This document summarizes a study on the clinical outcomes of patients who underwent extracorporeal shock wave lithotripsy (ESWL) to treat renal stones. The study included 150 patients between 18-73 years old with renal stones measuring 0.5-2.5cm who received ESWL. Most patients were male, with stones composed primarily of calcium oxalate. Following ESWL, 98% of patients became asymptomatic after 3 months, though larger stones required more treatment sessions. Complications included hematuria and loin pain in about 20-30% of patients respectively. The study concludes ESWL is an effective treatment for renal stones, with outcomes dependent on stone size, location and composition.
2. Urinary calculi are very common disease of urinary
tract
The incidence of urinary tract stone disease is
increasing*
*Epidemiological data of National Health and Nutrition Examination
Survey (USA)
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3. To study the clinical outcomes of patients who have
undergone ESWL for Renal stones
MATERIAL AND METHODS
This study was done in the Department of Urology, of a
tertiary care military hospital
Study design: Prospective observational study
Study group:
All patients diagnosed as having renal calculi (size0.5cm
to 2.5cm).
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4. Exclusion criteria
Radiolucent stones
Age <18 yrs
Stone size >2.5cm & Stone size< 0.5cm
Repeated presentation who undergone ESWL
All absolute contraindication for ESWL
Pregnancy.
Uncorrected bleeding diatheses.
Uncontrolled urinary tract infections.
Severe skeletal malformations and severe obesity
Arterial aneurysm in the vicinity of the stone treated.
Anatomical obstruction distal to the stone
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5. STATISTICAL METHODS
◦ SPSS version 19
◦ Chi square test, paired “t” test used for comparative
analysis
◦ ‘P’ value of 0.05 was taken as significant
Equipment
Electro Magnetic
Lithotripter
(Make- Dornier Compact Delta )
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Dornier Compact Delta
Electro Magnetic Lithotripter
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6. Age ( years) Frequency %
16 - 25 15 10.00%
26 - 35 48 32.00%
36 - 45 32 21.33%
46 - 55 19 12.67%
56 - 65 26 17.33%
66 - 75 10 6.67%
Demographic data of the patients
Age distribution.
6
Description Age(yrs)
Mean(SD) 42.13(14.09)
Range 18 - 73
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7. Sex Frequency Percent Ratio
Female 41 27.33% 1
Male 109 72.67% 2.65
Gender description.
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8. Co morbidities Frequency %
Diabetes Mellitus 25 16.67%
Hypertension 22 14.67%
Parkinsonism 1 0.67%
IHD 1 0.67%
NIL 109 72.66%
Co-morbidity status
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9. Description Duration of Illness (weeks)
Mean 25.77(15.11)
Range 3 – 52
Description of duration.
Description of no of episodes
Number of Episodes Frequency %
1st 128 85.33%
2nd or more 22 14.67%
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10. Pain Frequency %
No 5 3.33%
Yes 145 96.67%
Description of chief complaints.
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18. Description Size of Stone
Mean(SD) 1.47(.43)
Range 0.80 - 2.50
Stone Size
Size description.
Location Frequency %
Lower 35 23.33%
Pelvis 3 2.66 %
Mid 74 49.33%
Upper 38 24.67%
Anatomical locations of stones.
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19. Stone size and number of sittings.
No of
sittings
n Mean S D Min Max P value
1 16 1.09 0.37 .80 2.20
<0.001
2 38 1.30 0.36 .80 2.30
3 48 1.47 0.33 .80 2.30
4 48 1.76 0.43 .80 2.50
total 150 1.48 0.44 .80 2.50
10.67%
25.33%
32.00%
32.00%
Number of Sittings
1.0
2.0
3.0
4.0
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20. Complications of ESWL
Complications Frequency %
Hematuria 30 20.00%
Loin pain 48 32.00%
UTI 7 4.67%
Dysuria 1 0.67%
Steinstrasse 5 3.33%
Total no of patients 91 60.66%
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23. Extra corporal shock wave lithotripsy was introduced
in 1983.
The clinical outcome of ESWL depends on
◦ size
◦ location
◦ chemical composition of the stone
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24. More common among male gender
◦ male and female was 1.7:1 as per a study done by Scale C
D et al [1]
Age group of 40 -60 yrs
◦ Strope SA et al showed the age group 40-60 yrs having highest
incidence of urolithiasis [2]
Calcium oxalate
◦ Bangash K et al, showed that calcium oxalate was the
commonest chemical type of stones (87.5%)[3]
Pain is the commonest symptom of renal stones
Pearle MS et al illustrated that 48.1% had pain , 25.9%
presented with gross haematuria, 14.3% had microscopic
hematuria and [6]
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25. E - Coli is the commonest
◦ E- coli were the commonest among patients with urinary tract
stones[4]
Larger stones required more number of sittings for
stone clearance
◦ Joshi HN et al in relation to size of the stone and respective
stone free rates were concluded as <1cm, 1-1.5 cm and > 1.5
cm was 97%, 97% and 90% [5]
Following ESWL 98% patients become
asymptomatic after three months time
◦ Joshi HN et al 95.4% within three months of follow up after
completion of ESWL [5]
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26. 26
Reference
1.Scales CD Jr, Curtis LH, Norris RD. Changing gender prevalence of
stone disease. J Urol. 2007; 177:979–82.
2. Strope SA, Wolf JS Jr, Hollenbeck BK. Changes in gender
distribution of urinary stone disease. Urology. 2010; 75:543-6.
3. Bangash K, Shigri F, Jamal A, and Anwar K. Spectrum of Renal
Stones Composition; Chemical Analysis of Renal Stones. International
Journal of Pathology. 2011; 9(2): 63-66
4. Mohammed A. Kadir, Majida N. Ibrahim ,Najeeba M. Salih.
prevalence of urinary tract infections in patients with renal stones. J.
Ayub Med. Coll. Abbottabad ; 2010: 20: 60-62
5. Joshi HN, Karmacharya RM, Shrestha R, Shrestha B, de Jong IJ,
Shrestha RK. Outcomes of extra corporeal shock wave lithotripsy in
renal and ureteral calculi. Kathmandu Univ Med J (KUMJ). 2014 Jan-
Mar;12(45):51-4.
Pearle MS, Calhoun EA, Curhan GC. Urologic Diseases in America
project: urolithiasis. J Urol. 2005; 173:848–57
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Editor's Notes
Statistical methods:
SPSS version 19 was used for evaluation of results. Chi square test, paired “t” test used for comparative analysis and a ‘P’ value of 0.05 was taken as significant
Age Distribution
Mean age of the patients of this study group was 42.13 yrs (18-73 yrs). The maximum number of patients was in the age group between 26-35 yrs (32%) (Table 1&2).
Out of 150 patients, 41(27.33%) were females and 109(72.67%) were males. Male to female ratio was 2.65: 1 (Table 3).
Out of 150 patients 25(16.67%) had diabetes mellitus, 22(14.67%) had hypertension 1(0.67%) had parkinsonism, 1(0.67%) had ischemic heart disease(IHD) and 109(72.66%) patients were free of comorbidities (Table 4).
1.Mean duration of the presenting complain as per the history was 25.77 weeks (3 – 52) (Table 5 )
2. Out of 150 patients 128(85.33%) patients presented as fresh cases and 22(14.67) presented with past history of stone diseases (Table 6).
Main presenting complaint of the study group was pain. Out of 150 patients, 145 (96.67%) had pain of various clinical grades. Only 5(3.33%) patients did not complaint pain and renal stones were incidental findings in those cases (Table 6).
Chemical composition of Stones
In this study group 77 patients underwent chemical analysis of voided stone particles. Calcium Oxalate (CaC2O4) stones were found among 48(62.33%) patients, 10(12.98%) patients had mixed stones, 7(9.09%)patients had Struvite (MgNH4PO4.6H2O) stones, 4(5.19%) patients had Calcium Phosphate(Ca3(PO4)2)stones, 2(2.59%) patients had Calcium Carbonate (CaCO3) and 6(7.79%) patients had uric acid stones
Pain in relation to size of the renal stones
Mean size of the renal stones of patients who presented with pain was 1.48cm and without pain was 1.44 cm. There was no statistical significance between stone size and pain as presenting complaint, p value was 0.894 (Table 9).
There was no statistical significance between location of stone and pain as a presenting complaint, p value was 0.742 (Table 10).
Haematuria was a common presentation which 53(35.33%) showed microscopically and 2(1.33%) patient presented with gross haematuria. However 95(63.33%) patient did not have haematuria (Table 11
There was no statistically significant relationship with stone size and haematuria P value was 0.238 (Table 13).
There was no statistically significant association with location of stones and haematuria, P value was 0.299 (Table 14).
Associated Urinary tract infection (UTI)
In this study group 37(24.66%) patients had concomitant UTI and 113(75.36%) had sterile culture. Urinary culture of UTI patients showed the growth of E. coli 20(54.05%), Proteus 12(32.43%), Klebsiella 3(8%) and Enterococcus Sp 2(5.4%) (Table 15
Anatomical locations of stones
Middle zone of the caliceal system (CS) of the kidney was found to be the commonest anatomical location of stones 74(48%). Upper CS stones were
found in 38(24.67%) patients, Lower CS stones among 35(23.33%) patients and pelvic stones in 3(4%) patients
Number of sittings and size of the stones
Mean stone size of the group which achieved complete stone clearance with single sitting was 1.09 cm
mean stone size of the group which required 2 sittings for complete stone clearance was 1.3cm
group which required 3 sittings the mean stone size was 1.47
mean size of the stone which patients required four sittings was 1.76cm
Total 428 sittings of ESWL being given for 150 numbre of patients in which 91(60.66%) patients developed complications. Commonest complication was loin pain which 48(32%) presented with, hematuria was observed among 30(20%) patients, UTI 7(4.67%), steinstrasse 5(3.33%) and dysuria (culture sterile) 1(0.67%). Most of the complications are self limited or managed with OPD basis and fully recovered by subsequent visits (Table 49).
Protocol follow up was done in one month and three months after completion of treatment
mixed stones, MgNH4PO4 (struvite)stones, Ca3(PO4)2 stones, and uric acid stones are the different chemical composition in descending order of frequency
