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Experience of Upper Urinary Tract Stones with Dornier MPL 9000 Lithotripter.

Byline: Abdul Rasheed Shaikh, Nisar Ahmed Shaikh, Akbar Ali Soomro, and Abdul Haleem Shaikh

Abstract

Objectives: To report our experience with Dornier MPL9000X Lithotripter in terms of safety, efficacy and complications in the management of upper urinary tract stones.

Study design: Retrospective study.

Study period and place: From 19th April 1998 to 15 August 2007 in the department of Nephrology, Chandka Medical College, Larkana.

Patients and Methods: All patients who had renal calculi up to 2.5cm in size were selected for extra corporeal shock wave lithotripsy with Dornier MPL 9000 on the basis of clinical examination, laboratory investigations, X-Ray, intravenous urography and ultrasonography. Simple analgesics /sedation were used before the procedure, except in children where general anesthesia was used.

Results: A total of 1965 patients were treated with 3930 sessions (Average 4.1 sessions per patients). Male to female ratio was 1.8:1. Average age of the patients was 35.3 years. The average stone burden was 1.8cm in diameter. Stone did not break in 3.3% cases, where as in 53(2.69%) cases partial fragmentation had occurred. Over all success rate was 84%. About 10.2% cases were lost to follow up. Complications like colic/ pain, transient haematuria and stein Strasse was observed in 33%, 17% and 2.5% respectively.

Conclusions: Extra corporeal shock wave lithotripsy for renal calculi was simple, safe and effective in selected group of patients.

Key words: Upper urinary tract stones, extra corporeal shock wave lithotripsy, dornier lithotripter.

Introduction

Renal lithiasis is one of the oldest health disorder1 affecting both kidneys equally and about 40% of patients have bilateral stones2. Pakistan falls in the Afro-Asian stone belt stretching from Egypt, Iran, India, and Thailand to Indonesia3.

Various modalities of treatment for renal lithiasis are available, of which surgery has been most widely used with high morbidity. The last two decade's has revolutionized the treatment and surgical treatment is replaced with non-invasive technique. The invention of Extra corporeal shock wave lithotripsy technique was introduced in 19804, and since then many studies have labeled this method now as the primary modality for renal calculi, and many authors call it a safe procedure with neither damage to kidney or soft tissue organ nor generates expulsion5.

With the refinement of technology, various models of lithotripters like Dornier, litho-star, modulith SL-20, Chinese and EDAP LT 02 were launched. Among them 3rd generation Dornier MPL 9000 Lithotripter (Figure-1) was claimed to be a state of art lithotripter. This lithotripter was installed in our department in April 1993 and in 2007 a new 4th generation (Sigma Compact) lithotripter replaced the older Dornier lithotripter. The aim of this study was to perform an audit of our previous Dornier MPL9000X Lithotripter in terms of safety, efficacy and complications and see the role of extra corporeal shock wave lithotripsy in the management of upper urinary tract stones.

Patients and Methods

This retrospective study was done by going through the records of patients who underwent lithotripsy between April 1998 and August, 2007 at department of nephrology, Larkana. All patients who had renal calculi less than 2.5cm (Figure-2) or upper ureteric stones less than 1.5cm in size were selected on the basis of clinical examination. The laboratory investigations included complete blood count, blood urea, serum creatinine, blood sugar, urine analysis, X-Ray intravenous urography and ultrasonography for extra corporeal shock wave lithotripsy treatment with Dornier MPL 9000.

Patients with distal obstruction, having larger stones, pregnant ladies and those with poor kidney function were excluded from the study. Prophylactic antibiotics were used in few patients, with history of urinary tract infection. Anesthesia was used in children. However, intra-muscular analgesic or intravenous sedation was given on 1st session or on the following sessions, if requested by the patients. The JJ stent was used in cases that had recurrent renal stones or had compromised renal function. Patients were followed up fortnightly with repeated KUB x-ray or ultrasound till clearance of the stone fragments. Failure of treatment was considered in cases where stone remained unchanged after 3 sessions of treatment.

Results

The present study included 1965 patients who had upper urinary tract stones for extra corporeal shock wave lithotripsy treatment. All patients were adults except 30(1.52%) who were children. Among them 1236(62.9%) were males and 729(37.09%) females with male to female ratio of 1.8:1. The ages of the patients ranged from 3-60 years with an average of 35.3 years (Figure-2). Stones were present in 845(43%) patients on the left side and in 979(57%) patients on right side. The average stone diameter was 1.8cm (ranged from 01 to 2.5cm). Ureteric stenting with JJ stent was carried on 30(1.52%) cases. All the patients were treated with simple analgesics and sedation before the procedure, except in children where general anesthesia was used. The treatment sessions ranged from 01 to 07 session's with average 4.1 per patients (Table-1). A total of 1029(52.36%) patients who had stones up to 1cm required 1-3 sessions, 526(26.76%) patients having stones

Table 1: Sessions of shockwaves.

No. of patients with renal stone (n=1965)

No. of Treatments Shock/patient

653(33.23%) 02 Sessions 5000 at 14 KV

376(19.13%) 04 Sessions 10000 at 14 KV

326(16.59%) 05 Sessions 12500 at 14 KV

327(16.64%) 06 Sessions 15000 at 14 KV

283(14.40%) 07 Sessions 17500 at 14 KV

Total 1965

(100%) Average Sessions/Patient 4.167 times 10417 at 14 KV up to 2cm required 4-5 sessions and 410(20.88%) patients who had stones up to 2.5cm required 6-7 sessions. The duration of each extra corporeal shock wave lithotripsy treatment session varied from 30 to 50 minutes. The clearance of the stone was achieved in 1650(84%) patients (Figure-3and4) KUB and intravenous urography within 2-12 weeks of therapy. The stone did not break in 65(3.35%) patients due to hard stone density and large stone size. The common complications noted were renal colic/pain in 648(33%) patients, transient haematuria in 334(17%), and stein strasse in 50(2.55%) cases. The residual fragments in kidney were noted in 118(6.03%) cases. (Figure-5)

Discussion

Since decades, surgery has been the most common modality of treatment for stone disease, but it is associated with long surgical incision, significant blood loss, post operative pain, wound dehiscence, ugly scar, incision hernia and prolonged hospitalization and 4-6 weeks convalescence6.

Since 1980 the modern technology has dramatically revolutionized the surgical management of stone disease by adding extra corporeal shock wave lithotripsy, and percutaneous-nephrolithotomy to its management line7.

In the present study, the stones were disintegrated and cleared from urinary tract in 84% of cases within 2-12 weeks. Our success rate is compared with the other international published data. (Table-2)

Table 2: Efficacy of Various Lithotripters.

Lilhotriptor Stone free rate Study

Dornier MPL 9000X 84.46% Present study

Dornier HM3 90% Putman et al 2004

Lithostar HM3 92% Sayed et al 2001

Storz Modulith 92% Liston d al 1992

EDAP LT 02 75% Tung et al 1990

EDAP LT 02 75% Robert 1995

These results are slightly lower than those reported by Putman8 and Sayed et al, who used Dornier HM3 and lithostar9 and showed 90% and 92% stone free rates respectively. We operate the machine at 14KV level which is lower than that used by others. Although with this level, more sessions are required but it has the advantage of being painless, and highly acceptable by patients. Shaikh et al10 reported 80% stone free rate which is very close with our results. Our results are even better than those presented by Tung 199011 and Robert 199512 using EDAP LT-02 lithotripters. They showed 75% and 76% stone free rates respectively (Table-2). In our series Stone did not break in 65(3.35%) cases even after 3 sessions of treatment, where as in 118(6.03%) cases partial fragmentation occurred.

In our series the main complications noted were renal colic/pain, transient haematuria, and stein strasse. The factor responsible for these events was the passage of rather larger fragment through the ureter. These Patients were managed on conservative treatment except some cases that developed obstruction, and stain stresse who were dealt with by endoscopic intervention. Keeping in view these complications in mind, many centers all over the globe are using JJ stent routinely13-15. We used JJ stent in 30(1.52%) cases that had recurrent renal stones or had compromised renal function.

Regarding partial fragmentation and residual stones, our findings are comparable with Grace16 who also demonstrated a linear relationship between stone size and number of shock waves sessions required to achieve fragmentation. Although stone density is also important but stone burden is directly related to multiple sessions of treatment and are associated with more morbidity17-19. Dretier18, Argyropoulos and Tolly20 and Yan and Wei21 stated that extra corporeal shock wave lithotripsy is not appropriate for larger stone because its debris causes ureteric obstruction. For these reasons we excluded patients having large or multiple stones from the treatment.

References

1. Robertson and Peacock: Urinary calculi. In: Marsh F, editor. Post graduate nephrology, London: William Heinemann Medical book Ltd; 1985. Pp.:354-5.

2. Khan FA, Khan JH. Stone surgery of Punjab Hospital. Pak Postgrad Med J 1990;10:7-13.

3. Tipu SA, Malik HA, Mohhayuddin N, Rizvi HA..SIUT, Karachi. Treatment of Ureteric Calculi- Use of Holmium: YAG Laser Lithotripsy Versus Pneumatic Lithoclast; J Pak Med Assoc 2007;57:440:

4. Krishna MV, Steven B. Stream: long term radiographic and functional outcomes of ESWL Induced peri-renal haematoma. J Urol 1995: 154:1673-5.

5. Kim SC. Ohew, Moon YT, Kim KD. Treatment of stein strasse with repeat ESWL with piezoelectric lithotripter. J Urol 1991; 145:489-91.

6. Drach GW. Surgical over view of urolithiasis. J Urol 1989:141(pt-2):711-3.

7. Masuda F. Open surgery for urinary stones. Asian Med J 1987; 30:74-80.

8. Putman SS, Hamilton BD, Johnson DB. The use of shock wave lithotripsy for renal calculi. Curr Opin Urol 2004; 14: 117-21.

9. Sayed MA, el-Taher AM, Aboul-Ella HA, Shaker SE. Stein strasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJU Int 2001; 88: 675-8.

10. Shaikh AR, Siyal AR, Shaikh NA. Extra corporeal shock wave lithotripsy. Prof Med J 2001; 8: 71-5.

11. Tung KH, Tan KC, Foo KT. In situ extracorporeal shock wave lithotripsy for upper ureteric stone using EDAPLT:01 lithotirptor. J Urol 1990; 143:481-2.

12. Robert M, Delbos O, Guiter J, Grasset D. In situ piezpelectric extracorporeal shock wave lithotripsy of ureteric stone. Br J Urol 1995:76:435-9.

13. Junaid HK, Safdar HJ, Saleem I, Zahid I and Khan FA. Role of ESWL in management of upper urinary tract stone disease. Pak Post graduate Med: J 1992; 3(3-4):87-94.

14. Liston TG, Mantgomery BSI, Bultitude MI, TI Ptoft RC. Extracorporeal shock wave lithotripsy with the storz modulith SL 20: the first 500 patient. Br J Urol 1992;69:459-65.

15. Raja Gopal V, Bailey MJ. Mobile ESWL Br J Urol 1991; 67:6-8.

16. Grace PA, Gillen Psmith JM.Fitzpatrick. ESWL with the lithostar lithotripter. Br J Urol 1989; 64:117-21.

17. Lingeman JE, LH, Woods JR, Newman DM. Cost effective of urolithiasis option: In, Urology calculi. Philadelphia: Lea and Febiger, 1989:397.

18. Dretler SP. Ureteral stone disease option for management. Urol Clin North Am 1990:17:217-30.

19. Chaussy C, Bergsdorf T. Extracorporeal shockwave lithotripsy for lower pole calculi smaller than one centimeter. Indian J Urol 2008;24:517-20.

20. Argyropoulos AN, Tolley DA. Failure after shockwave lithotripsy: is outcome machine dependent? Int J Clin Pract 2009; 63:1489-93.

21. Yan SB, Wei Q. Open stone surgery: is it justified in the era of minimally invasive therapies? Zhonghua Wai Ke Za Zhi.2009;47:244-7.
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Author:Shaikh, Abdul Rasheed; Shaikh, Nisar Ahmed; Soomro, Akbar Ali; Shaikh, Abdul Haleem
Publication:Pakistan Journal of Medical Research
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2010
Words:1974
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