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Surg Endosc (2011) 25:943946

DOI 10.1007/s00464-010-1291-8

NEW TECHNOLOGY

How effective is extracorporeal shock wave lithotripsy of ureteral


stones with Dornier Lithotripter S EMSE 220F-XXP?
A prospective and preliminary assessment
Maria Chiara Sighinolfi Salvatore Micali
Stefano De Stefani Giovanni Alberto Pini
Massimo Rivalta Filippo Cianci Giampaolo Bianchi

Received: 15 August 2009 / Accepted: 27 February 2010 / Published online: 16 September 2010
Springer Science+Business Media, LLC 2010

Abstract Keywords Urology  Instruments  Technical


Aim To report our preliminary series with the Doli S
EMSE 220F-XXP, the upgraded version of the previous
Dornier Lithotripter S EMSE 220, for treatment of ureteral Management of urolithiasis was revolutionized by the
stones. introduction of extracorporeal shock wave lithotripsy
Methods Since July 2006, a total of 200 patients with (SWL) by Chaussey et al. in the early 1980s [1]. Pre-
ureteral stones were submitted to shock wave lithotripsy liminary results were very encouraging, with stone-free
(SWL) with Doli S EMSE 220F-XXP. Mean stone size was rates ranging from 72 to 90% [2]. The success of the HM3
9.3 mm (range 618 mm). Ureteral stone location was machine (Dornier Medical Systems, Wessling, Germany)
proximal in 75, middle in 34, and distal in 91. Follow-up led the way for additional research and significant inno-
was carried out at 6 weeks after the treatment, by means of vations. Further technological changes involved the
kidneyureterbladder (KUB) film and ultrasound, or shockwave source, the diameter of the focal zone, stone
helical computed tomography (CT). localization, and coupling techniques [3]. The results of
Results The overall stone-free rate was 89.5%, and the those newer-generation lithotripters have not always been
effectiveness quotient was 80. Stratifying by stone site, the able to match previous results, and limitations of extra-
stone-free rate was 93.3, 67.6, and 94.5% for proximal, corporeal SWL (ESWL) treatment have been identified. In
middle, and distal location, respectively. Mean number of this setting, although SWL is still recommended as a first-
sessions per patient was 1.14. Analgesia with intravenous line treatment for proximal ureteral calculi less than 10 mm
ketorolac or tramadol was required in 42.5% of cases. No in size, its outcomes for middle and distal ureteral stone
significant side-effects were recorded. location are disappointing [4]. Since 2005, a number of
Conclusions The new Doli S EMSE 220F-XXP provides reports about upgraded prototypes, such as the Dornier
similar characteristics to the Doli S EMSE 220 in terms of electromagnetic emitter XP and XXP, have progressively
safety and lack of major complications, when dealing with appeared [5, 6], in which decreased focal zone and
ureteral stones; the improvement in stone disintegration is increased focal pressure aim to achieve better stone
particularly evident for distal location, for which the disintegration.
number of pulses and the intensity of treatment can be We report our preliminary experience on 200 patients
greatly increased and the upgraded power of the device can with ureteral stones treated with the Dornier Lithotripter S
be widely applied. EMSE 220F-XXP (Dornier MedTech Europe GmbH,
Germany).

M. C. Sighinolfi (&)  S. Micali  S. De Stefani  Materials and methods


G. A. Pini  M. Rivalta  F. Cianci  G. Bianchi
Department of Urology, University of Modena and Reggio
Emilia, Modena, Italy Since July 2006, when the upgraded Doli S EMSE 220F-
e-mail: sighinolfic@yahoo.com XXP was set up at the Urologic Unit of the University of

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Modena and Reggio Emilia, we have enrolled in a pro- Table 1 Outcomes stratified by stone location in terms of stone-free
spective observational analysis all patients affected by rate and effectiveness quotient (EQ)
ureteral stones. Routine urine, culture, serum creatinine, Stone location Stone-free rate at 3 weeks EQ
and coagulation profile investigations were carried out in
Proximal ureteral 93.3% (70/75) 87
all subjects according to hospital protocols; stone size and
location were assessed by KUB X-ray and ultrasound, or Middle ureteral 67.6% (23/34) 60
helical CT scan. Distal ureteral 94.5% (86/91) 89
Inclusion criterion was presence of a single ureteral
stone up to 18 mm in size, independent of location along
the ureter. Exclusion criteria were as follows: (1) urinary was easily obtained with intravenous ketorolac or tramadol
tract infection and/or fever, urinoma, (2) presence of ure- injection. Except for 21 cases requiring auxiliary proce-
teral stent, (3) body mass index [30 kg/m2 or (4) general dures (in all cases, endoscopic extraction), no significant
SWL contraindications (pregnancy, uncorrected coagula- side-effects were recorded.
tion disorders). Patients were submitted to SWL with the
Dornier Lithotripter S EMSE 220F-XXP, and all treat-
ments were performed by a single operator. Follow-up was Discussion
carried out 6 weeks after the treatment, by means of KUB
film and ultrasound, or helical CT. In all subjects, interim Since its introduction, advances in SWL technologies have
renal ultrasound assessment was performed 23 weeks aimed to improve its safety as a noninvasive procedure,
after the treatment, to avoid the risk of undiagnosed with outpatient basis, low analgesia requirement, and low
hydronephrosis. morbidity being typical of third-generation lithotripters.
Stone-free rate (defined by complete absence of residual However, to date the Dornier HM3 has been considered the
fragments), number of SWL sessions per patient, analgesia gold standard in terms of stone fragmentation and overall
requirements, and complications were prospectively outcomes. Due to the reduced efficacy of second- and third-
recorded. generation lithotripters, the current attitude is to replace
SWL by endoscopic approach, due to a concomitant
improvement in both endoscopic equipment and surgical
Results skills.
In 2007, the European and American Urological Asso-
Two hundred patients (mean age 51.4 years, range ciation (EAU and AUA) Nephrolithiasis Panel performed a
1987 years) were considered and elected to receive systematic review of the English-language literature about
ESWL. One hundred fifty-five of them had their treatment treatment of ureteral stones published since 1997 [4].
within 23 weeks from renal colic onset. Mean stone size Based upon those findings, SWL seems to be more effec-
was 9.3 mm (range 618 mm). Ureteral site was upper in tive than uretereroscopy only in cases of proximal ureteral
75, middle in 34, and distal in 91. Focusing was obtained stones of less than 10 mm; for other locations and stone
with fluoroscopy in 172 patients, with echographic moni- sizes, endoscopic approach is considered the most effec-
toring for upper and distal location; the remaining stones tive [4].
were focused with ultrasound, and consisted of completely These findings will be challenged by the introduction of
radiolucent calculi. An average of 3,000 shock waves was new-generation lithotripters. Since 2005, preliminary
delivered, except for upper ureteral stones, for which reports about new prototypes have progressively appeared;
2,8002,900 pulses were administered. Progression of at that time, the Doli S EMSE 220F-XXP was already
power to the maximal tolerable dose was incremental [7]. considered a promising device, and it has been considered
In all cases, 6070 pulses per minute were applied, a possible new gold standard beyond the HM3 [5, 6]. Other
according to the most recent literature [8]. The overall novel lithotripters have been described in recent years, such
stone-free rate was 89.5% (179/200), and the effectiveness as the Siemens Lithoskop or the Modulith SLX-F2 [9, 10];
quotient (EQ) was 80. Twenty-seven patients required outcomes on ureteral stones reported by Tiselius are par-
repeated treatments (maximum three treatments), for an ticularly significant, as the author described an overall
overall mean number of sessions per patient of 1.14. In stone-free rate of 97% [10]. The first published series about
case of SWL failure (21 cases), patients were successfully Dornier enhanced prototypes dates back to 2006, consisting
submitted to ureteroscopy and endoscopic lithotripsy. of the initial experience with the EMSE XP, which resulted
Table 1 reports outcomes stratified by stone location, in in 67% global EQ [11].
terms of both stone-free rate and EQ. Eighty-five patients The upgraded Doli S EMSE 220F-XXP represents a
(42.5%) required analgesia during the treatment, which further improvement in SWL progress. Since July 2006, the

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Surg Endosc (2011) 25:943946 945

standard Dornier Lithotripter S at our institution has been invoked as an effective tool to manage both pain and
equipped with this novel emitter, and we have performed obstruction [1719]. When performed soon after renal
more than 1,300 treatments to date. Herein we report colic, ESWL can be considered an effective treatment. As
prospective efficacy assessment of in situ SWL in 200 confirmation, the five cases of failure in the distal ureter
patients affected by ureteral stones. Follow-up was carried consisted of stones impacted in their site for more than
out 6 weeks after treatment by means of KUB film and 46 weeks [17, 18].
ultrasound, or helical CT, the choice being based upon Based upon other findings and European Association of
stone radiodensity, patient age, and obstruction degree. In Urology (EAU)/American Urological Association (AUA)
fact, routine use of noncontrast CT to detect ureteral stones guidelines [4, 19], routine ureteral stenting is not recom-
is still subject to debate, as collimation thickness and the mended as part of SWL, since overall outcomes showed no
arbitrary choice of multiplying reconstruction may affect improved fragmentation with stenting prior to treatment.
outcomes [12, 13]. Given these limitations, we believe that Based on those statements, with upgraded lithotripters such
the tools and the timing we applied can be considered an as that discussed herein, SWL can still be considered a
adequate choice to detect residual or persisting stones and/ first-line treatment for ureteral stones.
or their signs.
Herein, we report an overall stone-free rate and EQ of
89.5 and 80%, respectively. The current EQ seems to be Conclusions
higher than that described in our previous experience with
the Doli S EMSE 220 (EQ 57.1 for ureteral stones) [14]. Although the unmodified Dornier HM3 is considered the
Middle ureter continues to be one of the most challenging gold standard in terms of efficacy, third-generation litho-
locations (EQ 60); fluoroscopic focusing, which is man- tripters provide added advantages, such as lack of need for
datory for this site, may be difficult in several conditions, anesthesia, outpatient basis, and low morbidity. The Dor-
i.e., stones projecting in front of the sacroiliac joint, nier Lithotripter S EMSE 220F-XXP shows improved
residual fecal air and content, or pathological body mass effectiveness, especially when considering low retreatment
index (BMI). rate and need for auxiliary procedures. Those characteris-
The present series confirms the role of SWL for proxi- tics, together with the safety typical of third-generation
mal ureteral stones, with 93.3% stone-free rate and EQ of lithotripters, make it a novel device potentially challenging
87. However, the most remarkable topic is the treatment of the previous gold standard.
distal ureteral stones. When describing the results with the
previous Doli S EMSE 220, we reported a stone-free rate of Disclosures Authors Maria Chiara Sighinolfi, Salvatore Micali,
Massimo Rivalta, Giovanni Alberto Pini, Filippo Cianci, Stefano De
83.3% for this location, considering stones 415 mm in Stefani, and Giampaolo Bianchi have no conflicts of interest or
size [14]. The use of the new Doli S EMSE 220F-XXP led financial ties to disclose.
to pioneering outcomes for the distal ureter location, with
higher stone-free rate and EQ. One possible explanation
may be the extensive application of enhanced effective References
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