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PubMed1990

Percutaneous transhepatic cholangioscopic lithotripsy.

Since 1983, 14 patients with intrahepatic and common bile duct stones have undergone percutaneous transhepatic cholangioscopic lithotripsy because the stones were too large to be removed using ordinary percutaneous transhepatic cholangioscopy. Stones were completely fragmented in seven cases (six with intrahepatic stones and one with common bile duct stone) and partially disrupted in five cases with intrahepatic stones. Intrahepatic duct angulation and stricture was the factor most often responsible for failure. All the disintegrated stones were removed by subsequent transhepatic cholangioscopy. Amongst the seven patients with complete stone fragmentation, six stones were found with electrohydraulic shock-wave lithotripsy and one with NdYAG laser lithotripsy. Complications of percutaneous transhepatic cholangioscopic lithotripsy using electrohydraulic shock waves were found in three cases, two had transient haemobilia and one had fever and chills after the procedures. They all recovered by conservative treatment. NdYAG laser treatment was expensive, time consuming and inconvenient to use. Percutaneous transhepatic cholangioscopic lithotripsy by using electrohydraulic shock wave is an effective and safe method to fragment biliary stones and to facilitate their removal.

Adult↗
PubMed1988

The pulsed dye laser versus the Q-switched Nd:YAG laser in laser-induced shock-wave lithotripsy.

To date, there are two fairly well-established alternatives for laser-induced shock-wave lithotripsy in clinical practice. The Q-switched Nd:YAG laser is distinguished by the high-stone selectivity of its coupler systems. The necessity of a coupler system and its fairly small conversion rate of light energy into mechanical energy present serious drawbacks. Furthermore, the minimal outer diameter of the transmission system is 1.8 mm. The pulsed-dye laser can be used with a highly flexible and uncomplicated 200-micron fiber. However, the laser system itself is more complicated than the Q-switched Nd:YAG laser and requires a great deal of maintenance. Biological evaluation of damage caused by direct irradiation shows that both laser systems produce minor damage of different degrees. YAG laser lithotripsy with the optomechanical coupler was assessed in 31 patients with ureteral calculi. The instability and limited effectiveness of the fiber application system necessitated auxiliary lithotripsy methods in 14 cases. Dye-laser lithotripsy is currently being tested in clinical application. Further development, such as systems for blind application or electronic feedback mechanisms to limit adverse tissue effects, have yet to be optimized. Nevertheless, laser-induced shock-wave lithotripsy has the potential to become a standard procedure in the endourologic management of stone disease.

Animals↗
PubMed1992

Laser lithotripsy of pancreatic and biliary stones via 3.4 mm and 3.7 mm miniscopes: first clinical results.

The pulsed dye laser is safe and effective in lithotripsy of biliary and pancreatic ductal stones, however delivery of the laser energy to the site of the calculi is technically difficult. A 3.4 mm miniscope inserted through a standard duodenoscope was used for transpapillary laser application under direct vision in one patient with an impacted pancreatic stone and in three patients with bile duct stones not amenable to treatment by routine endoscopy. Lithotripsy and ductal clearance was achieved in 3 of the 4 patients within a single treatment session. Percutaneous transhepatic laser lithotripsy via a 3.7 mm miniscope succeeded in the patient in whom the peroral approach had failed and in two further patients with bile duct stones not accessible by a retrograde approach. There were no major complications. The miniscopes provide an appropriate direct visual control for laser lithotripsy of pancreatobiliary calculi. This approach using miniscopes seems to be an effective, minimally invasive and time-saving alternative to conventional endoscopic laser lithotripsy.

Adult↗
PubMed1992

Endoscopic laser lithotripsy with an automatic stone recognition system for basket impaction in the common bile duct.

In a patient with a common bile duct stone 28 mm in diameter, the traction wires of two basket catheters fractured during endoscopic mechanical lithotripsy. Disintegration of the concrement and removal of the impacted baskets failed even after extracorporeal application of 8,000 shockwaves. Pulsed dye laser lithotripsy was carried out via a 250 microns fiber which was advanced to the stone through a 6 French ERCP guiding catheter. Lithotripsy could be safely performed under fluoroscopic control since the laser used provides an automatic cut-out system upon tissue contact. 3,600 of 11,800 applied pulses were emitted with the total power setting and complete disintegration of the calculus was achieved. The baskets and the fragments could be removed endoscopically in the same session. Laser lithotripsy with a stone recognition system would seem to improve the applicability and safety of intracorporeal lithotripsy even when performed without direct visual guidance.

Aged↗
PubMed1998

Laboratory and clinical assessment of pneumatically driven intracorporeal lithotripsy.

A pneumatically driven intracorporeal lithotripter (the Swiss Lithoclast) has recently been approved for use in the United States. We compared its performance in vitro with ultrasonic, electrohydraulic and laser lithotripsy devices using a standard plaster-of-Paris stone phantom. The probe sizes and output settings were identical to those used during clinical treatment. The fragmentation efficiency index (measured as the lithotripsy time needed to reduce the stone phantom to particles <2 mm divided by the initial stone weight) ranged from 5.0 to 8.5 min/g of stone mass, with this value increasing from pneumatic to electrohydraulic to laser and to ultrasonic lithotripsy. We also performed an objective study in a swine model, which showed no adverse consequence of pneumatic lithotripsy. Finally, we evaluated our initial 41 patients who had undergone pneumatic stone fragmentation. We treated 8 patients having 11 renal calculi, 30 patients having 37 ureteral calculi, and 3 patients having 6 bladder calculi employing pneumatic probes ranging in size from 0.8 to 2.0 mm. Stone fragmentation was successful in a single session in 95% of the ureteral calculi and 100% of both renal and bladder calculi. Stone analysis in 23 patients revealed 17 (74%) calcium oxalate monohydrate and 1 (4%) cystine calculi. Our clinical and laboratory assessment of this newly developed pneumatic lithotripsy device further validates its efficacy in fragmenting stone of all compositions and its overall safety associated with clinical application.

Adolescent↗
PubMed1989

How many Americans will be eligible for biliary lithotripsy?

Extracorporeal shock wave lithotripsy has received increasing attention as a possible alternative to cholecystectomy. Good data, however, are not available on what percentage of the 500,000 Americans presently undergoing cholecystectomy annually might be eligible for extracorporeal shock wave lithotripsy. Therefore, we studied 100 consecutive adult patients undergoing cholecystectomy and applied present exclusion criteria to determine their suitability for extracorporeal shock wave lithotripsy. In each patient, preoperative history and operative findings were reviewed. Gallstone size and number were recorded, and cholesterol content and radiopacity were determined. Cholesterol stones were found in 74 patients, pigment stones in 21, and acalculous cholecystitis in 5. Of the 100 patients, only 19 (19%) had no exclusion criteria and, thus, would have been eligible for extracorporeal shock wave lithotripsy. These data suggest that approximately 95,000 Americans a year will be candidates for shock wave biliary lithotripsy.

Adolescent↗
PubMed2006

An Er:YAG laser endoscopic fiber delivery system for lithotripsy of salivary stones.

BACKGROUND AND OBJECTIVES: Endoscopic applications of Erbium:YAG lasers are still very limited due to lack of appropriate fiber delivery capabilities. Recent reports on potential advantages of this laser for lithotripsy of ureteral stones prompted us to develop an Er:YAG fiber delivery system for endoscopic lithotripsy of salivary stones. We report on the development of this system and its clinical use on 17 patients. STUDY DESIGN/MATERIALS AND METHODS: Ho:YAG and Er:YAG laser fragmentation performances were initially compared. Optimal laser parameters for lithotripsy of salivary stones were then established ex vivo using a commercial dental Er:YAG laser (Lumenis Opusdent 20). Metal hollow waveguides optimized for Er:YAG laser transmission were end sealed with a polished sapphire rod of 0.63 mm diameter and designed to adapt to the Opusdent laser and to a Storz sialoendoscope. The system was tested ex vivo for durability and clinical compatibility at input energies up to 700 mJ, 10-20 Hz. Following Helsinki approval the system was clinically tested on 17 patients with sialolithiasis. RESULTS: Lithotripsy threshold was around 80 mJ/pulse (26 J/cm2) while efficient fragmentation, with microscopic fragments, was observed at an output energy range of 150-300 mJ/pulse. At 10 Hz, fragmentation rates of about 1.8 mm3/second were achieved enabling lithotripsy of a 6 mm stone in about 2 minutes. Front surface damage to the sapphire rod occurred but did not contribute to significant loss in fragmentation efficiency. Of the 21 stones treated clinically, 5 were fully fragmented, 7 were prepared for extraction by mini forceps, and 9 were released from surrounding soft tissues for subsequent removal. Fifteen of the 18 treated glands returned to normal function without any symptoms. CONCLUSIONS: The Er:YAG endoscopic delivery system described is a clinically viable and cost-effective device for a range of hard and soft tissue wet field applications accessible through rigid or semi-rigid endoscopes. Further improvements in the waveguide may allow access also through fully flexible endoscopes.

Adolescent↗
PubMed1993

Effect of extracorporeal shock wave lithotripsy and ursodeoxycholic acid on gallbladder motility.

Extracorporeal shock wave lithotripsy and dissolution agents are useful nonsurgical therapies for gallstones. Their effect on gallbladder emptying is unclear. We evaluated emptying by ultrasonography before and after lithotripsy in 50 patients on ursodeoxycholic acid or placebo and in nine controls. At baseline, patients had normal (68.8 +/- 3.2%) or delayed emptying (14.5 +/- 3.3%). In a subset of 24 patients, lithotripsy increased fasting volume (26.6 +/- 3.0 to 43.8 +/- 5.0 ml, P < 0.005), postprandial volume (11.3 +/- 3.1 ml to 22.9 +/- 3.0 ml, P < 0.05), and decreased ejection fraction (70.0 +/- 4.1% to 42.7 +/- 6.0%, P < 0.0005). There was an inverse linear correlation between power and ejection fraction, r = -0.43, P < 0.005. Ursodeoxycholic acid increased fasting (23.3 +/- 2.2 ml to 36.7 +/- 4.6 ml, P < 0.005) and postprandial volume (11.1 +/- 1.8 to 17.6 +/- 2.5, P < 0.005). Treatment with ursodeoxycholic acid resulted in a greater decrease in fragment size compared to placebo after lithotripsy in patients with fragment size greater than 6 mm. In conclusion, both lithotripsy and ursodeoxycholic acid have an effect on gallbladder emptying.

Adult↗
PubMed1994

Gallbladder emptying determines early gallstone clearance after shock-wave lithotripsy.

BACKGROUND/AIMS: Disappearance of gallbladder stones after shock-wave lithotripsy combined with bile acid therapy depends on mechanical evacuation and dissolution of fragments. Many patients with gallstones have impaired gallbladder emptying and may show delayed stone clearance after lithotripsy. METHODS: The effect of gallbladder emptying on gallstone clearance after lithotripsy was prospectively studied in 57 patients with one radiolucent gallbladder stone < or = 20 mm. Gallbladder emptying was assessed sonographically before and after 2 weeks of ursodeoxycholic acid (UDCA) treatment. RESULTS: UDCA increased gallbladder fasting and residual volume and decreased ejection rate but did not affect ejection fraction. Patients with an ejection fraction > 60% achieved complete gallstone clearance after lithotripsy in a higher percentage than patients with smaller ejection fractions (1 month, 31% vs. 7%, P = 0.022; 2 months, 55% vs. 18%, P = 0.003; 3 months, 66% vs. 29%, P = 0.005). Patients who became stone-free within 1 month showed larger ejection fractions than patients with retained fragments (67% +/- 4% vs. 56% +/- 3% before UDCA, P = 0.032; 65% +/- 4% vs. 53% +/- 3% with UDCA, P = 0.017). Further, ejection rate during UDCA therapy was larger in patients with complete gallstone disappearance within 1 month than in patients with delayed fragment clearance (1.57%/min +/- 0.36%/min vs. 0.76%/min +/- 0.09%/min; P = 0.002). CONCLUSIONS: Gallbladder emptying is a major determinant of early gallstone clearance after lithotripsy.

Adult↗
PubMed2006

Can Phyllanthus niruri affect the efficacy of extracorporeal shock wave lithotripsy for renal stones? A randomized, prospective, long-term study.

PURPOSE: Phyllanthus niruri is a plant used in Brazilian folk medicine for the treatment of urolithiasis. We assessed the efficacy of P. niruri after extracorporeal shock wave lithotripsy for renal stones. MATERIALS AND METHODS: We prospectively evaluated 150 patients with renal stones that were as large as 25 mm and composed of calcium oxalate. All patients received 1 to 3 extracorporeal shock wave lithotripsy sessions by Dornier Lithotriptor S. After treatment 78 of 150 patients (52%) underwent therapy with Uriston, a P. niruri extract (2 gm daily) for at least 3 months (group 1). Otherwise 72 of 150 patients (48%) were used as a control group (group 2). No significant difference in stone size between the 2 groups was found. Stone clearance was assessed after 30, 60, 90 and 180 days by abdominal x-ray and ultrasound scan. RESULTS: Stone-free rate (stone-free defined as the absence of any stone or residual fragments less than 3 mm) was 93.5% in group 1 and 83.3% in group 2 (p = 0.48) at the end point of the followup (180 days). For lower caliceal stones (56 patients) the stone-free rate was 93.7% in the treatment group and 70.8% in the control group (p = 0.01). Re-treatment need for group 1 was 39.7% and for group 2 it was 43.3% (p = 0.2). No side effects were recorded with extracorporeal shock wave lithotripsy or P. niruri therapy. CONCLUSIONS: Regular self-administration of P. niruri after extracorporeal shock wave lithotripsy for renal stones results in an increased stone-free rate that appears statistically significant for lower caliceal location. Its efficacy and the absolute lack of side effects make this therapy suitable to improve overall outcomes after extracorporeal shock wave lithotripsy for lower pole stones.

Adult↗
PubMed2006

Is pre-shock wave lithotripsy stenting necessary for ureteral stones with moderate or severe hydronephrosis?

PURPOSE: We performed a prospective, randomized clinical trial to evaluate the outcome of ureteral stents for solitary ureteral stones 2 cm or less in moderately or severely obstructed systems using shock wave lithotripsy. MATERIALS AND METHODS: Between 2001 and 2004, 186 patients who met study criteria were randomized into 2 groups. Group 1 received a pre-shock wave lithotripsy 6Fr Double-J stent and group 2 had no stent. Patients were treated with a Dornier MFL 5000 lithotripter. Results were compared in terms of clearance rates, number of shock waves and sessions, irritative voiding symptoms, incidence of complications and secondary interventions. Failure was defined as the need for additional procedure(s) for stone extraction. RESULTS: Overall 164 patients (88.2%) became stone-free after shock wave lithotripsy. Complete stone fragmentation was achieved after 1 to 3 and more than 3 session in 108 (58.1%), 30 (16.1%), 13 (7%) and 14 patients (7.5%), respectively. Ureteral stent insertion did not affect the stone-free rate, which was 84.9% and 91.4% in groups 1 and 2, respectively (p = 0.25). There was no statistical difference in the re-treatment rate, flank pain or temperature in the 2 groups. However, all patients in the stented group significantly complained of side effects attributable to the stent, including dysuria, suprapubic pain, hematuria, pyuria and positive urinary culture. CONCLUSIONS: Pretreatment stenting provides no advantage over in situ shock wave lithotripsy for significantly obstructing ureteral calculi. Shock wave lithotripsy is reasonable initial therapy for ureteral stones 2 cm or less that cause moderate or severe hydronephrosis.

Adult↗
PubMed1998

Holmium:YAG lithotripsy: photothermal mechanism converts uric acid calculi to cyanide.

PURPOSE: Holmium:YAG lithotripsy fragments stones through a photothermal mechanism. Uric acid when heated is known to be converted into cyanide. We test the hypothesis that holmium: YAG lithotripsy of uric acid calculi produces cyanide. MATERIALS AND METHODS: Human calculi of known uric acid composition were irradiated with holmium:YAG energy in water. Stones received a total holmium:YAG energy of 0 (control), 0.1, 0.25, 0.5, 0.75, 1.0 or 1.25 kJ. The water in which lithotripsy was performed was analyzed for cyanide concentration. A graph was constructed to relate holmium:YAG energy to cyanide production. RESULTS: Holmium:YAG lithotripsy of uric acid calculi in vitro produced cyanide consistently. Cyanide production correlated with total holmium:YAG energy (p <0.001). CONCLUSIONS: Holmium:YAG lithotripsy of uric acid calculi risks production of cyanide. This study raises significant safety issues.

Aluminum Silicates↗
PubMed1998

Holmium:YAG lithotripsy efficiency varies with energy density.

PURPOSE: We test the hypothesis that holmium:YAG lithotripsy efficiency varies with optical fiber size and energy settings (energy density). MATERIALS AND METHODS: The 272, 365, 550 and 940 microm. optical fibers delivered 1 kJ. total holmium:YAG energy to calcium oxalate monohydrate calculi at energy output/pulse of 0.2 to 1.5 J. Stone mass loss was measured for each fiber energy setting. Stone crater width was characterized for single energy pulses. Fiber energy outputs were compared before and after lithotripsy. RESULTS: Stone mass loss correlated inversely with optical fiber diameter (p <0.05). Stone loss correlated with energy/pulse for the 365, 550 and 940 microm. fibers (p <0.001). The 272 and 365 microm. fibers yielded equivalent stone loss at 0.2 and 0.5 J. per pulse. At energies of 1.0 J. per pulse or greater the 272 microm. optical fiber was prone to damage, and yielded reduced energy output and stone loss compared to the 365 microm. fiber (p <0.01). Stone crater width for single pulse energies correlated with energy settings for all fibers (p <0.001). CONCLUSIONS: Lithotripsy efficiency with the holmium:YAG laser depends on pulse energy output and diameter of the optical delivery fiber, implying that lithotripsy efficiency correlates with energy density. The 365 microm. fiber is indicated for most lithotripsy applications. The 272 microm. fiber is susceptible to damage and inefficient energy transmission at energies of 1.0 J. per pulse or greater. The 272 microm. fiber is indicated at energies of less than 1.0 J. per pulse for small caliber ureteroscopes or when maximal flexible ureteroscope deflection is required.

Aluminum Silicates↗
PubMed1999

Intraluminal pneumatic lithotripsy for the removal of encrusted urinary catheters.

PURPOSE: Urologists frequently treat patients requiring long-term urinary drainage with a percutaneous nephrostomy tube or ureteral stent. When such tubes are neglected and become encrusted, removal challenges even experienced urologists. We describe a new, minimally invasive technique for safely and rapidly removing encrusted, occluded tubes using the Swiss Lithoclast pneumatic lithotriptor. MATERIALS AND METHODS: Patients presenting with an encrusted urinary catheter were evaluated by excretory urography for renal function and obstruction. Gentle manual extraction of the tube was attempted, followed by traditional extracorporeal shock wave lithotripsy and/or ureteroscopy. When the tube was not extracted, patients were then treated with intraluminal insertion of a pneumatic lithotripsy probe. RESULTS: One patient presented with an encrusted, occluded nephrostomy tube and 2 had an encrusted, occluded, indwelling ureteral stent. None was removed by manual traction. Intraluminal encrustations prevented the pigtail portions of these tubes from uncoiling and removal. In each case a pneumatic lithotripsy probe was inserted into the lumen of the catheter and advanced in a jackhammer-like fashion. This technique resulted in disruption of the intraluminal encrustations and straightening of the tubes so that they were removed in an atraumatic manner. CONCLUSIONS: Intraluminal pneumatic lithotripsy is a safe, easy and rapid technique for removing encrusted urinary catheters. It is unique in that the pneumatic lithotripsy probe functions in an aqueous and nonaqueous environment, and dislodges intraluminal calcifications. We recommend its use as first line treatment for removing encrusted urinary catheters.

Female↗
PubMed1989

Ureteral stenting during extracorporeal shock wave lithotripsy: help or hindrance?

We retrospectively reviewed the outcome of extracorporeal shock wave lithotripsy in patients with renal calculi less than 3 cm. in size who were treated at a large multi-user lithotripsy center. Patients in whom indwelling ureteral stents were placed before lithotripsy treatment were subjected to higher levels of total power (shocks times voltage), yet the rate free of stones did not differ from those treated without a stent. In addition, the patients with internal ureteral stents experienced a significantly higher incidence of urinary urgency (43 versus 25 per cent) and hematuria (40 versus 23 per cent) than nonstented patients, respectively (p less than 0.05). Also, the duration of bladder discomfort was longer for stented patients (26 versus 13 per cent) as was the duration of urinary frequency (31 versus 16 per cent), compared to nonstented patients (p less than 0.05). The results suggest that use of an indwelling ureteral stent may not contribute to a higher rate free of stones for the treatment of small to medium sized renal calculi and, in fact, it may make the treatment more uncomfortable for the patient than performing lithotripsy without ureteral stenting. Of course, in selected cases (solitary kidney, large stone burden and aid in stone localization) ureteral stenting has a useful adjunctive role in extracorporeal shock wave lithotripsy.

Catheters, Indwelling↗
PubMed1989

Extracorporeal shock wave lithotripsy treatment of calculi in horseshoe kidneys.

From June 1985 to November 1986, 17 patients with calculi in horseshoe kidneys presented to our hospital for evaluation and possible treatment with extracorporeal shock wave lithotripsy. Of these patients 14 were treated with extracorporeal shock wave lithotripsy; the calculi in 2 could not be localized and focused at the F2 focal point, and 1 was asymptomatic and has been followed conservatively. Four patients required repeat extracorporeal shock wave lithotripsy. Adjunctive procedures included preoperative retrograde catheter placement (5 patients), postoperative percutaneous nephrostolithotomy (1), ureteroscopy for ureteral fragments (2) and placement of a double pigtail stent (1). Of 14 patients 11 (79 per cent) have been rendered free of fragments with extracorporeal shock wave lithotripsy and adjunctive measures as needed. We conclude that most patients with calculi in a horseshoe kidney can be managed primarily with extracorporeal shock wave lithotripsy.

Adult↗
PubMed1990

Absence of persisting parenchymal damage after extracorporeal shock wave lithotripsy as judged by excretion of renal tubular enzymes.

Four renal tubular enzymes, N-acetyl-beta-glucosaminidase, beta-galactosidase, angiotensin-converting enzyme and gamma-glutamyltransferase, were measured in the urine before, and 24 hours and 1 week after extracorporeal shock wave lithotripsy in 20 consecutive patients. Extracorporeal shock wave lithotripsy was performed on the Sonolith 2000 device with the patient under intravenous narcotic sedation with fentanyl. Enzymatic activity per gram of urinary creatinine was consistently but not significantly higher before extracorporeal shock wave lithotripsy than in control subjects. All 4 enzymes were elevated 24 hours after extracorporeal shock wave lithotripsy, with the increases in beta-galactosidase and angiotensin-converting enzyme being statistically significant. However, by 7 days after the procedure the enzymes had decreased to pre-procedure concentrations or below. These data suggest that any renal tubular damage induced by extracorporeal shock wave lithotripsy is of limited magnitude and brief duration.

Acetylglucosaminidase↗
PubMed1990

Electrohydraulic lithotripsy of renal and ureteral calculi.

Electrohydraulic lithotripsy was used to manage 45 upper tract calculi (23 renal and 22 ureteral stones) in 40 patients. Electrohydraulic lithotripsy successfully fragmented 91% of the calculi. All ureteral fragments cleared; in 2 patients with renal calculi solitary 4 mm. stone fragments remained. There were no intraoperative or long-term complications directly related to the use of electrohydraulic lithotripsy in the upper urinary tract. We conclude that intrarenal and intraureteral electrohydraulic lithotripsy is a safe, effective, inexpensive means to perform intracorporeal lithotripsy.

Adolescent↗