STONE DISEASE

Emergency extracorporeal shockwave lithotripsy for acute renal colic caused by upper urinary-tract stones
Kravchick S, Bunkin I, Stepnov E, Peled R, Agulansky L, Cytron S
Department of Urology, Barzilai Medical Center, Ashkelon, Israel
J Endourol. 2005; 19: 1-4

• Purpose: To evaluate emergency SWL for the treatment of upper urinary-tract stones causing renal colic.
• Patients and Methods: Between January 1999 and June 2003, 53 patients with a mean age of 46.6 years (range 22-65 years) were enrolled. The inclusion criteria were acute renal colic, radiopaque 5-mm to 1.5-cm calculi in the ureteropelvic junction (N=10) or upper ureter (N=43), and no evidence of urinary-tract infection or acute renal failure. The mean stone size was 7.14 mm (range 5-13 mm). Patients were randomly assigned to the control (N=28) and study (N=25) groups using previously prepared cards in envelopes. Patients in the study group underwent emergency SWL, while patients in the control group underwent scheduled SWL within 30 days. Stone status was evaluated 4 weeks after lithotripsy. There was no significant difference between the control and study groups with respect to age, sex, stone location or volume, renal obstruction, or days spent in the hospital for pain control. Available fragments of stones were sent for infrared spectroscopy. Preoperative and postoperative data were compared in the two groups using SPSS 10.0 statistical software.
• Results: The SWL treatment lasted 50 +/-11 minutes. The stone-free rates were 72% and 64% and the efficiency quotients were 53% and 44% in study and control groups, respectively. Patients in the control group spent more time in the hospital (P=0.014) and in recovery at home (P=0.011).
• Conclusion: Emergency SWL for acute renal colic caused by upper-ureteral stones is a safe procedure and offers effective release from pain and obstruction. It also decreases hospitalization days and hastens return to normal activity.
  
  
• Editorial Comment
  In most patients, acute renal colic resolves within 24-48 hours, and thus when treatment of an obstructing stone is deemed necessary, the procedure can be scheduled electively. However, symptoms may recur, are unpredictable and can necessitate repeat emergency room or office visits prior to planned treatment. As such, for patients experiencing acute renal colic who have a low likelihood of spontaneous stone passage, acute treatment may be desirable. However, it is not clear if SWL success rates are compromised by the state of acute colic or if pain resolves promptly with SWL treatment.
  Kravchick and colleagues randomized 53 patients with acute renal colic due to 5 to 15 mm isolated UPJ or proximal ureteral calculi to undergo “emergency” SWL (within 48-72 hours) or elective SWL (within 30 days). Stone free rates, need for retreatment and auxiliary procedure rates were comparable between the 2 groups; however, the group treated “emergently” required fewer days in the hospital and missed fewer work days compared with the group treated electively. Furthermore, no patients treated “emergently” required upper tract drainage compared with 2 patients in the electively treated group. Unfortunately, time to resolution of obstruction was not addressed.
  This study suggests that SWL treatment of patients during or within a short time of an episode of acute renal colic avoids unnecessary pain or need for intervention without compromising stone free rates. Other investigators have likewise demonstrated that SWL treatment of patients with high grade or complete obstruction is associated with acceptable stone free rates and results in resolution of the obstruction in most patients within 72 hours, thereby confirming the safety and efficacy of treatment under conditions of acute renal colic and/or obstruction (1,2).

References
1. Cass AS: In situ extracorporeal shock wave lithotripsy for obstructing ureteral stones with acute renal colic. J Urol. 1992; 148: 1786-1787, 1992.
2. Baert L, Willemen P: Immediate in situ ESWL as monotherapy in acute obstructive urolithiasis: useful or not? J Lithotr Stone Dis.: 2: 46-48, 1990.

Dr. Margaret S. Pearle
Associate Professor of Urology
University of Texas Southwestern Med Ctr
Dallas, Texas, USA