ExtracorporealShock Wave
Lithotripsy (ESWL)
Oakland Medical Center
General Discussion of Extracorporeal Shock Wave Lithotripsy (ESWL) OverviewofTreatmentofUrinaryStones...........................................2 TheSiemensLithotripter.......................................................................3 ExtracorporealShockWaveLithotripsy(ESWL)Treatment................5 AuxiliaryProcedures.............................................................................6 AfterTreatmentCareandFollow-up....................................................7 Complications........................................................................................8
Specific Requirements for Individual Patient Treatment BeforeYourLithotripsy(ESWL)............................................................9 ListofDrugsWhichShouldBeStopped............................................11 OntheDayofYourLithotripsy(ESWL).............................................12 AfterYourLithotripsy(ESWL).............................................................14
Maps ToKaiserPermanenteMedicalCenteratOakland............................15 TotheLithotripterSuitewithintheOaklandFacility........................17
Glossary ..........................................................................................................18
Overview: Treatment ofUrinary Stones
Urinary stones(urolithiasis),whichareoftenpainful,requireathoroughdiagnosticevaluation,andanindividualizedtherapeuticapproach.Urolithiasisisadiseasewhichoccursin5–12%oftheAmericanpopulation.Morementhanwomenareaffected,especiallythosebetween30and50yearsofage.
Kidneystoneslookandfeellikeapieceofgravel.Theyformintheurinecollectingsystemofthekidneywhichtransportstheurinetowardtheurinarybladder.Moststonesarenolargerthanagrainofsandandarespontane-ouslypassedfromthebodyintheurineatleast60%ofthetime.Forthosestoneswhichdonotpass,somesortofurologicaltreatmentisappropriate.Unfortunately,onlyafewurinarystonescanbedissolvedwithmedication;furthertherapeuticproceduresareusuallyneeded.
Moderntechnologieshavereducedtheneedforopensurgerytolessthan1%.Inthelate1970s,twolessinvasivetreatmentsofstonesweredeveloped.Specializedendoscopesforlookingatandtreatingstonesinthekidney(nephroscope)andureter(ureteroscope)allowedmanytobeextracted.Lithotripsy,fromtheGreekwordmeaning“stonecrushing,”hasdramaticallychangedthemanagementofurinarystones.Ultrasonic,electrohydraulic,andlaserlithotriptershavebeenadaptedforusewithnephroscopes(percutane-ousnephrostolithotomy,orPNL)andureteroscopes(transureteraluretero-scopiclithotripsy,orTUL)topulverizeurinarystones.
Since1980,kidneyandureteralstoneshavebeenpulverized(lithotripsy)noninvasivelybymeansofshortduration,highenergywaves(shockwaves)whichareproducedoutsidethebody(extracorporeal)byamachinecalledanExtracorporealShockWaveLithotripter(ESWL).
ExtracorporealShockWaveLithotripsy(ESWL)cantreatupto95%ofkidneystonesandmanyureteralstones;insomecases,ESWLiscombinedwiththeabovementionedendoscopictechniques(PNLandTUL).
2
The Siemens Lithotripter
3
Extracorporeal Shock Wave Lithotripsy(ESWL)wasdevelopedinGer-manyandisthemostfrequentlyusedprocedurefortreatmentofkidneystones.Focusedshockwavestravelthroughthewatertubethatrestsagainstyourbody.Theshockwavesbreakthestoneintopassablefragments.
Targetingofstonesisachievedbyfluoroscopy.Thestonecanbepositionedpreciselyintothehigh-energyfocusoftheshockwaves.Thenumberofshockwavesandtreatmentsneededforbreakageofstonesdependsupontheirsizeandhardness.
Theshockwavesaredeliveredatratesupto120/minute.Theshocksmaybeinterruptedtomovethetabletokeepyourstoneinthetargetzone.Stonepositionandbreakageismonitoredbyfluoroscopy.Littleornoanesthesiaisneeded.Upto4,000shockwavesareuseduntilX-rayshowsadequatepulverization.Theproceduretimevariesfrom30–60minutes.Forlargerstones,orformultiplestones,asecondtreatmentmaybeneeded.Becausemostbodytissueissimilartowater,theshockwavesusuallypassthroughthebodywithnosignificantharm.Theywill,however,breakahardstructuresuchasakidneystone.TissuewhichcouldbedamagedbyshockwavesisprotectedbycarefultargetingandmonitoringbyX-rayfluoroscopiccontrol.MinimalsideeffectsoccurafterESWL,andyoucaneasilyresumenormalactivitieswithin1–3days.
The Siemens Lithotripter (continued)
4
ESWLTreatment
Before treatment,youmaybegivenmedication,eitherbymouthorintravenously,andmonitoringdevicesareattached.Mosttreatmentsaredonewithsedation.Anesthesiaisseldomneeded.Youwillbeplacedonyourbackorabdomenonthetreatmenttable,dependinguponthelocationofthestone.Thestoneispositionedinthefocusoftheshockwaveusingfluoroscopicimaging.Theshocktubeisthenpressedagainstyoursideand“coupled”withsomegel-likematerial.Treatmentisbegunandshockwavesaredeliveredatratesupto120perminute.Duringtreatment,itisextremelyimportantforyoutoremainverystilltokeepthestoneinfocus.Medicationcanbegivenfordiscomfortduringtreatment.Treatmenttimedependsuponthesizeandhardnessofthestone.ProgressofthetreatmentwillbedeterminedbyX-ray.Afterlithotripsycompletion,ashortobservationperiodisnecessary.Youmaythenreturnhome.
Certainurologicandmedicalconditionsrequirelimitationsoftreatment:
• Untreated urinary tract infection
• Nonfunctioning kidney
• Obstruction of the ureter beyond the stone being treated
• Blood coagulation disorder, permanent anticoagulation therapy, and certain drugs
• Cardiac pacemakers and implanted defibrillators in some instances
• Anatomy, which prevents targeting of the stone
• Pregnancy
5
THE URINARY TRACT
An additional procedure may be required beforeorafteryourvisittoLithotripsy.Referredtoasauxiliaryprocedures,theyincludecystoscopy,basketextraction,ureteralcatheterizationorstenting,ureteroscopywithorwithoutstonemanipulation,andultrasonicorlaserlithotripsy.(Seeglossary).
AuxiliaryProcedures
6
KIDNEY
BLADDER
KIDNEY
URETER
URETHRA
URETER
Extracorporeal Shock Wave Lithotripsy(ESWL)doesnotremovestonesbutattemptstodisintegratestonesintoparticlessmallenoughtopassspontaneously.Inordertoassistpassageoftheparticles,patientsareaskedtodrinklargequantitiesofwater.Whilepassingthestoneparticles,somepatientsmayexperiencesomepainorcolic,nauseawithorwithoutvomiting,orfever.Youshouldcheckwithyoururologistifthesesymptomsoccur.Ifthepainornauseaareunrelievedbytheprescribedmedications,orifyoudevelopahighfeverover101º,gototheEmergencyDepartmentatthefacilitywhereyourphysicianislocated.
Itisnormaltoexperiencebloodintheurineafteryourtreatment.Ittypicallywillclearupin24to48hours.Ifyoustillhavebrightredurineafter72hours,youshouldnotifyyoururologist.Itisnormaltooccasionallyexperienceaslightpinkurinewhilepassingfragments.
Youshouldhaveareturnvisittoyourphysicianwithintwotofourweeksfollowingalithotripsytreatment.Afollow-upX-raywillbetakentodeterminethesuccessofthetreatmentandneedforfurtherfollow-up.Metabolicevaluationandmedicaltreatmentmaybenecessarytopreventfuturestonerecurrence.
After Treatment Careand Follow-up
7
Complicationsrelatedtoproblemsofpassingstonefragmentsinclude:
n Residualstonefragmentsinthekidney.Mostpatientspassallstonefragmentswithin3months,butsomepatientsmayretainportionsofthefragmentedstonewhichmaygrowandcausesymptoms.Thismayormaynotrequirefurthertreatment,includingESWL.
n Ureteralobstructionfromstonefragmentsnecessitatinginterventionoccursinupto10%ofpatients.Proceduresinclude:
–Cystoscopywithureteralcatheterization,orstentplacement
–Ureteroscopy
–Percutaneousnephrostolithotomy(PNL)
–Percutaneousnephrostomy
n Feversecondarytoinfectionrequiringantibiotics.
n Severecolic(pain)whichisunrelievedbyoralpainmedicine.
n Nauseaand/orvomiting.
ComplicationsseldomoccurafterESWLtreatment,andseriouscomplica-tionsareextremelyrare.Complicationsaremostcommonlyrelatedtoprob-lemsofpassingstonefragments,ratherthantheshockwaveexposureitself.
ComplicationsfromESWLitself,whichmayoccurshortlyafterwards,include:
n Bleedingaroundthekidney(5patientsin1,000).Occasionally,thismayrequireatransfusion.Inextremelyrareinstances,surgeryisneeded.
n IncompletestonefragmentationofsomelargeorveryhardstoneswhichmayrequireauxiliarytreatmentsorasecondESWL.Thenum-berofshocksinasingletreatmentislimited.
n Bruisingatthetreatmentsite.
Complications8
Before Your Lithotripsy(ESWL)
Before your lithotripsy (ESWL)isperformed,certainrequirementsarenecessaryandwillbearrangedbyyourphysician:
• Anappropriatehistoryandphysicalexaminationbyaphysician, nursepractitioner,orphysicianassistant
• Acompletebloodcount(CBC)donewithin7daysoftheESWL
• Pregnancytestifyouareafemaleunder50.
• Aurineculturedonewithin7daysoftheESWL
• AnIVPorCTscandonewithin1yearoftheprocedure
• Anelectrocardiogram(EKG)within3monthsifyouareover45or haveheartdisease
Youmusthavethesedoneasindicatedpriortoyourlithotripsyappointment,inordertoproceedwiththeESWL.
Afewdaysbeforeyourlithotripsy(ESWL),anursewillcontactyoutoreviewyourpreoperativeinstructionsandconfirmthetimeyouhavebeenaskedtoreporttotheLithotripsyUnit.Pleasehavealistavailableofmedicationsandanyherbsyouaretaking.Ifyouhavenotheardfromthenurse3daysbeforeyourappointment,pleasecalltheLithotripsyDepartment.Ifyouhaveanyquestions,youmayreachthelithotripsynurseat(510)752-7001between8a.m.and4p.m.
Day Before Lithotripsy:Becauseintestinalgasandbowelcontentsinterferewithlocalizationandtargetingofyourstone,duringthe48hourspriortoyourLithotripsyprocedure,youshouldavoidallfoodsthatcausegas.
Foodsthatcancausegasincludecarbonatedbeverages,milkproducts,andchewinggum.Fiberfoodssuchasbran,beans,peas,andmostfruits.Oatmealandwholegrainbreadsshouldbeavoided.
Vegetablessuchascabbage,broccoli,cauliflower,Brusselssprouts,celery,cucumbers,eggplant,onions,andradishescancausegas.Starchesincludingpotatoes,corn,noodles,andwheatcausegas.
Last Minute Illness:Ifyoudevelopacold,sorethroat,fever,orotherillnessbeforeyourlithotripsy,callyourphysicianassoonaspossible,aswellastheLithotripsyDepartmentat(510)752-7001.
9
Food and Drink for Adults and Children:Donoteatordrinkanythingaftermidnight.Thisisaveryimportantrequirement.ApatientwhoeatsordrinksanythingonthemorningofESWLmayvomitduringESWL.Vomitedfluidsmayenterthelungsandcausesevereinjuryordeath.Certainmedicationthatisordinarilytakenshouldbeswallowedwithonlyasipofwateronthemorningoflithotripsy.(Pleasecheckwiththenurseonyourpre-opvisitorthelithotripsynursewhenyouarecontactedbyphone.)
If You Are Under 18 Years Old and Unmarried:Aparentorlegalguardianmustbepresenttosigntheconsentform.
Medication:Askyourphysicianwhetheryouneedtodiscontinueyourregularmedicationbeforelithotripsy.Bringyourregularmedicationwithyouforyourtreatment.Anticoagulants(bloodthinners),aspirin,aspirin-containingcompounds,andallnonsteroidalanti-inflammatorydrugsneedtobestoppedoneweekpriortotreatment.Attachedisapartiallistofover-the-counterorprescriptiondrugswhichcontainaspirinorbloodthinners.Thesemustbestoppedfor7daysbeforelithotripsyinordertopreventexcessivebleeding.
The effects of herbal supplementsonbloodcoagulationarenotcompletelyunderstood.Itisquiteclearthatsomedothintheblood.Intheinterestofyoursafety,youshoulddiscontinuetheuseoftheseherbalsupplements7daysbeforeESWL.
Ginkgo biloba Garlic Ginseng St. John’s Wort Ephedra Kava Valerian Echinacea Vitamin E Fish oil
10
List of drugswhich should be stopped
AdvilAleveAlka-SeltzerAnacinAnaproxAPACAPAPFortAPCArthritis Pain FormulaASAAscriptinAspergumAspirinBayerBayer BufferedBC tabs/powderBufferinButalbitalClinorilCoricidinCoumadinDarvon CompoundDayproDipyridamoleDisalcidDoan’s PillsDolobidDristan
Patientsshouldstoptakingdrugswhichcontainaspirinandothernonsteroidaldrugs.Thefollowingisapartiallist.Anyquestionsaboutthesedrugscanbeansweredbyyoururologist,orcalltheLithotripsyUnit.
DuragesicEcotrinEmpirinEquagesicEtodalacExcedrinFeldeneFenoprofenFiorinalFour Way ColdGoodysIbuprinIbuprofenIndocinIndomethacinKeterolacLodineLortab-ASAMethocarbamol CompMidolMotrinNabumetoneNaprosynNaproxenNorgesicNuprinOxycodone/AspirinPamprin
PentosaPepto-BismolPercodanPersantinePiroxicamPlavixPropoxyphene/AspirinRelefenRobaxisalSalsalateSine-aidSine-aid IBSine-offSoma CompoundTalwin CompoundTiclidToradolTrigesicTrilisateVanquishVolterenVoleren/SR/XRWarfarinZorprin
11
On the Day of Your Lithotripsy (ESWL)
The Lithotripsy DepartmentatOaklandisintheHospitalToweronthe2ndFloor.Theaddressis280W.MacArthurBlvd.(Seemap,page17)
PleasearriveatthereceptionareaintheLithotripsyDepartmentatthescheduledtime.Dependingontheflowoftreatmentsandavailablespace,youmayhavetowaitbeforeactuallyhavingyourtreatment.Bringyourfavoritereadingmaterial.
Clothing and Valuables:Pleaseleavealljewelryandvaluablesathome.Wecannotberesponsibleforanylossordamageofpersonalitems.Wearloosecomfortableclothingsuchassweatsorjogsuits.
Toprepareforlithotripsy,youwillbeaskedtochangeclothes.Anassessmentwillbedonebythenurse.Afamilymembermaystaywithyouuntilyouactuallygotothelithotripsytreatmentroom.Afterbeingplacedonthelithotripsytable,monitoringdevicesareattached,anintravenous(IV)lineisinserted,andthestonetargeted.Thentheshockwavelithotripsytreatmentisstarted.Afterthetreatment,ashortperiodofobservationisnecessary.Thelengthofthisperioddependsuponthetypeanddosageofdrugswhichwereadministered.Beforeyouleave,youwillbegivenafter-careinstructions.Planonreturninghomeandrestingfortheremainderoftheday.
12
Contact Lenses May Need to be Removed Before ESWL:PleasebringanappropriatecontainerandsolutiontostoreyourcontactlensesduringESWL,orweareyeglassesthedayofESWL.
Transportation:Itisalegalrequirementthatyoumustbedischargedtothecareofaresponsibleadult.Afamilymemberorfriendmustdriveyouhome.Itisnotsafeforyoutoleavealone!YourLithotripsywillbeCANCELLED IF YOU DO NOT HAVE A MEANS OF GETTING HOME. Yourescortmustbeconfirmedbeforethetreatmentstarts.Yourfriendorfamilycanwaitforyouinthelithotripsysuitewaitingroomorinthecentralhospitallobby.
Important Decisions and Plans After Procedural Sedation:Youshouldnotplantodrive,work,engageinrecreationalactivities,usemachinery,orperformanyactivitywhichrequiresconcentrationorquickreactiontime,ormakeimportantdecisionsfor24hoursafterlithotripsy.Whilethemedicationiswearingoff,youwillnotbeasalertasnormal.Itisrecommendedthatsomeonestaywithyouuntilyouarefullyalert.
13
Oncethelithotripsystaffdeterminesthatyouareadequatelyrecoveredfromanysedation,analgesic,oranestheticmedicines,youwillbeallowedtobedrivenhome.Youarenotpermittedtodriveyourselfhomeafterthisprocedure.
Whenyouarriveathomeyoushouldrestanddrinkonlyclearliquidsfor4to5hours.Taketheprescribedmedicinesforpainandnauseaorvomitingiftheyshouldoccur.Ifthesemedicinesdonotrelieveyoursymptoms,contactyourregularurologistorgototheEmergencyRoomofyourclosestKaiserPermanentefacility.(ThereisnoneedtoreturntotheOaklandfacilityunlessyoureceiveyourregularhealthcarethere.)
Thedayafterlithotripsyyoumayeatnormally.For2weeksafterESWL,itisrecommendedthatyoudrinkatleast2quartsofliquidsdaily(waterispreferred).Thishelpsclearyoururineofthestoneparticlesandblood.YoushouldstrainyoururineandcollectthestoneparticlesthefirstsevendaysafterESWL.AstrainerandcontainerwillbegiventoyouupondischargefromtheLithotripsyUnit,ifneeded.
Unlessyoururologiststatesotherwise,youmayresumenormalactivities,includingwork,1to3daysafterESWL.Nocontactsportsareallowedfor1month.
Youshouldbeseenbyyourregularurologist1to2weeksafterESWLforhiscontinuedmanagement.Withinafewdays,lithotripsystaffwillcontactyoubytelephonetoassessyourconvalescencefromESWL.
After YourLithotripsy (ESWL)
14
�
�
� HOSPITAL TOWER
PARKING
4
5 1
2
3
EMERGENCY
EAST ENTRANCE
3779 PIEDMONT
3772 HOWE
HOSPITAL ENTRANCE
BROADWAY
PARKIN
G
280 W. MacArthur
HO
WE
ST.
PIE
DM
ON
T A
VE
NU
E
WEST MacARTHUR BLVD.
PATIENT DROP-OFFAND PICK-UP
�
Parking:ParkingisavailableintheHoweStreetvisitors’parkinggarage,locatedacrossfromtheEmergencyentranceofthemedicalcenter.
REMEMBER: You musthavesomeonegiveyouaridehomeafterlitho-tripsy.Youarenottodrivefor24hoursaftertheprocedure.
Getting to theOakland Medical Center
1. OaklandMedicalCenter2. EmergencyEntrance3. EastEntrance4. Parking5. ParkingEntrance
15
Map and Directionsfor getting to KPMC, Oakland
HOWE
BROADWAY
PIEDMONT AVE.
HARRISON ST.
MA
CA
RT
HU
R
EAST
MA
CA
RT
HU
R
From Walnut Creek,Martinez, etc.
Take Broadway exitoff of 24. TakeBroadway to MacArthur,turn left. Turn left onHowe St.
From San Francisco
Take Bay Bridge 101to 580 East. Then 580East to MacArthurexit (on left). TakeMacArthur to Broadway.Turn left on Howe Street.
From Sacramento,Vallejo & Richmond
Take 80 South to580 East. TakeMacArthur exit off580 East (exitto the left). TakeMacArthur toBroadway. Turnleft on Howe Street.
From Hayward, etc.
Take 580 to Harrison-MacArthur exit. Stayto right after exit. Turnright on Howe Street.
From Hayward, Fremont, & San Jose
Take 880 North toBroadway exit. ThenBroadway to MacArthur. Turn right. Turn left on Howe Street.
From Walnut Creek,Martinez, etc.
From Hayward, etc.
From Sacramento,Vallejo & Richmond
From San Francisco
From Hayward,Fremont & San Jose
16
Where to find theESWL suite
Emergency
PULMONARY MEDICINE
Handicap Entrance
Elevator B
Elevator E
EMERGENCY
Elevator D
CASTROOM
RESTROOM
RESTROOM
SOCIAL SERVICE
SURGERY CLINIC
PRE-SURGERY CENTER
BUSINESS OFFICE CUSTOMER SERVICE ADMITTING PHARMACY
MED STATION
1
ORTHOPEDICS
CAFETERIA
Tower Elevators
INFO DESK
INFO DESK
LOBBY
Elevator C
East Ent.
Patient Pickup
Front Entrance
MacArthur Blvd.
Ho
we
Str
eet
Bro
adw
ay
1st Floor
GIFT SHOP
Main Hospital - First Floor
Han
dic
ap D
rop
Off
Par
kin
g G
arag
e
Lithotripsy Unit
Nuclear Medicine
Phase II
Elevator B
Elevator E
Cardiology Ambulatory Surgery
PACU Amb. Surgery Echo
Legend: Elevator Stairs
Second Floor
17
basket: specialureteralcathetertoremoveureteralstonesusedthroughcystoscope,ureteroscopeornephroscope
colic: painassociatedwiththepassageofstoneorstonefragments
CT scan: ComputedTomography;Radiographyinwhichathree-dimensionalimageofabodystructureisconstructedbycomputerfromaseriesofplanecross-sectionalimagesmadealonganaxis.
cystoscope: optical instrument with fiber-light illumination forcystoscopy
electrohydraulic endoscopicstonecrushingwithanelectrohydrauliclithotripsy: electrodeforlocalapplicationof“minishockwaves”
endoscopy: visual inspection of internal organs (general)withspecial instruments (endoscopes) inserted throughtheurethraorthroughtheskin(percutaneously)
extracorporeal: outsidethebody
extracorporeal nonsurgicaldisintegrationofkidneyandureteralshock wave stonesbypressurewavesgeneratedoutsidethebodylithotripsy (ESWL):
fluoroscope: X-rayunitwithTVcameraandTVmonitor
IVP (intravenous X-raystudywithintravenouslyadministeredcontrastpyelogram): dyeforvisualizationofkidneys,uretersandbladder
KUB (kidney, plain(withoutcontrastdye)X-rayfilmoftheureter, bladder): abdomenforidentificationofstones
laser lithotripsy: disintegrationofstonesusinglaserenergy
Glossary18
lithotripsy: stonecrushing,disintegrationofstones
lithotripter: instrumentforstonecrushing(extracorporealorendoscopic)
nephroscope: opticalinstrumentwithfiber-lightilluminationforpercutaneousnephrolithotomy(PNL)
obstruction: blockageofurinarydrainage
percutaneous: throughtheskin
percutaneous tractintothekidneyestablishedbypuncturethroughnephrostomy theskinintheside(PCN):
percutaneous endoscopicremovalofkidneystonesthroughanephrostolithotomy percutaneouslyestablishedtractusingaspecial(PNL): opticalinstrument(nephroscope);forthis
purpose,differentworkinginstrumentsforstonedisintegration(ultrasoniclithotripsy,electrohydrauliclithotripsy)andstoneextraction(forceps,basket)areinsertedintothenephroscope
retrograde X-raystudywithacystoscopeandureteralcatheterforpyelogram: backward(retrograde)injectionofcontrastdyeinto
theureterandkidney
shock wave: high-energypressurewaveofshortduration
ultrasonic endoscopicstonecrushingwithanultrasoundprobelithotripsy: forlocalapplicationofmechanicalenergy(vibration)
ureteral along,thincatheterforinjectionofcontrastmaterialcatheter: into the ureter or for ureteral stonemanipulation,
usedthroughacystoscopeorureteroscope
19
ureteral stent: along,thincatheterplacedbetweenthekidneyandbladder;itisleftindwellingforvaryingperiodsoftime
ureteroscope: opticalinstrumentwithfiber-lightilluminationforureter
oscopy
ureteroscopy: visual(endoscopic)inspectionoftheureterwithaspecial optical instrument (ureteroscope),which isinserted through the urethra and bladder into theureter;workinginstrumentsforstonedisintegration(ultrasonic lithotripsy, electrohydraulic lithotripsy,laserlithotripsy)andstoneextraction(forceps,basket)canbeinsertedintotheureteroscope
20
07303-000 (REV. 5-08)
The information presented here is not intended to diagnose health problems or to take the place of professional
medical care. If you have persistent health problems orif you have further questions, please consult
your health care provider.
Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.
©1994 KFH; KFHP, Inc.; TPMG, Inc.
Top Related