LITHOTRIPSY

Lithotripsy is a non-invasive alternative to surgery for the treatment of kidney stones (urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) known as Lithotriptors. Lithotripsy was developed in the early 1980s in Germany by Dornier Medizintechnik GmbH (now known as Dornier MedTech Systems GmbH) and came into widespread use with the introduction of the HM-3 lithotriptor in 1983. It uses carefully focused, high-energy shock waves to disintegrate the kidney stones. Once the stone is disintegrated the sand-like fragments pass out of the body in the urine. Large stones may require more than one lithotripsy treatment.

What are Kidney Stones?

A kidney stone develops from crystals that separate from urine and build up on the inner surfaces of the kidney. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors do not seem to work for everyone, however, and some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without even being noticed. Kidney stones may contain various combinations of chemicals. The most common type of stone contains calcium in combination with either oxalate or phosphate. These chemicals are part of a person's normal diet and make up important parts of the body, such as bones and muscles. A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Much less common are the uric acid stone and the rare cystine stone. Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Doctors also use terms that describe the location of the stone in the urinary tract. For example, a ureteral stone (or ureterolithiasis) is a kidney stone found in the ureter. To keep things simple, the term "kidney stones" is used throughout this entire document. Gallstones and kidney stones are not related. They form in different areas of the body. If a person has a gallstone, he or she is not necessarily more likely to develop kidney stones.

Surgical Treatment
Some type of surgery may be needed to remove a kidney stone if the stone:

does not pass after a reasonable period of time and causes constant pain is too large to pass on its own blocks the urine flow causes ongoing urinary tract infection damages the kidney tissue or causes constant bleeding has grown larger (as seen on follow up x-ray studies).

Until recently, surgery to remove a stone was very painful and required a lengthy recovery time (four to six weeks). Today, treatment for these stones is greatly improved. Many options exist that do not require major surgery.

How does Lithotripsy Work?

Lithotripsy uses shock waves to pulverize urinary calculi (kidney stones) non-invasively. In contrast, other methods of stone removal require open surgery (surgical nephrotomy); extraction of the stone through a puncture in the side of the patient (percutaneous extraction); or the insertion of a ureteroscope via the urethra with subsequent stone fragmentation and removal by mechanical means. All invasive procedures carry a higher risk of infection complications than non-invasive procedures such as lithotripsy.

Occasionally, if the stone blocks the flow of urine (an obstructive calculus) the patient experiences severe pain (renal colic). This pain can be controlled by introducing a stent into the ureter. The stent is basically a tube which is placed in the ureter and allows the urine to drain past the obstruction. The stent may be left in after lithotripsy in case of obstruction due to fragments becoming lodged in the ureter A shock wave is characterized by a very rapid pressure increase in the transmission medium and is quite different from Ultrasound. The shock waves are transmitted through the patient's skin and pass harmlessly through the patient's soft tissue. The shock wave passes through the kidney and strikes the stone. At the stone boundary, energy is lost, and this causes small cracks to form on the

edge of the stone. The same effect occurs when the shock wave exits the stone. With successive shocks, the cracks open up, and in turn, smaller cracks form within the large cracks. Eventually, the stone is reduced to small particles, which are then flushed out of the kidneys or ureter naturally during urination. The process generally takes about 1 hour during which up to 8,000 shocks are administered. The patient will experience some discomfort during the treatment depending on the patient's pain tolerance. Analgesics may be administered to make the patient more comfortable.

How Are Kidney Stones Diagnosed?

Sometimes "silent" stones-those that do not cause symptoms-are found on x-rays taken during a general health exam. These stones would likely pass unnoticed. More often, kidney stones are found on an x-ray, CT scan, or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation. The doctor may decide to scan the urinary system using a special x-ray test called an IVP (intravenous pyelogram) or CT scan. Together, the results from these tests help determine the proper treatment. IVP x-rays will miss some stones. CT scan will often call things stones that are not. Occasionally a patient will need both an IVP and CT scan or a repeat of the first test to confirm the presence of stones. A variety of the techniques are available for dealing with nephrolithiasis. These include laser, electrohydraulic, pneumatic, ultrasonic, electromagnetic, piezoelectric, and shockwave lithotripsy. This article reviews the techniques for the primary forms of lithotripsy utilized in urology. If a kidney stone is too big to be passed naturally (6-7mm in diameter or larger), you may need to have treatment to remove it another way. This could include:

extracorporeal shock wave lithotripsy (ESWL) laser lithotripsy

Electrohydrolic Lithotripter (EHL) Pneumatic Lithotripters Ultrasonic Lithotripsy Cystolithalopaxy forceps percutaneous nephrolithotomy (PCNL) open surgery

These procedures are explained in more detail below. The type of treatment you have will depend on the size and location of your stones.

Extracorporeal shock wave lithotripsy (ESWL)

About extracorporeal shockwave lithotripsy
Extracorporeal shockwave lithotripsy (ESWL) is a procedure used to break down kidney stones. Kidney stones are small, solid masses that form when salts or minerals normally found in urine become solid crystals inside the kidney. Usually, the crystals are very small and pass harmlessly out of your body. But if they build up inside your kidney, they can cause pain, infection and damage your kidney function. Sometimes, smaller kidney stones move out of the kidneys into the tubes that carry urine from your kidneys to the bladder (ureters). These small stones can cause severe pain if they rub against or get stuck in your ureters. ESWL works by producing shockwaves from an external source aimed and focused on an intracorporeal source. The shockwaves build strength and force as they approach the stone to cause fragmentation. The shockwaves are produced from either an electrohydraulic, electromagnetic, or piezoelectric source. The patient is placed on the ESWL table and fluoroscopy is used to place the stone close to the crosshairs, indicating the point of maximal energy delivery. Once appropriately positioned the procedure can begin. Most ESWL machines have a standard protocol for energy delivery, all of which start with minimal energy delivery that can then be increased during the procedure. The shocks per minute can begin at range of 60-90 shocks/minute and are often increased to up to 120 shocks per minute. There is some evidence that a slow shock rate (60-80 shocks/minute) is more effective than fast shock rates (eg. 120 shocks/minute). Throughout the procedure, fluoroscopy should be intermittently used to ensure that the stone is in the crosshairs. Once the stone begins to break, the energy no longer needs to be increased. ESWL can induce cardiac arrhythmias by way of energy delivery to the heart. If the patient starts to have premature ventricular contractions (PVCs) during the case, he/she should be gated. This allows the shockwave production to correlate with the R wave of the QRS complex of the heart rate, thus delivering the shock during the resting phase of the cardiac cycle. Leaving a patient that is beginning to show signs of cardiac instability (eg. PVCs) ungated is dangerous as these patients can progress to ventricular tachycardia, supraventricular tachycardia, or other cardiac arrhythmias. Other potential

complications of ESWL include perinephric hematoma, bleeding, obstruction from stone fragments, and pain.

What are the alternatives?

Depending on the size, density and position of your kidney stone, your doctor may recommend alternative treatment options. Medical expulsive therapy (MET) if the stone is less than 10mm (1cm), your doctor may give you medicines to help the stone pass out in your urine. Ureteroscopy if the stone is lodged in your ureter, your surgeon will use a long fine, flexible instrument called ureteroscope to remove it. This procedure is usually done under general anaesthesia and a laser may be used to break up the stone before flushing it out. Often a stent is left in the ureter to stop further blockage. Percutaneous nephrolithotomy (PCNL) if the stone is large or in an awkward place, your surgeon will pass a fine instrument through your back into the kidney to remove the stone. This procedure is usually done under general anaesthesia.

Preparing for extracorporeal shockwave lithotripsy

Lithotripsy is routinely done as an out-patient or day-case procedure, without the need for anaesthesia. This means you will be awake during the procedure and can go home the same day. You will usually be offered a sedative to relieve anxiety and help you relax, and an injection of painkiller. You can drink fluids as normal on the day of your procedure. But you will need to go without food for four hours before your treatment. If you normally take any medication (eg tablets for blood pressure), continue to take this as usual unless your doctor specifically tells you not to. If youre unsure about taking your medication, contact the hospital.

At the hospital, your nurse will check your heart rate and blood pressure, and test your urine.
Your doctor or radiographer will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

What happens during extracorporeal shockwave lithotripsy

Lithotripsy takes about 30 to 60 minutes. Usually only one kidney is treated per session. You will be asked to lie down on a couch. Ultrasound is used to pinpoint the exact position of the kidney stone(s). Your doctor will spread gel onto your skin to allow good contact with the lithotripter sensor. The sensor focuses the shockwaves precisely onto each stone. The intensity of the shockwaves is increased gradually. Try not to make any movements during the treatment, otherwise the kidney stone may move out of focus. The shockwaves can cause pain in your kidneys and a stinging pain in the skin on your back.

Recovering from extracorporeal shockwave lithotripsy

Continue to take your painkillers as directed by your doctor. Always read the patient information that comes with your medicine and if you have any questions, ask your doctor or pharmacist for advice. It's sensible to take it easy for the rest of the day. Most people feel able to resume normal activities within a couple of days. Drink plenty of clear fluids when you get home, to help flush the kidney stone fragments out of your urinary system. Contact your GP if you develop any of the following symptoms as you may have developed a urinary tract infection (UTI): severe pain or pain that lasts for more than 48 hours high temperature burning sensation on passing urine or smelly urine inability to pass urine worsening blood-staining in your urine

Side-effects These are the unwanted but mostly temporary effects of a successful treatment. Side-effects of lithotripsy include: pain and discomfort some blood and fragments of stone in urine for two or three days bruising or blistering of the skin of your tummy or groin

Complications This is when problems occur during or after the treatment. Most people are not affected. Your doctor will be experienced at performing lithotripsy but, even so, there is a chance it may not be successfully completed and may need to be repeated. Specific complications of lithotripsy are uncommon, but include: infection you may need antibiotics to treat this blockage of ureters you may need surgery to unblock the tubes kidney damage this can be permanent and affect your kidney function and blood pressure (this is very rare) The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your doctor to explain how these risks apply to you.

Laser lithotripsy
Laser lithotripsy is performed under general anesthesia. The light energy of the laser is transported through a flexible light guide to the stone. For ensuring a safe procedure the laser fiber is observed with an ureterorenoscope. The fiber tip must be in contact with the stone during the firing of the laser. The stone breaking mechanism of laser lithotripsy is a thermal one. The stone fragments when pulses of intense laser light from the Dornier Medilas H20 are applied. Based upon the principle that Holmium laser energy is strongly absorbed by water, the short laser pulses create a shockwave that causes fragmentation of both ureteral and intrarenal stones. Due to the flexibility and control of the system, different treatment techniques can be applied depending upon the location and shape of the stone. For example, smaller stones can be fragmented directly, whereas with larger concrements, holes are first made in the center, after which the edges can then be fragmented. Finally, the stone residues can be flushed out utilizing the endoscopes rinsing fluid. Lasers produce energy by exciting electrons that can then release the energy in the form of light. Most lasers function by turning this energy into a plasma bubble that produces a shockwave upon collapse. The most widely used laser lithotripter is the holmium:YAG laser and is available in 200, 365, 550, and 1000 micrometer fibers. The holmium:YAG laser has a pulse duration of 250-350 microseconds, functions at a wavelength of 2140 nm, and a depth of penetration of 0.5-1.0 mm. This particular laser works by causing stone vaporization through a photothermal mechanism, rather than by producing a shockwave. When performing laser lithotripsy, the fiber should be placed in contact with the stone and irrigation should be available as fragmentation may cause decreased visibility. The tip of the laser must be visible at all times while activated as it will fragment whatever is in front of it, including a wire or the ureteral wall. It is best to avoid drilling a hole through the stone. In general, the best technique is to start on the center of the stone and work outward, vaporizing the stone. By the end of the procedure, there should only be one fragment left that may

be removed with a basket. If being placed through a flexible instrument then a 200 or 365 mm fiber should be used. The procedure should begin with 0.6 joules and a pulse rate of 6 hertz. If need be, the pulse rate can be increased for quicker fragmentation.

Laser lithotripsy carries a slightly greater risk of complications than extracorporeal shock wave lithotripsy. However, lithotripsy using the holmium laser is characterized by a high success rate and low complication rate for all types of stones.

Benefits
Immediate relief of symptoms In most cases, you may go home the same day Faster recovery with fewer complications Works well on all types of stones A greater than 95% success rate with a single treatment

Risks
Laser Lithotripsy is generally safe. However, as with any medical procedure, complications can occur. Those related to lithotripsy include: Pieces of stone are left in the body. You may need more treatments. Bleeding around the kidney which, in rare cases, may require a blood transfusion. Blockage of urine flow from the kidney due to pieces of stone. If this causes severe pain or blockage of the kidney, a tube may be placed through your back and into the kidney to keep

the kidney drained until all the fragments pass out. Sometimes, a thin mesh tube called a stent is placed into the body (from the kidney to the bladder) before ESWL to prevent this from happening. A stent is usually put in the body after laser lithotripsy.

Electrohydraulic Lithotripsy
Electrohydraulic lithotripsy (EHL) is primarily used in the endoscopic fragmentation of difficult bile and pancreatic duct stones. It was originally used in the Soviet Union as an industrial tool for fragmentation of rocks. It was first used to treat bile duct stones in 1975 when it was performed through a T-tube tract using fluoroscopic guidance. Electrohydraulic lithotripsy (EHL) was the first form of contact lithotripsy developed. EHL can fragment urinary calculi of all compositions but it has the narrowest margin of safety. Injuries to structures surrounding a stone occur when the probe discharges too close to the tissues. An advantage of EHL compared with other methods for treating difficult stones is that it is portable rapid, efficient, and relatively inexpensive. EHL is typically used during peroral or percutaneous choledochoscopy or peroral pancreatoscopy. Because these techniques are not widely available, EHL is mostly used in tertiary centers with expertise in the endoscopic management of biliary tract disorders. The EHL uses an underwater spark discharge to generate a plasma channel that vaporizes the water near the electrode and produces a hydraulic shockwave. The hydraulic shockwave impacts and fragments the stone. If the shockwave misses the stone, it will release energy on whichever portion of the urothelium encountered and can cause ureteral or bladder perforation. Also, if the stones are loose, the shockwave can propel stones in a retrograde fashion. The probe should be placed >2 mm from the end of the endoscope and within 1 mm of the stone. The procedure should begin with 5060 volts in short or single bursts. The energy can be increased as need to effectively fragment the stone. If the insulation from the tip of the catheter loosens, a new probe should be used. EHL has also been used for treatment of urinary tract stones, a setting where it has largely been replaced by other methods to achieve stone fragmentation (particularly Holmium laser lithotripsy). Laser lithotripsy for bile duct stones has not been widely adopted in part because of the costs and limited availability of equipment , but Holmium laser lithotripsy has been used successfully at various endoscopy centers, including ours, for the management of biliary and pancreatic stones.

Electrohydraulic lithotripsy, the first technique used for intracorporeal stone fragmentation, utilizes a probe containing two electrodes separated by an area of insulation. While electric current is passed between two electrodes, a spark is created which vaporizes the water or other surrounding fluids at the end of the probe. This spark gap creates a cavitation bubble, which rapidly expands, creating a shock wave. Once the cavitation bubble collapses a secondary pressure wave is created which is then transmitted to the adjacent stone. At the stone-water interface, the difference in acoustic impedance causes energy to be released, resulting in stone fragmentation. This process is exactly similar to shock wave lithotripsy in generating a spark gap, however, the difference in EHL is that the shock wave is not focused, so the stone must be placed where the shock wave is generated.

Advantages of EHL
Widely available Inexpensive

Disadvantages of EHL

When utilized next to the ureteral wall it will likely perforate the ureteral wall. The risk for
perforation is proportional to the size of the cavitation bubble. The perforation rate is 17.6% in one series.

Probe deterioration with possible shedding pieces of insulation, and possible break off of
probe requiring retrieval of the device.

 This device is not reusable. Multiple probes may be required during a single operation
increasing the cost of the procedure.

EHL may be ineffective against some stones.

Pneumatic Lithotripsy
A pneumatic lithotripter works by essentially jackhammering the stone by direct contact. This mechanism is very effective in fragmenting stones and is also very safe, unless the lithotripter probe is moved off of the stone, potentially damaging whatever is in front of the probe. Success rates are 73%- 100%, with ureteral perforation rates up to 2.6%. However, given the mechanism of action, the chance of retrograde migration is greater than with other modalities. The probe is placed in direct contact with the stone, a clear visual is imperative, and the stone is pinned against the bladder, ureteral wall, or kidney prior to activating the probe. Again, the goal is to fragment the stone into multiple small fragments that can be removed or pass spontaneously Several pneumatic lithotriptors are in current use. In the Swiss Lithoclast compressed air repeatedly drives a metal bullet onto a metal rod creating a chisel and hammer effect that fragments the targeted stone. The Lithoclast and the Browne Pneumatic Impactor (BPI) are capable of fragmenting all stones, irrespective of their size or composition. Unlike laser and ultrasonic lithotriptors, there are no thermal sequelae.

Pneumatic lithotripsy utilizes compressed air forcing a metal projectile against a probe, which causes the probe to move back and forth very quickly, resulting in a "jackhammer" effect to fragment the stone.

Advantages of Pneumatic Lithotripsy

1. 2. 3. 4. 5.

Simple to use No disposable parts Easy to maintain Relatively inexpensive Pneumatic lithotripsy comes in both rigid and flexible fibers and can be utilized in rigid and flexible ureteroscopy

Disadvantages

1. 2.

A tendency to propel the stone or fragmented stone toward the upper ureter Flexible fibers may have some decline in force compared to a standard rigid probes