In situ extracorporeal shockwave lithotripsy of middle and lower ureteral stones: A boosted, stentless, ventral technique

Objectives: To assess the outcome of a boosted, stentless, ventral in situ extracorporeal shockwave lithotripsy (ESWL) of middle and lower ureteric stones using a shockwave head from the opposite side of the stone using a Lithostar Siemens lithotriptor for stones larger than average size and of longer duration in place. The purpose was to attain a high clearance rate in a short time thereby avoiding auxiliary procedures. Methods: A prospective study of 132 patients (134 stones) with middle and lower ureteric stones >6 mm in place for more than 2 weeks were treated with a Siemens Lithostar lithotriptor in the prone position with sedoanalgesia on an outpatient basis. No stents were planned ahead of treatment. The shock head from the opposite side of the stone transversing only through the soft tissue of abdomen and pelvis was used routinely. Localization was done using fluoroscopy and snapshots and intravenous contrast was given when needed. The boosted sessions were done on day 1 (S1), day 2 (B1), day 7 (S2) and day 14 (S3) when needed or till adequate fragmentation after any session, even the first one. This procedure was evaluated at the 6th week of management or at adequate fragmentation and clearance if before that time. Results: This study inlcuded 115 males and 17 females with a mean age of 47 +/- 15 and 53 +/- 11 years. Stone size defined as the longest stone diameter as measured in plain film of the abdomen was 0.75-2.6 cm with a mean of 1.1 cm. All but two stones were successfully fragmented. Only 12% needed interference for developing obstruction and/or complication during the planned treatment. 106 patients needed only SI or B1, 20 patients needed session 2, 6 patients needed session 3. Clearance was 43% by the 2nd day, 79% by the 7th day, 94% by the 14th day and 98.5% by the end of the 6th week. Conclusion: For larger ureteric stones a boosted stentless ventral shockwave lithotripsy for in situ middle and lower ureteric stones gave good results with short time clearance and without unusual side effects. The ventral application of shockwave from the opposite side was found more convenient with the Siemens Lithostar lithotriptor. We recommend this approach to be the initial procedure for middle and lower ureteric stones when they are larger than average, of longer duration and/or expected to be of harder texture as an outpatient procedure under sedoanalgesia to minimize the need for auxiliary procedures.