Treatment of painful caliceal stones.

Nonmobile caliceal stones cause pain more often than previously appreciated. The character and intensity of the pain differs from typical renal colic. Twenty-six patients with caliceal stones and pain underwent attempted treatment for pain control via stone removal or disintegration: 15 were treated with percutaneous stone extraction (PSE), 10 with extracorporeal shock-wave lithotripsy (ESWL), and 1 required open surgery after failing PSE. One patient had persistent pain after ESWL and subsequently underwent PSE; 25 of 26 patients had complete relief of pain. Morbidity was minimal. Patients with painful caliceal stones should be offered ESWL, followed by PSE if pain persists.

Creatinine kinase concentrations and electrocardiographic changes in extracorporeal shock-wave lithotripsy.

A total of 114 consecutive patients undergoing extracorporeal shock-wave lithotripsy had serial creatinine kinase (CK) with isoenzymes and serial electrocardiograms (ECG). There were significant changes in both heart rate and CK post-lithotripsy. However, this did not appear to be due to elevation of the myocardial component of CK. While there were some random ECG changes pre- and post-lithotripsy, none appeared to be directly related to the procedure.

Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy.

Two new therapies, percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy, are revolutionizing the treatment of upper urinary tract calculi. We report the success and morbidity rates in 110 patients undergoing percutaneous nephrostolithotomy and 982 patients treated with extracorporeal shock wave lithotripsy. Staghorn calculi were excluded from this series. The over-all success rate (free of stones plus small asymptomatic residual fragments) was comparable with both modalities (percutaneous nephrostolithotomy 98 per cent and extracorporeal shock wave lithotripsy 95 per cent), although the presence of residual fragments was more common in kidneys treated with extracorporeal shock wave lithotripsy (24 versus 7 per cent). Patient morbidity as measured by temperature elevation, length of postoperative stay, pain and blood loss was significantly less (p less than 0.05) with extracorporeal shock wave lithotripsy than with percutaneous nephrostolithotomy. Re-treatment rates were similar with both procedures, and tended to increase in relation to increasing stone size and stone number. Post-treatment ancillary procedures (cystoscopy and stone manipulation, and percutaneous nephrostomy) were used more frequently with extracorporeal shock wave lithotripsy. Because of its efficacy and low morbidity, we conclude that extracorporeal shock wave lithotripsy is the treatment of choice for upper urinary tract calculi less than 2 cm. in diameter. However, percutaneous nephrostolithotomy will continue to have a primary role in the management of larger stones and cystine stones, and it will be used as a secondary procedure after unsuccessful extracorporeal shock wave lithotripsy treatments. In addition, because of the complimentary nature of these 2 new technologies certain complex stones, such as staghorn calculi, may be handled best by a combination of the 2 techniques.

Efficacy of glucagon in the relief of ureteral colic following treatment by extracorporeal shock wave lithotripsy: a randomized double-blind trial.

In a prospective, double-blind, placebo-controlled study 18 patients were evaluated in regard to the effectiveness of glucagon to treat ureteral colic following extracorporeal shock wave lithotripsy. The study groups were comparable. There was no significant difference between glucagon and placebo in relief of pain or in the amount of gravel passed within 48 hours of treatment. We conclude that despite its desirable physiological attributes, glucagon has no demonstrable benefit in the treatment of ureteral colic following extracorporeal shock wave lithotripsy.

Extracorporeal shock wave lithotripsy in patients with a solitary kidney.

Extracorporeal shock wave lithotripsy was used to treat 68 patients with renal calculi in a solitary kidney. Epidemiological information, including stone number, size and location, was similar to that of other patients treated with extracorporeal shock wave lithotripsy. Renal function as measured by serum creatinine changed negligibly in the majority of the patients. Three patients had transient serum creatinine elevations greater than 2 mg. per dl. that were caused by obstruction from stone fragments. There were 2 perirenal hematomas that required transfusion. One patient required retrograde manipulation of a ureteral stone before extracorporeal shock wave lithotripsy, while 6 required stone manipulations after therapy for steinstrasses. Of 59 patients evaluable after extracorporeal shock wave lithotripsy 58 (98.3 per cent) had a successful result: 38 (64.4 per cent) were completely free of stones and 20 (33.9 per cent) had clinically insignificant residual fragments. Extracorporeal shock wave lithotripsy is effective and safe in a solitary renal unit. We believe that in most patients it is the procedure of choice. Attention to fever, urine output and fragment size perioperatively is crucial.

Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience.

A total of 982 patients underwent 1,416 treatments with extracorporeal shock wave lithotripsy for upper urinary tract calculi between February 23 and December 17, 1984. A single treatment was performed in 90 per cent of the patients. Morbidity was extremely low and hospital stay was short (3.0 days). Adjunctive procedures were required in 13 per cent of the patients. Of the kidneys 72 per cent were free of stones at the 3-month followup, while 23 per cent contained small (less than 5 mm.), asymptomatic fragments believed to be passable spontaneously. Only 1 per cent of the patients required surgical removal of the calculi. Morbidity was related directly to stone burden, while results were inversely related to stone burden. Extracorporeal shock wave lithotripsy is the preferred form of management for symptomatic upper ureteral and renal calculi less than 2 cm. in diameter.

Ureteral stone management: emerging concepts.

A total of 206 procedures was performed on 193 patients with ureteral calculi. The success rate was 62 per cent for stones proximal to the pelvic brim and 94 per cent for stones distal to the pelvic brim (87 per cent success over-all). Of the procedures 61 were done for fragments lodged in the ureter following extracorporeal shock wave lithotripsy. Ureteroscopy was done in 147 cases. Our current management concepts (including extracorporeal shock wave lithotripsy) for proximal and distal ureteral calculi are presented.

Combined percutaneous and extracorporeal shock wave lithotripsy for staghorn calculi: an alternative to anatrophic nephrolithotomy.

Combinations of percutaneous and extracorporeal shock wave lithotripsy were performed on 46 patients with 52 staghorn calculi. Of the renal units 15 per cent had minute residual fragments but only 9.7 per cent with struvite had residual stones. The morbidity of this combined approach is less than that of anatrophic nephrolithotomy. We believe that the majority of staghorn calculi can be removed in this manner. Nephrostolithotomy should be the initial procedure in most instances. This less invasive approach is especially advantageous in patients at high risk for recurrence.