What is the role of extracorporeal shockwave lithotripsy in the treatment of struvite and staghorn calculi?

Answer

SWL was introduced in 1982 and is used to fragment urinary stones in a variety of locations without requiring an incision or instrumentation of the urinary tract.

Struvite calculi are effectively broken by SWL because of the multiple laminations within the stones. However, even with excellent stone fragmentation by primary SWL, repeat therapy via SWL must be performed in 50% of patients because of a large stone burden. If multiple sessions are anticipated, the renal pelvis should be treated first. Real-time monitoring of stone fragmentation using fluoroscopy is important to target and shock all areas of the stone.

In addition, the potential for urinary obstruction during spontaneous stone passage usually requires the placement of an indwelling ureteral stent. In up to 40% of patients, a percutaneous nephrostomy (PCN) tube is subsequently required to allow adequate renal drainage.^[17]

If the renal infundibula are narrow, stone fragments that stem from SWL are unlikely to pass and remain in the calyces. Percutaneous nephrolithotomy (PNL) is the preferred surgical therapy in these cases. Large, wide infundibula that permit easy passage of fragments increase the stone-free rate and overall success of SWL treatment for staghorn calculi.

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Media Gallery

Struvite and staghorn calculi. Plain abdominal radiograph demonstrating a right staghorn calculus and a smaller left renal pelvic stone. The patient is a 72-year-old woman.
Struvite and staghorn calculi. Plain abdominal radiograph of a 72-year-old woman. She underwent right percutaneous nephrolithotomy, with the path of renal access demonstrated by the remaining nephrostomy tube. She was rendered stone free in the single-session procedure.

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Author

Maxwell Meng, MD Associate Professor-in-Residence, Department of Urology, University of California, San Francisco, School of Medicine

Maxwell Meng, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Chi, MD Assistant Professor, Department of Urology, University of California, San Francisco, School of Medicine

Thomas Chi, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Western Section of the American Urological Association

Disclosure: Received honoraria from Bard Medical for speaking and teaching.

Marshall L Stoller, MD Professor and Vice Chairman, Medical Director of Urinary Stone Center, Department of Urology, University of California, San Francisco, School of Medicine

Marshall L Stoller, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AUA Journal of Urology<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus, .

Additional Contributors

Martha K Terris, MD, FACS Professor and Chief of Urology, Witherington Distinguished Chair, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia at Augusta University; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, Society of Women in Urology

Disclosure: Nothing to disclose.

Acknowledgements

Thomas Minor, MD Resident Physician, Department of Urology, University of California, San Francisco, School of Medicine

Thomas Minor, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

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