Extracorporeal shock waves lithotripsy in patients with ileal neobladder stones.

Objective

Extracorporeal shock waves lithotripsy (ESWL) is being practiced in Italy and worldwide since over 30 years. Later generations of lithotriptors, thanks to lower and controlled output powers and compact focal area, consent lithotripsy to be performed without anesthesia and therefore to be less invasive.
The size of the stones and their location are the main factors for the choice of this method. ESWL is applied to kidney and ureteral, but rarely to bladder stones.
The aim of this work is to underline the importance of the application of shock waves for bladder stones, (1) (2) (3), and above all, to highlight the effectiveness of the treatment for localized ileal neobladders stone, while surgical or endoscopic removal might be invasive and cause damage to the neobladders.

Methods and results

A 75 year old woman, who in 2005 underwent a radical cystectomy with lymphadenectomy and ileal neobladder, was treated by us in April 2013 to extracorporeal shock waves for 2 neobladder stones of 1.5 cm each presumably caused by incomplete emptying. The patient in fact periodically emptied her bladder using a Nelaton type catheter. She was put under three ESWL treatments 2 and 6 day intervals between them. After the first treatment one stone was completely crushed and100% of fragments were eliminated 24 hours later. The second and third treatment resulted in complete crushing of the second stone. The Rx of the bladder, after 3 treatments, showed complete elimination of both stones. The patient felt no pain during treatment. The patient was in a supine position for the first treatment, while prone in the second and third, because the supine position did not allow a complete centering/targeting of the stone. A total of 9000 SW with Kv at 70-80% was utilized. We used a Lithotripter Dornier S lithotripsy. Although in the second treatment the bladder was drained to prevent the movement of the stone in bladder, but this did not improve the targeting or the shock waves. In the third treatment, like the first, the bladder was not emptied, resulting in completely ground stones. A year after the treatment the patient is still free from stones.

Discussion

Extracorporeal shock waves lithotripsy is a method that is not burdened with particularly serious complications. Side effects are mainly related to the fragmentation of the stones. They mainly consist in fragments piling along the ureter which sometimes require ancillari intervention such as ureteroscopy, ureteral stent or even placement of a nefrostomy. Another complication linked directly to the shock wave is renal hematoma which being reabsorbed in 2-6 months auto-resolves this. The extracorporeal shock wave applied to the bladder does not necessarily comport all these complications, since the fragments are eliminated in a few hours. These stones of secondary nature, mostly phosphatic due to the high incidence of urinary infection, can be easily crushed. Often the stones are formed by a lack of bladder emptying (4) (7), or, in the case of ileal neobladders, with a percentage from 5 to 20% (5) (8), in the presence of copious amounts of mucus and chronic bacteriuria provoked by intermittent catheterization. Another cause of the formation stones in neobladders is the accumulation of mucus and crystals on suture clips that create the core stone. The absence of invasiveness allows the patient to choose this method, saving on anaesthetic medications necessary for endoscopic or surgical intervention (6). Endoscopic intervention would also entail the use of tools such as cistoscopy and Mauermayer’s punch lithotrite large gauges that would be traumatic for urethral anastomosis and ileal wall. Another important factor is that lithotripsy treatment can be done on outpatients with considerable savings on medical costs. According to all of this considerations, the authors suggest and recommend to use this non-invasive and relatively simple method to address secondary stones in bladders and ileal neobladders.

References

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