ESWL IN LARGE PELVIC CALCULUS: EXCELLENT RESULTS IN SELECT CASES

A 30 year old lady presented with left flank pain on and off.On investigation she was found to have a large calculus 21 mm in renal pelvis( USG and X Ray).
She was offered the option of PCNL but she was reluctant for the same.We offered her ESWL with DJ stenting and explained her the possible need of PCNL ( in case of non fragmentation), RIRS and multiple sessions of ESWL.

We did ESWL and there was excellent fragmentation on real time imaging obviating any need of secondary procedures.
We take into consideration certain aspects like... body habitus , stone location ande density as compared to nearest bony landmarks etc.

The X Ray characteristics of the stone can give a fair idea to the treating urologist about the stone fragmentation chances after ESWL.

We have seen that the pelvic stone, irregular stone, stone having a density less than tip of the 12th rib; if these criteria are met then even a borderline stone for PCNL also we have taken up for ESWL and got excellent results.We keep stent in all big stones for ESWL. If stone doesn't get cleared totally we do secondary  RIRS.

....

Mete UK, Naveen A. Ranagnathan P et al. Can X-ray KUB replace costly CT density measurement of renal stones to predict fragmentation buy ESWL? J. Endourol. (Abstract) 2004, 18 (Suppl) A-110.

There are certain protocols we follow :

1) we ensure good sedation/anesthesia: for effective administration of optimum shock waves ; the patient needs to be totally comfortable.Any compromise in intensity can  affect the outcome and add the morbidity of secondary /auxiliary procedures like second/third session of ESWL,PCNL or RIRS.

2)We ensure pre-operative antibiotics,  sterile urine culture and bowel preparation

3)The stone is continuous focussed on real time imaging and the whole procedure is continuous monitored by Urologist.This goes a long way in achieving good fragmentation and pulverisation. The failure of ESWL may not be always because of the hard stones ; it can sometimes because of losing focus, failure to continuously monitor the stone pulverisation.

Dornier machine what we possess has excellent and proven results  even in bigger calculi...

if properly done we can avoid the auxiliary/invasive procedures...This is an excellent data of how Dornier machine can clear even bigger calculi.

 Stone free rates based on stone size and location for ESWL of solitary kidney stones, using Methodist Hospital's Dornier HM3 Lithotripter

Stone location and size	0-10 mm	11-20 mm	21-30 mm
Pelvis	316/351 (90%)	225/272 (83%)	48/59 (81%)
Upper Calyx	53/69 (77%)	21/28 (75%)	8/12 (67%)
Middle Calyx	61/76 (80%)	12/17 (71%)	1/2 (50%)
Lower Calyx	253/317 (80%)	60/103 (58%)	6/19 (32%)