Do you think shock wave lithotripsy should be retired?

Author(s):

Despite ureteroscopy's high success results, there is still a role for shock wave lithotripsy in treating stones, urologists say.

Dr. Conlin“It’s a complicated issue. The numbers for ureteroscopy have increased dramatically since I started my practice, so it’s kind of happening whether we want it to or not.

Ureteroscopy has superior results to shock wave lithotripsy, and it’s improved over the years due to the improvement in ureteroscopes and the holmium laser and improved techniques. But shock wave lithotripsy still has reasonably good results and fewer complications for the patient, primarily related to not having to have a ureteral stent. It works well for a lot of patients, so it’s not something that should go away.

The funny thing is that I never really did shock wave lithotripsy. I trained with Dr. Demetrius Bagley, one of the founding fathers of ureteroscopy, so I was confident in my ability to treat patients ureteroscopically very early in the holmium laser era, and never felt as confident using shock wave lithotripsy. I’ve done thousands of ureteroscopies, but probably only a half-dozen shock wave lithotripsies. I’ve been arguing in favor of ureteroscopies for many years, but looking at the big picture I would say ESWL still serves many patients very well. Patient satisfaction is very high with it, and it shouldn’t be retired completely-even if I haven’t done one in more than a decade.

I’m better able to get patients stone free with ureteroscopy, so although they may have less discomfort with ESWL, the result will be better. But some urologists are still more comfortable with ESWL, and the instruments for ureteroscopy aren’t always available. Thinking about it more globally, we don’t want to remove a tool from our armamentarium.”

Michael Conlin, MD

Portland, OR

Next: “I think there’s still a big role for ESWL."

“I think there’s still a big role for ESWL, and not all stones are appropriately treated with ureteroscopy, nor percutaneously. So I think shock wave lithotripsy still has a big role in treating stones.

Also see: Difficult stones present treatment, training challenges

Ureteroscopy is so much more labor intensive for both the patient and the doctor, and more expensive overall for treating bigger stones. I don’t think ESWL is always appropriate. I think lithotripsy has to be used correctly. I think there are cases where it’s clearly the best thing to do.

We do everything. I do a lot of ureteroscopy, a lot of flexible ureteroscopy. We also do percutaneous surgery so we have everything available, but for appropriate patients, I think ESWL is still going to be first-line treatment for things like kidney stones that are less than 2 cm, especially if they’re not obstructing, or upper ureteral stones. I prefer ureteroscopy for ureteral stones, but ESWL has a place for stones in the kidney.

Read: What drives unplanned returns post-URS lithotripsy?

If I give a patient the choice between putting a scope up there and stent for 5 days and then taking the stent out, or an ESWL without a stent and having to pass the stone, I think most of them would rather try ESWL. I don’t think anyone would argue that ESWL would not have a role in kidney stones.”

John Benedict, MD

Cincinnati

Next: "You have to customize treatment to the patient."

Dr. Choe“Absolutely not. A lot of patients are benefiting from lithotripsy, and some people do not want invasive treatments for stones. For different stone sizes and locations, treatment options vary. My success rate for ureteroscopies is greater than 97% over the last 23 years; however, for upper ureteral stones and stones that are near the kidneys, some patients prefer to try shock wave lithotripsy as a first choice. The success rate for lithotripsy is somewhere between 80% and 90%-higher with the smaller stones, and some people are happy with that if they don’t have to be treated invasively.

Risks can be higher with ureteroscopies, especially going up the proximal ureter or the virgin ureter, with a ureteroscope; obviously, there is a risk of injury, perforation, and so forth.

You have to customize treatment to the patient. You can’t do everything the same way for everyone. We’ve been doing lithotripsies for more than 30 years and people benefit from them.

You can't throw everybody into one corner and do everything the same way. Young people coming out don't know how to do open procedures; they want to do things the modern way. We don’t want to lose the skills we have. You need to know every skill that's possible because there will be a time where it will get you out of trouble.”

Eric Choe, MD

Fairfax, VA