1617008
EurUrol 1992;21(suppl 1 ):53—56
Department of Urology, University of Sassari, Italy
Key Words Echography Amylasemia Creatine phosphokinase Pseudocholinesterasemia Serum glutamic-oxaloacetic transaminase Glutamic-pyruvic transaminase
Evaluation of Hematochemical Parameters and Renal Echography after ESWL
Abstract Evaluation of hematochemical parameters and renal echography after ESWL treatment with Tripter XI was done on the first 95 patients treated and for whom we had a longer than 3-month follow-up. Creatinine phosphokinase values showed an increase in 24 patients. 12 patients demonstrated an increase in amylasemia. Echographie checks performed the day after treat ment revealed the presence of perirenal lesions in 3 cases. As far as amyla semia is concerned, only 1 patient was treated with aprotinin. One of the patients who developed perirenal hematoma had hypertension; another was following an antiaggregant therapy that was temporarily suspended.
Technological evolution has allowed the creators and constructors to develop lithotripters on the one hand effi cient and, at the same time, less complex and less expen sive [1], Our direct experience applies to the Tripter XI, an Israeli-made lithotripter built by Direx Inc.: it is char acterized by a system modularity, low initial and running costs and an extreme simplicity of operation [2], In-depth studies were carried out on the first 95 patients treated and for whom we had a longer than 3-month follow-up. This work covers the characteristics of patients and stones treated, the type of treatment, the results obtained, any complications, and, finally, observations based on exami nation of variations in diverse hematochemical parame ters. We hold that an account of our experience may be use ful to Italian urologists insofar as it concerns the first lithotripter of this type used in our country.
Materials and Methods The Tripter X1 lithotripter is characterized by the modulatory of its construction. The most important part consists in a shock wave generator (SWAG) on wheels. The patient is placed upon a table designed to facilitate endourological maneuvers. The SWAG is then maneuvered in such a way that its flexible membrane is in contact with the patient’s skin surface. The three-dimensional localization of the stone is performed by means of a portable C-arm unit after align ment of the axes to the SWAG. The patient is placed on the X-ray table in such a way as to ensure that the stone be exactly positioned at the focus of shock wave concentration. Once the correct position is obtained, the flexible membrane, which sticks to the patient’s skin surface by means of a layer of silicone oil, is inflated. Since the SWAG is quite noisy, both patient and operators are supplied with earphones. Parie« A'(tables 1,2) In the period from February to October 1988, we treated 95 patients (41 males and 54 females) whose age varied from 16 to 79. The patients were subjected to 99 treatments insofar as two treat ments were necessary in 4 of the cases. The total number of stones treated were 116(81 patients had a single stone and 14 were carriers of multiple stones).
Dr Carlo Trombetta Istituto di Clinica Urologica Università degli Studi 1-07100 Sassan (Italy)
© 1992 S Karger AG, Basel 0302-2838/92/0215-0053 $2 75/0
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
C. Trombetta A. Berretta S. Siracusano M. Gabriele E. Belgrano
Table 1. Details of tripter XI treatment performed at the Department of Urology, University of Sassari (Feb.-Oct. 1988) Patients Stones Treatments Kidneys
95 116 99 95
Table 2. Age distribution (41 males, 54 females) Age group
0-20
2 4 19 17 26 18 9
Table 3. kV used during treatments (wide reflector) always 20 kV (min. 190, max. 3,200)
0-250 250-500 500-750 750-1,000 1.000-1,250 1.250-1,500 1,500-1,750 1,750-2,000 2.000-2,250 2.250-2,500 2,500 +
All patients were subjected to shock wave of intensity of 20 kV. The number of shocks per treatment varied from a minimum of 250 to a maximum of 3,200. All procedures were done with the patient under general anesthesia. Auxiliary procedures adopted during treat ment were very limited: in 16 cases an ureteral stent was inserted before the procedure; 2 patients had a percutaneous nephrostomy. The length of treatment time varied from 30 to 120 min.
Characteristics of Treated Stones (table 4) 51 patients had a less than 15 mm stone; 26 patients had stones of between 15 and 30 mm in size, and in 39 cases stones were over 3 cm in size. 54 patients had a left stone; 72 patients had a kidney stone; in 23 cases the stones were localized at the level of the urether.
n
21-30 31-40 41-50 51-60 61-70 71-80
Shockwave intensity
Method (table 3)
Shocks per treatment
0 3 7
2
0 9 3
6 29 19
21
Results All the patients taken into account were evaluated in the immediate postoperative period and after 3 months by means of echotomography and X-ray tomography. Out of 95 patients, 15 were not present for the follow-up checks and 4 repeated the ESWL treatment during the 3month follow-up period. Of the remaining 76 patients, 19 (25%) proved to be completely free of fragments when checked by X-ray and echotomography. 21 patients (27.6%) had one or more residual fragments of less than 5 mm in size, often situated in the lower calyx or along the juxtavesical tract of the ureter. These were residual stones susceptible to spontaneous elimination that at the level of the kidney were identified only by means of renal echog raphy. The remaining 36 patients (47.3%) of our initial experience proved to have greater than 5 mm fragments. If we consider those patients free of stones we can state that: 2 (10.5%) had been treated in presence of a smaller than 15 mm stone; 8 (42.1 %) had been treated for stones of a diameter between 15 and 30 mm, and 9 (47.3 %) had larger than 30 mm stones. If we consider stone localization in the 19 patients that resulted ‘stone-free’ 3 months after the treatment we can see that: in 9 cases the stones were pyelic; in 8 cases they were calyceal (4 localized in the upper calyx, 2 in the mid dle calyx and 2 in the lower), and in 2 cases the stones were ureteral.
Table 4. Sizes of the treated stones n
5-15 15-30 30 +
51 26 39
Total
116
Complications Hematuria was always present. 12 patients had fever (more than 39 °C). No pulmonary or cardiovascular prob lem (myocardial infarction, cerebrovascular accident) was encountered. In 1 case an asymptomatic pancreatitis was diagnosed on the basis of hematochemical values of amylasemia (see below). Bleeding never required transfu-
Trombetta/Berretta/Siracusano/Gabriele/ Belgrano
Hematochemical Parameters and Renal Echography after ESWL
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
54
Size, mm
F3.5
CAM 1 RC J 0 G 66 ORBO
a
Fig. 1. Subcapsular hematoma after ESWL (1,500 shock waves). Echographie check the day after treatment.
sion. Echographie checks performed the day after treat ment revealed the presence of a perirenal hematoma in 3 cases. One of these patients had hypertension (190/110 mm Hg); another was following an antiaggregant therapy (antiplatelets) that was temporarily suspended (fig. 1,2). 31.5 % of patients reported pain after treatment. Evaluation ofHematochemical Parameters We checked hemochrome, azotemic and creatinemic values, SGOT, SGPT and the hematic levels of amylase, creatine phosphokinase (CPK) and pseudocholinesterase comparing pre- and postoperative levels. As far as amylasemia is concerned, 1 patient who had already had high preoperative levels (242 U/100 ml - normal values: 220 U/100 ml) showed a notable increase arriving at 495 U/100 ml. This patient was treated with aprotinin (Trasylol) 300,000 U intravenously followed by support doses of 50,000 U every 2 h. Another 11 patients demonstrated a slight increase in amylasemia of about 30% starting from low basal levels and remaining within the normal range. CPK values showed an increase in 24 patients (25%), thereby confirming the muscular tissue involvement and damage during ESWL treatment. 3 patients had an in crease in pseudocholinesterase outside the normal range. The majority demonstrated a drop in pseudocholinesterasemia of about 1,000 U. No significant alterations in transaminase values were encountered. Elemochrome, azotemic and creatinemic values did not present any sig nificant variations either.
Fig. 2. Asymptomatic perirenal lesion occasionally found by means of echography (11 X 37 mm) the day after ESWL treatment with, 3,200 shock waves.
Discussion In evaluating our initial experience with Tripter XI we sustain that four points must be taken into account: (1) efficacy; (2) analgesic treatment; (3) maneuverability, and (4) costs. Efficacy Tripter XI has been able to fragment stones of diverse dimension, form and chemical content into pieces small enough to allow expulsion (in presence of normal excre tory pathways). As with other lithotripters, the efficacy of the fragmentation depends upon precision in focusing (and, therefore, upon a good initial localization of the stone), and upon the site of the stone itself and upon its chemical content. The expulsion of fragments varies ac cording to characteristics particular to each patient (effi cacy of peristalsis, water load, how long the stone has been in the excretory pathway, etc.). The focusing system of the Tripter XI is, in our opinion, efficient for all stones of such a dimension to merit treatment. For radiolucent stones we have performed the treatment in the course of urography and/or ureteropyelography. Two patients hav ing cystine stones necessitated a higher number of shock waves, to obtain a good fragmentation and a discrete clearance of stones which were very large.
55
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
ec
Maneuverability This may be considered a weak point of Tripter XI, especially when compared to the computerized systems with which other lithotripters are provided. Focusing times are slightly longer so, as to shorten them and not move the portable C-arm unit, we preferred treating patients all presenting left localized stones during the same sitting. Time is gained, however, during the course of the filling of the membrane which must be stuck to the patient’s skin, when compared to lithotripters provided with thanks: in these latter, time is wasted in the changing of the water solution.
References
56
1
Costs The evaluation of the cost-benefit ratio must be con sidered on two levels: (a) cost-benefit for the patient, and (b) cost-benefit for the institute which acquires the lithotripter. In our opinion, the first point is only apparently of sole clinical interest and, therefore, both must be taken into consideration. Patient evaluation is complex and would necessitate comparative verification among differ ent lithotripters. From our initial experience we sustain that the real handicap lies in the necessity for anesthesia. As far as the relatively minor cost of Tripter XI is con cerned, this allows its acquisition by smaller clinical struc tures. This would relieve patients of the logistical prob lems which are quite important in those who have to be treated many kilometers away from the place of resi dence. These problems include long and uncomfortable trips after treatment and the impossibility of correct fol low-ups after ESWL.
Conclusions We have concentrated our attention on the follow-ups of patients subjected to ESWL using the Tripter XI. The study of hematochemical parameters has shown an incre ment of amylasemia in 1 patient who was asymptomatic. The accuracy of echographical follow-up places us in front of data of perhaps less positive a nature but, at the same time, more detailed even as regards renal parenchyma.
Servadio C, Livne P, Winkler H: Extracorpo real shock wave lithotripsy using a new. com pact and portable unit. J Urol 1988; 138:478.
Trombetta/Berretta/Siracusano/Gabriele/ Belgrano
2
Andrianne R, Bonnet P, Bouffioux C, Coppens L, De Leyal J, Similon B: A new generation of renal lithotripters using C-arm fluoroscopy and/or ultrasound stone localization - Tripter X1 (Direx). World Congess on ESWL, Indiana polis 1989, pers. commun.
Hematochemical Parameters and Renal Echography after ESWL
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
Analgesie Treatment In our experience we hold that it is better to subject the patient in any case to general anesthesia. The extent of shock wave impact on the patient’s skin may be easily noted and evaluated by simply placing a hand between the membrane and the patient’s skin: it is of such a degree as to be unbearable over a long period. General anesthesia allows the extension of the treatment for the time neces sary to achieve good fragmentation. In addition, the patient remains perfectly still and breathing is regular: thus, all shock waves are aimed solely at the stone, once it is well localized. The constant use of general anesthesia inevitably conditions the choice of ESWL where diverse successive treatments are envisioned for the fragmenta tion of larger staghorn stones.
EurUrol 1992;21(suppl 1 ):53—56
Department of Urology, University of Sassari, Italy
Key Words Echography Amylasemia Creatine phosphokinase Pseudocholinesterasemia Serum glutamic-oxaloacetic transaminase Glutamic-pyruvic transaminase
Evaluation of Hematochemical Parameters and Renal Echography after ESWL
Abstract Evaluation of hematochemical parameters and renal echography after ESWL treatment with Tripter XI was done on the first 95 patients treated and for whom we had a longer than 3-month follow-up. Creatinine phosphokinase values showed an increase in 24 patients. 12 patients demonstrated an increase in amylasemia. Echographie checks performed the day after treat ment revealed the presence of perirenal lesions in 3 cases. As far as amyla semia is concerned, only 1 patient was treated with aprotinin. One of the patients who developed perirenal hematoma had hypertension; another was following an antiaggregant therapy that was temporarily suspended.
Technological evolution has allowed the creators and constructors to develop lithotripters on the one hand effi cient and, at the same time, less complex and less expen sive [1], Our direct experience applies to the Tripter XI, an Israeli-made lithotripter built by Direx Inc.: it is char acterized by a system modularity, low initial and running costs and an extreme simplicity of operation [2], In-depth studies were carried out on the first 95 patients treated and for whom we had a longer than 3-month follow-up. This work covers the characteristics of patients and stones treated, the type of treatment, the results obtained, any complications, and, finally, observations based on exami nation of variations in diverse hematochemical parame ters. We hold that an account of our experience may be use ful to Italian urologists insofar as it concerns the first lithotripter of this type used in our country.
Materials and Methods The Tripter X1 lithotripter is characterized by the modulatory of its construction. The most important part consists in a shock wave generator (SWAG) on wheels. The patient is placed upon a table designed to facilitate endourological maneuvers. The SWAG is then maneuvered in such a way that its flexible membrane is in contact with the patient’s skin surface. The three-dimensional localization of the stone is performed by means of a portable C-arm unit after align ment of the axes to the SWAG. The patient is placed on the X-ray table in such a way as to ensure that the stone be exactly positioned at the focus of shock wave concentration. Once the correct position is obtained, the flexible membrane, which sticks to the patient’s skin surface by means of a layer of silicone oil, is inflated. Since the SWAG is quite noisy, both patient and operators are supplied with earphones. Parie« A'(tables 1,2) In the period from February to October 1988, we treated 95 patients (41 males and 54 females) whose age varied from 16 to 79. The patients were subjected to 99 treatments insofar as two treat ments were necessary in 4 of the cases. The total number of stones treated were 116(81 patients had a single stone and 14 were carriers of multiple stones).
Dr Carlo Trombetta Istituto di Clinica Urologica Università degli Studi 1-07100 Sassan (Italy)
© 1992 S Karger AG, Basel 0302-2838/92/0215-0053 $2 75/0
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
C. Trombetta A. Berretta S. Siracusano M. Gabriele E. Belgrano
Table 1. Details of tripter XI treatment performed at the Department of Urology, University of Sassari (Feb.-Oct. 1988) Patients Stones Treatments Kidneys
95 116 99 95
Table 2. Age distribution (41 males, 54 females) Age group
0-20
2 4 19 17 26 18 9
Table 3. kV used during treatments (wide reflector) always 20 kV (min. 190, max. 3,200)
0-250 250-500 500-750 750-1,000 1.000-1,250 1.250-1,500 1,500-1,750 1,750-2,000 2.000-2,250 2.250-2,500 2,500 +
All patients were subjected to shock wave of intensity of 20 kV. The number of shocks per treatment varied from a minimum of 250 to a maximum of 3,200. All procedures were done with the patient under general anesthesia. Auxiliary procedures adopted during treat ment were very limited: in 16 cases an ureteral stent was inserted before the procedure; 2 patients had a percutaneous nephrostomy. The length of treatment time varied from 30 to 120 min.
Characteristics of Treated Stones (table 4) 51 patients had a less than 15 mm stone; 26 patients had stones of between 15 and 30 mm in size, and in 39 cases stones were over 3 cm in size. 54 patients had a left stone; 72 patients had a kidney stone; in 23 cases the stones were localized at the level of the urether.
n
21-30 31-40 41-50 51-60 61-70 71-80
Shockwave intensity
Method (table 3)
Shocks per treatment
0 3 7
2
0 9 3
6 29 19
21
Results All the patients taken into account were evaluated in the immediate postoperative period and after 3 months by means of echotomography and X-ray tomography. Out of 95 patients, 15 were not present for the follow-up checks and 4 repeated the ESWL treatment during the 3month follow-up period. Of the remaining 76 patients, 19 (25%) proved to be completely free of fragments when checked by X-ray and echotomography. 21 patients (27.6%) had one or more residual fragments of less than 5 mm in size, often situated in the lower calyx or along the juxtavesical tract of the ureter. These were residual stones susceptible to spontaneous elimination that at the level of the kidney were identified only by means of renal echog raphy. The remaining 36 patients (47.3%) of our initial experience proved to have greater than 5 mm fragments. If we consider those patients free of stones we can state that: 2 (10.5%) had been treated in presence of a smaller than 15 mm stone; 8 (42.1 %) had been treated for stones of a diameter between 15 and 30 mm, and 9 (47.3 %) had larger than 30 mm stones. If we consider stone localization in the 19 patients that resulted ‘stone-free’ 3 months after the treatment we can see that: in 9 cases the stones were pyelic; in 8 cases they were calyceal (4 localized in the upper calyx, 2 in the mid dle calyx and 2 in the lower), and in 2 cases the stones were ureteral.
Table 4. Sizes of the treated stones n
5-15 15-30 30 +
51 26 39
Total
116
Complications Hematuria was always present. 12 patients had fever (more than 39 °C). No pulmonary or cardiovascular prob lem (myocardial infarction, cerebrovascular accident) was encountered. In 1 case an asymptomatic pancreatitis was diagnosed on the basis of hematochemical values of amylasemia (see below). Bleeding never required transfu-
Trombetta/Berretta/Siracusano/Gabriele/ Belgrano
Hematochemical Parameters and Renal Echography after ESWL
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
54
Size, mm
F3.5
CAM 1 RC J 0 G 66 ORBO
a
Fig. 1. Subcapsular hematoma after ESWL (1,500 shock waves). Echographie check the day after treatment.
sion. Echographie checks performed the day after treat ment revealed the presence of a perirenal hematoma in 3 cases. One of these patients had hypertension (190/110 mm Hg); another was following an antiaggregant therapy (antiplatelets) that was temporarily suspended (fig. 1,2). 31.5 % of patients reported pain after treatment. Evaluation ofHematochemical Parameters We checked hemochrome, azotemic and creatinemic values, SGOT, SGPT and the hematic levels of amylase, creatine phosphokinase (CPK) and pseudocholinesterase comparing pre- and postoperative levels. As far as amylasemia is concerned, 1 patient who had already had high preoperative levels (242 U/100 ml - normal values: 220 U/100 ml) showed a notable increase arriving at 495 U/100 ml. This patient was treated with aprotinin (Trasylol) 300,000 U intravenously followed by support doses of 50,000 U every 2 h. Another 11 patients demonstrated a slight increase in amylasemia of about 30% starting from low basal levels and remaining within the normal range. CPK values showed an increase in 24 patients (25%), thereby confirming the muscular tissue involvement and damage during ESWL treatment. 3 patients had an in crease in pseudocholinesterase outside the normal range. The majority demonstrated a drop in pseudocholinesterasemia of about 1,000 U. No significant alterations in transaminase values were encountered. Elemochrome, azotemic and creatinemic values did not present any sig nificant variations either.
Fig. 2. Asymptomatic perirenal lesion occasionally found by means of echography (11 X 37 mm) the day after ESWL treatment with, 3,200 shock waves.
Discussion In evaluating our initial experience with Tripter XI we sustain that four points must be taken into account: (1) efficacy; (2) analgesic treatment; (3) maneuverability, and (4) costs. Efficacy Tripter XI has been able to fragment stones of diverse dimension, form and chemical content into pieces small enough to allow expulsion (in presence of normal excre tory pathways). As with other lithotripters, the efficacy of the fragmentation depends upon precision in focusing (and, therefore, upon a good initial localization of the stone), and upon the site of the stone itself and upon its chemical content. The expulsion of fragments varies ac cording to characteristics particular to each patient (effi cacy of peristalsis, water load, how long the stone has been in the excretory pathway, etc.). The focusing system of the Tripter XI is, in our opinion, efficient for all stones of such a dimension to merit treatment. For radiolucent stones we have performed the treatment in the course of urography and/or ureteropyelography. Two patients hav ing cystine stones necessitated a higher number of shock waves, to obtain a good fragmentation and a discrete clearance of stones which were very large.
55
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
ec
Maneuverability This may be considered a weak point of Tripter XI, especially when compared to the computerized systems with which other lithotripters are provided. Focusing times are slightly longer so, as to shorten them and not move the portable C-arm unit, we preferred treating patients all presenting left localized stones during the same sitting. Time is gained, however, during the course of the filling of the membrane which must be stuck to the patient’s skin, when compared to lithotripters provided with thanks: in these latter, time is wasted in the changing of the water solution.
References
56
1
Costs The evaluation of the cost-benefit ratio must be con sidered on two levels: (a) cost-benefit for the patient, and (b) cost-benefit for the institute which acquires the lithotripter. In our opinion, the first point is only apparently of sole clinical interest and, therefore, both must be taken into consideration. Patient evaluation is complex and would necessitate comparative verification among differ ent lithotripters. From our initial experience we sustain that the real handicap lies in the necessity for anesthesia. As far as the relatively minor cost of Tripter XI is con cerned, this allows its acquisition by smaller clinical struc tures. This would relieve patients of the logistical prob lems which are quite important in those who have to be treated many kilometers away from the place of resi dence. These problems include long and uncomfortable trips after treatment and the impossibility of correct fol low-ups after ESWL.
Conclusions We have concentrated our attention on the follow-ups of patients subjected to ESWL using the Tripter XI. The study of hematochemical parameters has shown an incre ment of amylasemia in 1 patient who was asymptomatic. The accuracy of echographical follow-up places us in front of data of perhaps less positive a nature but, at the same time, more detailed even as regards renal parenchyma.
Servadio C, Livne P, Winkler H: Extracorpo real shock wave lithotripsy using a new. com pact and portable unit. J Urol 1988; 138:478.
Trombetta/Berretta/Siracusano/Gabriele/ Belgrano
2
Andrianne R, Bonnet P, Bouffioux C, Coppens L, De Leyal J, Similon B: A new generation of renal lithotripters using C-arm fluoroscopy and/or ultrasound stone localization - Tripter X1 (Direx). World Congess on ESWL, Indiana polis 1989, pers. commun.
Hematochemical Parameters and Renal Echography after ESWL
Downloaded by: University of Exeter 144.173.6.94 - 1/27/2020 4:17:53 AM
Analgesie Treatment In our experience we hold that it is better to subject the patient in any case to general anesthesia. The extent of shock wave impact on the patient’s skin may be easily noted and evaluated by simply placing a hand between the membrane and the patient’s skin: it is of such a degree as to be unbearable over a long period. General anesthesia allows the extension of the treatment for the time neces sary to achieve good fragmentation. In addition, the patient remains perfectly still and breathing is regular: thus, all shock waves are aimed solely at the stone, once it is well localized. The constant use of general anesthesia inevitably conditions the choice of ESWL where diverse successive treatments are envisioned for the fragmenta tion of larger staghorn stones.
