Extracorporeal Shock Wave Therapy: Current Perspectives and Future Directions
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Purpose of Review
Since its introduction, extracorporeal shock wave lithotripsy (ESWL) has undergone a variety of changes; however, it remains one of the most utilized treatment modalities for urolithiasis. The goal of this review is to provide the practicing urologist an update on contemporary trends, new technologies, and related controversies in utilizing ESWL for stone treatment.
ESWL use has come under scrutiny with a shift in focus to cost-effectiveness and healthcare outcomes. Fortunately, advances in lithotripter technology have spawned several generations of devices that strive to improve stone-free rates and decrease complications. Most of all, a focus on patient selection criteria has helped improve procedural success.
Years of experience utilizing ESWL for stone treatment have helped urologists better optimize its use and minimize complications. Improvements in technique along with more stringent patient and stone selection have helped ESWL remain a mainstay in the treatment of stone disease.
KeywordsESWL Urinary tract stones Urolithiasis Lithotripter Ureteroscopy Percutaneous nephrolithotomy
Compliance with Ethical Standards
Conflict of Interest
Andrew C. Lawler, Eric M. Ghiraldi, and Carmen Tong each declares no potential conflicts of interest.
Justin I. Friedlander is a consultant for Retrophin.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.Chaussy, C. “Extracorporeal Shock Wave Lithotripsy: Past, Present, and Future.” Shock Wave Lithotripsy. New York: Springer US, 1988. Springer Book Archive. Web. 11 Dec 2016.Google Scholar
- 10.• Faragher SR, Cleveland RO, Kumar S, et al. In Vitro assessment of three clinical lithotripters employing different shock wave generators. J Endourol. 2016;30(5):560–66. This in vitro investigation demonstrated that lithotripters with electromagnetic and piezoelectric generators did not have statistically significant differences in stone reduction rates as compared to each, but both had significantly higher rates than the electroconductive lithotripter. The electroconductive lithotripter also decreased in efficacy after 6000 shocks.CrossRefPubMedGoogle Scholar
- 28.Ng CF, Luke S, Yee CH, et al. A prospective randomized study comparing the effect of different kidney protection treatment protocols on acute renal injury after extracorporeal shockwave lithotripsy. J Endourol. 2017;31:57–65.Google Scholar
- 32.•• Garcia-Galisteo E, Sanchez-Martinez N, Molina-Diaz P, et al. Invasive treatment trends in urinary calculi in a third level hospital. Actas Urol Esp. 2015;39(1):32–7. An observational review of ESWL utilization at a tertiary care facility from 1998 to 2012. Nearly 11,000 patients were available for review, 90% of which were treated with ESWL. A clear peak in ESWL treatments was observed in 2006, with a progressive decline thereafter with an associated increase in endoscopic procedures. The study is relevant to our review as it describes contemporary trends of ESWL utilization.CrossRefPubMedGoogle Scholar
- 34.Manzoor S, Hashmi AH, Sohail MA, et al. Extracorporeal shockwave lithotripsy (ESWL) vs. ureterorenoscopic (URS) manipulation in proximal ureteric stone. J Coll Physicans Surg Pak. 2013;23(10):726–30.Google Scholar
- 37.Pearle et al. Smith’s Textbook of Endourology. Chapter 66: Cost effective strategies for management.Google Scholar
- 39.•• Cone EB, Eisner BH, Ursiny M, et al. Cost-effectiveness comparison of renal calculi treated with ureteroscopic laser lithotripsy versus shockwave lithotripsy. J Endourol. 2014;28(6):639–43. Cost effectiveness for ESWL versus URS to treat renal and ureteral stones relies on selecting the ideal candidate. Cone et al. creates a decision analysis model using two retrospective cohorts for renal and ureteral stones, respectively. For renal stones, ESWL is more cost-effective than URS if a stone free rate of greater than 67% is achieved. For ureteral stones, ESWL is more cost effective than URS if a stone free rate of greater than 64% is achieved. Each study identifies URS as a superior treatment to ESWL for managing renal and ureteral stones <1.5 cm. Both studies stress the importance of careful patient selection for ESWL to limit health care costs.CrossRefPubMedGoogle Scholar
- 40.Cone EB, Pareek G, Ursiny M, et al. Cost-effectiveness comparison of ureteral calculi treated with ureteroscopic laser lithotripsy versus shockwave lithotripsy. World J Urol. 2017;35:161–166.Google Scholar
- 43.Kim JK, Ha SB, Jeon CH et al. Clinical nomograms to predict stone-free rates after shock-wave lithotripsy: development and internal-validation. PLoS One. 2016;11:e0149333.Google Scholar
- 44.•• Tran TY, McGillen K, Cone EB, et al. Triple D score is a reportable predictor of shockwave lithotripsy stone-free rates. J Endourol. 2015;29(2):226–30. Predictive tools to help identify the ideal candidate for ESWL is very important as it is the most cost-effective treatment we have in our armamentarium if successful at rendering patients stone free. The triple D score identifies three quantitative variables, stone density, skin to stone distance, and stone diameter (volume) that are associated improved stone free rates.CrossRefPubMedGoogle Scholar
- 46.Türk C, Knoll T, Petrik A, et al. Guidelines on Urolithiasis. Available at: http://uroweb.org/wp-content/uploads/22-Urolithiasis_LR.pdf. Uroweb. 2014. Accessed November 22, 2016.
- 47.• Denburg MR, Jemielita TO, Tasian GE, et al. Assessing the risk of incident hypertension and chronic kidney disease after exposure to shock wave lithotripsy and ureteroscopy. Kidney Int. 2016;89(1):185–92. A large epidemiologic study utilizing The Health Improvement network (THIN) database to compare the risk of hypertension and CKD in patients without urolithiasis, patients managed conservatively for urolithiasis, and patients managed with ESWL or URS. This is a timely and contemporary study challenging the controversy of ESWLs associated risk of HTN and CKD, for which several studies in the literature are underpowered. Within this large patient database, Denburg et al. identified an increased risk of HTN with ESWL to the kidney in all age groups, ESWL to the ureter in patient’s younger than 40, and no associating of increased risk of HTN or CKD in patients receiving URS for kidney or ureteral stones.CrossRefPubMedPubMedCentralGoogle Scholar