American Lithotripsy Society Patient Care Clinical Considerations


 

Guideline for the Treatment of Urinary Tract Stones with Extracorporeal Lithotriptors

SCOPE OF CARE
 I. Treatment Setting

II. Patient Selection

Ill. Pre-Treatment Evaluation

 IV. Treatment Parameters

V. Stone Factors

VI. Post Treatment Evaluation

 

I. THE SETTING FOR EXTRACORPOREAL RENAL LITHOTRIPSY

 

A. A medical care facility providing renal lithotripsy may be utilized by patients with a wide range of medical fitness. Thorough preoperative assessment of a patient's medical condition is essential in planning safe, effective lithotripsy. A facility should be structured to offer preoperative evaluation including second opinions when required.

B. Treatment guidelines should be available, consistent with specific manufacturers recommendations and the state of the art as determined by experience and medical literature. The staff should meet standard requirements for training and certification. A Quality Assurance program must be in place and function regularly. Postoperative care must be available and meet urologic standards for surgical procedures. Data collection is necessary for outcome analysis.

C. High quality, cost effective stone treatment includes consideration of all methods including observation, medical management, open surgery, percutaneous and endoscopic technique, and alternative methods of lithotripsy. There should be reasonable availability of adjunctive and alternative techniques. Knowledge of the advantages and disadvantages of all alternatives is necessary for patient selection, safety and efficacy.

D. Cognitive skills required for the successful management of stone disease are considerable, and must be coupled with the technical skills necessary for lithotripter treatment. Patient safety and effective outcome are the ultimate goals. The appropriate setting is that which meets these parameters and goals.

 

II.CRITERIA FOR PATIENT SELECTION

 

A. Anesthesia

A wide choice of anesthetic methods are available and appropriate. Successful lithotripsy requires the appropriate choice of anesthesia for patient comfort and compliance. A patient's health, habitus, and history must be such that he/she can safely undergo anesthesia/analgesia for lithotripsy. Appropriate monitoring during treatment must be provided using ASA Guidelines. Some lithotripters do not require the use of any anesthetic methods.

B. Pregnancy Pregnant women are not candidates for extracorporeal lithotripsy, at present.

C. Medication

Patients on medication which inhibit normal coagulation or affect platelet adhesiveness should be off medication before treatment. Return to normal coagulation must be documented. Any coagulopathy must be corrected before treatment, or managed by a physician-developed coagulation protocol.

D. Size

Manufacturers recommendations as to size and weight should be followed. Pretreatment simulation may be used to resolve questions of imaging and/or positioning.

E. Age

No limitation. Pediatric patients must receive appropriate care, positioning and protection.

F. Miscellaneous

Urinary obstruction distal to the treated site should be appropriately managed before treatment. Urinary infection should be under adequate treatment. Major vessel aneurysms must not lie in the path of the shock wave.

 

III. PRETREATMENT EVALUATION

 

A. Review of clinical history and imaging study by an ESWL trained physician. The imaging review should include assessment of the anatomy on the side to be treated as well as the stone burden.

B. History and physical.

C. Laboratory tests consistent with appropriate patient evaluation and anesthesia requirements.

D. Patient education program:

F. Informed consent by physician.

F. Immediate pretreatment documentation of stone location.

 

IV. TREATMENT PARAMETERS

 

A. Stone Position

There is evidence to indicate that stone fragmentation occurs more readily when a fluid expansion chamber is present around the stone; however, impacted stones have been treated successfully. Careful urologic judgment is necessary concerning risk versus benefit factors in pretreatment repositioning of stones. Following treatment, a high percentage of retained fragments are located in the gravity dependent portions of the kidney. Vigorous post treatment regimens, including position adjustments, may be helpful in clearing fragments from these dependent areas.

B. Stone Composition

The chemical composition of the stone has great influence upon successful fragmentation by shock wave lithotripsy. This composition may also play a role in the choice of imaging alternatives. Analysis of past stones treated and assessment of the current stone to be treated is helpful in choosing the best treatment option for the patient. Post treatment analysis of stone composition is useful in future management of the patient.

C. Technical Factors

Extracorporeal lithotripters currently available offer several difference energy sources, imaging alternatives, and alternatives for patient coupling to shock waves. There are different requirements for anesthesia/analgesia. At present, no single device is ideal or multipurpose. Each modality has positive attributes balanced by certain drawbacks. A thorough knowledge of the advantages and disadvantages of all alternatives is necessary for patient selection, treatment safety, and efficacy.

 

V. STONE FACTORS (ONE OR MORE)

 

A. The stones must be amenable to imaging and localization so that effective treatment is likely to occur

1. Renal or ureteral calculi producing pain and/or obstruction where spontaneous passage is not likely on a timely basis.

2. Urinary tract calculi causing gross hematuria or contributing to the presence of documented upper tract infection.

3. Asymptomatic renal calculi 5mm or greater with a history of previous surgery for stones, passage of stones, or conditions making future stone morbidity likely.

4. Primary, secondary or staged treatment of large renal calculi.

5. Presence of renal calculi in patients traveling to or residing in areas of limited medical care.

6. Asymptomatic stones where employment may be denied or restricted as a result of such stones.

7. Appropriately selected and managed cases of bilateral stone disease may receive simultaneous or staged treatment.

 

VI. POST TREATMENT EVALUATION

 

A. Evaluation of the clinical status of the patient until recovered.

B. Serial imaging studies until stone-free or stable.

C. Metabolic evaluation appropriate for patient education and recommendations for future management.

D. Other evaluation as appropriate for unique circumstances presented by the patient.

 

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