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Comparison of Ultrasound-Assisted and Pure Fluoroscopy-Guided

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Comparison of Ultrasound-Assisted and Pure Fluoroscopy-Guided Chang et al. BMC Urol (2020) 20:183 https://doi.org/10.1186/s12894-020-00756-6 RESEARCH ARTICLE Open Access Comparison of ultrasound-assisted and pure fuoroscopy-guided extracorporeal shockwave lithotripsy for renal stones Tsung‑Hsin Chang1*, Wun‑Rong Lin1,2, Wei‑Kung Tsai1,2, Pai‑Kai Chiang1,2, Marcelo Chen1,2,3, Jen‑Shu Tseng1* and Allen W. Chiu1,4 Abstract Background: In this study, we aimed to compare the efcacy and clinical outcomes of shock wave lithotripsy (SWL) for patients with renal stones using pure fuoroscopy (FS) or ultrasound‑assisted (USa) localization with two lithotripters. Methods: We retrospectively identifed 425 patients with renal calculi who underwent SWL with either a LiteMed LM‑9200 ELMA lithotripter (209 cases), which combined ultrasound and fuoroscopic stone targeting or a Medispec EM‑1000 lithotripter machine (216 cases), which used fuoroscopy for stone localization and tracking. The patient demographic data, stone‑free rates, stone disintegration rates, retreatment rates and complication rates were analyzed. Results: The USa group had a signifcantly higher overall stone‑free rate (43.6 vs. 28.2%, p < 0.001) and stone disinte‑ gration rate (85.6 vs. 64.3%, p < 0.001), as well as a signifcantly lower retreatment rate (14.8 vs. 35.6%, p < 0.001) and complication rate (1.9 vs. 5.5%, p 0.031) compared with the FS group. This superiority remained signifcant in the stone size < 1 cm stratifed group.= In the stone size > 1 cm group, the stone‑free rate (32.4 vs. 17.8%, p 0.028), disin‑ tegration rate (89.2 vs. 54.8%, p 0.031) and retreatment rate (21.6 vs. 53.4%, p < 0.001) were still signifcantly= better in the USa group, however there was= no signifcant diference in the complication rate. The most common complication was post‑SWL‑related fank pain. Conclusion: SWL is a safe and non‑invasive way of treating renal stones. This study compared two electromagnetic shock wave machines with diferent stone tracking systems. LiteMed LM‑9200 ELMA lithotripter, which combined ultrasound and fuoroscopic stone targeting outperformed Medispec EM‑1000 lithotripter, which used fuoroscopy for stone localization and tracking, with better stone‑free rates and disintegration rates, as well as lower retreatment rates and complications with possible reduced radiation exposure. Keywords: Shock wave lithotripsy, Nephrolithiasis, Kidney, Ultrasonography Background Extracorporeal shock wave lithotripsy (SWL) has been used as a non-invasive method of urolithiasis manage- ment since the 1980’s [1]. It has been proven to be a safe, efcient way of treating non-infected upper urinary tract *Correspondence: [email protected]; [email protected] 1 Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, stones and remains one of the most commonly used Zhongshan N. Rd., Taipei City 10449, Taiwan treatment modality for renal stones worldwide today. Full list of author information is available at the end of the article © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chang et al. BMC Urol (2020) 20:183 Page 2 of 7 Contemporary studies have shown that the success rate intravenous urography (IVU) and abdominal computed of SWL for renal stones ranges from 47 to 92% [2–7]. tomography (CT) were used to diagnose and identify the Tis highly variable result is due to various crucial fac- stones. Te size of the stones were measured on the KUB tors, including stone composition and size [8–11], skin using maximal stone diameters. to stone distance [12], lithotripter energy power [13] and Patients underwent SWL at two branches of our frequency [14, 15], patient positioning [16], and patient medical center with either a LiteMed LM-9200 ELMA tolerance and respiration [16, 17]. Less than half of the lithotripter or Medispec LTD EM-1000 lithotripter, administered shockwaves may be accurately focused on depending on their location. Te distance between the the targeted calculus [18], and the excessive energy and two branches of our medical center were about 10 km shockwaves can cause damage to the parenchyma and with about a 20 min driving time and both were located adjacent organs. Chen et al. [19] demonstrated increased in the northern part of the city. Tere were no regional accuracy of stone targeting by using an electromagnetic characteristics diferent between the patients of the two lithotripter integrated with both ultrasound real-time branches, such as water composition and eating hab- tracking system and traditional fuoroscopy (LiteMed its. Te energy source of both lithotripters was an elec- LM-9200 ELMA). Trough the alternative use of ultra- tromagnetic shockwave source. Te focal length was sound and fuoroscopy, the energy of the lithotripter may 145 mm for EM-1000 and 125 mm for LM-9200. All be more focused on the target stone during the whole SWL treatments were performed on an ambulatory basis session, thus increasing SWL efciency. However, only by the same group of urologists. Both machines were a few studies have compared the efcacy of ultrasound- operated by the same two experienced technicians. Te based lithotripters with fuoroscopy-based lithotripters. LiteMed LM-9200 ELMA lithotripter used ultrasonogra- It is difcult to compare efcacy between diferent insti- phy and fuoroscopy for dual focusing of stone localiza- tutions due to variabilities in treatment protocols and tion and tracking, while the EM1000 machine used only operators. Te current study compared the efcacy and fuoroscopy for stone visualization, with an integrated clinical outcomes of two electromagnetic lithotripters computerized fuoroscopic X-ray (Visionspec™). Te using diferent stone localization methods (LiteMed LiteMed LM-9200 machine has a auto-fring system, the LM-9200 ELMA lithotripter: combined ultrasound shockwaves will only be fred when the stone is in the and fuoroscopic stone targeting; Medispec EM-1000 focal zone. lithotripter: pure fuoroscopic stone targeting), in a single Te same standardized SWL protocol was used for center with 2 hospital branches, using the same group of both machines except for the stone localization method. urologists and the same set of patients and surgical indi- Te patient was placed in a supine position without a cations. Te machines were operated by the same two restraint belt. Te cushion size and lubricating jelly used experienced technicians, which minimizes operator and were the same in both branch. and the stone was located institutional related bias. by the fuoroscopy in both group. In the USa group, Te aim of the current study was to compare the ef- ultrasound was combined use for dual stone localization cacy and clinical outcomes of these two diferent stone before initiating the SWL session and during the treat- localization modalities in the treatment of renal stones in ment for real time tracking of the stone. While in the FS one single medical center. group, only pure fuoroscopy was used throughout the whole session. During SWL, the initial energy level was Methods set at 14KV and could gradually increased up to 19 kV if Te present study retrospectively reviewed the medical the stones did not show adequate fragmentation under records of patients with radio-opaque kidney stones with low energy settings. Te shock wave rate was set at 60 stone size between 0.5 to 2.0 cm who underwent SWL in shocks per minute for both lithotripters. Te maximum a single medical center with 2 hospital branches between number of shockwaves delivered in one session was January 2013 and March 2019. Exclusion criteria were 3,000. Light intravenous propofol and dormicum were patients with congenital anomalies or urinary diver- used as analgesics or for sedation if the patient sufered sion, pediatric patients or patients who received SWL from pain or could not tolerate lying still in the supine as a combination therapy with other treatment modali- position throughout the SWL session. Te patient’s posi- ties. Patients with radiolucent stones were also excluded tion was adjusted throughout the SWL session for better as plain x-rays were used as the standard follow-up stone visualization. If the patient’s stone is still in focal modality. zone, the position of the patient will not be changed to All patients underwent imaging and laboratory stud- avoid constant de-coupling and re-coupling. In the FS ies prior to SWL. Plain abdominal radiography of the group, the position was checked and adjusted after every kidneys, ureter and bladder (KUB), renal sonography, 600 shocks or when the patient moved. While in the USa Chang et al. BMC Urol (2020) 20:183 Page 3 of 7 group, positioning was adjusted based on the ultrasound Statistical analysis revealed better treatment outcomes tracking of the stone location throughout the SWL ses- in the USa group. Te overall stone free rate was sig- sion.
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