Lithotripsy

Uses

Lithotripsy is a sometimes non-invasive procedure used to break up hardened masses like kidney stones, bezoars or gallstones.

Contraindications

Commonly cited absolute contraindications to shock wave lithotripsy (SWL) include pregnancy, coagulopathy or use of platelet aggregation inhibitors, aortic aneurysms, severe untreated hypertension, and untreated urinary tract infections.

Techniques

• Extracorporeal shock wave therapy (lithotripsy)
• Intracorporeal (endoscopic lithotripsy):
  • Laser lithotripsy: effective for larger stones (2 cm) with good stone-free and complication rates.
  • Electrohydraulic lithotripsy
  • Mechanical lithotripsy
  • Ultrasonic lithotripsy: safer for small stones (

History

Surgery was the only method to remove stones too large to pass until French surgeon and urologist Jean Civiale in 1832 invented a surgical instrument (the lithotrite) to crush stones inside the urinary bladder without having to open the abdomen. To remove a calculus, Civiale inserted his instrument through the urethra and bored holes in the stone. Afterwards, he crushed it with the same instrument and aspirated the resulting fragments or let them flow normally with urine.

Lithotripsy replaced using lithotrites as the most common treatment beginning in the mid 1980s. In extracorporeal shock wave lithotripsy (ESWL), external shockwaves are focused at the stone to pulverize it. Ureteroscopic methods use a rigid or flexible scope to reach the stone and direct mechanical or light energy at it. Endoscopy can use lasers as well as other modes of energy delivery: ultrasound or electrohydraulics.

ESWL was first used on kidney stones in 1980. It is also applied to gallstones and pancreatic stones. External shockwaves are focused and pulverize the stone which is located by imaging. The first shockwave lithotriptor approved for human use was the Dornier HM3 (human model 3) derived from a device used for testing aerospace parts. Second generation devices used piezoelectricity or electromagnetism generators. American Urological Association guidelines consider ESWL a potential primary treatment for stones between 4 mm and 2 cm.

Electrohydraulic lithotripsy is an industrial technique for fragmenting rocks by using electrodes to create shockwaves. It was applied to bile duct stones in 1975. It can damage tissue and is mostly used in biliary tract specialty centers. Pneumatic mechanical devices have been used with endoscopes, commonly for large and hard stones. Pneumatic lithotripsy has also been successfully applied in the treatment of salivary stones during sialendoscopy, offering a minimally invasive alternative for large or impacted calculi while preserving the salivary duct anatomy.

Laser lithotripsy was introduced in the 1980s. Pulsed dye lasers emit 504 nm (cyan-colored) light that is delivered to the stone by optical fibers through a scope. Holmium:YAG lasers were developed more recently and produce smaller fragments.

Endovascular lithotripsy is an angioplasty procedure using a balloon internally fitted with an ultrasound generator. It can be used in the reduction of very calcified coronary arteries, with or without the combined usage of stents.Hill JM, Kereiakes DJ, Shlofmitz RA et al. Intravascular lithotripsy for treatment of severely calcified coronary artery disease, J Am Coll Cardiol, 2020;76: 2635-2646

References

References

1. Königsberger R, Feyh J, Goetz A, Kastenbauer E. Endoscopically-controlled electrohydraulic intracorporeal shock wave lithotripsy (EISL) of salivary stones. J Otolaryngol. 1993 Feb;22(1):12-3
2. (October 2018). "Indications and contraindications for shock wave lithotripsy and how to improve outcomes". Asian Journal of Urology.
3. (August 2023). "Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones". The Cochrane Database of Systematic Reviews.
4. (October 2012). "Flexible ureteroscopy and laser lithotripsy for stones >2 cm: a systematic review and meta-analysis". Journal of Endourology.
5. "Extracorporeal Shock Wave Lithotripsy (ESWL) for Kidney Stones". WebMD.
6. (March 2011). "The natural history of renal stone fragments following ureteroscopy". Urology.
7. (March 2022). "A Novel Approach for the Treatment of Sialolithiasis that Preserves Salivary Duct Anatomy". Ann Otol Rhinol Laryngol.
8. Brinton TJ, Ali ZA, Hill JM et al. [https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.036531 ''Feasibility of shockwave coronary intravascular lithotripsy for the treatment of calcified coronary stenoses''], Circulation, 2019;139:834-836
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10. (December 2008). "Persimmon bezoar successfully treated by oral intake of Coca-Cola: a case report". Cases Journal.