References 1. Grases F, Conte A, March JG, et al. Epidemiology of urinary stone disease in the Balearic Islands Community. Int Urol Nephrol. 1994; 26:145-150. 2. Hesse A, Siener R. Current aspects of epidemiology and nutrition in urinary stone disease. World J Urol. 1997;15:165-171. 3. Pak CY. Kidney stones. Lancet. 1998;351:1797-1801. 4. Carstensen HE, Hansen TS. Stones in the ureter. Acta Chir Scand Suppl. 1973;433:66-71. 5. Osman MM, Alfano Y, Kamp S, et al. 5-Year follow-up of patients with clinically insignificant residual fragments after extracorporeal shock wave lithotripsy. Eur Urol. 2005;47:860-864. 6. Cervenakov I, Fillo J, Mardiak J, et al. Speedy elimination of ureterolithiasis in lower part of ureters with the alpha 1-blocker— tamsulosin. Int Urol Nephrol. 2002;34:25-29. 7. Jenkins AD, Gillenwater JY. Extracorporeal shock wave lithotripsy in the prone position: treatment of stones in the distal ureter or anomalous kidney. J Urol. 1988;139:911-915. 8. Hara N, Koike H, Bilim V, et al. Efficacy of extracorporeal shock wave lithotripsy with patients rotated supine or rotated prone for treating ureteral stones: a case-control study. J Endourol. 2006;20: 170-174. 9. Zeng GQ, Zhong WD, Cai YB, et al. Extracorporeal shock wave versus pneumatic ureteroscopic lithotripsy in treatment of lower ureteral calculi. Asian J Androl. 2002;4:303-305. 10. Peschel R, Janetschek G, Bartsch G. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study. J Urol. 1999;162:1909-1912. 11. Erturhan S, Erbagci A, Yagci F, et al. Comparative evaluation of efficacy of use of tamsulosin and/or tolterodine for medical treatment of distal ureteral stones. Urology. 2007;69:633-636. 12. Dellabella M, Milanese G, Muzzonigro G. Medical-expulsive therapy for distal ureterolithiasis: randomized prospective study on role of corticosteroids used in combination with tamsulosin-simplified treatment regimen and health-related quality of life. Urology. 2005; 66:712-715. 13. Sayed MA, Abolyosr A, Abdalla MA, et al. Efficacy of tamsulosin in medical expulsive therapy for distal ureteral calculi. Scand J Urol Nephrol. 2008;42:59-62. 14. Lipkin M, Shah O. The use of alpha-blockers for the treatment of nephrolithiasis. Rev Urol. 2006;8:35-42. 15. Kupeli B, Irkilata L, Gurocak S, et al. Does tamsulosin enhance lower ureteral stone clearance with or without shock wave lithotripsy? Urology. 2004;64:1111-1115. 16. Seitz C, Tanovic E, Kikic Z, et al. Rapid extracorporeal shock wave lithotripsy for proximal ureteral calculi in colic versus noncolic patients. Eur Urol. 2007;52:1223-1227. 17. Bapat SS, Pai KV, Purnapatre SS, et al. Comparison of holmium laser and pneumatic lithotripsy in managing upper-ureteral stones. J Endourol. 2007;21:1425-1427. 18. Lee YH, Tsai JY, Jiaan BP, et al. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopic lithotripsy for management of large upper third ureteral stones. Urology. 2006;67: 480-484; [Discussion: 484]. 19. Lingeman JE, Woods JR, Nelson DR. Commentary on ESWL and blood pressure. J Urol. 1995;154:2-4. 20. Pearle MS, Lingeman JE, Leveillee R, et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005;173:2005-2009. 21. Bierkens AF, Hendrikx AJ, De La Rosette JJ, et al. Treatment of mid- and lower ureteric calculi: extracorporeal shock wave lithotripsy vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness. Br J Urol. 1998;81:31-35. 22. Weizer AZ, Auge BK, Silverstein AD, et al. Routine postoperative imaging is important after ureteroscopic stone manipulation. J Urol. 2002;168:46-50.
EDITORIAL COMMENT The authors retrospectively reviewed 117 patients over a 2-year period who underwent shock wave lithotripsy (SWL) for treatment of ureteral stones using a Siemens Lithostar modularis Uro plus lithotriptor. Stones were treated at 120 shocks per minute for distal ureteral stones and at 90 shocks per minute for mid and proximal ureteral stones. Plain radiographs plus renal ultrasound were obtained within the first 2 days to determine stone-free status. If stones were not fragmented within 2 days, another SWL treatment session was immediately planned. They categorized patients into stone sizes of 5-10 mm (group 1), 11-15 mm (group 2), ⱖ16 mm (group 3). The success rate was, as expected, lowest in the largest stone size (55.5%) and 100% in the other 2 groups. The number of sessions required to render patients stone free was also the greatest in the largest stone group (mean of 2.27 sessions compared with 1.01 and 1.58 sessions for groups 3, 1, and 2, respectively). Stones in the distal ureter (3.1 days) were faster to clear than mid (6.1 days) or proximal (13.1 days) ureteral stones. Mean clearance times were also fastest with the smallest stones (mean 2.2, 7.7, and 12.2 days for groups 1, 2, and 3, respectively). It should be noted that these times are calculated from their first SWL treatment and this time also includes any subsequent SWL treatment sessions. This current study provides good data to perform SWL in patients with stones smaller than 15 mm, with the caveat that approximately half of the patients with stones over 10 mm may require a second lithotripsy treatment. There would be a good argument to perform ureteroscopy in these patients and certainly in patients with stones ⬎15 mm if you wish to make the patient stone free in one procedure. Of course, this study did not measure pain scores or symptoms and, arguably, ureteroscopy would result in more postoperative symptoms than SWL. Patients must be counseled regarding this trade-off in multiple procedures for SWL vs a single procedure that would render them stone free, but potentially at a higher rate of complications. The AUA Guidelines’ recommendation for the treatment of ureteral stones is (1) observation with medical expulsive therapy (MET) if there is good preservation of renal function, stone is ⬍10 mm and no signs of urosepsis; or (2) treatment of the stone with SWL or ureteroscopy for stones of any size. Patients must be informed of the differences in anesthesia requirements, stone-free rates, need for ancillary procedures, and complications. Ureteroscopy is associated with a higher stone-free rate with a single procedure, but at a cost of potentially higher complications. The days to passage of stone fragments post SWL for stones ⬍15 mm is certainly faster than most studies regarding spontaneous stone passage using MET. These authors show that SWL is a viable option for stones up to 15 mm, although I believe that patients with stones ⬎15 mm or in the proximal ureter may best be served by ureteroscopy. Ben H. Chew, M.D., M.Sc, F.R.C.S.C., Department of Urology, University of British Columbia, Vancouver, BC, Canada doi:10.1016/j.urology.2010.11.039 UROLOGY 78: 30, 2011. © 2011 Elsevier Inc.
UROLOGY 78 (1), 2011