STONE DISEASE

Impact of Shockwave Coupling on Efficacy of Extracorporeal Shockwave Lithotripsy
Weiland D, Lee C, Ugarte R, Monga M
Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
J Endourol. 2007; 21: 137-40

• Purpose: To evaluate the impact of a slow gated treatment rate on the efficacy of extracorporeal shockwave lithotripsy (SWL).
  Patients and Methods: From August 1990 to July 2002, 40,462 SWL procedures were performed using the slow frequency electrocardiography (ECG)-gated lithotripter (82.5%) and fast frequency ECG-ungated (17.5%) modes for the Medstone STS lithotripter. Treatment characteristics, including the mode of SWL, location and size of the stone, re-treatment status, auxiliary procedures required, perioperative complications, and treatment outcomes, were recorded. The stone-free rate was reported by the treating physician on the basis of the finding of no residual stone fragments on a plain radiographic image.
  Results: The treatment rate for the slow mode was a mean of 79.6 shocks/min, while the rate for the fast mode was 120/min. The total procedure time was 47.0 minutes for the slow mode and 40.6 minutes for the fast. The overall stone-free rate was higher for slow (66.9%) than fast (63.6%) procedures (P < 0.001). The stone-free rate for 1- to 10-mm stones was higher for the slow procedures (75.7%) than the fast procedures (70.7%; P < 0.001). Upper-ureteral stones responded better to slow treatment in terms of stone-free rate (79.5% v 72.6%; P < 0.001), re-treatment rate (6.5% v 8.0%, P = 0.05), auxiliary-procedure rate (6.1% v 8.9%; P = 0.01), and efficiency quotient (71 and 62). There was no significant difference in complication rates overall between slow and fast treatment.
• Conclusions: With a minimal increase in procedure time, greater efficacy can be obtained for the treatment of radiopaque stones with a slower shock-delivery rate. In particular, upper-ureteral calculi and calculi <10 mm benefit from a slower treatment rate.
  
  
• Editorial Comment
  Treating at a gated setting has been demonstrated to decrease the risk of cardiac dysrhythmias from 20% to 0.3% (Reference 15 in the article). In vitro and clinical trials have demonstrated that stone fragmentation and stone-free rates are superior with a slower (60 shocks/min) versus faster (120 shocks/min). This study suggests that a practical approach to slower treatments is to revert back to gating shockwave to the cardiac rhythm – thereby improving stone-free rates while preventing cardiac morbidity. Stones greater than 3 cm in size and distal ureteral stones did not benefit from a slower treatment protocol – as such, these stones are better suited for an endoscopic procedure.

Dr. Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA