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Chapter 28 / Extracorporeal Shockwave Lithotripsy 555
555
From: Current Clinical Urology, Urinary Stone Disease:
A Practical Guide to Medical and Surgical Management
Edited by: M. L. Stoller and M. V. Meng © Humana Press Inc., Totowa, NJ
28
Extracorporeal Shockwave Lithotripsy
Patient Selection and Outcomes
Christopher S. Ng, MD, Gerhard J. Fuchs, MD,
and Stevan B. Streem, MD
CONTENTS
INTRODUCTION
PATIENT SELECTION
OUTCOMES
COMPLICATIONS
CONCLUSIONS
REFERENCES
Key Words: Shockwave lithotripsy; nephrolithiasis; stone free; outcome.
INTRODUCTION
Since its first scientific and clinical descriptions by Chaussy more than 20 years ago,
extracorporeal shockwave lithotripsy (SWL) has truly revolutionized the urologic
management of stone disease and remains the sole noninvasive surgical treatment
modality for urinary tract calculi (1–3). During the 1980s, the explosion of clinical
experience with SWL was joined by that of other emerging “endo-urologic” modalities,
such as percutaneous nephrolithotomy and ureteroscopy. As these technologies have
continued to improve over the last decade, the relative roles of each endo-urologic
approach have likewise continued to evolve. As is often the case, more controversies
have been raised than have been settled as a result. This chapter details the contempo-
rary role of SWL in the surgical management of urinary tract calculi and addresses areas
of debate with its use.
PATIENT SELECTION
The indications for intervention with SWL for urinary tract stone disease remain
unchanged. Thus, potential candidates for this treatment modality include patients with
556 Ng, Fuchs, and Streem
increasing stone size despite appropriate medical management or patients in whom the
stones are associated with obstruction, refractory pain, urinary tract infection, or signifi-
cant bleeding. In fact, the large majority of patients with urolithiasis who eventually
present to the urologist will meet these criteria, and SWL will be the primary treatment
of choice for almost all of such patients. Therefore, it becomes increasingly important
not only to “rule out” certain absolute contraindications before proceeding with SWL,
but also to identify correctly special patient conditions for which specific perioperative
measures should be taken to allow for safe delivery of SWL. Furthermore, it is important
to understand the technical limitations of SWL to allow for informed patient preference
and improved patient selection.
Contraindications
Absolute contraindications to SWL include pregnancy, acute pyelonephritis or uri-
nary sepsis, irreversible coagulopathy, implanted cardiac devices containing an abdomi-
nal crystalline component, and calcified vascular aneurysms located within 5 cm of the
target stone, or measuring greater than 2 and 5 cm in absolute diameter for renal and
aortic aneurysms, respectively. It is evident that these are very specific conditions that
are presented by a minority of patients considered for SWL; nevertheless, they must be
remembered, sought after, and ruled out.
Pregnancy remains an absolute contraindication to SWL, primarily owing to the
potential risk to the fetus from radiation exposure, anesthesia, or the shockwaves (4).
However, definitive clinical or scientific evidence to suggest either injury or safety is
lacking, for obvious reasons. Interestingly, in a recent review of six women who were
post facto determined to be 1–4 wk pregnant at the time of SWL, all women bore healthy
children without chromosomal abnormalities (5). Furthermore, women of child-bearing
age who undergo SWL do not appear to be at increased risk for infertility or fetal
teratogenesis (6,7). Increased experience with piezoelectric lithotriptors with tiny focal
points that enable radiation-free and anesthesia-free treatments may someday prove to
be safe and effective during pregnancy.
Special Patient Conditions
Certain patient conditions, such as proximate calcified vascular aneurysms, implanted
cardiac devices, and bleeding diatheses, were initially believed to be contraindications
to SWL. However, clinical and scientific evidence accrued over the last two decades
suggests that SWL can be performed safely in most of such patients, provided that certain
guidelines are followed.
V
ASCULAR CALCIFICATIONS
Patients with calcified aortic or renal arterial aneurysms in close proximity to the
target stone were once believed to be at risk for embolic events or aneurysm rupture from
SWL. However, in vitro studies using calcified vascular tissue demonstrated no
shockwave-induced injury (8,9). Furthermore, available clinical reports suggest that
patients with ipsilateral calcified aneurysm could cautiously be selected as candidates
for SWL if the aneurysm is asymptomatic and more than 5 cm away from the target stone,
and if the diameter is less than 2 and 5 cm for renal artery and aortic aneurysms, respec-
tively. In addition, the aneurysm should not be positioned in a path parallel to the
shockwaves, and a lower level of energy should be used (10,11).