Clinical Paper 1617071
Eur Urol 1992;22:134-136
Department of Urology, Liège University Hospital Sait Tilman, Liège, Belgium
Key Words Ureteral stone Lithotomy positioning Extracorporeal shockwave lithotripsy
Original Lithotomy Positioning for T ransperineal Extracorporeal Shockwave Lithotripsy for Distal Ureteric Calculi with Tripter X1
Abstract Extracorporeal shockwave lithotripsy (ESWL) has been initially designed for stones located in the kidney and the upper ureter. Our lithotripter is no excep tion. Its components (the table and the orientation of the semi-ellipsoid reflec tor) are adapted for the treatment of kidney or lumbar ureter stones. However, the elements forming the unit of treatment (the table, the C-arm and the Tript er) can be modified in such a way that focalization of stones of the lower ureter becomes possible through a perineal exposure. The aim is to avoid the pelvic bone shield while a good focalization of the stone is realized. From June 1989 to March 1991, 35 patients were treated for distal ureteric stones by ESWL in this original positioning.
Introduction Extracorporeal shockwave lithotripsy (ESWL) thera peutic success with upper tract [ 1, 3-6] urolithiasis treat ment authorizes to elaborate plans for a monotherapy treatment of lower ureteric stones. The use of shockwaves in the distal 10 cm of the ureter can only be imagined if an acoustic window without interposition of a bone screen or gas is available. Depending on the type of lithotripter, this window can be approached by either using the hypogas tric route with piezoelectric or electromagnetic lithotripsy [8] or the perineal route with Dornier spark gap lithotrip sy: patients are seated in an upright position [7, 9-12] with perineal shockwave exposure. Apart from one or two studies on the mutagenic effect of shockwaves in fertile women [2], few experiments on periureteral trauma in this area have been completed. To allow this type of treat-
ment with Tripter XI from the DIREX Company, we studied the ideal positioning of the patient in relation to the shockwave generator.
Materials and Methods Tripter XI is a mobile underwater spark gap lithotripter coupled at a 30° angle with a classic C-arm as available in any hospital. The semiellipsoid structure, 177-mm diameter reflector opening, with F2 at 135 mm from FI, forms a 55° angle with the floor surface. This angle allows for perfect coaptation to the lumbar fossa of a patient lying on the table for the treatment of a renal stone (fig. 1). Unfortu nately, this angle makes the transvesical approach for the treatment of lower ureteric stones awkward if the patient lies prone with this lithotripter. For these reasons, we introduced the following modifica tions: the patient is positioned on an ordinary cystoscopy table in the lithotomy position. This allows, by deduction of the pelvis, to bring the ureteral area nearest to the focus F2 of the ellipsoid, i.e., approxi-
R. Andrianne, MD Service d’Urologie Centre Hospitalier Universitaire du Sart Tilman B-4000 Liège (Belgium)
© 1992 S. Karger AG, Basel 0302-2838/92/0222-0134 $2.75/0
Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 8:16:42 PM
R. Andrianne C. Vandeberg P. Bonnet H. Nicolas L. Coppens C. Bouffioux J. de Levai
T
SWG
3Z
Fig. 1. Lithotripsy unit composed of 3 elements: shockwave generator (SWG), C-arm fluoroscopie control (C-a) and table (T) as set for renal stone ESWL.
SWG T C-a
[
SWG
Fig. 2. Organization of the elements (SWG, C-a, T) to allow for good coaptation of the water cushion to the perineum. The C-arm is oriented at a right angle with SWG and T.
of adequate focusing by simulation. All patients were treated under sedoanalgesia with laryngeal mask by intravenous Profoliol 600 mg, alfentanil 0.5 mg and O2/N2O inhalation. Intravenous hydratation and prophylactic antibiotics were given in all cases. Mean age was 52 years (men 5-79). Mean body weight was 69 kg (22-88). Mean shockwave number was 1,460 (400-2,700) for a mean voltage of 19 kV (11-20). Mean stone diameter was 10 mm (7-17); stasis was present in 7 cases. To obtain good coaptation of the perineum to the water cushion, silicon oil was applied to the skin in a thick layer. A 5-yearold boy (22 kg) could be focused by interposing a bag of isotonic solution between the perineum and the cushion.
135
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mate the ischiatic spur plane to the focus area. The bath cushion is applied to the perineum of the patient, shaved if required. The testes are taped to the pubic bone. The C-arm is positioned at a right angle with the table and the shockwave generator in order to allow its pas sage between the legs (fig. 2). Neither ureteral nor urethral catheters were inserted. The only preoperative preventions were an empty bladder, normal clotting parameters and possible focusing of a radi opaque stone demonstrated by simulation. This consists of a posi tioning trial with the patient on the table to check if the stone can be adequately focalized in both planes. 35 patients (27 men and 8 women) were treated deliberately in one single session without ancillary maneuvers after demonstration
Two types of minor complications were encountered and were managed conservatively: renal colics in 14% (4 patients/35), mild perineal skin erosion in 14% (4 patients/35). No patient experienced pelvic or perineal discomfort, prolonged hematuria (> 24 h) or sex ual and prostatic disorders during the post-ESWL period.
Results As a result of the simulation with this setting, all eligi ble patients had a stone located between the ischiatic spur and ureteral meatus. This was enforced by the F1-F2 dis tance of the semi-ellipsoid reflector (135 mm). With 35 patients treated in one single session, ideal fragmentation (< 3 mm) was obtained in 84% of the cases. Despite ade quate focusing, 6 stones (16%) did not show any sign of fragmentation on the 15th day post-treatment X-Ray film. For 4 of these, absence of breakage was further con firmed at ureteroscopic extraction. On the 3-month XRay film, without any further active urological maneu vers, 26 patients (74%) were stone free. Of 35 patients, 9 had auxiliary treatment (ancillary post-ESWL proce dures, i.e., URS, Dormia, Push Bang and secondary ESWL).
Discussion A mobile and modulated lithotripter allows for a disso ciation of the elements: shockwave generator, fluoro scopic control of fragmentation (C-arm) and the table. Our original setting allows the use of shockwaves through an unusual acoustic window by water cushion. Although this exposure has already been experimented by Domier users, our method allows an excellent visualization of the stone and renders trivial the use of any contrast material or retrograde ureteral catheter [5], This perineal in situ treatment of lower ureteric stones gives a very comfort able percentage of fragmentation rate despite the deliber ate decision to allow one treatment session only. Early ureteroscopy performed for 4 unfragmented stones showed no evidence of ureter or bladder lesions. Compli cations observed in this series were of little significance. The results obtained and low morbidity rate encouraged us to propose in situ ESWL, through the perineal route with Tripter XI, as the first choice therapy for lower ure teric stones, whenever adequate focusing is possible.
Acknowledgment We thank Mr Farhad Baharloo for the English translation.
References
136
5 Dretler SP: In situ extracorporeal shock wave lithotripsy versus ureteroscopy: The case for ureteroscopy; in Lingeman J, Newman D, (eds): Shock Wave Lithotripsy, ed 2. New York, Plenum Press, 1989, p 351. 6 Fuchs G, Miller K, Rassweiler J, Eisenberger F: One-year experience with the Domier litho tripter. Eur Urol 1985; 11:147-149. 7 Jenkins A: ESWL treatment of ureteral calculi. J Urol 1986; 135:2. 8 Jenkins A, Gillenwater J: Extracorporeal shock wave lithotripsy in the prone position: Treat ment of stones in the distal ureter or anormalous kidney. J Urol 1988; 139:911. 9 Miller K, Fuchs G, Rassweiler J, Eisenberger F : Treatment of ureteral stone disease: The role of ESWL and endourology. World J Urol 1985:3: 53.
Andrianne/V andeberg/Bonnet/Nicolas/ Coppens/Bouffioux/de Levai
10 Miller K, Bubeck JR, Flautmann R: Extracor poreal shockwave lithotripsy of distal ureteral calculi. Eur Urol 1986; 12:305. 11 Rassweiler J, Halth U, Lutz K, Eisenberger F: In situ ESWL beim tiefen Hamleiterstein. Acta Urol 1986; 17:328. 12 Rassweiler J, Hath U, Bub P, Eisenberger F: Extracorporeal shockwave lithotripsy (ESWL) for distal ureteral calculi. Endourology 1986; 1/4:15.
Positioning for ESWL for Distal Ureteric Calculi
Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 8:16:42 PM
1 Andrianne R, Bonnet P, Similon B, Nicolas H, Coppens L, Bouffioux C, de Levai J: Belgian experience with the Direx Tripter X1 ; in Linge man J, Newman D (eds): Shock Wave Litho tripsy, ed 2. New York, Plenum Press, 1989, voi 65, p 359. 2 Carrol PR, Shi RY: Genetic toxicity of high energy shockwaves. J Urol 1986; 135:2. 3 Chaussy Ch, Schmiedt E, Joachim D, Brendel W, Forssmann B, Walter V: First clinical expe rience with extracorporeally induced destruc tion of kidney stones by shockwaves. J Urol 1982:127:417. 4 Drach GW, Dretler S, Fair W, Finlayson B, Gillenwater J, Griffith D, Lingeman J, New man D: Report of the United States coopera tive study of extracoporeal shock wave litho tripsy. J Urol 1986; 135:1127.
Eur Urol 1992;22:134-136
Department of Urology, Liège University Hospital Sait Tilman, Liège, Belgium
Key Words Ureteral stone Lithotomy positioning Extracorporeal shockwave lithotripsy
Original Lithotomy Positioning for T ransperineal Extracorporeal Shockwave Lithotripsy for Distal Ureteric Calculi with Tripter X1
Abstract Extracorporeal shockwave lithotripsy (ESWL) has been initially designed for stones located in the kidney and the upper ureter. Our lithotripter is no excep tion. Its components (the table and the orientation of the semi-ellipsoid reflec tor) are adapted for the treatment of kidney or lumbar ureter stones. However, the elements forming the unit of treatment (the table, the C-arm and the Tript er) can be modified in such a way that focalization of stones of the lower ureter becomes possible through a perineal exposure. The aim is to avoid the pelvic bone shield while a good focalization of the stone is realized. From June 1989 to March 1991, 35 patients were treated for distal ureteric stones by ESWL in this original positioning.
Introduction Extracorporeal shockwave lithotripsy (ESWL) thera peutic success with upper tract [ 1, 3-6] urolithiasis treat ment authorizes to elaborate plans for a monotherapy treatment of lower ureteric stones. The use of shockwaves in the distal 10 cm of the ureter can only be imagined if an acoustic window without interposition of a bone screen or gas is available. Depending on the type of lithotripter, this window can be approached by either using the hypogas tric route with piezoelectric or electromagnetic lithotripsy [8] or the perineal route with Dornier spark gap lithotrip sy: patients are seated in an upright position [7, 9-12] with perineal shockwave exposure. Apart from one or two studies on the mutagenic effect of shockwaves in fertile women [2], few experiments on periureteral trauma in this area have been completed. To allow this type of treat-
ment with Tripter XI from the DIREX Company, we studied the ideal positioning of the patient in relation to the shockwave generator.
Materials and Methods Tripter XI is a mobile underwater spark gap lithotripter coupled at a 30° angle with a classic C-arm as available in any hospital. The semiellipsoid structure, 177-mm diameter reflector opening, with F2 at 135 mm from FI, forms a 55° angle with the floor surface. This angle allows for perfect coaptation to the lumbar fossa of a patient lying on the table for the treatment of a renal stone (fig. 1). Unfortu nately, this angle makes the transvesical approach for the treatment of lower ureteric stones awkward if the patient lies prone with this lithotripter. For these reasons, we introduced the following modifica tions: the patient is positioned on an ordinary cystoscopy table in the lithotomy position. This allows, by deduction of the pelvis, to bring the ureteral area nearest to the focus F2 of the ellipsoid, i.e., approxi-
R. Andrianne, MD Service d’Urologie Centre Hospitalier Universitaire du Sart Tilman B-4000 Liège (Belgium)
© 1992 S. Karger AG, Basel 0302-2838/92/0222-0134 $2.75/0
Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 8:16:42 PM
R. Andrianne C. Vandeberg P. Bonnet H. Nicolas L. Coppens C. Bouffioux J. de Levai
T
SWG
3Z
Fig. 1. Lithotripsy unit composed of 3 elements: shockwave generator (SWG), C-arm fluoroscopie control (C-a) and table (T) as set for renal stone ESWL.
SWG T C-a
[
SWG
Fig. 2. Organization of the elements (SWG, C-a, T) to allow for good coaptation of the water cushion to the perineum. The C-arm is oriented at a right angle with SWG and T.
of adequate focusing by simulation. All patients were treated under sedoanalgesia with laryngeal mask by intravenous Profoliol 600 mg, alfentanil 0.5 mg and O2/N2O inhalation. Intravenous hydratation and prophylactic antibiotics were given in all cases. Mean age was 52 years (men 5-79). Mean body weight was 69 kg (22-88). Mean shockwave number was 1,460 (400-2,700) for a mean voltage of 19 kV (11-20). Mean stone diameter was 10 mm (7-17); stasis was present in 7 cases. To obtain good coaptation of the perineum to the water cushion, silicon oil was applied to the skin in a thick layer. A 5-yearold boy (22 kg) could be focused by interposing a bag of isotonic solution between the perineum and the cushion.
135
Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 8:16:42 PM
mate the ischiatic spur plane to the focus area. The bath cushion is applied to the perineum of the patient, shaved if required. The testes are taped to the pubic bone. The C-arm is positioned at a right angle with the table and the shockwave generator in order to allow its pas sage between the legs (fig. 2). Neither ureteral nor urethral catheters were inserted. The only preoperative preventions were an empty bladder, normal clotting parameters and possible focusing of a radi opaque stone demonstrated by simulation. This consists of a posi tioning trial with the patient on the table to check if the stone can be adequately focalized in both planes. 35 patients (27 men and 8 women) were treated deliberately in one single session without ancillary maneuvers after demonstration
Two types of minor complications were encountered and were managed conservatively: renal colics in 14% (4 patients/35), mild perineal skin erosion in 14% (4 patients/35). No patient experienced pelvic or perineal discomfort, prolonged hematuria (> 24 h) or sex ual and prostatic disorders during the post-ESWL period.
Results As a result of the simulation with this setting, all eligi ble patients had a stone located between the ischiatic spur and ureteral meatus. This was enforced by the F1-F2 dis tance of the semi-ellipsoid reflector (135 mm). With 35 patients treated in one single session, ideal fragmentation (< 3 mm) was obtained in 84% of the cases. Despite ade quate focusing, 6 stones (16%) did not show any sign of fragmentation on the 15th day post-treatment X-Ray film. For 4 of these, absence of breakage was further con firmed at ureteroscopic extraction. On the 3-month XRay film, without any further active urological maneu vers, 26 patients (74%) were stone free. Of 35 patients, 9 had auxiliary treatment (ancillary post-ESWL proce dures, i.e., URS, Dormia, Push Bang and secondary ESWL).
Discussion A mobile and modulated lithotripter allows for a disso ciation of the elements: shockwave generator, fluoro scopic control of fragmentation (C-arm) and the table. Our original setting allows the use of shockwaves through an unusual acoustic window by water cushion. Although this exposure has already been experimented by Domier users, our method allows an excellent visualization of the stone and renders trivial the use of any contrast material or retrograde ureteral catheter [5], This perineal in situ treatment of lower ureteric stones gives a very comfort able percentage of fragmentation rate despite the deliber ate decision to allow one treatment session only. Early ureteroscopy performed for 4 unfragmented stones showed no evidence of ureter or bladder lesions. Compli cations observed in this series were of little significance. The results obtained and low morbidity rate encouraged us to propose in situ ESWL, through the perineal route with Tripter XI, as the first choice therapy for lower ure teric stones, whenever adequate focusing is possible.
Acknowledgment We thank Mr Farhad Baharloo for the English translation.
References
136
5 Dretler SP: In situ extracorporeal shock wave lithotripsy versus ureteroscopy: The case for ureteroscopy; in Lingeman J, Newman D, (eds): Shock Wave Lithotripsy, ed 2. New York, Plenum Press, 1989, p 351. 6 Fuchs G, Miller K, Rassweiler J, Eisenberger F: One-year experience with the Domier litho tripter. Eur Urol 1985; 11:147-149. 7 Jenkins A: ESWL treatment of ureteral calculi. J Urol 1986; 135:2. 8 Jenkins A, Gillenwater J: Extracorporeal shock wave lithotripsy in the prone position: Treat ment of stones in the distal ureter or anormalous kidney. J Urol 1988; 139:911. 9 Miller K, Fuchs G, Rassweiler J, Eisenberger F : Treatment of ureteral stone disease: The role of ESWL and endourology. World J Urol 1985:3: 53.
Andrianne/V andeberg/Bonnet/Nicolas/ Coppens/Bouffioux/de Levai
10 Miller K, Bubeck JR, Flautmann R: Extracor poreal shockwave lithotripsy of distal ureteral calculi. Eur Urol 1986; 12:305. 11 Rassweiler J, Halth U, Lutz K, Eisenberger F: In situ ESWL beim tiefen Hamleiterstein. Acta Urol 1986; 17:328. 12 Rassweiler J, Hath U, Bub P, Eisenberger F: Extracorporeal shockwave lithotripsy (ESWL) for distal ureteral calculi. Endourology 1986; 1/4:15.
Positioning for ESWL for Distal Ureteric Calculi
Downloaded by: University of Exeter 144.173.6.94 - 5/3/2020 8:16:42 PM
1 Andrianne R, Bonnet P, Similon B, Nicolas H, Coppens L, Bouffioux C, de Levai J: Belgian experience with the Direx Tripter X1 ; in Linge man J, Newman D (eds): Shock Wave Litho tripsy, ed 2. New York, Plenum Press, 1989, voi 65, p 359. 2 Carrol PR, Shi RY: Genetic toxicity of high energy shockwaves. J Urol 1986; 135:2. 3 Chaussy Ch, Schmiedt E, Joachim D, Brendel W, Forssmann B, Walter V: First clinical expe rience with extracorporeally induced destruc tion of kidney stones by shockwaves. J Urol 1982:127:417. 4 Drach GW, Dretler S, Fair W, Finlayson B, Gillenwater J, Griffith D, Lingeman J, New man D: Report of the United States coopera tive study of extracoporeal shock wave litho tripsy. J Urol 1986; 135:1127.
