Original Paper Urol Int 1992:48:415-419
Department o f Urology. School o f Medicine, Kinki University, Osaka, Japan
Keyw ords Extracorporeal shock wave lithotripsy Magnetic resonance imaging Gd-D TPA
Renal Damages after Extracorporeal Shock Wave Lithotripsy Evaluated by Gd-DTPA-Enhanced Dynamic Magnetic Resonance Imaging Abstract Renal damages after extracorporeal shock wave lithotripsy (ESWL) were evaluated by magnetic resonance imaging (MRI) including Gd-DTPA-enhanced dynamic M RI in 37 patients with renal stone byspin echo methods (Tt and T^-weighted scan) and small tip angle gradient echo method (T^-weighted scan). Sixty-eight percent of the patients had changes in the MRI findings after ESW L. The frequently observed findings were perirenal fluid collection (38%), loss of corticomedullary junction (35%), and increased signal intensity of muscle and other adjacent tissue (34%). Preoperative Gd-DTPA-enhanced dynamic MRI showed low intensity band which suggests G d-D TPA secretion from the glomerulus into the renal tubulus. In all cases the low intensity band became unclear after ESW L because of renal contusion due to ESWL. M RI, including Gd-DTPA-enhanced dynamic M R I, is considered to be a good pro cedure for evaluation of renal damages due to ESWL.
Introduction
Subjects and Methods
Extracorporeal shock wave lithotropsy (ESWL) is a noninvasive therapy used worldwide to disintegrate uri nary stones with shock waves. It is the first-choice therapy for urinary tract stones. However, the influences of shock waves on the human body have not been studied suffi ciently. In the present study, acute renal damages result ing from ESW L were evaluated with magnetic resonance imaging (MRI), including Gd-DTPA-enhanced dynamic M RI.
Received: September 9. 1991 Accepted: December 4. 1991
The subjects included 37 patients (12 females, 25 males; average age 49 years) selected at random from 112 renal stone patients who received an initial ESW L therapy at Kinki University School o f Med icine Hospital between April and September 1989. The patients who received nephrostomy before ESW L and those with stone street for mation requiring additional postoperative measures were excluded. The lithotriptor used was a Siemens Lithostar and the M R I sys tem was Shimadzu SM T-50. The static magnetic intensity was 0.5 Tesla. M R I was examined under T r weighted scan SE(500/30) and Ti-weighted scan SE(2,000/12) before and 24 h after ESW L. G dDTPA-enhanced dynamic M R I was also examined under the same conditons. G d -D T P A was injected intravenously (0.1 mmol/kg body weight) and dynamic M R I was examined continuously at 30-second intervals by the small tip angle gradient echo (ST A G E ) method (TR: 100, TE: 23, flip angle: 20°; Ti-weighted scan). The pulse sequence is shown in figure 1.
T. Umekawa. M D Department of Urology. Kinki University School of Medicine, 377-2, Ohno-Higashi Osaka Sayama City. Osaka 589 (Japan)
© 1992 S. Karger AG, Basel 0042-1138/92/0484-0415 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
T. Umekawa K. Kohri T. Yamate N. Amasaki Y. Ishikawa M . Takada M. Iguchi T. Kurita
Results Table 1 shows M RI results for the 37 patients. On the whole, one or more findings were observed in 25/37 (67%) patients and no change was observed in the other
a
Te
Slice selector
Gz
IZ Z T
Gy
I------ 1
Gx
[
Table 1. Acute renal changes due to ESW L as shown bv M R I ( n - 37)
-
_n_
__ n_________
RF
12 (33%) patients. The most frequently observed finding was perirenal fluid collection in 14/37 (38%) patients. Preoperative M RI detected definite corticomedullary junction (CM J) in 23/37 (62%) patients. Postoperative loss of the C M J was seen in 8/23 (35%) of them. Other
Spoiler Pulse
Patients
_r
Phase Encode
n
%
14/37 8/23
38 35
11/37 5/37 1/37 1/37 0/4
30 14 3 3 0
J = L Read Out
1----- 1
J
Echo-
Fig. 1. Pulse sequence o f Gd-DTPA-enhanccd dynamic M R I in the present study. R F = radiofrcqucncies: G z = slice selection gra dient: G y = phase encoding gradient; G x = read out gradient.
Perirenal fluid collection Loss o f C M J Increased signal intensity o f muscle and other adjacent tissue Renal enlargement Subcapsular hematoma Perinephric stranding Hemorrhage into a preexisting renal cyst
4I6
U mekawa/Kohri/Y amate/Amasaki/ Ishikawa/Takada/Iguchi/Kurita
Gd-DTPA-Enhanccd Dynamic M R I for ESW L
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
Fig. 2. Conventional M R I, before and af ter ESW L. Perinephric stranding, loss o f the C M J and swelling o f renal parenchyma were observed after ESW L (Î: direction o f shock waves).
observed changes were increased signal intensity of mus cle and other adjacent tissue in 11 (30%) patients, renal enlargement in 5 (14%) patients, subcapsular hematoma in 1 (3%) patient, and an appearance of perinephric stranding in 1 (3%) patient. Preexisting renal cyst was observed in 4 patients before ESW L, but increased signal intensity suggesting post-ESWL hemorrhage in renal cyst was not found in any of the patients. Typical cases are shown in figures 2 and 3. Gd-DTPA-enhanced dynamic M RI was done in 12 renal stone patients before and after ESWL. A typical case of normal kidney is shown in figure 4a-c. A vascular phase (fig. 4a, arrow) was observed 30 min after GdDTPA injection. The low intensity band (fig. 4b, arrow) was found 1 min after injection of Gd-D TPA and moved gradually from the renal cortex to the medulla. After 3 min, a reduction of renal pelvis intensity due to concen tration of G d-D TPA was observed (fig. 4c). The low intensity band disappeared after ESWL in all 12 patients (fig. 5b), and conventional M RI showed clear C M J in patients (fig. 5a).
Discussion ESW L is the first-choice therapy for upper urinary tract stones. On the other hand, ESW L has been reported to cause renal damages. Many studies using isotopes, computed tomography and blood chemical parameters were evaluated, and it was concluded that ESW L is not a completely noninvasive therapy [1-4], We studied the renal damages due to ESWL by MRI including GdDTPA-enhanced dynamic MRI for evaluating acute renal damages. Our result of 38% for the incidence of perirenal fluid collection almost agreed with other reports [2, 5,6], These fluids represent the occurrence of renal and adjacent tis sue contusion due to ESWL, and consist of blood, urine and lymph liquid. All these fluids were absorbed within a few days. Subcapsular hematoma is a severe adverse reduction of ESW L. The incidence varies among reports by various authors [2, 5, 6], In the present study, we found only 1 patient who suffered from subcapsular hematoma, but it was not absorbed completely 3 months after ESWL.
p re -E SW L
T ,-w eighted scan
T j-w eighted scan
p o st-E SW L
T ,-w eighted scan
T 2-w eighted scan
417
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
Fig. 3. Conventional M R I, before and af ter ESW L. Perirenal fluid collection and high intensity lesion due to bleeding in the muscle tissue were observed after ESW L, but the C M J was clearly identified.
Fig. 4. Gd-DTPA-cnhanced dynamic M R I a A vascular phase was observed just after administration o f G dD T P A (arrow), b A low intensity band was observed 1 min after administration of G d -D T P A (arrow), moved to renal pelvis, c A low intensity area was observed in the renal pelvis due to concentration p f G d -D T P A .
pre ESWL pre ESWL
post ESWL
post ESWL
418
U mekawa/Kohri/Yamate/Amasaki/ Ishikawa/Takada/Iguchi/Kurita
Gd-DTPA-Enhanccd Dynamic M R I for ESW L
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
Fig. 5. a Conventional M R I, before and after ESW L. Perinephric stranding and perirenal fluid collection were found, but the C M J was clearly identified, b Gd-DTPA-enhanced dynamic M R I, before and after ESW L. The low intensity band in the renal parenchyma was unclear after ESW L.
Also, her blood pressure was not changed before and after ESW L. Loss of the C M J occurred by the renal contusion due to ESWL, edema and extravasation of urine and blood, decreasing renal circulatory blood flow [6], In creased signal intensity of muscle and other adjacent tis sue was due to hemorrhage in these lesions out of the treated focus. The reports on elevation of serum G O T , G P T and other parameters before and after ESWL came to the same conclusion by way of muscle and liver contu sion [4], In a study using C T scan, Rubin et al. [7] reported the occurrence of perinephric stranding due to bridging septal hypertrophy and Gerota’s fascia enlarge ment observed after ESWL in 70% of the ESWL-treated patients. Judging from our result of its occurrence rate of 3%, these C T scan findings were difficult to evaluate by M RI. In recent years, a high-speed scanning technique has been proposed using oblique magnetic field echoes and small flip angles and sound clinical applications. In the present study we utilized ST A G E, which is one of the applications of this technique. Gd-D TPA is a recently developed contrast medium for use in MRI; this sub stance is a chelate compound of gadolinium. When it is injected in the human it is filtrated in the glomerulus and
affects the relaxation time of the hydrogen atom in the renal tissue. Susceptibility occurred in the T|-weighted scan under 0.1 mmol/kg Gd-DTPA administration. In this study we chose To-weighted scan (flip angle: 20°) because susceptibility is observed in T|-weighted scan under 0.1 mmol/kg Gd-DTPA administration [8-10]. Normal human kidney is divided into four phases by GdDTPA-enhanced dynamic MRI under T|-weighted scan with 0.1 mmol/kg Gd-DTPA administration. Phase 1 is the renal cortex phase associated with an increased signal intensity in the renal cortex 30 s after administration of Gd-D TPA . Phase 2 is an early tubular phase in the renal medulla 60 s after injection of Gd-D TPA . Phase 3 is a col lecting tubules phase which starts at 90 s, but signal inten sity conversely decreases because of hyperconcentration of G d-D TPA which has susceptibility effects. Phase 4 is a secretion phase of secretion of Gd-D TPA into the renal pelvis 120 s after Gd-DTPA administration [11], Becom ing unclear, low intensity band was thought to be a renal circulatory system damage due to renal contusion by ESW L. It is suggested that MRI (including Gd-DTPA dynamic MRI) is a very sensitive and useful diagnostic procedure for evaluation of renal damages after ESWL treatment.
References 5 Baumgartner BR. Dickey K W . Ambrose SS. et al: Kidney changes after extracorporeal shock wave lithotripsy: Appearance on M R imaging. Radiology 1987;163:531-534. 6 Torii T , Machida T , Oonishi Y , et al: Renal damage after extracorporeal shock wave litho tripsy detected by magnetic resonance imaging. Jpn j Urol 1988;79:1323-1327. 7 Rubin J I , Arger P H . Pollack H M : Kidney changes after extracorporeal shock wave litho tripsy: C T evaluation. Radiology 1987; 162:21 — 24. 8 Hasse A , Frahm J , Matthaei D , Hanicke W , et al: Flash imaging. Rapid N M R imaging using low flip-angle pulse. J Magn Reson 1986:67: 258-266.
9 Mabuchi N , Hamada T , Yoshioka H: Evalua tion o f fast M R imaging with suspended respi ration in hepatic tumors. Nippon Acta Radiol 1989:49:1122-1140. 10 Semclka R C , Hricak H . Tomei E, et al: Dy namic Gd-DTPA-enhanced M R imaging to distinguish dilated nonobstructcd and acutely chronically obstructed kidneys. Radiology Selected Reports from R SN A Scientific Pro gram, ed 1. Chicago. Biomedics, 1990, pp 5455. 11 Kikins R. von Schulthess G K , Jager P. et al: Normal and hydronephrotic kidney: evalua tion o f renal function with contrast-enhanced M R imaging. Radiology 1987:165:837-842.
419
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
1 Robert P G : Extracorporeal shock wave litho tripsy for renal and ureteral calculi; in William H B (ed): Urologic Imaging and Interventional Techniques. Munich, Urban & Schwarzenberg, 1989, pp 251-260. 2 Kaude J V . Williams C Y . Millner M R . et al: Renal morphology and function immediatery after extracorporeal shock wave lithotripsy. A JR 1985;145:305-313. 3 Grantham JR . Millner M R . Kaude J V . et al: Renal stone disease treated with shock wave lithotripsy: Short-term observation in 100 pa tients. Radiology 1986:158:203-206. 4 Haupt G , Haupt A . Donovan JM . et al: Short term changes o f laboratory values after extra corporeal shock wave lithotripsy: A compara tive study. J Urol 1989:142:2592267.
Department o f Urology. School o f Medicine, Kinki University, Osaka, Japan
Keyw ords Extracorporeal shock wave lithotripsy Magnetic resonance imaging Gd-D TPA
Renal Damages after Extracorporeal Shock Wave Lithotripsy Evaluated by Gd-DTPA-Enhanced Dynamic Magnetic Resonance Imaging Abstract Renal damages after extracorporeal shock wave lithotripsy (ESWL) were evaluated by magnetic resonance imaging (MRI) including Gd-DTPA-enhanced dynamic M RI in 37 patients with renal stone byspin echo methods (Tt and T^-weighted scan) and small tip angle gradient echo method (T^-weighted scan). Sixty-eight percent of the patients had changes in the MRI findings after ESW L. The frequently observed findings were perirenal fluid collection (38%), loss of corticomedullary junction (35%), and increased signal intensity of muscle and other adjacent tissue (34%). Preoperative Gd-DTPA-enhanced dynamic MRI showed low intensity band which suggests G d-D TPA secretion from the glomerulus into the renal tubulus. In all cases the low intensity band became unclear after ESW L because of renal contusion due to ESWL. M RI, including Gd-DTPA-enhanced dynamic M R I, is considered to be a good pro cedure for evaluation of renal damages due to ESWL.
Introduction
Subjects and Methods
Extracorporeal shock wave lithotropsy (ESWL) is a noninvasive therapy used worldwide to disintegrate uri nary stones with shock waves. It is the first-choice therapy for urinary tract stones. However, the influences of shock waves on the human body have not been studied suffi ciently. In the present study, acute renal damages result ing from ESW L were evaluated with magnetic resonance imaging (MRI), including Gd-DTPA-enhanced dynamic M RI.
Received: September 9. 1991 Accepted: December 4. 1991
The subjects included 37 patients (12 females, 25 males; average age 49 years) selected at random from 112 renal stone patients who received an initial ESW L therapy at Kinki University School o f Med icine Hospital between April and September 1989. The patients who received nephrostomy before ESW L and those with stone street for mation requiring additional postoperative measures were excluded. The lithotriptor used was a Siemens Lithostar and the M R I sys tem was Shimadzu SM T-50. The static magnetic intensity was 0.5 Tesla. M R I was examined under T r weighted scan SE(500/30) and Ti-weighted scan SE(2,000/12) before and 24 h after ESW L. G dDTPA-enhanced dynamic M R I was also examined under the same conditons. G d -D T P A was injected intravenously (0.1 mmol/kg body weight) and dynamic M R I was examined continuously at 30-second intervals by the small tip angle gradient echo (ST A G E ) method (TR: 100, TE: 23, flip angle: 20°; Ti-weighted scan). The pulse sequence is shown in figure 1.
T. Umekawa. M D Department of Urology. Kinki University School of Medicine, 377-2, Ohno-Higashi Osaka Sayama City. Osaka 589 (Japan)
© 1992 S. Karger AG, Basel 0042-1138/92/0484-0415 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
T. Umekawa K. Kohri T. Yamate N. Amasaki Y. Ishikawa M . Takada M. Iguchi T. Kurita
Results Table 1 shows M RI results for the 37 patients. On the whole, one or more findings were observed in 25/37 (67%) patients and no change was observed in the other
a
Te
Slice selector
Gz
IZ Z T
Gy
I------ 1
Gx
[
Table 1. Acute renal changes due to ESW L as shown bv M R I ( n - 37)
-
_n_
__ n_________
RF
12 (33%) patients. The most frequently observed finding was perirenal fluid collection in 14/37 (38%) patients. Preoperative M RI detected definite corticomedullary junction (CM J) in 23/37 (62%) patients. Postoperative loss of the C M J was seen in 8/23 (35%) of them. Other
Spoiler Pulse
Patients
_r
Phase Encode
n
%
14/37 8/23
38 35
11/37 5/37 1/37 1/37 0/4
30 14 3 3 0
J = L Read Out
1----- 1
J
Echo-
Fig. 1. Pulse sequence o f Gd-DTPA-enhanccd dynamic M R I in the present study. R F = radiofrcqucncies: G z = slice selection gra dient: G y = phase encoding gradient; G x = read out gradient.
Perirenal fluid collection Loss o f C M J Increased signal intensity o f muscle and other adjacent tissue Renal enlargement Subcapsular hematoma Perinephric stranding Hemorrhage into a preexisting renal cyst
4I6
U mekawa/Kohri/Y amate/Amasaki/ Ishikawa/Takada/Iguchi/Kurita
Gd-DTPA-Enhanccd Dynamic M R I for ESW L
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
Fig. 2. Conventional M R I, before and af ter ESW L. Perinephric stranding, loss o f the C M J and swelling o f renal parenchyma were observed after ESW L (Î: direction o f shock waves).
observed changes were increased signal intensity of mus cle and other adjacent tissue in 11 (30%) patients, renal enlargement in 5 (14%) patients, subcapsular hematoma in 1 (3%) patient, and an appearance of perinephric stranding in 1 (3%) patient. Preexisting renal cyst was observed in 4 patients before ESW L, but increased signal intensity suggesting post-ESWL hemorrhage in renal cyst was not found in any of the patients. Typical cases are shown in figures 2 and 3. Gd-DTPA-enhanced dynamic M RI was done in 12 renal stone patients before and after ESWL. A typical case of normal kidney is shown in figure 4a-c. A vascular phase (fig. 4a, arrow) was observed 30 min after GdDTPA injection. The low intensity band (fig. 4b, arrow) was found 1 min after injection of Gd-D TPA and moved gradually from the renal cortex to the medulla. After 3 min, a reduction of renal pelvis intensity due to concen tration of G d-D TPA was observed (fig. 4c). The low intensity band disappeared after ESWL in all 12 patients (fig. 5b), and conventional M RI showed clear C M J in patients (fig. 5a).
Discussion ESW L is the first-choice therapy for upper urinary tract stones. On the other hand, ESW L has been reported to cause renal damages. Many studies using isotopes, computed tomography and blood chemical parameters were evaluated, and it was concluded that ESW L is not a completely noninvasive therapy [1-4], We studied the renal damages due to ESWL by MRI including GdDTPA-enhanced dynamic MRI for evaluating acute renal damages. Our result of 38% for the incidence of perirenal fluid collection almost agreed with other reports [2, 5,6], These fluids represent the occurrence of renal and adjacent tis sue contusion due to ESWL, and consist of blood, urine and lymph liquid. All these fluids were absorbed within a few days. Subcapsular hematoma is a severe adverse reduction of ESW L. The incidence varies among reports by various authors [2, 5, 6], In the present study, we found only 1 patient who suffered from subcapsular hematoma, but it was not absorbed completely 3 months after ESWL.
p re -E SW L
T ,-w eighted scan
T j-w eighted scan
p o st-E SW L
T ,-w eighted scan
T 2-w eighted scan
417
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
Fig. 3. Conventional M R I, before and af ter ESW L. Perirenal fluid collection and high intensity lesion due to bleeding in the muscle tissue were observed after ESW L, but the C M J was clearly identified.
Fig. 4. Gd-DTPA-cnhanced dynamic M R I a A vascular phase was observed just after administration o f G dD T P A (arrow), b A low intensity band was observed 1 min after administration of G d -D T P A (arrow), moved to renal pelvis, c A low intensity area was observed in the renal pelvis due to concentration p f G d -D T P A .
pre ESWL pre ESWL
post ESWL
post ESWL
418
U mekawa/Kohri/Yamate/Amasaki/ Ishikawa/Takada/Iguchi/Kurita
Gd-DTPA-Enhanccd Dynamic M R I for ESW L
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
Fig. 5. a Conventional M R I, before and after ESW L. Perinephric stranding and perirenal fluid collection were found, but the C M J was clearly identified, b Gd-DTPA-enhanced dynamic M R I, before and after ESW L. The low intensity band in the renal parenchyma was unclear after ESW L.
Also, her blood pressure was not changed before and after ESW L. Loss of the C M J occurred by the renal contusion due to ESWL, edema and extravasation of urine and blood, decreasing renal circulatory blood flow [6], In creased signal intensity of muscle and other adjacent tis sue was due to hemorrhage in these lesions out of the treated focus. The reports on elevation of serum G O T , G P T and other parameters before and after ESWL came to the same conclusion by way of muscle and liver contu sion [4], In a study using C T scan, Rubin et al. [7] reported the occurrence of perinephric stranding due to bridging septal hypertrophy and Gerota’s fascia enlarge ment observed after ESWL in 70% of the ESWL-treated patients. Judging from our result of its occurrence rate of 3%, these C T scan findings were difficult to evaluate by M RI. In recent years, a high-speed scanning technique has been proposed using oblique magnetic field echoes and small flip angles and sound clinical applications. In the present study we utilized ST A G E, which is one of the applications of this technique. Gd-D TPA is a recently developed contrast medium for use in MRI; this sub stance is a chelate compound of gadolinium. When it is injected in the human it is filtrated in the glomerulus and
affects the relaxation time of the hydrogen atom in the renal tissue. Susceptibility occurred in the T|-weighted scan under 0.1 mmol/kg Gd-DTPA administration. In this study we chose To-weighted scan (flip angle: 20°) because susceptibility is observed in T|-weighted scan under 0.1 mmol/kg Gd-DTPA administration [8-10]. Normal human kidney is divided into four phases by GdDTPA-enhanced dynamic MRI under T|-weighted scan with 0.1 mmol/kg Gd-DTPA administration. Phase 1 is the renal cortex phase associated with an increased signal intensity in the renal cortex 30 s after administration of Gd-D TPA . Phase 2 is an early tubular phase in the renal medulla 60 s after injection of Gd-D TPA . Phase 3 is a col lecting tubules phase which starts at 90 s, but signal inten sity conversely decreases because of hyperconcentration of G d-D TPA which has susceptibility effects. Phase 4 is a secretion phase of secretion of Gd-D TPA into the renal pelvis 120 s after Gd-DTPA administration [11], Becom ing unclear, low intensity band was thought to be a renal circulatory system damage due to renal contusion by ESW L. It is suggested that MRI (including Gd-DTPA dynamic MRI) is a very sensitive and useful diagnostic procedure for evaluation of renal damages after ESWL treatment.
References 5 Baumgartner BR. Dickey K W . Ambrose SS. et al: Kidney changes after extracorporeal shock wave lithotripsy: Appearance on M R imaging. Radiology 1987;163:531-534. 6 Torii T , Machida T , Oonishi Y , et al: Renal damage after extracorporeal shock wave litho tripsy detected by magnetic resonance imaging. Jpn j Urol 1988;79:1323-1327. 7 Rubin J I , Arger P H . Pollack H M : Kidney changes after extracorporeal shock wave litho tripsy: C T evaluation. Radiology 1987; 162:21 — 24. 8 Hasse A , Frahm J , Matthaei D , Hanicke W , et al: Flash imaging. Rapid N M R imaging using low flip-angle pulse. J Magn Reson 1986:67: 258-266.
9 Mabuchi N , Hamada T , Yoshioka H: Evalua tion o f fast M R imaging with suspended respi ration in hepatic tumors. Nippon Acta Radiol 1989:49:1122-1140. 10 Semclka R C , Hricak H . Tomei E, et al: Dy namic Gd-DTPA-enhanced M R imaging to distinguish dilated nonobstructcd and acutely chronically obstructed kidneys. Radiology Selected Reports from R SN A Scientific Pro gram, ed 1. Chicago. Biomedics, 1990, pp 5455. 11 Kikins R. von Schulthess G K , Jager P. et al: Normal and hydronephrotic kidney: evalua tion o f renal function with contrast-enhanced M R imaging. Radiology 1987:165:837-842.
419
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 10:44:49 PM
1 Robert P G : Extracorporeal shock wave litho tripsy for renal and ureteral calculi; in William H B (ed): Urologic Imaging and Interventional Techniques. Munich, Urban & Schwarzenberg, 1989, pp 251-260. 2 Kaude J V . Williams C Y . Millner M R . et al: Renal morphology and function immediatery after extracorporeal shock wave lithotripsy. A JR 1985;145:305-313. 3 Grantham JR . Millner M R . Kaude J V . et al: Renal stone disease treated with shock wave lithotripsy: Short-term observation in 100 pa tients. Radiology 1986:158:203-206. 4 Haupt G , Haupt A . Donovan JM . et al: Short term changes o f laboratory values after extra corporeal shock wave lithotripsy: A compara tive study. J Urol 1989:142:2592267.
