Urolithiasis is one of the most frequent urological diseases, occurring in at least 1-20% of the population [Trinchieri A., Health Publications: Paris, 2003], and most often in people of working age (20-60 years). If we analyze patients undergoing treatment in urological hospitals, 30-40% of them are patients with urolithiasis. Taking into account the rate of growth (more than 37% over the last 20 years [Gambaro G., J Urol, 2017]) and the prevalence, duration of the disease (sometimes throughout life), which causes loss of working capacity, on the one hand, and on the other – leading to sepsis, acute and chronic renal failure and death, makes the problem not only medical but also social.
Currently, the emergence of new methods of diagnosis and treatment, as well as the use of new organizational and methodological approaches, has changed the quality of life of patients with urolithiasis. Thus, over the past decades, the share of open surgical interventions for urolithiasis has decreased almost to zero [Basiri A., Urol J, 2014]. This happened thanks to the widespread introduction into clinical practice of the latest medical technologies, first of all, extracorporeal shock wave lithotripsy (ESWL), as well as endoscopic methods of treatment: ureteral, pyeloscopy, contact lithotripsy of ureteral, kidney, bladder stones.
In the arsenal of the New Life Clinic, there are the most modern methods of treating urolithiasis, such as endovideoscopic interventions (ureterorenoscopy, fibronephrocalycoscopy, contact lithotripsy of urinary tract stones using various types of lithotripters), remote shock wave lithotripsy.
When you should consult a urologist for stone removal:
- Growth of kidney stone by more than 5 mm (since last examination);
- high risk of stone formation;
- obstruction caused by stones;
- infection caused by stones;
- symptomatic stones (pain, hematuria);
- kidney stones size > 5 mm (the risk of clinical manifestation or the need for treatment of asymptomatic stones localized in the renal calices is about 10-25% per year [Inci K., et al. J. Urol, 2007];
- patient choice;
- social status (profession or travel);
- planned pregnancy.
When treatment at the New Life Clinic, the patient has a choice between extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy.
Extracorporeal shock wave lithotripsy: how are stones crushed using ultrasound?
Extracorporeal shock wave lithotripsy (ESWL) is one of the basic methods of treating urolithiasis and recommended methods for removing small and medium-sized stones (<20mm) in most international manuals.
Indications for extracorporeal shock wave lithotripsy [Guidelines on urolithiasis; EAU Guidelines, 2020 – first 3 points]:
- Kidney stones up to 20mm in size, excluding the lower calyx.
- Concretions of the lower calyx of the kidney up to 10 mm in size.
- Concretions of the upper and lower parts of the ureter with a stone size of <10mm.
- Bladder stones.
The principle of operation of a remote lithotripter is based on the destruction of stones in the human urinary tract by focused acoustic shock waves created in water by an underwater spark electric discharge or other energy source. Destruction occurs gradually and continues until the stone fragments into sand and small fragments, which are painlessly excreted along with urine. In this case, the shock wave passing through the patient’s body outside the focal zone in which the calculus is located does not damage tissues and organs. When performing remote crushing, there is no need to make incisions, punctures, or introduce special endoscopic instruments into the lumen of the urinary tract, which makes this treatment method non-traumatic and highly effective.
In our hospital we work with one of the best devices for external lithotripsy on the world market, the Modulith SLK from Storz Medical (Switzerland).
The SLK MODULIT features a revolutionary new design: a compact shock wave source mounted on a flexible, movable articulated arm provides a wide energy range for all shock wave readings.
The device allows for remote crushing of kidney stones, upper, middle and lower parts of the ureter and bladder stones.
The patient is placed on the operating table. The doctor places a soft pillow filled with water on the patient’s body. Under ultrasound control, the shock wave penetrates the patient’s body and is precisely focused on the stone.
Crushing a kidney stone, positioning the patient.
Ultrasound visualization of a kidney stone in the same patient.
Crushing the stone in the upper third of the ureter, positioning the patient.
Ultrasound visualization of a stone in the upper third of the ureter in the same patient.
Fragmentation of a stone in the middle third of the ureter, patient’s conclusion.
Ultrasound visualization of a stone in the middle third of the ureter in the same patient.
Fragmentation of a stone in the lower third of the ureter, patient’s conclusion.
Ultrasound visualization of a stone in the lower third of the ureter in the same patient.
It should be noted that this method is used in both adults and children. The duration of the procedure is 40-60 minutes. External shock wave lithotripsy is so minimally invasive that it can be performed on an outpatient basis. After the crushing procedure, the urologist observes the patient for 1 hour, and then, if there is no pain, the patient is sent home. In the postoperative period, it is recommended to drink plenty of fluids, filter urine to collect stone fragments for analysis, and take painkillers, if necessary.
Contraindications to shock wave lithotripsy:
- pregnancy;
- blood clotting disorders (hemophilia, taking anticoagulants, menstruation in women);
- active phase of the inflammatory process of the urinary tract;
- deformation of the musculoskeletal system or severe obesity, which does not allow the patient to be positioned correctly and the shock wave to be accurately aimed at the stone;
- aneurysm of the aorta or any artery located in the zone of action of the shock wave;
- obstruction of the urinary tract below the location of the stone.
Ureteroscopy and laser lithotripsy of ureteral stones.
Ureteroscopy is a procedure in which a thin tube (ureteroscope) is inserted into the bladder and then into the ureter (the “tube” that connects the kidney to the bladder) and is used to diagnose and treat various urinary tract diseases. For ureteral stones, ureteroscopy allows the urologist to examine the ureter, find the stone and remove it. The ureteroscope can be rigid or flexible and allows the urologist to pass up the ureter to the stone and see it on a video monitor through a fiber optic.
The reduction in the outer diameter of ureteroscopes and the emergence of modern semi-rigid, flexible miniscopes (fibroureteroscopes) made it possible to avoid, in most cases, the need to expand the cell and the lower part of the ureter, and to significantly reduce the frequency of cases when pathological formation of the upper urinary tract was unattainable for the ureteral trauma instrument.
Ureteroscopic lithotripsy has become the treatment of choice for the treatment of ureteral stones due to its safety and effectiveness [Lane, J., et al., Curr Urol Rep, 2020]. Endoscopic lithotripsy involves visualizing the stone in the urinary tract and simultaneously applying energy to fragment the stone or stones into small pieces and sand. The holmium laser currently remains one of the most popular tools in urological procedures, including lithotripsy. One of the main advantages of the holmium laser is that it can effectively fragment urinary stones regardless of their size, hardness, chemical composition or physical consistency; accordingly, a high stone removal rate can be achieved. Therefore, ureteroscopic laser lithotripsy is recommended as the gold standard intracorporeal lithotripsy for the endoscopic treatment of urinary tract stones [Aboumarzouk, O.M., et al. J Endourol, 2012].
Methodology for ureteroscopy and contact lithotripsy.
Contact lithotripsy is performed under anesthesia. Its option is selected by the anesthesiologist depending on the age and condition of the patient. It is possible to use endotracheal, intravenous and epidural anesthesia.
The sequence of ureteroscopy and contact lithotripsy includes a number of stages:
1. Entry into the bladder and visualization of the ureteral cell. Mahesh R., B J U, 2011.
2. Passage of the cell and intramural part of the ureter. Mahesh R., B J U, 2011.
3. Visualization of the calculus, determination of its size and shape, assessment of the condition of the nearby mucosa, choice of removal method.
4. Conducting contact laser lithotripsy.
5. Removing stone fragments using forceps or a loop.
6. Ureteral stenting is performed after removal of large stones, in cases of severe swelling of the ureteral mucosa, or the presence of a urinary tract infection. A stent is a plastic tube with a diameter of approximately 1.6-2.0 mm, which has two rounded ends in the form of a pig’s tail, which is why it is called a JJ stent. A stent connects the kidney to the bladder, thereby eliminating ureteral obstruction, swelling of the ureteral mucosa, and resulting in small stone fragments after crushing. Most patients tolerate the stent well, although discomfort or frequent urination may occasionally occur. Fortunately, the stent is placed temporarily, usually for a few days. Removing it is painless and takes 30-40 seconds.
The advantages of laser lithotripsy over remote lithotripsy are:
- Possibility of instant removal of a stone, ensuring unblocking of the upper urinary tract in the shortest possible time.
- Removal of ureteral stones located beyond the reach of ultrasound and x-ray.
- Removal of stones associated with anatomical abnormalities or distal obstruction of the upper urinary tract.
- Possibility of performing CRT in pregnant women.
Data from Guidelines on urolithiasis; EAU Guidelines, 2020:
The overall rates of complete ureteral stone removal for ureteroscopic laser lithotripsy and ultrasound assisted lithotripsy appear comparable. However, with a larger stone size, complete removal of the fragments is achieved earlier after laser stone removal. At the same time, ureteroscopic laser lithotripsy is associated with a higher risk of complications. Compared with ESWL, laser lithotripsy for ureteral stones has a higher stone clearance rate at 4 weeks, but this difference is not statistically significant at 3 months follow-up. After laser fragmentation, there is a lower rate of re-treatment, but a higher rate of additional interventions, complications and length of hospitalization. ESWL has low morbidity.
Conclusions. ESWL is the least invasive method for stone removal and has a high treatment success rate if the indications for its use are followed. At the same time, its effectiveness is low in the treatment of large stones, cystine stones, and stones that cause ureteral obstruction. Laser lithotripsy is more traumatic than ESWL, but has a higher rate of complete removal of ureteral and renal stones. The holmium laser is the most efficient and widely used laser available today.
We often use remote crushing with ultrasound for kidney stones, and laser crushing for ureteral stones, but we do not always follow these rules. Our patients often prefer ESWL because it is less traumatic and does not require insertion of an endoscope or installation of a stent. However, in some cases, ureteroscopic laser lithotripsy remains the best treatment method.
In some patients, to remove the stone, we perform several sessions of remote crushing or combine remote lithotripsy with contact laser lithotripsy. We use an individual approach to choosing treatment for each patient and the effectiveness and safety of treatment comes first.
