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The Complications of Extracorporeal Shockwave Lithotripsy: Management and Prevention
226
CALCULUS
is instilled through a cystoscopically placed 5F ureteral catheter. This procedure serves to dilate and to image the collecting system while also providing anesthesia. With the patient in the prone position fluoroscopy is performed briefly, and then ultrasonic guidance is used to find the distance to the kidney surface and the appropriate calix. Then, 1 per cent lidocaine is injected in the tract site and parenteral sedation is administered. A 20 cm. long 1.3 cm. wide needle is used to puncture the kidney and a Lunderquist wire is used to establish access. An Olympus lumbotome is used to open the tract to the level of the kidney. Metal dilators expand the tract to 30F to allow placement of the 27F nephroscope. Ultrasonic probes have use in fragmenting stones. The authors are not fond of flexible nephroscopes because of the small working ports. Charts of 620 patients were reviewed. The average hospital stay was 7 days and the average length of the procedure was 1 hour, after which the local anesthetic wore off. Approximately 67 per cent of the patients can be treated in 1 session. The over-all rate of residual stones is 7.3 per cent (4.7 per cent for uninfected stones and 21 per cent for struvite calculi). Mild complications occurred in 12.6 per cent of the patients (only 3 suffered a pneumothorax). Transfusion was necessary in 10 per cent of the patients. The authors highly recommend the technique as safe and effective. G. F. S. 15 figures, 8 references
Extracorporeal Shock Wave Lithotripsy D. JOCHAM, C. CHAUSSY AND E. SCHMIEDT, Department of Urology, Ludwig Maximilians University, Klinikum Grosshadern, Munich, Federal Republic of Germany, and Department of Surgery, Division of Urology, University of California, Los Angeles, California Urol. Int., 41: 357-368 (Sept.-Oct.) 1986 The authors review their experience with extracorporeal shock wave lithotripsy (ESWL), which extends back to February 1980. The first lithotriptors used a water cushion to transmit the shock wave to the patient but immersion of the patient in a water bath seemed to be safer and less cumbersome, and also allowed for less energy loss. Precise radiographic localization of the stone still is required for success and computerized ultrasonic localization falls short of theoretical expectations as a superior method. Most small stones (less than 1.5 cm.) can be treated by ESWL alone, whereas larger stones frequently require a combination of ESWL and percutaneous techniques. Electrocardiographically monitored triggering of the shock waves has prevented effectively cardiac arrhythmias. General and epidural anesthesias have been used with good results. ESWL is not contraindicated if the patient has a cardiac pacemaker. ESWL is effective in cases of infection stones but the patients must be treated with antibiotics before the procedure. Patients with disorders of coagulation can be treated provided that the clotting disturbance is corrected at the time of ESWL. Although small intrarenal hematomas frequently can be found after shock wave therapy, bleeding per se is infrequent, with only 3 of 2,821 patients requiring posttreatment transfusion. Difficulty in passing stone fragments required post-treatment instrumentation in 16 per cent of the patients treated primarily with ESWL. Of the patients 6 per cent required percutaneous nephrostomy after ESWL. Such placement often results in rapid spontaneous passage of the retained ureteral stone fragments. In a review of the total experience, 83 per cent of the patients were free of stones 3
months after ESWL, 20 per cent required a second ESWL treatment to become free of calculi and only 0.6 per cent required an open operation for stone extirpation. G. F. S. 12 figures, 7 tables, 28 references
Combination of Percutaneous Surgery and Extracorporeal Shockwave Lithotripsy for the Treatment of Large Renal Calculi
I. K. DICKINSON, M. 8. FLETCHER, M. J. BAILEY, M. J. COPTCOAT, T. A. MCNICHOLAS, M. J. KELLETT, H. N. WHITFIELD AND J. E. A. WICKHAM, London Stone Clinic, Department of Urology, St. Bartholomew's Hospital, and Institute of Urology, London, United Kingdom Brit. J. Urol., 58: 581-584 (Dec.) 1986 While the management of renal calculi has changed dramatically in recent years, with the trend being toward less invasive surgery, large and complex stones still remain a difficult challenge. However, by a combination of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL) it is possible to debulk large stones with the former technique and then to treat the remaining calculi with ESWL to render the fragments less than 2 mm. in diameter. The authors reviewed their experience with 67 patients who presented between November 1984 and May 1986. It was possible to remove large stones in 71 per cent of the patients with a combination of percutaneous nephrolithotomy and ESWL. There was no mortality. The morbidity rate for both procedures was low and it was less than when either method was used alone for the treatment of complex stones. E. D. W. 1 figure, 2 tables, 8 references
The Complications of Extracorporeal Shockwave Lithotripsy: Management and Prevention M. J. COPTCOAT, D. R. WEBB, M. J. KELLETT, M. S. FLETCHER, T. A. MCNICHOLAS, I. K. DICKINSON, H. N. WHITFIELD AND J. E. A. WICKHAM, Institute of Urology, London Stone Clinic and Department of Urology, St. Bartholomew's Hospital, London, United Kingdom Brit. J. Urol., 58: 578-580 (Dec.) 1986 The authors analyze the complications that have occurred at 1 lithotripsy center. The experience from 600 consecutive cases is reviewed and the methods of prevention of complications are discussed. The major complications were hemorrhage (0.5 per cent), steinstrasse or stone street (5 per cent), septicemia (0.5 per cent) and cardiac arrhythmia (1 per cent). Minor complications included cutaneous bruising at the site of shock wave entry (15 per cent), prolonged ileus (10 per cent), transient pyrexia (30 per cent) and ureteral colic requiring narcotic analgesia for up to 48 hours after treatment (25 per cent). Late complications were owing to incomplete stone clearance (10 per cent) but these patients were asymptomatic. Extracorporeal shock wave lithotripsy is the optimum treatment for most upper urinary tract stones. E. D. W. 1 table, 3 references
Ureterorenoscopy in the Treatment of Ureteral Stones K.-H. BICHLER AND S. HALIM, Department of Urology, University of Tubingen, Tubingen, Federal Republic of Germany Urol. Int., 41: 369-374 (Sept.-Oct.) 1986
CALCULUS
is instilled through a cystoscopically placed 5F ureteral catheter. This procedure serves to dilate and to image the collecting system while also providing anesthesia. With the patient in the prone position fluoroscopy is performed briefly, and then ultrasonic guidance is used to find the distance to the kidney surface and the appropriate calix. Then, 1 per cent lidocaine is injected in the tract site and parenteral sedation is administered. A 20 cm. long 1.3 cm. wide needle is used to puncture the kidney and a Lunderquist wire is used to establish access. An Olympus lumbotome is used to open the tract to the level of the kidney. Metal dilators expand the tract to 30F to allow placement of the 27F nephroscope. Ultrasonic probes have use in fragmenting stones. The authors are not fond of flexible nephroscopes because of the small working ports. Charts of 620 patients were reviewed. The average hospital stay was 7 days and the average length of the procedure was 1 hour, after which the local anesthetic wore off. Approximately 67 per cent of the patients can be treated in 1 session. The over-all rate of residual stones is 7.3 per cent (4.7 per cent for uninfected stones and 21 per cent for struvite calculi). Mild complications occurred in 12.6 per cent of the patients (only 3 suffered a pneumothorax). Transfusion was necessary in 10 per cent of the patients. The authors highly recommend the technique as safe and effective. G. F. S. 15 figures, 8 references
Extracorporeal Shock Wave Lithotripsy D. JOCHAM, C. CHAUSSY AND E. SCHMIEDT, Department of Urology, Ludwig Maximilians University, Klinikum Grosshadern, Munich, Federal Republic of Germany, and Department of Surgery, Division of Urology, University of California, Los Angeles, California Urol. Int., 41: 357-368 (Sept.-Oct.) 1986 The authors review their experience with extracorporeal shock wave lithotripsy (ESWL), which extends back to February 1980. The first lithotriptors used a water cushion to transmit the shock wave to the patient but immersion of the patient in a water bath seemed to be safer and less cumbersome, and also allowed for less energy loss. Precise radiographic localization of the stone still is required for success and computerized ultrasonic localization falls short of theoretical expectations as a superior method. Most small stones (less than 1.5 cm.) can be treated by ESWL alone, whereas larger stones frequently require a combination of ESWL and percutaneous techniques. Electrocardiographically monitored triggering of the shock waves has prevented effectively cardiac arrhythmias. General and epidural anesthesias have been used with good results. ESWL is not contraindicated if the patient has a cardiac pacemaker. ESWL is effective in cases of infection stones but the patients must be treated with antibiotics before the procedure. Patients with disorders of coagulation can be treated provided that the clotting disturbance is corrected at the time of ESWL. Although small intrarenal hematomas frequently can be found after shock wave therapy, bleeding per se is infrequent, with only 3 of 2,821 patients requiring posttreatment transfusion. Difficulty in passing stone fragments required post-treatment instrumentation in 16 per cent of the patients treated primarily with ESWL. Of the patients 6 per cent required percutaneous nephrostomy after ESWL. Such placement often results in rapid spontaneous passage of the retained ureteral stone fragments. In a review of the total experience, 83 per cent of the patients were free of stones 3
months after ESWL, 20 per cent required a second ESWL treatment to become free of calculi and only 0.6 per cent required an open operation for stone extirpation. G. F. S. 12 figures, 7 tables, 28 references
Combination of Percutaneous Surgery and Extracorporeal Shockwave Lithotripsy for the Treatment of Large Renal Calculi
I. K. DICKINSON, M. 8. FLETCHER, M. J. BAILEY, M. J. COPTCOAT, T. A. MCNICHOLAS, M. J. KELLETT, H. N. WHITFIELD AND J. E. A. WICKHAM, London Stone Clinic, Department of Urology, St. Bartholomew's Hospital, and Institute of Urology, London, United Kingdom Brit. J. Urol., 58: 581-584 (Dec.) 1986 While the management of renal calculi has changed dramatically in recent years, with the trend being toward less invasive surgery, large and complex stones still remain a difficult challenge. However, by a combination of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL) it is possible to debulk large stones with the former technique and then to treat the remaining calculi with ESWL to render the fragments less than 2 mm. in diameter. The authors reviewed their experience with 67 patients who presented between November 1984 and May 1986. It was possible to remove large stones in 71 per cent of the patients with a combination of percutaneous nephrolithotomy and ESWL. There was no mortality. The morbidity rate for both procedures was low and it was less than when either method was used alone for the treatment of complex stones. E. D. W. 1 figure, 2 tables, 8 references
The Complications of Extracorporeal Shockwave Lithotripsy: Management and Prevention M. J. COPTCOAT, D. R. WEBB, M. J. KELLETT, M. S. FLETCHER, T. A. MCNICHOLAS, I. K. DICKINSON, H. N. WHITFIELD AND J. E. A. WICKHAM, Institute of Urology, London Stone Clinic and Department of Urology, St. Bartholomew's Hospital, London, United Kingdom Brit. J. Urol., 58: 578-580 (Dec.) 1986 The authors analyze the complications that have occurred at 1 lithotripsy center. The experience from 600 consecutive cases is reviewed and the methods of prevention of complications are discussed. The major complications were hemorrhage (0.5 per cent), steinstrasse or stone street (5 per cent), septicemia (0.5 per cent) and cardiac arrhythmia (1 per cent). Minor complications included cutaneous bruising at the site of shock wave entry (15 per cent), prolonged ileus (10 per cent), transient pyrexia (30 per cent) and ureteral colic requiring narcotic analgesia for up to 48 hours after treatment (25 per cent). Late complications were owing to incomplete stone clearance (10 per cent) but these patients were asymptomatic. Extracorporeal shock wave lithotripsy is the optimum treatment for most upper urinary tract stones. E. D. W. 1 table, 3 references
Ureterorenoscopy in the Treatment of Ureteral Stones K.-H. BICHLER AND S. HALIM, Department of Urology, University of Tubingen, Tubingen, Federal Republic of Germany Urol. Int., 41: 369-374 (Sept.-Oct.) 1986