Extracorporeal shock wave lithotripsy (ESWL)

a procedure where sound waves are used to break up kidney

stones. The kidney stone is broken up into small fragments, which then pass in the urine.

History
The first ESWL

treatment was performed in Germany in 1980, and was approved for use in the United States beginning in l984.

Etiology
Lithotripsy comes from the Greek words :

-Lithos and Tripsis -literally means stone breaking.

Machine
sends the sound waves through the body, so no incision is needed.

4 basic components:
shockwave generator focusing system coupling mechanism imaging/localization unit

Shockwave Generator
Can be generated in 1 of 3 ways: Electrohydraulic Piezoelectric Electromagnetic

Electrohydraulic
The original method of shockwave generation (used in

the Dornier HM3) was electrohydraulic, meaning that the shockwave is produced via spark-gap technology.

Piezoelectric
The piezoelectric effect

produces electricity via application of mechanical stress.

Electromagnetic
In an electromagnetic

generator, a high voltage is applied to an electromagnetic coil, similar to the effect in a stereo loudspeaker.

Focusing System
used to direct the

generatorproduced shockwaves at a focal volume in a synchronous fashion.

Coupling Mechanism
needed to minimize the

dissipation of energy of a shockwave as it traverses the skin surface

Localization Systems
used to localize the stone and to direct the shockwaves onto the

calculus, as well as to track the progress of treatment and to make alterations as the stone fragments.

Two Methods:
Fluoroscopy
involves ionizing radiation to visualize calculi excellent for detecting and tracking calcified and otherwise radioopaque stones, both in the kidney and the ureter

Utrasonographic
allows for

visualization of both radiopaque and radiolucent renal stones and the realtime monitoring of lithotripsy.

Procedure
Preparation and After Procedure

Procedure
Done in an operating room that has a built

in ESWL machine The patient is positioned on the x-ray table and a water-filled cushion is placed under their back. The patient is put under anesthesia and the stone is localized on the x-ray screen.

 The shock wave machine is started and the

procedure usually takes 30-45 minutes. During the procedure the stone is continually monitored on the x-ray screen. The patient is awakened after the procedure and usually dismissed to home a short time later.

Preparation
done under anesthesia, so the patient will

have to fast for 8 hours prior to the treatment. patients to take several laxatives the night before to help with visualization of the stone. patient must not be on any blood thinners for a week prior to the procedure (aspirin, coumadin and most arthritis drugs).

 Herbal products that may thin the

blood (such as vitamin E) should also be stopped patient may also be asked to bring their x-ray films to help in the ESWL planning.

After the Procedure

The patient is transferred to the

recovery room after the procedure, and can usually be discharged home within an hour. Patients may experience some soreness on the part of the back where the procedure was done.

 They will usually have blood in their

urine for the first 24 hours. Patients should limit their activities for the first 48 hours and drink plenty of fluids.

Indications
Individuals who work in professions in

which unexpected symptoms of stone passage may prompt dangerous situations Individuals with solitary kidneys in whom attempted conservative management and spontaneous passage of the stone may lead to an anuric state Patients with hypertension, diabetes, or other medical conditions that predispose to renal insufficiency

Treatment
may be used on people with a kidney stone

that is causing pain or blocking the urine flow. Stones that are between 4mm and 2cm in diameter are most likely to be treated with ESWL. may work best for kidney stones in the kidney, not in the ureter.

Contraindications
Acute urinary tract infection or

urosepsis Uncorrected bleeding disorders or coagulopathies Pregnancy Uncorrected obstruction distal to the stone

Are there any contraindications?

This procedure usually is not

used if you: Have a bleeding disorder. Have a kidney or urine infection

Do I need any preparation for the procedure? Stop any blood-thinning medication, such as Aspirin and Plavix 1 week beforehand as such medications can increase the risk of bleeding. You can take your usual essential medication, eg. hypertension drugs.

What should I expect afterwards?

Some blood in the urine is common.
The stone fragments may take a period of a few days

or weeks to pass out. You may experience colicky pain as the small stone fragments pass down the ureter. Drink plenty of fluids to help flush out the stone fragments. Contact the clinic or emergency after office hrs if you experience: recurrent pain not relieved with analgesics large amount of bloody urine high fever (over 38 deg C) with attacks of chills / shivers

What are the complications?

Blood clot around the kidney

(haematoma) Pain and blood in the urine caused by the passage of stone fragments. Swollen kidney as a result of stone fragments getting stuck along the ureter Urinary tract infection due to release of bacteria within the stone.

Can I have a recurrence after ESWL?

Even if your stone is cleared, another stone can recur if you do

not control the underlying factors, esp. dehydration, gout and oxalate-rich foods.

References:
http://www.webmd.com/kidney-

stones/extracorporeal-shock-wavelithotripsy-eswl-for-kidney-stones http://emedicine.medscape.com/article/44 4554-overview www.ccmurology.com/surgery/eswl.php www.guysandstthomas.nhs.uk http://www.theurologygroup.cc/stone.asp