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et al.
percutaneous pigtail nephrostomy tube were odds ratios (95% confidence intervals)
Study Type – Therapy (case series)
excluded. We divided patients into groups by of 19.54 (8.25–46.30) (P < 0.001), 0.67
Level of Evidence 4
chronic kidney disease (CKD) stage according (0.55–0.82) (P < 0.001) and 0.16 (0.05–0.50
to the estimated glomerular filtration rate (P = 0.002), respectively. A logistic regression
OBJECTIVE (eGFR) of ≥60 and <60 mL/min/1.73 m2. model was developed to estimate the
Stone-free status was defined as no visible probability of SFR after ESWL, the equation
To investigate the effect of renal function on stone fragments on a plain abdominal film at being 1/(1 + exp [−(3.8137 − 0.3967 × (stone
the stone-free rate (SFR) of proximal ureteric 3 months after ESWL. A logistic regression width) + 2.9724 × eGFR − 1.8120 × Male)]),
stones (PUS) after extracorporeal shock wave model was used to evaluate the possible where stone width is the observed value
lithotripsy (ESWL), as urinary obstruction significant factors that influenced the SFR of (mm), eGFR = 1 for eGFR ≥60 and 0 for <60,
caused by PUS can impair renal function, PUS after ESWL, and to develop a prediction and male = 1 for male, 0 for female.
and elevated serum creatinine levels are model.
associated with decreased ureteric stone CONCLUSIONS
passage.
RESULTS Gender, eGFR ≥60 and a stone width of
PATIENTS AND METHODS >7 mm were significant predictors affecting
The overall SFR of PUS (276/319 patients) the SFR after one session of ESWL for PUS.
From January 2005 to December 2007, 1534 was 86.5%; the SFR was 93% in patients
patients had ESWL for urolithiasis, 319 with an eGFR of ≥60 and 50% in those with KEYWORDS
having ESWL in situ for PUS; they were an eGFR of <60 (P < 0.001). After univariate
reviewed retrospectively. Patients requiring and multivariate analysis, the three stone-free rate, extracorporeal shock wave
simultaneous treatment of kidney stones, significant factors affecting SFR were an lithotripsy, ureteric calculi, chronic kidney
placement of a double pigtail stent, or eGFR of ≥60, stone width, and gender, with disease
INTRODUCTION significant factor that influences stone for PUS after ESWL was 82%, vs 81% after
passage. ureteroscopy [2,3], and the SFR increased to
A ureteric stone (US), if not treated correctly, 90% after ESWL if the stone was <10 mm.
will impair renal function by causing long- A meta-analysis showed that both stone size Several other factors have been reported to
term obstructive uropathy [1]. In a review, the and stone position influence the spontaneous influence the SFR of US after ESWL, including
management of US causing obstructive passage rate; the spontaneous passage rate the duration since renal colic pain before
uropathy included watchful waiting, ESWL was 1.2% for ureteric stones of >5 mm and receiving ESWL [10–13], stone location, stone
and ureteroscopic lithotripsy, according to 38% if <5 mm, and 12% for PUS and 45% for transverse diameter, presence of a ureteric
stone size and location [2,3]. According to the distal US [8]. Therefore, the treatment method stent [14,15], and renal function [16]. Lee
recent guidelines [2,3], the optimal treatment might differ according to the stone size and et al. [16] reported that the SFR was 56.7% for
for proximal US (PUS) depends on the size of location. Expectant management and medical patients with serum creatinine values of
the stone. Spontaneous stone passage can be expulsive therapy were suitable for distal US 2.0–2.9 mg/dL and 66.2% if <2.0 mg/dL
expected in up to 80% of patients with US of of <5 mm [9], but its role in PUS has not yet (P < 0.05). However, reports from other
<4 mm in diameter, and the chance of been defined. authors failed to find a difference in outcome
spontaneous passage is very low for those after ESWL treatment of renal and US
with a diameter of >7 mm [4–7]. These Both ESWL and ureteroscopy can be first-line between patients with chronic renal
findings imply that the size of PUS is the only treatments for PUS. The stone-free rate (SFR) insufficiency and those who had normal renal
Estimated Stone-Free
Diabetes mellitus 23 (8) 9 (21) 0.010 0.8
Probability
Hyperuricaemia 91 (33) 19 (44) 0.150
0.6
Pyuria before ESWL 121 (44) 22 (51) 0.370
0.4
Stone site (right/left) 116/160 19/24 0.790 eGFR >
= 60 and female
0.2 eGFR >
= 60 and male
Stone width, mm 5.9 (1.8) 7.3 (1.8) 0.510 eGFR < 60 and female
0.0 eGFR < 60 and male
Stone width >7 mm 52 (19) 19 (35) <0.001
2 4 6 8 10 12
Stone length, mm 9.1 (3.2) 10.9 (4.3) 0.270 Stone Width, mm
Stone length >10 mm 77 (28) 16 (37) 0.210
CKD, eGFR >60 247 (89) 19 (44) <0.001
SFR of PUS after ESWL (Table 4 and Fig. 1). A Overall, 27 patients (8.5%) in the present 3 Preminger GM, Tiselius HG, Assimos DG
logistic regression model was designed by series of 319 had ureteroscopy for auxiliary et al. 2007 guideline for the management
Abdel-Khaleketal et al. [14] to predict the procedures of managing the PUS, and six of ureteral calculi. J Urol 2007; 178:
probability of SFR after ESWL according to males (1.9%) had a ureteric stricture that 2418–34
three significant factors, including stone needed regular JJ stent replacement in three, 4 Ibrahim AI, Shetty SD, Awad RM, Patel
position, transverse diameter of the stone, endoscopic ureterotomy in two, and uretero- KP. Prognostic factors in the conservative
and the presence of a ureteric stent. Salman ureteroneostomy in one. Only one patient treatment of ureteric stones. Br J Urol
et al. [25] also reported the same three (0.3%) was admitted from the emergency 1991; 67: 358–61
significant predictors. They found that the department for acute pyelonephritis. Abdel- 5 Miller OF, Kane CJ. Time to stone
SFR was higher for PUS than distal US after Khalek et al. [14] reported a complication rate passage for observed ureteral calculi: a
ESWL [14,25]. However, the factors affecting of 3.4%, and auxiliary procedures were guide for patient education. J Urol 1999;
the SFR of PUS after ESWL have not yet been required in 3%, in patients with US treated 162: 688–90
defined. Furthermore, ureteric stent insertion with ESWL. In the present series the overall 6 Morse RM, Resnick MI. Ureteral calculi:
is an optional choice during the primary complication rate was 2% (seven of 319), the natural history and treatment in an era of
treatment of PUS [14,25]; therefore, it was re-treatment rate was 2% and auxiliary advanced technology. J Urol 1991; 145:
clearer in the present study to evaluate procedures after ESWL were required in 8.5% 263–5
prognostic factors under natural conditions of patients. 7 Sandegard E. Prognosis of stone in the
that might influence the SFR after ESWL ureter. Acta Chir Scand Suppl 1956; 219:
because no patients had a ureteric catheter The limitations of our study are that it was 1–67
indwelling. Our result was consistent with retrospective and we had no CT images before 8 Hubner WA, Irby P, Stoller ML. Natural
their finding, that the width of the US was a ESWL of the US to measure skin-to-stone history and current concepts for the
significant factor, but the threshold was distance. We did not routinely check the treatment of small ureteral calculi. Eur
7 mm. serum creatinine level after ESWL, and we Urol 1993; 24: 172–6
cannot evaluate the effect of PUS on the 9 Bensalah K, Pearle M, Lotan Y. Cost-
Hsu et al. [28] reported the risk of acute renal changes in renal function before and after effectiveness of medical expulsive therapy
failure increased in the patients with diabetes ESWL. We will follow these patients in the using alpha-blockers for the treatment of
mellitus, diagnosed hypertension and known future and attempt to better understand distal ureteral stones. Eur Urol 2008; 53:
proteinuria in the population with CKD. In the whether or not this event could affect their 411–8
present study, patients with an eGFR <60 had renal function. 10 Seitz C, Fajkovic H, Remzi M et al. Rapid
a higher coincidence of hypertension and extracorporeal shock wave lithotripsy
diabetes, and therefore these patients might In conclusion, the current standard treatment treatment after a first colic episode
be at greater risk of acute renal failure. for PUS is ESWL, and the SFR is affected by correlates with accelerated ureteral stone
After multivariate analysis, diabetes and stone size. Gender, eGFR and stone width clearance. Eur Urol 2006; 49: 1099–105
hypertension were not significant factors were significant factors affecting the SFR of 11 Tombal B, Mawlawi H, Feyaerts A, Wese
affecting SFR. The discrepant results for the PUS after ESWL, by multivariate analysis, and FX, Opsomer R, Van Cangh PJ.
role of hypertension and diabetes in the SFR we developed a logistic regression model to Prospective randomized evaluation of
of PUS after ESWL might be due to the predict the probability of SFR of PUS after emergency extracorporeal shock wave
enrolled patients being stratified according to ESWL, to enable the appropriate treatment for lithotripsy (ESWL) on the short-time
their eGFR before they were analysed by patients with PUS. More aggressive treatment outcome of symptomatic ureteral stones.
multivariate analysis. Therefore, these two is indicated if the patient is male, the stone Eur Urol 2005; 47: 855–9
factors (hypertension and diabetes), which width is >7 mm and the eGFR is <60. ESWL is 12 Tligui M, El Khadime MR, Tchala K et al.
affect SFR via their effect on renal function, not adequate for such patients and auxiliary Emergency extracorporeal shock wave
had no significant role on multivariate procedures might be necessary. lithotripsy (ESWL) for obstructing ureteral
analysis. Other factors affecting the SFR of stones. Eur Urol 2003; 43: 552–5
renal stones after SWL include the stone 13 Seitz C, Tanovic E, Kikic Z,
CONFLICT OF INTEREST
Hounsfield density, skin-to-stone distance Memarsadeghi M, Fajkovic H. Rapid
and stone composition [29]. CT is not used extracorporeal shock wave lithotripsy for
None declared.
routinely to evaluate stone status in our proximal ureteral calculi in colic versus
hospital, so the stone Hounsfield density and noncolic patients. Eur Urol 2007; 52:
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