|Year : 2007 | Volume
| Issue : 2 | Page : 200-205
|Comparison of the Effect of Body Position, Prone or Supine, on the Result of Extracorpreal Shock Wave Lithotripsy in Patients with Stones in the Proximal Ureter
Afshar Zomorrodi, Amirreza Elahian, Nematollah Ghorbani, Anahita Tavoosi
Urology Transplant ward, Imam Hospital, Tabriz, Iran
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| Abstract|| |
The aim of this study was to determine whether positioning of the patient, prone or supine, plays a significant role on the treatment of stones in the proximal ureter with extracorporeal shock wave lithotripsy (ESWL). 68 patients with proximal ureteric stones underwent ESWL. The procedure was performed in the supine position in 35 (Group 1) and the prone position in 33 patients (Group 2). Stone-free rates, repeat ESWL rates, shocks per patient and shocks per session were compared in both groups. The mean session number per patient was 1.93 ± 0.82 in Group 1 and 1.88 ± 0.79 in Group 2 (P = 0.786). The stone-free rates, three months after ESWL, were 81.8% in Group 1 and 82.9% in Group 2 (P = > 0.05). Thus, these two parameters were similar in both Groups. Also, the number of shocks per session was 3066.1 ± 346.3 in Group 1 and 3148.5 ± 621.0 in Group 2. This difference was nonsignificant (P = 0.49). Our study suggests that the treatment of proximal ureteric stones with ESWL in the prone position is as safe and effective as when the patient is placed in the supine position.
Keywords: Extracorporeal shock wave lithotripsy, Supine position, Prone position, Ureteric stone,
|How to cite this article:|
Zomorrodi A, Elahian A, Ghorbani N, Tavoosi A. Comparison of the Effect of Body Position, Prone or Supine, on the Result of Extracorpreal Shock Wave Lithotripsy in Patients with Stones in the Proximal Ureter. Saudi J Kidney Dis Transpl 2007;18:200-5
|How to cite this URL:|
Zomorrodi A, Elahian A, Ghorbani N, Tavoosi A. Comparison of the Effect of Body Position, Prone or Supine, on the Result of Extracorpreal Shock Wave Lithotripsy in Patients with Stones in the Proximal Ureter. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Nov 18];18:200-5. Available from: http://www.sjkdt.org/text.asp?2007/18/2/200/32310
| Introduction|| |
Since the initial application in 1980, the indications for the use of extracorporeal shock wave lithotripsy (ESWL) have rapidly extended from stones in the kidney to stones in almost the entire urinary tract. Extracorporeal shock wave is the least invasive and most widely accepted form of treatment for ureteric stones.,,,, In situ ESWL has been shown to be effective for ureteric stones at all levels., The least invasive procedure, urgent in situ ESWL, appears to be the preferred treatment option for ureteric stones associated with obstruction. Chang et al. reached a similar conclusion for upper ureteric stones, causing varying degrees of obstruction. The AUA guidelines state that ESWL and ureteroscopic lithotripsy (ULT) are both acceptable choices for stones of < 1 cm in size located in the distal adult ureter. Stone clearance after ESWL can vary and is influenced by stone size, location, chemical composition and type of lithotripter. The success rate of ESWL is reportedly inversely proportional to stone size. It has been reported that ESWL with the patient in prone position is a safe and effective form of treatment for calculi in the distal ureter. ESWL has become the favored treatment for most urinary tract stones. Overall stone-free rates after ESWL vary from 50 to 87% , depending on many factors affecting the overall success rate. Coz et al. analyzed the outcome of ESWL according to site in 2016 urinary tract stones. Stone-free rates for lower calyceal stones and upper or iliac ureteral stones are lower than the overall stone-free rate. After disintegration, the clearance of fragments depends upon their location. Successful ESWL is usually defined as being stone-free, three months after treatment. Residual fragments larger than 5 mm in diameter are generally considered a failure of the ESWL session. If the residual fragments are between 1 and 4 mm in size in an asymptomatic and un-infected patient, they are likely to be cleared spontaneously. Elevated serum calcium was found to influence the outcome of ESWL adversely. Elevated urinary excretion of citrate was found to be positively associated with stone clearance.
The Body mass index (BMI) is a nonurological patient factor that influences the outcome of ESWL.,[ 18],  Obesity may cause difficulty in imaging and placement of the calculus at the shock wave focal point. The best chance for successful ESWL was found in patients with a BMI of 20 to 28. Consistent with this, Robert et al  found patients with a BMI > 25 as having significantly deeper urinary calculi and a worse outcome after ESWL.
Stones located in the bony pelvis were not originally amenable to ESWL. However, Jenkins  et al reported that some modifications in patient positioning, such as placement in the prone position, allowed for successful fragmentation.
In this study, we decided to evaluate the influence of patient body positioning, prone or supine, on the success of treatment of patients with ureteric stones using ESWL in our center.
| Materials and Methods|| |
The study included 68 patients with solitary upper ureteric stones treated with ESWL. It was conducted between November 2003 and July 2004 at The Imam Hospital, Tabriz, Iran. 33 patients were placed in the supine position during lithotripsy, while the remaining 35 were in the prone position. Excretory urography and/or plain abdominal X-ray were used to confirm the location of the stone. Upper ureteric stones were defined as stones located between the ureteropelvic junction and pelvic brim. Patients with stones in other parts of the urinary system, and those with stones smaller than 10 mm or larger than 20 mm were excluded from the study.
The two groups were established as follows: If stone targeting in the supine position was possible, the patient was assigned to be treated supine (Group one) .If the stone targeting was not possible in the supine position, the patient was assigned to be treated prone (Group two). The ESWL device used was lithostar with Xray control for targeting. Two weeks after ESWL, a plain X-ray of the abdomen was taken to assess stone fragmentation. If no stone or fragments were detected at this stage, the patient was considered to be stone-free and was asked to return three months later for a repeat X-ray. If the film revealed any stone material, ESWL was repeated and the patient was radiographed two weeks later. This system was repeated three times.
In each patient, the stone size, number of shockwaves applied per treatment and number of sessions required to achieve stone-free status were recorded. Stone size was registered as the maximum diameter measured on a plain abdominal film. The number of shockwaves per treatment was established by dividing the total number of shockwaves received by the patient by the number of sessions required to become stone-free. Treatment failure was defined as radiologically confirmed persistence of the stone with no fragmentation after three ESWL sessions.
The results were analyzed statistically using a Student's t-test and chi-square test. P< 0.05 indicated statistical significance.
| Results|| |
Of the 68 patients included in this study, 47 were male (69.1%) with an age-range of 18 to 81 years and 21 were female (30.9%) aged 24 to 78 years. The mean ages of the patients in supine and prone groups were 46.0 and 43.6 years, respectively. Overall, 56 of the patients (82.3%) became stone-free after ESWL; in the remaining 12 (17.7%), ESWL failed to clear the stones. The rate of stone-free status in the prone group was 82.9% and the corresponding rate in the supine group was 81.8%. There was no significant difference between the two groups. (P=0.91).
Patients in both groups had minor complications, such as self-limiting hematuria, dysuria and pain that responded to oral analgesics. None of the patients required hospitalization or placement of a ureteric catheter or a JJ stent.
The stone was 10-15 mm in size in 55 patients (80.8%) and > 15 mm in 12 (19.2%). The mean stone size in the prone and supine groups was 13.6 and 12.8 mm, respectively. The number of sessions necessary to achieve stone-free status was similar in the prone (1.8 ± 0.7) and supine (1.9 ± 0.8) groups (P=0.78). The mean number of shock waves applied per treatment in the prone group (3148.5 ± 621.0) was not significantly different from that in the supine group (3066.1 ± 346.3).(P=0.95)
Comparison of the results of the two groups using the Chi-Square test did not show any significant difference between them.
| Discussion|| |
The treatment of urinary lithiasis has been transformed in the last 15 years, with the advent of ESWL.,, ESWL is widely accepted today, despite the initial skepticism expressed by many urologists when Christian Chaussy, an unknown young urologist from Germany, first presented the innovative technique for fragmenting renal stones extracorporeally in 1980. 
It is believed that there are about 5500 lithotriptors throughout the world, with more than one third of them practicing in Europe. In 1998, two million ESWL treatments were performed. ESWL is safe and effective in about 98% of patients., Nevertheless, controversy still exists concerning the longterm complications and whether ESWL actually reduces relapses.,
Lumbar ureteric stones are stones that exist in the upper ureter, which lies between the iliac crest and the ureteropelvic junction. Ureteric stones located above the iliac crest are primarily amenable to treatment with ESWL. Ureteric stones treated in situ give a success rate no higher than 75%; however this rises to 90% after manipulation of the stone.,,,
Since the introduction of ESWL by Chaussy in 1980, the therapeutic strategy for urolithiasis has completely changed. In 1986, Newman et al. presented the first reports on ESWL in children. Since then, numerous reports have been published on the safety and efficacy of ESWL in children.,[ 32]
Currently, the primary method for treatment of symptomatic urolithiasis is ESWL. However, clinicians argue about the position of patients (supine or prone) during ESWL. Some authors believe that supine positioning is cost effective,  has low morbidity  and prone positioning carries the risk of small intestinal perforation. On the other hand, some authors are in favor of prone positioning.,,,,,
In their study of 96 patients, Goktas et al observed that patients tolerated supine positioning better, in general. In their report, the mean number of sessions per patient was 1.64 +/- 0.75 in the supine group and 1.33 +/0.59 in the prone group (p = 0.224). In this study, the stone-free rates three months after ESWL were 88.3% in the supine group and 90.6% in the prone group. The difference between the results was statistically nonsignificant (p < 0.05). Similarly, in our study, we could not find any significant difference in outcomes of ESWL in prone and supine positions. Also, treatment of proximal ureteral stones with lithostar devices in the prone position was not associated with any significant complications.
A limitation of the study was that stone composition was not considered. Also, 17.6% of the present patients who had ESWL underwent some ancillary procedures to become stone-free; an impacted stone was the most frequent reason for failure in these cases.
| Conclusion|| |
Treatment of proximal ureteral stones by ESWL in the prone position is safe and as effective as that in the supine position.
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Associate Professor Urology Transplant ward Imam Hospital, Tabriz
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