Efficacy and Safety of Ultrasound Guided Extracorporeal Shock Wave Lithotripsy (SONO ESWL) In Patients with Radiopaque Renal Stone

Wadhah Abbas Al-Marzooq
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Keywords : ESWL: Extracorporeal shock wave lithotripsy, KUB: Kidney, Ureter, and Bladder X-ray, CT: Computed tomography.
Medical Journal of Babylon  14:2 , 2017 doi:1812-156X-14-2
Published :24 October 2017


To assess the advantages and disadvantages of using ultrasound to guide ESWL in patients with radiopaque renal stone. This study included 80 patients with radiopaque renal stone who visited the ESWL unit in urology department at Hillah teaching hospital. Thirty-eight of those patients underwent US guided ESWL while in the other 42 patients the procedure done under fluoroscopy control. The results, complications and operative time were compared between both groups. Both groups were comparable regarding stone size, site and body mass index. Operative time was significantly longer in group 2, there was no significant difference regarding passage of gravels, stone free rate, postoperative hematuria and loin pain between both groups. Therefore, we conclude that even in patients with radiopaque stones, ultrasound can be used to guide ESWL as effectively as fluoroscopy, without any risk of radiation.


Renal stones is one of the common diseases that affect the urinary system and it is estimated that it affect more than 10 % of the general population [1]. There are many options for treatment of renal stones and the choice of one of theme is depends on many factors including patient age and comorbidity, stone size, type, site, anatomy of the kidney, and some time patient preference [2]. These options include oral chemical dissolution, extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, retrograde intrarenal lithotripsy, or open surgery [3]. The year 1980 saw the first use of extracorporeal shock wave lithotripsy for treatment of renal stone, and since that time the use of (ESWL) expand greatly in treatment of many urological and non-urological diseases [4]. Because of its efficacy and relative safety, ESWL is now the most commonly used treatment modality for renal stone, although ESWL is not without side effect as perirenal hematoma can occur in about 0.6 % of cases, steinstrasse, cardiac dysrhythmia, is also a possible complications [5, 6]. To visualize the stone and monitor its fragmentation an imaging system is required, either fluoroscopy, ultra-sonography or combination of bothis commonly used to achieve this purpose [7]. The main disadvantages of fluoroscopy imaging are the high maintenance cost and the risk of patients and staff radiation exposure. Ultrasonographic localization eliminate the risk of radiation exposure to both patients and staff, in addition small or radiolucent calculi can be localized with ultrasound rather than fluoroscopy. The main disadvantages of ultrasonography are the difficulty of localizing ureteral stone and the longer learning curve [8].

Materials and methods

Our study was conducted at the extracorporeal shock wave lithotripsy unit of urology center at Hillah teaching hospital, 80 patients with radiopaque renal stones were included in the study, 38patients underwent  a single session of  an ultrasound guided ESWL while in the other42 patients the procedure done under fluoroscopic guidance.
All patients underwent full evaluation including history, examination and the following investigation; urinalysis, renal function tests, bleeding profile test, an ultrasound, a KUB X-ray film, and native abdominal CT scan.
All patients advised to remain fasting over the preoperative night, all patients received a single intramuscular injection of ketorolac 30 mg as a form of analgesia 60 minute preoperatively.
Lithotripsy system description:
Our lithotripsy system is (MODULITH® SLX-F2) made by STORZ MEDICAL company in Germany.


The total number of patients was 80, divided in to 2 groups, in group 1 which involved 42 patients, the procedure done under fluoroscopic control, group 2 involved 38 patients underwent the procedure under ultrasonic control. The mean age of patients in group 1 was 37.19 years while it was 36.68 years for group 2 patients, 28 and 14 patients in group 1 was male and female respectively, while in group 2 there was 20 male and 18 female, and as shown in tale number 1 there was no statistical difference between both groups regarding age and sex of the patients.


Although ultrasound is mostly used to guide ESWL for radiolucent stone, however the fact that all renal stones are echogenic makes ultrasound useful to guide ESWL for all stones regardless of its radiological appearance [9]. Advantages of ultrasound guided ESWL (SONO ESWL) are elimination the risk of radiation exposure, real time monitoring of lithotripsy, ability to identify other pathology of the kidney (hydronephrosis, cyst, tumor, etc), ability to differentiate between stone and stent, identify the exact site of the stone within the kidney and lastly making the operator (urologist) more familial with this fundamental imaging method [9]. The overall (SONO and FLURO ESWL) stone free rate in our study was 80 %,this is slightly lower than the study of Kumar A, et al who reported 88.75 % stone free rate at 3 months follow-up, the lower stone free rate in our study may be due to shorter follow up duration [10]. The stone free rate for ultrasound guided ESWL was 78.9 % at 6 weeks post ESWL, Xi-Zhao S. reported stone free rate for ultrasound guided ESWL of about 63.6 % and 86.4 % at 3 weeks and 3 months respectively [11]. Complications of ultrasound guided ESWL in our study were macroscopic hematuria 94.4 % and sustained renal colic 10.5 %, moderate hematuria occur in about 45.7 % and renal colic 30.4 % according to Xi-Zhao S. study [11]. The operative time was significantly longer in ultrasound guided ESWL 41.58 minute, in fact most of this time elapsed in stone localization, the time decreased gradually with increase our experience in using ultrasonography for ESWL guidance.


Even in patients with radiopaque renal stones, ultrasound can be used to guide extracorporeal shock wave lithotripsy as effectively as fluoroscopy, without any risk of radiation.


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7. Campbell –walsh urology, 10th edition, section XI, p.1390.
8. Emil A. Tanagho. Jack W McAninch, smith s general urology 17th edition p. 267.
9. Gary S. Karlin, Celeste Marino, GopalBadlani, Arthur D. Smith. Shock wave lithotripsy, chap. 78, Benefits of Ultrasound-Guided Shock Wave Litho-tripsy, p. 427-430. 1989.
10. Kumar A, Gupta NP, Hemal AK, Wadhwa P. Comparison of three analgesic regimens for pain controlduring shock wave lithotripsyusing Dornier Delta Compact lithotripter: a randomized clinical trial. J Endourol. 2007 Jun. 21(6): 578-82.
11. Xi-Zhao S.,Zhi-Wei Z. Shock Wave Lithotripsy for Uric Acid Stones, Asian J Surg. 2006 Jan;29(1):36-39.

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