Acute complications during and after extracorporeal shockwave lithotripsy

Pankaj N Maheshwari

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Year : 2002 \| Volume : 19 \| Issue : 1 \| Page : 95-97

Acute complications during and after extracorporeal shockwave lithotripsy

Pankaj N Maheshwari
Chief Urologist & Head of Department, RG Stone Urological Research Institute, 14-A Road, Khar - W, Mumbai - 400 052, India

Correspondence Address:
Pankaj N Maheshwari
Chief Urologist & Head of Department, RG Stone Urological Research Institute, 14-A Road, Khar - W, Mumbai - 400 052
India

Source of Support: None, Conflict of Interest: None

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Keywords: ESWL; Complications

How to cite this article:
Maheshwari PN. Acute complications during and after extracorporeal shockwave lithotripsy. Indian J Urol 2002;19:95-7

How to cite this URL:
Maheshwari PN. Acute complications during and after extracorporeal shockwave lithotripsy. Indian J Urol [serial online] 2002 [cited 2023 Jan 28];19:95-7. Available from: https://www.indianjurol.com/text.asp?2002/19/1/95/20307

Ind J Urol 2001; 17 (2) 118-120

Schmidt ME, Sharma S, Schoeneich G, Albers P, Muller SC.

I read this article on the acute complications during and after Extra-corporeal Shockwave Lithotripsy by Schmidt ME and colleagues^[1] with immense interest. This is indeed a timely article in view of the great increase in the number of lithotripsy centers and lithotripsy patients in India. The fact that there life-threatening complications are reported on a FDA approved electromagnetic lithotripsy unit should serve as a revelation.

Sir, though this report of complications of ESWL in this multi-center study is commendable, I beg to differ with their conclusions. Extensive laboratory examinations and sonography after each session of ESWL are unnecessary due to the low incidence (less than 1%) of clinically significant post-ESWL renal or perirenal hematoma. Such frequent and excessive use of sonography would not be cost effective. Evaluation is needed only in those patients presenting with unexplainable post-ESWL symptoms like severe pain, fever or backache.^[2] The 3 interesting case reports would rather suggest different conclusions:

Case number I is a case of cardiac arrest during ESWL. There are ample reports in literature regarding altered cardiac rhythm during ESWL. Both brady- and tachyarrhythmias are known after ESWL. In view of these findings, all lithotripsy patients must have a continuous ECG and blood pressure monitoring during the first ESWL session. Monitoring is done in subsequent sessions in elderly patients, patients with previous cardiac ailments, or patients showing ECG changes in first session. Cases number 2 and 3 describe a retroperitoneal and splenic hematoma after ESWL. Hematoma, though a rare complication, is more frequent in elderly patients, patients with uncontrolled diabetes and hypertension and patients with urinary tract infection.^[3] This is also related to the shockwave source and to the intensity and frequency of shockwave treatment.^[4] A safe spacing between two treatment sessions is at least 48 hours.

Sir, this article's emphasis is on early detection of complications. Rather the aim should be to avoid complications. With the literature review and a large personal experience of over 4500 lithotripsy patients, I would want to suggest some precautions to make lithotripsy a safer treatment modality.

All patients need a thorough pre-ESWL evaluation. The vital components of this evaluation are complete urological investigations like sonography, intravenous urography and other radiological tests when indicated;^[5] complete coagulation profile' and urine culture and sensitivity tests.

A proper case selection is very important. Only those patients would be ideal for treatment if complete stone clearance can be achieved in less than three sessions of ESWL. Proper case selection should also help in avoiding Steinstrasse. A need for frequent endourological treatment of Steinstrasse is a definite sign of wrong case selection for ESWL.^[7]

The best results of ESWL are obtained when ESWL is conducted by an experienced urologist who uses adequate number of shockwaves and utilizes enough fluoroscopy time for accurate tareting of the calculi.^[8]

All patients must have a continuous ECG and blood pressure monitoring during the first ESWL session.

Monitoring is done in subsequent sessions in elderly patients, patients with previous cardiac ailments, or patients showing ECG changes in first session. Whenever needed adequate analgesia should be provided. Need for analgesia is higher in women, younger patients or patients where a higher voltage is applied.^[9]

Patients need some evaluation before every subsequent session of ESWL. This is the time when evaluation is commonly missed.^[10] It is necessary to look for control of diabetes and urinary infection. Complications like renal hematoma and infections are also common in second session of ESWL.

It is necessary to space ESWL sessions. The safe spacing between ESWL session is at least 48 hours. If possible, longer space of 1 week may be given.

Antibiotic cover is necessary for each session of ESWL.^[11]

Further evaluation is necessary if patient presents with unexplained symptoms like pain, backache or fever.^[8]

Patients need to be regularly followed up till complete stone clearance is achieved. The term 'clinically insignificant' should not be employed to describe residual fragments after ESWL. Efforts should be performed to obtain true stone-free status after ES WL.^[12]

References

1.	Schmidt ME, Sharma S, Schoeneich G, Albers P, Muller SC. Acute complications during and after extracorporeal Shock-wave Lithotripsy. Indian Journal of Urology Vol.17(2), pp. 118-120, March 2001.
2.	Gallego Sanchez JA, Ibarlucea Gonzalez G, Gamarra Quintanilla M. Guisasola J, Bernuy Malfaz C. Renal hematomas after extracorporeal lithotripsy with the lithotriptor "lithostar multiline de Siemens". Actas Urol Esp 24(1): 19-22; discussion 23, Jan 2000.
3.	Bataille P, Cardon G, Bouzenidj M, EL Esper N, Pruna A, Ghazali A, Westeel PF, Achard JM, Fournier A. Renal and hypertensive complications of extracorporeal shock wave lithotripsy : who is at risk? Urol Int 62(4): 195-200, 1999.
4.	Chow GK, Streem SB. Extracorporeal lithotripsy. Update on technology. Urol Clin North Am 27(2): 315-22, May 2000.
5.	Gallagher HJ, Tolley DA. 2000 AD: Still a role for the intravenous urogram in stone management ? Curr Opin Urol 10(6): 551-555, Nov 2000.
6.	Czaplicki M, Jakubczyk T, Judycki J, Borkowski A, Jaskowiak W, Ziemski JM, Scharf R, Misiak A, Szalecki P. ESWL in hemophiliac patients. Eur Urol 38(3): 302-05, Sept 2000.
7.	Al-Awadi KA, Abdul Halim H. Kehinde EO, Al-Tawheed. A Steinstrasse : a comparison of incidence with and without J-stenting and the effect of J-stenting on subsequent management. BJU Int 84(6): 618-21, Oct 1999.
8.	Logarakis NF, Jewett MA, Luymes J, Honey RJ. Variation in clinical outcome following shock wave lithotripsy. J Urol 163(3): 7215. March 2000.
9.	Salinas AS, Lorenzo-Romero J, Segura M, Calero MR. HernandezMillan I, Martinez-Martin M, Virseda JA. Factors determining analgesic and sedative drug requirements during extracorporeal shock wave lithotripsy. Urol Int 63(2): 92-101. 1999.
10.	Collado Serra A, Huguet Perez J, Monreal Garcia de Vicuna F. Rousaud Baron A. lzquierdo de la Tone F. Vicente Rodriguez J. Renal hematoma as a complication of extracorporeal shock wave lithotripsy. Scand J Urol Nephrol 33(3): 171-5. Jun 1999.
11.	Fujita K, Mizuno T, Ushiyama T, Suzuki K. Hadano S, Satoh S. Kambayashi T. Mugiya S, Nakano M. Complicating risk factors for pyelonephritis after extracorporeal shock wave lithotripsy. Int J Urol 7(6): 224-30. Jun 2000.
12.	Candau C. Saussine C, Lang H. Roy C. Faure F. Jacgmin D. Natural history of residual renal stone fragments after ESWL. Eur Urol 37(1): 18-22. Jan 2000.