA, Nowlan P, et al: Paediatric extracorporeal shock wave lithotripsy (ESWL): The effect of shockwave injury on growth and function of the developing kidney. J Ural 145:173,1991 (abstr) 13. Arsdalen KNV, Kurzweil S, Smith J, et al: Effect of lithotripsy on immature rabbit bone and kidney development. J Urol146:213-216, 1991 14. Kaji DM, Xie HW, Hardy BE, et al: The effect of extracorporeal shock wave lithotripsy on renal growth, function and arterial blood pressure in an animal model. J Ural 146:544-547, 1991
1.5. Nijman RJM, Ackaert K, Schltmeijer RJ, et al: Long term results of extracorporeal shock wave lithotripsy in children. J Ural 142609-611, 1989 16. Graff J, Berding Ch, Herne JP: Transmission of shock waves through bone-Treatment of iliac ureteral stones in a supine position. J Urol 143:170,1990 (abstr) 17. Carroll PR, Yang SR: Genetic toxicity of high energy shock waves: Assessment using the induction of mutations in Chinese hamster ovary cells. J Ural 135:749, 1986 (abstr) 18. McCullough DL, Yeaman LD, Bo WJ, et al: Do extracorporeal shock waves affect fertility and fetal development? A study of shock wave effects on the rat ovary and fetus. J Ural 139:650, 1988 (abstr) 19. Swearingen FLV, McCullough DL, Dyer R, et al: Radiation exposure to patients during extracorporeal shock wave lithotripsy. J Urol 138:18-20, 1987 20. Lin PJP, Hrejsa AF: Patient exposure and radiation environment of an extracorporeal shock wave lithotripsy system. J Urol 138:712-715,1987 21. Bush WH, Jones D, Gibbons RP: Radiation dose to patient and personnel during extracorporeal shock wave lithotripsy. J Urol 138:716-719,1987 22. Mueller SC, Wilbert D, Thueroff JW, et al: Extracorporeal shock wave lithotripsy of ureteral stones: Clinical experience and experimental findings. J Urol135:831-834,1986 23. Parr NJ, Pye SD, Ritchie AW, et al: Why are ureteral calculi more difficult to fragment in situ? J Ural 145:231,1991 (abstr) 24. Lingeman JE, Newman DM, Mertz HO, et al: Ureterat stone manipulation preceding extracorporeal shock wave lithotriosv. J Ural 135:197, 1986 (abstr) 25. Evans RJ, Wingfield DD, Morollo BA, et al: Ureteral stone manipulation before extracorporeal shock wave lithotripsy. J Ural 139:33-36,1988 26. Preminger GM, Ketteehut MC, Elkins SL, et al: Ureteral stenting during extracorporeal shock wave lithotripsy: Help or hindrance? J Urol 142:32-36,1989 27. Holden D, Rao PN: Ureteral stones: The results of primary in situ extracorpotreal shock wave lithotripsy. J Urol 142:37-39, 1989 I
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