Table of Contents  
Year : 2020  |  Volume : 32  |  Issue : 3  |  Page : 113-116

Extracorporeal shock wave lithotripsy for bladder stones: Does it have any role in the modern endourology era?

Department of Urology, National and Kapodistrian University of Athens, Sismanoglio Hospital, Athens, Greece

Date of Submission23-Dec-2020
Date of Decision12-Jan-2021
Date of Acceptance22-Jan-2021
Date of Web Publication22-Feb-2021

Correspondence Address:
Theodoros Karagiotis
Department of Urology, Paediatric Urology and Urological Oncology, European Robotic Institute, St. Antonius Hospital Gronau
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HUAJ.HUAJ_20_20

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Bladder lithiasis accounts for around 5% of all urinary tract stones diseases with typical symptoms dysuria, hematuria, urgency and intermittent urination. therapy, percutaneous procedures, and open surgical treatments have been replaced by transurethral lithotripsy. The aim of this study is to investigate the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of vesical lithiasis. A total of 47 patients underwent ESWL for bladder calculi, using the electromagnetic Dornier Lithotripter S. Stone and prostate size as well as postvoid urine residual was determined with sonography. The success of the procedure was determined in the absence of stone fragments after 4 weeks. The mean age of patients was 69.1 years (34–93 ± 11.43) with a median prostate size at 50.1 cm3 (0–85 ± 15.81) and an average postvoid residual at 131 ml (50–190 ± 32.82). The mean size of lithiasis was found 1.97 cm (1–4.5 ± 0.79) and the median number of impact waves 2704.34 (1800–3000 ± 293.37) with the average duration of session 20.63 min (15–25 ± 2.63). Only two patients received analgesic treatment and the mean pain visual analog scale score was 1.73 (0–4 ± 0.98). The stone-free rate was found at 76.5% (36/47) and no severe complications (Clavien–Dindo >2) were observed. ESWL is a safe and efficient alternative for the management of vesical lithiasis, especially for high-risk patients that are not candidates for a more invasive treatment.

Keywords: Bladder calculi, extracorporeal shock wave lithotripsy, vesical lithiasis

How to cite this article:
Karagiotis T, Papatsoris A, Skolarikos A, Deliveliotis C. Extracorporeal shock wave lithotripsy for bladder stones: Does it have any role in the modern endourology era?. Hellenic Urology 2020;32:113-6

How to cite this URL:
Karagiotis T, Papatsoris A, Skolarikos A, Deliveliotis C. Extracorporeal shock wave lithotripsy for bladder stones: Does it have any role in the modern endourology era?. Hellenic Urology [serial online] 2020 [cited 2022 Nov 29];32:113-6. Available from:

  Introduction Top

Bladder lithiasis represents 5% of the total stone patients in the developed world.[1] In contrast with the upper tract, the urinary bladder serves as a temporary storage area for urine and its contents. Bladder outlet obstruction, for instance, benign prostate hyperplasia, or likely urinary infections can additionally worsen urine stasis, which can result in the increase of lithogenic factors inside the bladder. Bladder stone formation mainly depends on urinary pH and urine saturation.[2] The majority of the above-mentioned stones are mixed stones, with the struvite being a key ingredient when there is an infection.[3] Typical symptoms of vesical lithiasis are dysuria (mainly intermittent and painful urination) as well as final hematuria, with pain usually appearing more intense at the end of urination due to contact of the stone with the bladder neck. Patients experience urgency in 40%–50% of the cases, while intermittent urination is the second more prominent symptom in a rate of 30%–40%.[4] It is noteworthy that 50% of bladder stones are radiant and so plain radiography is not the diagnostic method of choice.[4]

Although a relatively recent prospective study has shown that the existence of bladder stone disease is not an absolute indication for surgical treatment of benign prostatic hyperplasia,[5] the management of obstruction and possible urinary infection remain important steps in its treatment. The aforementioned assumption could offer a potential role in a minimally invasive method that is easily tolerated by the patient, simple to use but at the same time effective especially for high-risk (for surgery) patients, such as extracorporeal shock wave lithotripsy (ESWL). The advantages of this modality are among others, no need for anesthesia, no need for bladder catheterization, and little or no stay in the hospital could make it an important 1-day operation for bladder lithiasis, if it was capable of removing the stone fragments (without requiring transurethral surgery) and if its efficacy was not so dependent on the stone size. The goal of our study is to test the efficacy and safety of shock wave lithotripsy for bladder stones and address its role in the modern urology era.

  Materials and Methods Top

From January 2014 to November 2019, 47 male patients with bladder lithiasis were subjected to ESWL at our department. Before treatment, a complete medical history, a complete physical examination, an electrocardiogram, a complete blood count and biochemical workup as well as a urinary culture were conducted. The diagnosis of lithiasis was carried out utilizing X-ray of the kidneys, ureters, and bladder (KUB), transabdominal ultrasound of the bladder, and in doubt cystoscopy. Stone and prostate size as well as postvoid urine residual was determined with ultrasound performed by an experienced radiologist. ESWL was performed without anesthesia and as an outpatient procedure if no complications were apparent. If necessary, the pain control was carried out using 50 mg of intravenous pethidine, whereas pain intensity was categorized according to the visual analog scale (VAS) score.[6] Exclusion criteria were coagulation abnormalities, positive urine culture, active urinary tract infection, history of urethral stenosis, and anatomical lower tract abnormalities. Multiple bladder stones over 5 cm and solitary stones under 1 cm were not included in the study. All patients signed a consent form before the intervention.

All operations were performed using the electromagnetic Dornier Lithotripter S (Dornier MedTech GmbH, Germany). This lithotripter includes an electromagnetic coil, which creates an electrical current within a membrane, which in its turn produces the shock waves. The gradual acceleration of the membrane produces pulsating waves which focus on the point of the stone with the help of an acoustic mirror. The opening of the elliptical mirror is 22 cm and the focal depth 14.5 cm. The pressure at the stone point varies from 27.8 to 84 MPa from 12 to 20 kV, respectively.[7] The impact waves were transferred to the patient through a pillow (filled with water) and as means of contact, an ultrasonic gel was used. The procedure started with 10% of its intense and gradually increased to 18 or 22 kV (ramping). The number of shock waves did not exceed 3000 for each treatment while the frequency was set at 80 waves per min. Patients were followed prospectively, with a KUB and an ultrasound of the bladder a week after ESWL. The success of the procedure was determined if there were no stone fragments inside the bladder in the follow-up period of 4 weeks. Complications were categorized according to the Clavien–Dindo system.[8] The statistical analysis was carried out using IBM SPSS v22 (IBM SPSS Statistics V22.0, IBM United States Software).

  Results Top

This study included 47 male patients. The average age of patients was 69.1 years (34–93 ± 11.43) and the mean body mass index 28.05 (21.67–34.89 ± 2.79). The median size of the prostate was found at 50.1 cm3 (0–85 ± 15.81) and the average postvoid residual at 131 ml (50–190 ± 32.82) [Table 1]. As for patient urination and symptomatology, the analysis highlighted an International Prostate Symptom Score (IPSS) value of 9.67 (7–14 ± 1.87) and an average Qmax of 12.42 ml/s (10–16.5 ± 1.71). Although most patients were diagnosed with only one stone, there were six patients with two stones, while the mean size of the lithiasis was 1.97 cm (1–4.5 ± 0.79) [Table 1]. Only six patients did not experience severe lower urinary symptoms before treatment, 17 patients were suffering from diabetes mellitus, eight patients were paraplegic, one patient suffered from Parkinson's disease, 1 carried a permanent catheter, and 1 performed intermittent catheterization. As for the history of previous urinary surgeries, five patients had previously undergone transurethral prostatectomy, 1 radical prostatectomy, and five patients ESWL for upper urinary tract stone. Finally, 11 patients were under treatment with the combination of a-blocker and a 5a-reductase inhibitor, eight patients only with a-blocker, and three patients have been prescribed anticholinergics.
Table 1: Baseline patients' characteristics

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The results of the intervention are shown in [Table 2]. The maximum number of sessions per patient was 2 (3 were submitted in a second session), the average number of impact waves was 2704.34 (1800–3000 ± 293.37) with average shock wave energy of 23.09 kV (22–24 ± 0.97) and average ESWL duration of 20.63 (15–25 ± 2.63). The mean time of radiation exposure was 2.54 min (1.5–3.5 ± 0.53). VAS score was 1.73 (0–4 ± 0.98) and only two patients received analgesic treatment. The success rate was found 76.5% (36/47), while the 11 remaining patients required additional transurethral surgery to remove residual fragments. Thirteen patients were treated with the transurethral treatment of benign hyperplasia. There were no severe complications Clavien–Dindo >2, while 25% of patients experienced mild hematuria or dysuria, which resolved without interference.
Table 2: Intra- and postoperative outcomes

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  Discussion Top

Bladder lithiasis has been known since antiquity with the majority of patients suffering from this disease to be male (due to benign prostate obstruction). Nevertheless, female patients can also encounter bladder calculi due to genital prolapse, female pelvic surgery, neurogenic bladder, or foreign bodies; there are reports concerning bladder migration of intrauterine devices and intravaginal accessories.[9] Calculus formation around the intravesical portion of tension-free vaginal tapes after anti-incontinence operations is well documented in the literature.[10] Irrespective of the etiology, many different management modalities have been developed throughout years, including conservative therapy,[4] open surgical treatment,[11] and percutaneous procedures,[12] but the above mentioned have been practically replaced by transurethral lithotripsy. The latter can be carried out with the use of appropriate lithotripters, either ultrasonic,[13] electrohydraulic,[14] or a combination of them (Swiss Lithoclast).[9] Recently with the development of laser technology, it has been implemented in the treatment of vesical lithiasis with holmium: YAG laser[15] and less frequently with Nd: YAG laser.[16] The outcomes of transurethral operations are excellent,[17],[18],[19] but anesthesia is required and the basic complications remain: bleeding, loss of good intraoperative visibility, increased surgical duration, postoperative infections, pain, and possibility of urethral trauma with subsequent urethral stricture, even though at reduced rates.[17],[18],[19]

Based on the above, a technique that would combine efficiency but also reduce or eliminate the above complications seems ideal. Especially for high-risk patients, where the anesthesia and the lithotomy position could be potential risk factors. ESWL was used in the treatment of vesical lithiasis in order to address these issues. There are only sparse data in the literature providing a low level of evidence for the use of ESWL in the management of vesical lithiasis and some of them report outcomes of past generation lithotripters. One of them studied 36 patients with bladder lithiasis utilizing the Dornier HM-4 lithotripter for their intervention. Authors report a 72% stone-free rate without reporting any complications.[20]

Bhatia and Biyani published their results with the use of Siemens Lithostar in 18 patients, with only two patients requiring more than one session in order to succeed full stone destruction. After the 1st week from the operation, it was reported a 100% stone-free rate, while the higher number of impact waves was 4500 with average time of ESWL being 55 min.[21] Similar outcomes were reported from three other relatively small studies.[22],[23],[24] In our study, a second session was required in only three patients while maintaining the lowest possible number of impacts (up to 3000), we accomplished a stone-free rate of more than 70% without serious complications (Clavien–Dindo >2).

It would be challenging the comparison of different lithotripsy techniques in order to test the efficacy of ESWL compared to the gold standard transurethral procedure. Comparison data are sparse and limited. Bhatia and Biyani compared mechanical transurethral lithotripsy transurethral resection (TUR) with ESWL in a total of 144 patients. Authors conclude that ESWL has several advantages over mechanical TUR lithotripsy, such as no need to carry out anesthesia, reduced hospital stay, and low complication rates.[25] Nevertheless, in the modern era, mechanical lithotripsy has a rather limited role due to increased rates of complications, which significantly reduces the impact of the outcomes of the above study. The same authors present corresponding results but adding a comparison with open surgery.[26] Although the study was heeded by considerable criticism for comparing ESWL with two of the less used and widespread methods – so possibly presents better outcomes[27] – it demonstrates the effectiveness and safety of the method and places it as a viable alternative to the established practice.

An important argument against the use of ESWL in the treatment of vesical lithiasis is its inherit inability to deal with the main co-existing causative factor, the benign prostatic hyperplasia which for many must be performed simultaneously in a single operation. However, this argument is not very popular and remains far from proven. In a recent study, Millán-Rodríguez et for, showed that only half of the patients with bladder lithiasis showed urodynamic findings of lower urinary tract obstruction and therefore a need for surgical treatment of the prostate adenoma.[28] Similarly, another prospective study showed that ESWL alone, not only led to 93% stone-free rates but also reduced the IPSS of patients by 8 points and significantly improved the quality of patients' life.[5] The latter study could lead to the conclusion that a significant proportion of lower urinary tract symptoms, in patients with vesical lithiasis, are a result of the stone disease and not the prostatic adenoma. This opens up potentially new horizons in the treatment of this disease by carrying out a combination of ESWL and medical treatment of prostatic hyperplasia, especially in high-risk patients.[29] In our study, only 13 were subjected to transurethral prostatectomy after treatment, in line with the findings of the available literature.

We acknowledge several limitations. First of all, the relatively small number of patients; however, we overcame this limitation following these patients prospectively. Second, all patients were male; however, this modality would be more effective to female patients. Furthermore, due to the short follow-up period, we may have missed stone recurrences. Another possible limitation is that we did not examine the composition of the stones and so we did not access the efficacy of ESWL in different types of stones. Finally, we accessed residual stone fragments with the aid of ultrasound and not cystoscopy and for that reason, we may have missed patients with small residual stones.

  Conclusions Top

ESWL is a safe and efficient alternative for the management of vesical lithiasis, especially for high-risk patients that are not candidates for a more invasive modality.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Millán-Rodríguez F, Izquierdo-Latorre F, Montlleó-González M, Rousaud-Barón F, Rousaud-Barón A, Villavicencio-Mavrich H. Treatment of bladder stones without associated prostate surgery: Results of a prospective study. Urology 2005;66:505-9.  Back to cited text no. 5
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  [Table 1], [Table 2]


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