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PubMed2005

Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy.

BACKGROUND AND STUDY AIMS: The widespread use of cholangioscopy in the management of difficult choledocholithiasis has been limited by the need for two expert operators. This report describes the use of a technique of single-operator duodenoscope-assisted cholangioscopy (SODAC) in the successful management of 75 patients with choledocholithiasis. PATIENTS AND METHODS: The single-operator technique, allowing simultaneous control of both the duodenoscope and cholangioscope, was prospectively studied between June 1999 and June 2001 in the diagnosis and treatment of choledocholithiasis. RESULTS: A total of 109 SODAC procedures were conducted in 75 patients to manage choledocholithiasis. The indications were: firstly, SODAC-guided electrohydraulic lithotripsy (EHL) of stones in which conventional methods, including mechanical lithotripsy, had not been successful (52 SODAC procedures in 26 patients); and secondly, direct visualization of the biliary tree after cholangiography to assess the presence of stones (57 SODAC procedures in 49 patients). The locations and numbers of the stones, but not their size, were predictive of the number of SODAC-guided lithotripsy sessions required. All of the patients were free of stones at the end of the study period, and no complications were recorded. CONCLUSIONS: Single-operator SODAC-guided electrohydraulic lithotripsy was effective in the treatment of difficult cases of choledocholithiasis in which conventional methods had previously failed. The technique may allow increased use of cholangioscopy in the management of choledocholithiasis.

Adult↗
PubMed1995

[Ultrasound-guided extracorporeal piezoelectric lithotripsy of bile duct calculi].

AIM: Extracorporeal shock-wave lithotripsy (ESWL) with underwater spark discharge and stone localisation via x-ray has become established in the treatment of difficult bile duct stones. First results with the piezoelectric lithotripter (EPL) in our department have also been promising. METHOD: Between 1989 and 1993 we were able to treat 79 patients (mean age 76 years) with problematic bile duct stones with the EPL. Twenty-seven patients had solitary stones, 52 patients presented with multiple stones. Seventy-one patients received a nasobiliary tube to decompress the biliary system. For extracorporeal lithotripsy, we used a piezoelectric lithotripter (Piezolith 2300, R. Wolf, Knittlingen, Germany). RESULTS: Visualisation of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%), and complete stone removal was achieved in 62 patients (78.5%) after 7,595 shock-waves were applied per patient on average. In 55 patients, endoscopic extraction of fragments was performed to avoid fragment complications. Nearly all patients in whom extracorporeal lithotripsy failed were cleared of their stones by additional use of intracorporeal electrohydraulic lithotripsy. Three patients received palliatively an endoprosthesis and two patients were referred to surgery. CONCLUSION: EPL with sonographic stone localisation and mild sedo-analgesia is a valuable adjunct in the treatment of difficult biliary tract calculi. It is a worthwhile alternative especially for elderly patients who would be at high risk on general anaesthesia.

Aged↗
PubMed1995

[Endoscopic and extracorporeal shock wave lithotripsy of salivary calculi].

Shock wave lithotripsy of salivary gland stones has become more and more efficient in the treatment of sialolithiasis during the last years. We use two different methods in our hospital: Extracorporeal shock wave lithotripsy (ESWL) and endoscopically intracorporeal lithotripsy (EISL). The results of both therapies are compatible; 60-70% could be successfully treated. The indication is different due to the localisation of the salivary gland stone. Stones that are located in the glandula or very proximal in the duct should be fragmented by extracorporeal lithotripsy. Stones located in the duct and multiple intraductal stones should be treated by the intracorporeal method. Clinical experiments showed that some salivary stones do not fragment easily. The reason is still unknown. We examined the ability of fragmentation in relation to the physicochemical analysis of the stone. The stones were examined by infrared spectroscopy. This study revealed that pure carbonate apatite stones are more difficult to destroy than stones containing some protein.

Combined Modality Therapy↗
PubMed1997

[Percutaneous and transpapillary laser lithotripsy of intrahepatic gallstones].

PROBLEM AND OBJECTIVE: In the last few years several intra- and extracorporeal endoscopic methods have been developed for treating intrahepatic gallstones, but as yet no ideal instrumentation has been found. This study was undertaken to test the efficacy and possible complications of intracorporeal laser lithotripsy for intrahepatic gallstones. PATIENTS AND METHODS: 16 consecutive patients were included (13 women and 3 men, median age 64 [28-82] years) with intrahepatic biliary tract stones which could not be removed by conventional endoscopy. A rhodamine-6G-laser with an integrated stone recognition system was used. The glass fibres of the laser instrument were introduced perorally or percutaneously and placed at the stone. RESULTS: The percutaneous procedure under cholangioscopic control succeeded in four of the patients, while 12 were treated by a transpapillary approach (two under fluoroscopic, ten under cholangioscopic control). In eight of the latter group all stones were completely fragmented, i.e. 12 of the total were successfully treated. Of the remaining four patients two were cleared of stone by additional measures (extracorporeal shockwave lithotripsy and electrohydraulic lithotripsy, respectively), two were treated pallatively by endoprosthesis. One patient developed an acute cholangitis which was successfully treated with antibiotics and biliary drainage. There were no deaths. CONCLUSIONS: Particularly when performed transcutaneously, laser lithotripsy provides effective treatment of intrahepatic gall stones. Cholangioscopic monitoring, to place the glass fibre at the stone, is usually required in the transpapillary approach.

Adult↗
PubMed2002

Salivary stone lithotripsy in the HIV patient.

OBJECTIVE: To investigate the use of shock-wave lithotripsy in the treatment of salivary gland disease in HIV-positive patients. STUDY DESIGN: Four patients infected with human immunodeficiency virus with ultrasonographically confirmed sialolithiasis (three male patients, mean age 33.5 years, range 19-41 years) were treated with extracorporeal electromagnetic shock-wave lithotripsy. RESULTS: All but one of the patients were successfully treated or experienced relief, with complete stone clearance demonstrated by ultrasonography 12 months after lithotripsy. CONCLUSION: Extracorporeal shock-wave lithotripsy is a safe, effective and minimally invasive technique for the nonsurgical treatment of HIV-positive patients with sialolithiasis.

Adult↗
PubMed1999

Renal hematoma as a complication of extracorporeal shock wave lithotripsy.

OBJECTIVE: To evaluate risk factors, clinical presentation, therapeutic management, and treatment of residual stones and subsequent development of renal hematoma following Extracorporeal Shock Wave Lithotripsy (ESWL). MATERIAL AND METHODS: A retrospective review was made of 31 post-ESWL renal hematoma cases diagnosed between May 1987 and June 1996. Lithotripsy treatments were outpatient procedures without anaesthesia. Our center has three electromagnetic sources, two with biplane X-ray centering and one ultrasound-guided (SIEMENS Lithostar II, SIEMENS Lithostar System C and SIEMENS Lithostar Ultra, respectively). We analysed findings from patient history, physical examination, blood analysis, and renovesical sonographs. Follow-up involved periodical checks, blood analyses and renovesical sonographs, scheduled first at three-month intervals and later at six-month intervals. RESULTS: Our center performed 21 699 lithotripsies on a total of 10 953 patients in this period. Thirty-one renal hematomas were diagnosed, giving an incidence rate of 0.28%. Twenty-four patients presented clinical onsets and the commonest symptom for consultation was low back pain (74%). Eleven patients of this group (46%) were hypertensive. All patients received conservative treatment. With a mean follow-up time of 18 months, ultrasound showed persistent hematoma in 11 patients (36%). There were residual stones in 71% of patients; further lithotripsy was performed on seven patients with no clinical or ultrasonographic signs of change in the hematoma. CONCLUSIONS: Renal hematoma post-ESWL is a rare complication. Main risk factors are hypertension, clotting disorders and previous ESWL sessions. Flank pain is the main symptom at presentation. Elective management is conservative. Presence of hematoma is not a contraindication for further treatments of residual stones.

Adult↗
PubMed2001

Flexible ureteroscopic lithotripsy: first-line therapy for proximal ureteral and renal calculi in the morbidly obese and superobese patient.

BACKGROUND AND PURPOSE: The surgical treatment of kidney and proximal ureteral stones in morbidly obese patients (>14 kg/m2) remains difficult because shockwave lithotripsy is precluded by weight limitations and percutaneous nephrolithotomy is associated with difficult access and a high (9%) rate of transfusion. We review our experience with retrograde ureteroscopic lithotripsy in morbidly obese patients with renal and proximal ureteral stones. PATIENTS AND METHODS: Between December 1992 and April 2000, five women and three men with a mean age of 46.5 years (range 33-68 years) and a mean body mass index of 54 (range 45-65.2) underwent 10 independent ureteroscopic procedures for urolithiasis. The average stone size was 11.1 mm (range 5-25 mm). Lithotripsy was performed with the holmium laser in eight patients (60%) the electrohydraulic lithotripter in four (30%), and the tunable-dye laser in the remaining patient. Stone-free status was defined as no stones visible on a plain film with nephrotomograms or CT scan at 3 months. RESULTS: The mean operation time was 101 minutes (range 45-160 minutes), and 60% of the procedures were done on an outpatient basis. After the initial procedure, the stone-free rate was 70%. Two patients had fragments <4 mm, and no further therapy was undertaken. There was one complication: transient renal insufficiency (serum creatinine concentration 3.7 mg/dL) secondary to aminoglycoside toxicity. No transfusions were needed. CONCLUSION: In the morbidly obese patient with symptomatic stones <1.5 cm, ureteroscopic lithotripsy is safe, successful, and efficient.

Adult↗
PubMed2003

Effect of lithotripsy on holmium:YAG optical beam profile.

PURPOSE: To determine the effect of holmium:YAG lithotripsy on the optical beam profile. MATERIALS AND METHODS: Beam profiles of the laser light from holmium:YAG optical fiber systems were characterized with a pyroelectric camera. Beam profiles were measured with 272-microm and 365-microm optical fibers both straight and bent to simulate lower-pole ureteronephroscopy. Struvite calculi were irradiated. Beam profiles and energy outputs were characterized for the fibers before and after ablation. Ablation crater geometry was characterized with optical coherence tomography. RESULTS: Undamaged, straight fibers produced a near-Gaussian beam profile. Craters showed a similar near-Gaussian shape. Undamaged, bent 272-microm fibers produced a near-Gaussian beam but slightly flatter profile than the straight fiber. The bent 272-microm fiber transmitted 99% to 100% of the energy, similar to the 100% transmission of the straight fibers. After ablation, measured energy output dropped by 30% within 50 pulses at 0.2 J pulse energy. The damaged fibers produced irregular beam profiles with hot spots. Craters showed irregular contours. CONCLUSIONS: During Ho:YAG lithotripsy, the beam profile at the optical fiber tip approaches a Gaussian distribution. This shape corresponds to the crater produced on the stone surface. With further ablation, the beam profile becomes erratic and unpredictable, with loss of lithotripsy efficiency. The findings provide further insight into the photothermal mechanism of Ho:YAG lithotripsy.

Humans↗
PubMed1994

Outpatient fragmentation of ureteral calculi with mini-ureteroscopes and laser lithotripsy.

Laser lithotripsy with mini-ureteroscopes is a minimally invasive method to fragment ureteral calculi. This study reviewed the efficacy and morbidity of outpatient laser lithotripsy for the treatment of ureteral calculi. The 248 patients were initially treated by outpatient ureteroscopy and laser lithotripsy with the Candela pulsed-dye laser over a period of 3 1/2 years. Thirty-six patients had prior unsuccessful fragmentation of ureteral calculi by SWL. Twenty-eight patients had undergone unsuccessful ureteroscopy with attempted basket extraction or attempted fragmentation with methods other than laser. Calculi were located in the upper ureter in 31% and in lower ureter in 69% of these patients. The 1-month stone-free rate was 92% for upper ureteral calculi and 96% for lower ureteral calculi, with an overall success rate of 94.7%. Ninety per cent of the patients were discharged the same day and 96% within 23 hours. Hospital admission was needed in only 4% of patients. Parenteral analgesia was required in 18% of patients, and major complications occurred in 0.8%. The combination of mini-ureteroscopes and laser lithotripsy is an effective method for fragmentation of ureteral calculi in outpatients with low morbidity and few complications.

Adolescent↗
PubMed1995

Applicability of Iceland spar as a stone model standard for lithotripsy devices.

The identification of a universal stone model standard would enable reproducible fragmentation data useful for the design, evaluation, and comparison of various lithotripsy devices. The clinical benefits of such a stone model include the elucidation of setting parameters that would optimize fragmentation strategies. Iceland spar is a pure form of calcite (CaCO3) that was subjected to experimental disintegration by electrohydraulic lithotripsy and extracorporeal shockwave lithotripsy. Iceland spar was fragmented with both lithotripsy methods in a reproducible fashion. The degree of fragmentation was directly related to alterations in either power or shock frequency. Iceland spar is radiopaque, inexpensive, easily obtained, homogenous in composition, and sizable. Iceland spar meets a variety of stone model criteria, warranting its continued investigation as a potential stone model standard.

Calcium Carbonate↗
PubMed1998

Combination of pneumatic lithotripsy and transurethral prostatectomy in bladder stones with benign prostatic hyperplasia.

We present our experience with combined pneumatic lithotripsy and transurethral resection of the prostate (TURP) in 52 patients with bladder stone(s) and benign prostatic hyperplasia (BPH). All stones were fragmented with the pneumatic Swiss Lithoclast. Pneumatic lithotripsy and evacuation caused a mean increase of 16 minutes in operating time. No complications, other than mild hematuria, were observed intraoperatively because of pneumatic lithotripsy. We observed early and long-term complications related to the procedure in 13% of patients. The average hospital stay was 3.2 days. The combination of pneumatic lithotripsy and TURP appears to be an effective, safe, and economical treatment method for patients with bladder stone(s) and BPH.

Aged↗
PubMed1999

Experimental utilization of the holmium laser in a model of ureteroscopic lithotripsy: energy analysis.

BACKGROUND AND OBJECTIVE: Medical lasers have rapidly expanded in both indications and utilization. We have developed a simple model for the investigation of various modalities of lithotripsy using readily available silicate stones of uniform mass. MATERIALS AND METHODS: The holmium:YAG VersaPulse Select (Coherent, Palo Alto, CA) was used in these experiments to define the relation between fiber diameter and efficacy of stone fragmentation. For each fiber, lithotripsy was performed in an incremental fashion at 0.6, 0.8, and 1.0 J at a frequency of 10, 16, and 20 pulses per second at each energy level. RESULTS: Total kilojoules did not differ between any fibers investigated, supporting the consistency of our methodology. The power density of the holmium laser energy, as expressed as total kJ/area, decreases in proportion to increasing fiber diameter. We expected an increase in fragmentation success as fiber diameter decreased (at equal energy output). However, peak lithotripsy occurred with the 365- and 550-microm fibers, whereas neither the 200- nor the 1000-microm fibers was effective. CONCLUSION: This model utilizing a silicate stone phantom supports our clinical observation that the 365-microm fiber (and additionally the 550-microm fiber) provides the best method for efficient intracorporeal lithotripsy.

Humans↗
PubMed2004

Erbium:YAG laser lithotripsy using hybrid germanium/silica optical fibers.

BACKGROUND AND PURPOSE: Previous studies have demonstrated that the erbium:YAG laser is two to three times more efficient for laser lithotripsy than the holmium:YAG laser. However, the lack of a suitable optical fiber delivery system remains a major obstacle to clinical application of Er:YAG laser lithotripsy. This paper describes the initial testing of a hybrid germanium oxide/silica optical fiber for potential endoscopic use with the Er:YAG laser. MATERIALS AND METHODS: Er:YAG laser radiation with a wavelength of 2.94 microm, a pulse energy of 10 to 600 mJ, a pulse length of 220 microsec, and pulse-repetition rates of 3 to 10 Hz was focused into either 350- or 425- microm-core hybrid germanium/silica fibers in contact with human uric acid or calcium oxalate monohydrate stones. RESULTS: Average Er:YAG pulse energies of 157 +/- 46 mJ (66 J/cm(2)) (N = 8) were delivered at 10 Hz through the 425-microm hybrid fibers in contact with urinary stones before fiber damage was observed. A maximum pulse energy of 233 mJ (98 J/cm(2)) was also measured through the hybrid fiber in contact with the stones. These values are significantly greater than the stone ablation thresholds of 15 to 23 mJ (6-10 J/cm(2)) and the fiber damage thresholds measured for germanium oxide, 18 +/- 1 mJ (13 J/cm(2)), and sapphire, 73 mJ (51 J/cm(2)), optical fibers during Er:YAG laser lithotripsy (P < 0.05). CONCLUSIONS: A prototype hybrid germanium/silica optical fiber demonstrated better performance than both germanium oxide and sapphire fibers for transmission of Er:YAG laser radiation during in vitro lithotripsy.

Aluminum Oxide↗
PubMed2005

Combined ureterorenoscopy and shockwave lithotripsy for large renal stone burden: an alternative to percutaneous nephrolithotomy?

PURPOSE: To investigate the feasibility and initial outcomes of a combination of ureterorenoscopy (URS) using holmium laser lithotripsy and extracorporeal shockwave lithotripsy (SWL) in a single outpatient session for the treatment of large renal stone burdens in patients refusing or unsuitable for percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Fourteen patients with a mean age of 52.7 years (range 34-81 years) having a mean stone burden of 847 mm2 (range 58 mm2-1850 mm2) were treated with combined URS laser lithotripsy and SWL as an alternative to PCNL. The SWL (mean 2800 shockwaves) was performed using the Storz Modulith SL-X, and flexible URS with holmium laser lithotripsy was performed either during or following SWL. RESULTS: Ninety-three percent of the patients (13/14) were treated successfully on an outpatient basis. Two patients were rendered stone free after the initial procedure alone (14%). Overall, including secondary outpatient treatment with a second session of URS alone (N = 7) URS and SWL (N = 1), SWL (N = 1), or oral alkalinization therapy (N = 1), the stone-free rate was 76.9% (10/13). One patient was excluded secondary to death from unrelated causes after the initial procedure, and the success rate (residual fragments <4 mm) was 84.6% (11/13). The two treatment failures included one patient who required a third URS procedure and one patient who developed urosepsis necessitating nephrostomy-tube placement who underwent subsequent PCNL. CONCLUSIONS: In comparison with traditional approaches using PCNL and second-look nephroscopy, single-session combined URS and SWL with a second outpatient procedure may offer equivalent results with decreased morbidity in carefully selected patients.

Adult↗
PubMed2000

Fast-tracking after immersion lithotripsy: general anesthesia versus monitored anesthesia care.

UNLABELLED: Both monitored anesthesia care (MAC) and general anesthesia (GA) offer advantages over epidural anesthesia for immersion lithotripsy. We compared propofol-based MAC and desflurane-based GA techniques for outpatient lithotripsy. After receiving midazolam 2 mg IV, 100 subjects were randomly assigned to one of two anesthetic treatment groups. In the MAC group, propofol 50-100 microg. kg(-1). min(-1) IV was titrated to maintain an observer's assessment of alertness/sedation score of 2-3 (5 = awake/alert to 1 = asleep). Remifentanil 0.05 microg.kg(-1). min(-1) IV supplemented with 0.125 microg/kg IV boluses, was administered for pain control. In the GA group, anesthesia was induced with propofol 1.5 mg/kg IV and remifentanil 0.125 microg/kg IV and maintained with desflurane (2%-4% inspired) and nitrous oxide (60%). Tachypnea (respiratory rate >20 breaths/min) was treated with remifentanil 0.125 microg/kg IV boluses. In the GA group, droperidol (0.625 mg IV) was administered as a prophylactic antiemetic. Recovery times and postoperative side effects were assessed up to 24 h after the procedure. Compared with MAC, the use of GA reduced the opioid requirement and decreased movements and episodes of desaturation (<90%) during the procedure. Although the GA group took longer to return to an observer's assessment of alertness/sedation score of 5, discharge times were similar in both groups. We conclude that GA can provide better conditions for outpatient immersion lithotripsy than MAC sedation without delaying discharge. IMPLICATIONS: A desflurane-based general anesthetic technique using the cuffed oropharyngeal airway device was found to be a highly acceptable alternative to propofol-based monitored anesthesia care sedation for outpatient immersion lithotripsy.

Ambulatory Care↗
PubMed1992

The acceleration of gallstone destruction with synchronous biliary lithotripsy and contact dissolution in vitro using three cholesterol-solubilizing solvent.

In the first-known application of its kind, shockwave lithotripsy and contact-solvent dissolution of large, calcified gallstone burdens were performed simultaneously with three chemical solvents, each tested separately in an in vitro model, with the combined effects on gallstone eradication examined. Two solvents, ethyl propionate and isopropyl acetate, were chosen for their solubilizing ability and potentially high level of patient safety. The third solvent, a 70%:30% mixture of methyl tert-butyl ether (MTBE) and dimethyl sulfoxide (DMSO), was chosen for its known ability to accelerate the dissolution of calcium-containing gallstones. All stones were matched for size, weight, and number. Gallstone lithotripsy performed in ethyl propionate was significantly more effective (P less than .02) in the production of fragments less than 2 mm when compared with bile; lithotripsy with isopropyl acetate and the MTBE/DMSO mixture showed no statistically significant effect. Biliary lithotripsy performed in an ethyl propionate medium may enhance gallstone dissolution and the production of small fragments (diameter less than 2 mm).

Acetates↗
PubMed1991

Detection of tissue injury after extracorporeal shockwave lithotripsy of gallstones.

We evaluated seven patients undergoing gallstone lithotripsy for evidence of hepatic or renal trauma after each of 10 lithotripsy treatments. Postlithotripsy magnetic resonance imaging (MRI) and sonography showed no evidence of hepatic or renal injury as compared with baseline studies. Four treatments resulted in sonographic evidence of gaseous hepatic microbubbles (analogous to "the bends") due to cavitation effects of the shockwaves. Three of these four treatments produced serum glutamicoxaloacetic transaminase and -pyruvic transaminase elevation. One patient had microscopic hematuria. Minimal tissue damage results from gallstone lithotripsy. MRI and ultrasound, performed after lithotripsy, appear to be less sensitive than transaminasemia in detecting this low-grade injury.

Adult↗
PubMed2006

Endoscopic treatment of an impacted pancreatic duct stone using a balloon catheter for electrohydraulic lithotripsy without pancreatoscopy.

Obstructing main pancreatic duct (PD) stones represent a challenge for endoscopic removal because they are frequently impacted within the duct, are hard, and process sharp edges. Multiple series have been published demonstrating that removal of obstructing stones in the main PD can improve symptoms in the majority of patients with chronic pancreatitis. Extracorporeal shock wave lithotripsy (ESWL) has become an accepted technique to facilitate stone clearance when standard endoscopic methods fail. More recently, direct contact lithotripsy with the use of smaller caliber endoscopes has been described as an alternative to ESWL. Limited experience suggests that intraductal electrohydraulic lithotripsy under direct endoscopic visualization with a small caliber pancreatoscope results in successful fragmentation of PD stones that have been refractory to standard endoscopic methods or ESWL. Herein, we report the use of intraductal electrohydraulic lithotripsy to fragment a large obstructing PD stone guided only by fluoroscopy without the utilization of a pancreatoscope.

Adult↗