Lithotripsy

Definition
Lithotripsy is the use of high-energy shock waves to fragment and disintegrate kidney stones. The shock wave, created by using a high-voltage spark or an electromagnetic impulse, is focused on the stone. This shock wave shatters the stone and this allows the fragments to pass through the urinary system. Since the shock wave is generated outside the body, the procedure is termed extracorporeal shock wave lithotripsy, or ESWL.

Purpose
ESWL is used when a kidney stone is too large to pass on its own, or when a stone becomes stuck in a ureter (a tube which carries urine from the kidney to the bladder) and will not pass. Kidney stones are extremely painful and can cause serious medical complications if not removed.

Precautions
ESWL should not be considered for patients with severe skeletal deformities, patients weighing over 300 lbs (136 kg), patients with abdominal aortic aneurysms, or patients with uncontrollable bleeding disorders. Patients who are pregnant should not be treated with ESWL. Patients with cardiac pacemakers should be evaluated by a cardiologist familiar with

ESWL. The cardiologist should be present during the ESWL procedure in the event the pacemaker needs to be overridden.

Description
Lithotripsy uses the technique of focused shock waves to fragment a stone in the kidney or the ureter. The patient is placed in a tub of water or in contact with a water-filled cushion, and a shock wave is created which is focused on the stone. The wave shatters and fragments the stone. The resulting debris, called gravel, then passes through the remainder of the ureter, through the bladder, and through the urethra during urination. There is minimal chance of damage to skin or internal organs because biologic tissues are resilient, not brittle, and because the the shock waves are not focused on them.

Preparation
Prior to the lithotripsy procedure, a complete physical examination is done, followed by tests to determine the number, location, and size of the stone or stones. A test called an intravenous pyelogram, or IVP, is used to locate the stones. An IVP involves injecting a dye into a vein in the arm. This dye, which shows up on x ray, travels through the bloodstream and is excreted by the kidneys. The dye then flows down the ureters and into the bladder. The dye surrounds the stones, and x rays are then used to evaluate the stones and the anatomy of the urinary system. (Some people are allergic to the dye material, so it cannot be used. For these people, focused sound waves, called ultrasound, can be used to see where the stones are located.) Blood tests are done to determine if any potential bleeding problems exist. For women of childbearing age, a pregnancy test is done to make sure the patient isn't pregnant; and elderly patients have an EKG done to make sure no potential heart problems exist. Some patients may have a stent placed prior to the lithotripsy procedure. A stent is a plastic tube placed in the ureter which allows the passage of gravel and urine after the ESWL procedure is completed.

Key terms
Aneurysm A dilation of the wall of an artery which causes a weak area prone to rupturing. Bladder Organ in which urine is stored prior to urination. Bleeding disorder Problems in the clotting mechanism of the blood. Cardiologist A physician who specializes in problems of the heart. EKG A tracing of the electrical activity of the heart. ESWL (Extracorporeal shock wave lithotripsy) The use of focused shock waves, generated outside the body, to fragment kidney stones. Gravel The debris which is formed from a fragmented kidney stone. IVP (Intravenous pyelogram) The use of a dye, injected into the veins, used to locate kidney stones. Also used to determine the anatomy of the urinary system. Kidney stone A hard mass that forms in the urinary tract and which can cause pain, bleeding, obstruction, or infection. Stones are primarily made up of calcium. Stent A plastic tube placed in the ureter prior to the ESWL procedure which facilitates the passage of gravel and urine Ultrasound Sound waves used to determine the internal structures of the body Ureter A tube which carries urine from the kidney to the bladder. Urethra A tube through which urine passes during urination. Urologist A physician who specializes in problems of the urinary system.

Aftercare
Most patients have a lot of blood in their urine after the ESWL procedure. This is normal and should clear after several days to a week or so. Lots of fluids should be taken to encourage the flushing of any gravel remaining in the urinary system. The patient should follow up with the urologist in about two weeks to make sure that everything is going as planned. If a stent has been inserted, it is normally removed at this time. Patients may return to work whenever they feel able.

Risks
Abdominal pain is not uncommon after ESWL, but it is usually not cause to worry. However, persistent or severe abdominal pain may imply unexpected internal injury. Colicky renal pain is very common as gravel is still passing. Other problems may include perirenal hematomas (blood clots near the kidneys) in 66% of the cases; nerve palsies; pancreatitis (inflammation of the pancreas); and obstruction by stone fragments. Occasionally, stones may not be completely fragmented during the first ESWL treatment and further ESWL procedures may be required.

(Electronics) the space between two electrodes across which a spark can jump Sometimes shortened to gap

Extracorporeal Shock Wave Therapy

ESWT also uses sound waves. The sound waves are of very high frequency, even more so than those used for ultrasound imaging. The sound waves are aimed exactly at a spot within the body to obliterate an undesired structure. The highfrequency sound waves pass easily through the soft tissues of the body but crash into solid structures like bone or mineral deposits.

ESWT for Treatment

Kidney stones and bone spurs are mineral deposits in the body that may cause pain or, in the case of kidney stones, a dangerous condition that may damage the kidneys. ESWT may be used when surgery may not be recommended or absolutely necessary. During an ESWT session, the therapist will aim the sound wave at the bone spur or kidney stone and shoot the sound waves. The highfrequency waves strike the minerals and dissolve them into smaller pieces that can be passed or absorbed by the body.

electrohydraulic lithotripsy a method used for large upper urinary tract calculi: a highcapacity condenser creates a high-voltage spark between two electrodes at the tip of a probe; in a fluid-filled organ this creates a hydraulic shock wave that can be directed toward a calculus, causing it to cavitate and fragment. extracorporeal shock-wave lithotripsy (ESWL) a noninvasive fragmentation of KIDNEY STONES or GALLSTONES with shock waves generated outside the body. It requires no incisions, catheters, or nephroscopes. The technique is based on the principle that shock waves are not destructive until they reach a surface in which there is a change in acoustical impedance, which is a form of resistance to the passage of sound waves. The impedance of calculi is different from that of water, bone, and soft tissue; therefore, tissue through which the wave travels as well as tissues surrounding the stone are not harmed

Every substance , such as a nerves, muscles, or fat, has a unique property called "acoustic impedance". Acoustic impedance is a somewhat complicated concept, but basically depends on the density of the substance and the speed of ultrasound in that substance. Substances with different acoustic impedances alter the course of ultrasound waves in an important manner. When an ultrasound wave (shown as a red arrow in image below) tries to pass from one substance to another substance with a different acoustic impedance, two things happen to it. Part of the ultrasound waves continues into the second substance, but becomes slightly bent away from their original direction (pink arrow). The bending away when ultrasound passes from one substance to another substance with a different acoustic impedance is called refraction. In addition to this, another very important thing happens. Part of the wave (shown as blue arrow in image below) is reflected back to the probe .The amount reflected back depends on the difference of the acoustic impedance between the two substances, more the difference, more the reflection. Reflected waves are extremely important, since it is only these waves that return back to the probe and provide information for the machine to show an image.
The plug is connected to the high voltage generated by an ignition coil or magneto. As the electrons flow from the coil, a voltage difference develops between the central electrode and side electrode. No current can flow because the fuel and air in the gap is an insulator, but as the voltage rises further, it begins to change the structure of the gases between the electrodes. Once the voltage exceeds the dielectric strength of the gases, the gases become ionized. The ionized gas becomes a conductor and allows electrons to flow across the gap. Spark plugs usually require voltage of 12,00025,000 volts or more to 'fire' properly, although it can go up to 45,000 volts. They supply higher current during the discharge process resulting in a hotter and longer-duration spark.

Other Treatments
Surgery is usually needed if the stone is too large to pass on its own, if there are signs that the stone is growing, or if the stone is blocking the urine flow and causing a urinary tract infection or kidney damage. Today, treatments for stones are much less invasive than in the past. Major surgery is performed in less than 2% of patients.

Stone removal procedures:

Extracorporeal shock wave lithotripsy (ESWL) is used for small stones (smaller than one centimeter, or slightly less than half an inch) that occur in the upper part of the ureter and do not pass on their own. Lithotripsy might even be safe and effective for patients whose stones are associated with malformed kidneys, although such patients are at higher risk for stone recurrence and should be carefully monitored. Percutaneous nephrolithotomy (PNL). PNL can be used for large stones in the upper urinary tract, when ESWL fails, for kidney transplant patients, or when the kidneys or surrounding areas are malformed. PNL is the preferred procedure for drug-resistant cystine stones, which are usually also resistant to shock wave therapy. Ureteroscopy. For stones in the lower tract, ureteroscopy is generally the best procedure, although lithotripsy is also usually feasible and patients ordinarily prefer it. Standard open surgery (nephrolithotomy) may be required if any of these procedures fail or are not appropriate, or in special cases, such as when the patient is very obese. Most procedures are more effective for calcium and uric acid stones and less effective for struvite and cystine stones, although new techniques may be improving their effectiveness on all stones. EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Extracorporeal shock wave lithotripsy (ESWL) is a technique that uses sound waves (ultrasound) to break up simple stones in the kidney or upper urinary tract. ("Extracorporeal" means "outside the body," and "lithotripsy" means stone-breaking.) ESWL is not used for cystine stones. The procedure generally does not work for stones larger than 3 centimeters in diameter (which is slightly over an inch). There are several variations of ESWL. The following is a typical procedure:

Most ESWL procedures use some anesthesia, although they are often done on an outpatient basis. The patient is positioned in a water bath. (In some procedures the patient lies on a soft cushion.) The procedure uses ultrasound to generate shock waves that travel through the skin and body tissues until they hit the dense stones. (The doctor pinpoints the stone during treatment by using x-rays or ultrasound.) The shock waves crush the stones into tiny sand-like pieces that usually pass easily through the urinary tract. I The shattered stone fragments may cause discomfort as they pass through the urinary tract. If so, the doctor may insert a small tube called a stent through the bladder into the ureter to help the fragments pass. This practice, however, does not usually speed up passage of the stones and is not used routinely.

Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to shatter simple stones in the kidney or upper urinary tract. Ultrasonic waves are passed through the body until they strike the dense stones. Pulses of sonic waves pulverize the stones, which are then more easily passed through the ureter and out of the body in the urine.

ESWL has a 50 - 90% success rate, depending on the location of the stone and the surgeon's technique and experience. Recovery time is short. Most people can resume normal activities in a few days. Complications. Complications may include:

Blood in the urine, the most common complication, may last for a few days after treatment. To reduce the chances of bleeding, doctors usually tell patients to avoid taking aspirin and other NSAIDs, which can promote bleeding, for 7 - 10 days before the treatment. Bruising and minor discomfort due to the shock waves are common in the back or abdomen. Sometimes the stone does not completely break up with one treatment, and additional treatments may be required. Inability to pass stone fragments may also be a particular problem in patients who have cysts or other kidney problems. ESWL does increase the risk of damage to the kidneys. ESWL appears to be safe for children. Experts recommend using the least amount of shocks and impact possible in young people. If more than one treatment is needed, the patient should wait at least 15 days before the next treatment. PERCUTANEOUS NEPHROLITHOTOMY Percutaneous nephrolithotomy may also be used for treatment of kidney stones when ESWL is not available or the patient is not a candidate for it (such as if the stone is very large, in an inaccessible location, or is a cystine stone). It is also preferred over ESWL for stones that have remained in the ureter for more than 4 weeks. It is more effective than ESWL for patients with severe obesity, and appears to be safe for the very elderly and the very young. Success rates are nearly 98% for kidney stones and 88% for ureteral stones. They may vary by the technique used and the specific patients. For example, success rates are slightly lower in children, although the procedure can be done safely in young patients. Long-term effects are unknown. A typical procedure is as follows:

The surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. The surgeon then inserts an instrument called a nephroscope through the tunnel. The stone is located and removed. If it is large, it is destroyed using ultrasound, lasers, or other devices. The surgeon then removes the fragments. An advantage of percutaneous nephrolithotomy over ESWL is that the surgeon is able to remove the stone fragments directly, instead of relying on their natural passage from the kidney. Generally, patients stay in the hospital for 5 or 6 days and may need a small device called a nephrostomy tube left in the kidney during the healing process. Devices Used to Destroy Stones. For large stones, some type of energy-delivering device may be needed to break the stone into small pieces. They are referred to as intracorporeal lithotripsy devices (meaning stone breakers within the body). The device may be one of the following:

Ultrasound is currently the preferred method. It results in a stone-free rate of over 90%. A rigid nephroscope delivers the ultrasound waves. Pneumatic (compressed air) lithotripsy uses a probe that comes in direct contact with a stone. Compressed air causes a piston to collide rapidly with the probe, and the result is a "jackhammer" action against the stone, to break up the stone. This method, however, can send stone fragments into other parts of the urinary tract. A more recent device uses a combination pneumatic probe and ultrasound. It produces stone-free rates of over 80%. It may prove to be superior to ultrasound alone, effective against stones of all types. The holmium laser literally melts the stones and destroys up to 100% of stones of any composition. It uses a flexible nephroscope and has an excellent safety record. It should be used sparingly, however, and with particular caution on large uric acid stones until more is understood about its effect. (Another device, the erbium: YAG laser, although showing promise in lithotripsy, is not currently practical.) Complications. Complication rates are about 3%. Major complications occur in about 1% of patients. These complications may include scarring of the tissue, but studies indicate that this scarring does not impair kidney function, even if the patient needs repeat surgery. There is also a risk for blood loss during and after the procedure, which sometimes can be significant. Because the procedure uses large volumes of fluid, fluid overload is a potential problem, particularly in children or patients with heart disease. Infection may result in some patients. Other complications may include a collapsed lung and injuries to areas outside the kidney (but within the operative area), such as the abdomen or chest. URETEROSCOPIC STONE REMOVAL Ureteroscopy may be used for stones in the middle and lower ureter. With the arrival of smaller instruments, this procedure can be done successfully in children as well. The procedure involves the following:

The patient receives a general anesthetic, though no incision is required for the procedure. The surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The surgeon locates the stone or stones. The surgeon can remove smaller stones by grasping them with small forceps. A laser or pneumatic device breaks up large stones. The surgeon may decide to leave a small tube, or stent, in the ureter for a few days after treatment, to help the lining of the ureter heal. Complication rates range from 10 - 20%, with major problems occurring in up to 6% of patients. In some cases, large stones are not broken up into small enough pieces. This can result in a blockage of the urinary tract and possible kidney damage.

Imaging tests, such as ultrasound or spiral CT, are useful within 3 months to check for residual stones, and a second procedure may be required. The risk of complications is highest when the procedure is performed by less experienced surgeons, or if stones are found in the kidney. The risk for perforation of the ureter increases the longer the procedure takes. OPEN SURGERY (NEPHROLITHOTOMY) Open surgery involves incisions through the patient's flank and into the kidney. The surgeon will cool the kidneys using ice. X-rays during the procedure help locate the stone. At the beginning of the surgery, the surgeon will isolate the arteries supplying the kidneys, ensuring they are not harmed during the surgery. The surgeon will then locate and remove the stone. The surgeon will also correct any blockage in the affected area. The surgery, called nephrolithotomy, is very invasive and is restricted to the following:

Patients with very large or complex stones that cannot be removed using less invasive measures Very obese patients Some centers report success with extracorporeal shock wave lithotripsy in patients who would normally be nephrolithotomy candidates. Therefore, even these patients should discuss other options with their surgeon. The procedure is not appropriate for patients with:

Bleeding or clotting disorders Untreated widespread infection Severe and chronic kidney insufficiency (unless removing the stone will improve kidney function)