Retrograde Intrarenal Surgery (RIRS) vs Extra Corporeal Shockwave Lithotripsy (ESWL)

Today we see lots of debate in the conference and seminar may be one of the most discussed topic on treating kidney stone with RIRS (fURS) vs. ESWL or mini-PCNL vs. RIRS (fURS). However at any point during the debate there is no emphasis on the technology by which shockwave is produced Electrohydraulic (EH) / Electromagnetic (EM) (most common technology of shockwave generation with few piezoelectric lithotripters). Since the maximum installations are of EH, they are cheaper than EM lithotripsy system. EH lithotripter have major market share.

It is not fair to compare RIRS with EH lithotripter. A fair trial would be to compare RIRS with USG guided ESWL on EM lithotripsy system. Today with such advancement in shockwave technology and better understanding of physics of stone fragmentation we fail to deliver results like HM3. One of the prime reason is we have left the therapeutic application in hands of Technicians and fail to take efforts to learn lithotripsy technology.

After all said we compare results of ESWL done by a technician or junior most residents. Technicians and junior residents who probably have never received any formal training on lithotripsy, they have learned on his own by trial and error basis to the results of RIRS which is done by a Surgeon and who has put his efforts to learn RIRS. A well trained and groomed Lithotripsy Technician will always deliver better results doing ultrasound guided ESWL on EM lithotripter when compared to RIRS with much lesser morbidity and financial burden on then patient and to the healthcare insurance provider.

Medical Shockwave was introduced long before it was used to treat stone disease. First Use of Shockwave Not many people know of..........

A patent application for the first shock wave generator to be used for the treatment of brain tumours was filed in the United States by F. Rieber as long ago as 1947. (click here to read more)

It started with soft tissue therapy and all the I need to say that today majority of the development and applications are in field of Shockwave Therapy.

USG guided SWL

Ultrasound guided SWL for lower ureteric calculus. 35 years old patient presented with dysuria. On investigation was diagnosed to have 24 mm right lower ureteric calculus.
Patient was treated with USG guided SWL. patient was given total of 3500 shockwaves under USG guidance.
Post SWL patient passed all the calculus fragments in 48 hours.

Treatment of kidney stone

All kidney stone below 20 mm can be treated with lithotripsy provided anatomy is favorable.

Investigation required prior to lithotripsy
1) Intravenous pyelography or CT Urography.
2) Urine culture and sensitivity.
3) Coagulation profile.

Results depends on type of lithotripay machine hence system should meeting following points.

1) Electromagnetic lithotripsy system.
2) Large focal zone (focal zone is area where energy ia delived)
-"IT IS MYTH THAT LARGE FOCAL CAUSES RENAL DAMAGE, IN FACT NARROW FOCAL ZONE MACHINE CAUSES MORE RENAL DAMAGE"
3) Dynamic viewing that is Ultrasound as imaging modality.
4) Energy ramping where sufficient number of energy level stepa are available to fragment stone.

If above this are fullfilled you stone is will definitely be cleared.

"IT IS NOT ONLY DOCTOR BUT SYSTEM COMTRIBUTES TO 75% When lithotripsy is advised. "

Inside Kidney Stone Disease

Treating Upper pole calculus with lithotripsy

If you come across a stone in Upper pole with rib overlying the stone. How will you treat such stones with lithotripsy? what to direct shockwave without damaging rib?
9 out of 10 Urologist would fail in such cases.
Some special skills are required how to do that. watch out.

Approach to treat ureteic calculus.

Direction of shockwave entry is most important as far as results and injury to the organ is concerned.

According to me the best direction to treat the Urinary stone disease is retroperitoneal (Posterior) approach for renal and upper ureteic calculus.

As illustrated in the diagram if we have anterior or transperitoneal (Anteriror) approach for ureteric calculus changes of intestinal injury is high. Ureter being retroperitoneal organ, its advisable that shockwave axis is retroperitoneal and not laterally or anteriorly.

Second energy and frequecy for ureteric stone is high, which can lead to more damage to abdominal organ in anterior approach of shockwave.

"ALWAYS USE POSTERIOR APPROACH IF YOU ARE TREATING URETERIC CALCULUS."