ESWL FAILURE: HOW MANY SESSIONS WE SHOULD REPEAT

A 50 year old gentleman came with one proximal ureteric calculus and two calculi in the middle and inferior calyx respectively. He was given an option of URS and PCNL but refused PCNL for the fear of undergoing an invasive surgery. He opted for ESWL; we was counselled for the need of multiple sessions and need of an auxilliary procedures like RIRS and PCNL in the event of the failure of the ESWL. We treated him with two sessions of ESWL( We have Dornier alpha machine - a state of art technology and we delivered 4000 shocks at the optimal intensity) ; the stones were fragmented but did not clear.They were scattered in all calyces.

He was then counselled for PCNL ; a midposterior calyceal approach was done and a two step

CT DENSITY GIVES AN IDEA ABOUT LIKELY STONE FRAGMENTATION; WE AVOID ESWL ABOVE 1500 H.U.   

THE ESWL SUCCESS CAN BE JUDGED WITH XRAY KUB:IF THE STONE LOOKS DENSER THAN THE 12 TH RIB TIP THEN PCNL IS A BETTER MODALITY

OUTCOME OF TWO SESSIONS OF ESWL: ALL RESIDUAL FRAG,MENTS IN DIFFERENT CALYCES

Dilatation technique was performed( first step a screw dilator and the second step 24 Fr dilator with Amplatz sheath).All scattered calculus fragments were cleared.

We as a rule follow ESWL sessions upto two times then declare the stone to be ESWL refractory and go ahead with RIRS or PCNL as per the bulk of the residual fragments.A second ESWL failure means that any further session also is bound to fail so an invasive procedure will clear the calculus once for all rather than subjecting the patients for mental and physical agony of repeated ESWL sessions.