Treatments

Extracorporeal Shock Wave Lithotripsy (ESWL)

Extracorporeal Shock Wave Lithotripsy (ESWL) uses sound waves or shock waves to break stones into small fragments that can pass spontaneously.

It is performed usually as an outpatient procedure whilst awake or sometimes with sedation. Usually, you can go home immediately after, although it may need to be repeated.

Prior to the introduction of extracorporeal shockwave lithotripsy (ESWL) in 1980, the only treatment available for calculi that could not pass through the urinary tract was open surgery. Since then, ESWL has become the preferred tool in the urologist’s armamentarium for the treatment of renal stones, proximal stones, and midureteral stones. Compared with open and endoscopic procedures, ESWL is minimally invasive, exposes patients to less anaesthesia, and yields equivalent stone-free rates in appropriately selected patients.  Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break a kidney stone into small pieces that can more easily travel through the urinary tract and pass from the body.

Hospital Stay: Hospital Stay: 2 days
Duration: Duration: 45 mins - 1 hr
Cost Estimate: Cost Estimate: 1000 USD - 1500 USD These are indicative prices in Indian Hospitals

ESWL may be used on a person who has a kidney stone that is causing pain or blocking the urine flow. Stones that are between 4 mm (0.16 in.) and 2 cm (0.8 in.) in diameter are most likely to be treated with ESWL.

ESWL may work best for kidney stones in the kidney or in the part of the ureter close to the kidney. Your surgeon may try to push the stone back into the kidney with a small instrument (ureteroscope) and then use ESWL.

Contra-indications:

  • Acute urinary tract infection or urosepsis
  • Uncorrected bleeding disorders or coagulopathies
  • Pregnancy
  • Uncorrected obstruction distal to the stone
  • Morbid obesity and orthopaedic or spinal deformities may complicate or prevent proper positioning.
  • Renal ectopy or malformations (like horseshoe kidneys and pelvic kidneys)
  • Poorly controlled hypertension (due to increased bleeding risk)
  • Gastrointestinal disorders: In rare cases, these may be exacerbated after ESWL treatment.
  • Renal insufficiency

Shockwaves are generated and then focused onto a point within the body. The shockwaves propagate through the body with negligible dissipation of energy (and therefore damage) owing to the minimal difference in density of the soft tissues. At the stone-fluid interface, the relatively large difference in density, coupled with the concentration of multiple shockwaves in a small area, produces a large dissipation of energy. Via various mechanisms, this energy is then able to overcome the tensile strength of the calculi, leading to fragmentation. Repetition of this process eventually leads to pulverization of the calculi into small fragments (ideally < 1 mm) that the body can pass spontaneously and painlessly.

  • You lie on a water-filled cushion, and the surgeon uses X-rays or ultrasound tests to precisely locate the stone. High-energy sound waves pass through your body without injuring it and break the stone into small pieces. These small pieces move through the urinary tract and out of the body more easily than a large stone.
  • The process takes about an hour.
  • You may receive sedatives or local anaesthesia.
  • Your surgeon may use a stent if you have a large stone. A stent is a small, short tube of flexible plastic mesh that holds the ureter open. This helps the small stone pieces to pass without blocking the ureter.
Advantages
  • There are several advantages of ESWL over other treatments for stones. These include: outpatient procedure that takes 1 hour, reasonably successful, no cutting or invasion of the body at all, low risk of infection from hospital bacteria
Disadvantages
  • About 1 in 10 people experience a problem. The main risks are: the treatment does not break the stone, pain as fragments of stone pass down the ureter, blocked urine flow if stone fragments cannot pass down the ureter, urine infection, bleeding around the outside of the kidney

Shock Wave Lithotripsy (SWL) is the most common treatment for kidney stones. Shock waves from outside the body are targeted at a kidney stone causing the stone to fragment. The stones are broken into tiny pieces. lt is sometimes called ESWL: Extracorporeal Shock Wave Lithotripsy.
These are what the words mean:

  • extracorporeal: from outside the body
  • shock waves: pressure waves
  • lithotripsy (the Greek roots of this word are “litho” meaning stone, “tripsy” meaning crushed)

So, ESWL describes a nonsurgical technique for treating stones in the kidney or ureter (the tube going from the kidney to the bladder) using high-energy shock waves. Stones are broken into “stone dust” or fragments that are small enough to pass in urine. lf large pieces remain, another treatment can be performed

ESWL works better with some stones than others. Very large stones cannot be treated this way. The size and shape of stone, where it is lodged in your urinary tract, your health, and your kidneys’ health will be part of the decision to use it. Stones that are smaller than 2 cm in diameter are the best size for ESWL. The treatment might not be effective in very large ones.

ESWL is more appropriate for some people than others. Because x-rays and shock waves are needed in SWL, pregnant women with stones are not treated this way. People with bleeding disorders, infections, severe skeletal abnormalities, or who are morbidly obese also not usually good candidates for ESWL. lf your kidneys have other abnormalities, your doctor may decide you should have a different treatment. lf you have a cardiac pacemaker, a cardiologist will decide if you can have ESWL.

lf the stone does not pass on its own, it will require treatment. lf you have an infection, severe pain, or if your kidney function is threatened, your doctors will act quickly. lf you only have one kidney or have had a kidney transplant, your stone will be treated more quickly. lf you have large stones or stones in both kidneys, your doctors will not wait to treat you.

You will be positioned on an operating table. A soft, water-filled cushion may be placed on your abdomen or behind your kidney. The body is positioned so that the stone can be targeted precisely with the shock wave. In an older method, the patient is placed in a tub of lukewarm water. About 1-2 thousand shock waves are needed to crush the stones. The complete treatment takes about 45 to 60 minutes.

Sometimes, doctors insert a tube via the bladder and thread it up to the kidney just prior to SWL. These tubes (called stents) are used when the ureter is blocked, when there is a risk of infection and in patients with intolerable pain or reduced kidney function.

After the procedure, you will usually stay for about an hour then be allowed to return home if all goes well. You will be asked to drink plenty of liquid, strain your urine through a filter to capture the stone pieces for testing, and you may need to take antibiotics and painkillers. Some studies have reported stones may come out better if certain drugs (calcium antagonists or alpha-blockers) are used after SWL.

Yes, even though there is no incision, there will be pain. You and your doctor will discuss whether light sedation and local or general anaesthesia will be used. The choice depends on the technique, the type of stone and the patient. SWL can be delivered with just mild sedation, but in general, some type of anaesthesia–either local, regional or general–is used to help the patient remain still, reduce any discomfort, and this improves the breaking of the stone.

Not usually. In most cases, lithotripsy is done on an outpatient basis.

The main advantage of this treatment is that it treats kidney stones without an incision. As a result, hospital stays and recovery time are reduced.

But, while ESWL can work, it doesn’t always work. After ESWL, about 5O% of people will be stone free within a month. In others, stone fragments of various sizes remain. Sometimes a repeat procedure (or a different procedure) is needed.

ESWL has the potential to cause kidney injury. Whether or not ESWL causes or leads to the development of high blood pressure and diabetes remains controversial.

The recovery time is usually fairly brief. After treatment, the patient can get up to walk almost at once, many people can fully resume daily activities within one to two days. Special diets are not required, but drinking plenty of water helps the stone fragments pass. For several weeks, you may pass stone fragments.

After treatment, you will have blood in your urine and possibly abdominal pain or aching for several days. Other people experience a severe cramping pain as shattered stone fragments make their way out of the body. Oral pain medication and drinking lots of water will help relieve symptoms.

Sometimes, the stone is not completely broken up, or big pieces remain and additional treatments may be needed.

Rarely, more serious problems occur, such as bleeding near the kidney that might require a blood transfusion, damage to the area around the stone, or pieces of the stone blocking the flow of urine.

Call your doctor if you feel the strong need to urinate even after you empty your bladder or if you are in extreme pain even when taking your pain medicine.

Drug treatment is being studied with such drugs as such as calcium channel blockers (nifedipine), steroids and alpha-adrenergic blockers. The idea is that the stone might be dissolved with medication. Other drugs such as K-citrate, thiazides or allopurinol are prescribed to prevent new stones from developing. Most doctors agree that more medical trials are needed.

When ESWL is not appropriate or doesn’t work, some people will need

  • ureteroscopy, a technique that goes through the bladder to reach the stone or
  • percutaneous nephrolithotomy, a technique that goes through a small incision created in your back.
  • Some people, in extremely rare cases, even need open surgery, a technique that involves a larger incision in your abdomen like ureterolithotomy or nephrolithotomy.

ln those patients who are thought to be good candidates for this treatment, some 50-75% are found to be free of stones within three months of SWL treatment. The highest success rates seem to be in those patients with smaller stones (such as less than 1 cm).
After treatment, some patients may still have stone fragments that are too large to be passed. These can be treated again if necessary with shock waves or with another treatment.

Most small ureteral stones (less than 1-5 mm in diameter) will pass on their own. lf they don’t pass, then another intervention is usually done. Ureteral stones that occur near the kidney are usually treated by ESWL with or without moving the stone to a better spot. Ureteral stones that occur lower (near the bladder) may also be treated with ESWL, but they usually require ureteroscopy especially if they are large (more than 1 cm in diameter).

Treatment is available at many hospitals, outpatient centers and sometimes even in mobile units. For information about where to have lithotripsy done in your area, contact your doctor, local hospital or health care facility.

Often, they can. People who have had more than one kidney stone are likely to form another. Once the cause is found, the doctor may recommend drinking more liquids, dietary changes and medication.

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