Year : 2008 | Volume
: 19 | Issue : 3 | Page : 397--400
Effect of Diuretics on Ureteral Stone Therapy with Extracorporeal Shock Wave Lithotripsy
A Zomorrodi, J Golivandan, J Samady
Imam Hospital, Tabriz Medical Science University, Tabriz, Iran
Associate Professor of Urology, Imam Hospital, Tabriz Medical University, Science, Tabriz
To evaluate the effect of diuretics on ureteral stone fragmentation and clearance during therapy with extra corporeal shock wave lithotripsy (ESWL), we studied 87 patients with ureteral stone at different levels and treated with ESWL. The patients were randomized into two groups treated by standard ESWL; the treatment protocol included 3500 shock wave per patient in each session, energy of the shock in two groups was 13 to 9 kv per patient, and the number of sessions was 3 per patient. The first group included 43 patients who received only ESWL, while the second group of 44 patients received as well 40 mg of furosemide. Stone fragmentation rate was 81% and 93.1% and stone clearance rate was 68.2% and 88.4% for the first and the second groups, respectively. With diuretics, fragmentation was18.8% more in the middle ureteral stones, 16.9% more in the upper tract stones, and 5.4% more in the distal stones. Moreover, clearance of fragmented stones was 38%, 28%, 15.4% more at middle and upper and distal ureteral stone, respectively. We conclude that the stone fragmentation and clearance were higher with ESWL and diuretics than without diuresis. Diuresis is safe and has some advantage at increasing the effect of ESWL on ureteral stones especially the middle ureteral calculi.
|How to cite this article:|
Zomorrodi A, Golivandan J, Samady J. Effect of Diuretics on Ureteral Stone Therapy with Extracorporeal Shock Wave Lithotripsy.Saudi J Kidney Dis Transpl 2008;19:397-400
|How to cite this URL:|
Zomorrodi A, Golivandan J, Samady J. Effect of Diuretics on Ureteral Stone Therapy with Extracorporeal Shock Wave Lithotripsy. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Jan 25 ];19:397-400
Available from: http://www.sjkdt.org/text.asp?2008/19/3/397/40499
Management of ureteral stone includes open surgery, laparoscopic surgery, ureteroscopic extraction, ureteroscopic lithotripsy and extracorporeal shock wave lithotripsy (ESWL), which is the least invasive procedure. However, some patients may require a repeat session of ESWL, or adjuvant surgical intervention in order to achieve a stone free status. Success rate of ureteral stone with ESWL depends on several factors that include stone size, degree of obstruction, impaction, and renal function.
The aim of this study is to investigate the role of diuretics during ESWL therapy on the outcome of the procedure in terms of fragmentation and clearance of ureteral stones.
Materials and Methods
The study included 87 patients with ureteral calculi at different ureteral levels. Patients were referred for ESWL at Urology Department of Imam Hospital. They were 56 male and 31 female and the range of age was from 12-52 years.
All patients had complete history, physical examination, and routine laboratory investigation including CBC, urinalysis, creatinine, BUN, prothrombine activity, and bleeding and coagulation time. All patients were examined by ultrasound and plain x-ray complemented in some patients with x-ray intravenous urography (IVU).
All the patients were treated by standard ESWL using Simons Lithostor plus machine. Patients with stones in the upper third of ureter were treated in supine position, while patients with middle or distal thirds of the ureter were treated in prone position. All the patients were advised to void before starting ESWL session. After exposing stones on monitor and targeting them, shock waves were administered at a rate of 90 shock per minute with energy started at range 13 that gradually increased according tolerance of patient till 19 kv. This gradual increase of energy is important at desensibilization of skin.
In every session, shock wave treatment was continued until stone disintegration or 3500 shock wave delivered. Follow-up plain x ray was obtained 2 weeks after treatment, and ESWL was repeated if a stone equal or more than 5mm was still evident. In evaluation of the results of ESWL, failure was defined as inability to fragment the targeted stones after three ESWL sessions, while success was defined as stone free-within three months after application of ESWL.
The patients were randomized into two groups. The groups were comparable as regards stone location, stone size, and associated hydronephrosis. All the stone were radiopaque. All the patients received 3500 shock every session in three sessions. The first group included 43 patients who were treated by standard ESWL without diuretics. In this group, upper stone was in 20 patient, middle ureteral stone in 6, and lower urinary stone in 17; stone size ranged from 8-16 mm. The second group included 44 patients who were treated by ESWL with addition of furosemide 40 mg before the start of the ESWL session.
In the first group, stone fragmentation was 81% and stone clearance 68.2%. In the second group, stone fragmentation was 93.1% and stone clearance was 88.4%. There were no complications following ESWL treatment. The results according to stone location are shown in [Table 1], while the results of fragmentation and clearance are shown in [Table 2].
ESWL is a perfect example of fruitful cooperation between the medical and Industrial world. Since its introduction into clinical practice in 1980 by Chaussy and associates,  It has revolutionized the management of urolithiasis and has become the first option for treatment of most upper urinary tract calculi, thus dramatically limiting the indication of endourological procedure and even open surgery.  Since 1986, ESWL has progressively acquired popularity as the gold standard treatment for upper urinary tract lithiasis in children as well as in adults.  Proximal ureteral stones and distal calculi in women past the childbearing age can be treated with in situ ESWL. 
To the treatment with ESWL is started at low power (11 kv) that is increased progressively so that the initial shocks desensitize the skin nerve receptors with a transcutaneous electrical nerve stimulator like effect.  Shock wave lithotripsy has four mechanisms of stone fragmentation that include compressive fracture, spallation, acoustic cavitations, and dynamic fatigue.  Cavitation is an important mechanism of ESWL action and has many roles in fragmentation. It is an acoustic phenomena that every ESWL can induce in f2 point, which requires low viscosity fluid.
Cavitation phenomena induces another energy called pitting in foil.  Patients are prepared best for ESWL by proper hydration and bowel cathertics one day before the procedure. Patients referred to ESWL department without preparation, i.e. dehydrated and/or constipated, will have less satisfactory results because dehydration reduces good flow of urine around the targeted stone especially if the treated kidney has reduced function due to obstruction. Diuretics can surmount this problem by increasing the urine flow around the stone, which improves the possibility for the cavitation phenomena to occur. 
In the actual disintegration of stones, the analysis of the high-speed films clearly demonstrates the progress of stone fragmentation related to time. First cracks appear to be produced by shock wave. Then, after the surrounding liquid enters the cracks, the actual disintegration of stone material occur as a result of collapsing cavitation bubble. ,
In our study, the administration of diuretics improved both the fragmentation and clearance as predicted in the patients who received the drug regardless of location of the ureteral stones.
In conclusion, diuretics seems to be safe adjunct to ESWL treatment of ureteral stone and coincide with better result.
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