Urinary stones are a pathological condition called “urolithiasis”, not “disease”. Urolithiasis in a broad sense includes stones in the kidney, ureter, bladder, prostate, vesicoureter, urethra and foreskin, and is a common and frequent condition in urology. Severe renal colic induced when a stone becomes lodged or moves in the urinary tract is one of the common urological emergencies, and asymptomatic urinary stones are often seen during physical examinations. Extracorporeal shock wave treatment of urinary tract stones (kidney and ureteral stones, other stones are not selected) is widely used because it is non-invasive, less painful, safe and efficient, does not require anesthesia, and can be treated on an outpatient basis. How to properly use shock wave, a modern technology, to achieve satisfactory treatment results is a common concern for both doctors and patients.
Before treatment.
The “3” refers to three determinations.
Determination one.
”Determine the presence of stone images”.
There are three methods.
1. Ultrasound, as a routine screening tool for urinary stones, has the advantage of being non-invasive, independent of the nature of the stone, and can be determined as long as the stone is in the homogeneous interface environment, i.e., the “acoustic window”; the disadvantage: stones in the middle part of the ureter are not easily detected due to intestinal gas interference, and are related to the experience, technology, skill, and confidence of the operator.
2.X-ray, advantage: the whole urinary tract can be displayed, disadvantage: the stone has high calcium content, can block the X-ray this condition, otherwise the stone can not be detected, known as “negative stones”.
3. If the diagnosis cannot be confirmed by ultrasound or X-ray, the diagnosis can be confirmed by the typical symptoms of renal colic, the normal form of red blood cells seen in urine routine, or even the indirect signs of urinary tract obstruction suggested by ultrasound.
Determination II.
”Determine that the stone image is in the urinary tract”. Ultrasound has the advantage of being definitive upon detection, whereas X-ray requires analysis of whether the stone image is located in the urinary tract, and needs to be differentiated from tissue calcification, venous stones, etc. The gold standard for determination is intravenous urography, which can directly show whether the stone image is located in the urinary tract and help to understand the function of both kidneys.
Determination III.
”Determining the effect of lithotripsy” includes whether the stone can be crushed and whether it can be completely expelled after crushing. Although extracorporeal shock wave treatment for urinary stones has many advantages, it is only one method and is not suitable for the treatment of all stones. With a good lithotripter, stones that are eligible for lithotripsy can generally be broken, depending on the size, location, composition, crystal structure, and residence time of the stone in the urinary tract. The most suitable conditions for extracorporeal shock wave lithotripsy are: single renal pelvic stones with a diameter of ≤2.0 cm or a total area of ≤3 cm2; ureteral stones with a longitudinal diameter of ≤1.5 cm. Patients with body weight >130Kg are restricted by the fact that the stone cannot fall in the second focus of the reflector of the lithotripter due to excessive obesity. Stones ≤0.4 cm in diameter are 80% self-expelled and are not selected for the time being. For larger stones a part of them can be treated with extracorporeal shock wave therapy by adding adjunctive conditions. The other part is based on the patient’s hospital conditions, the doctor’s skills, the patient’s economic status and knowledge of the disease, and the choice of percutaneous nephrolithotomy, ureteroscopic stone extraction, or lumpectomy with laser, ultrasound, or pneumatic ballistic lithotripsy. Regarding whether the stone particles can be completely excreted after lithotripsy, it mainly depends on the degree of stone being crushed, the anatomical geometry of the site where the stone is located, and the physiological status, the presence of urinary stricture, occlusion, diverticulum, history of previous surgery, lithotripsy, infection, and the presence of inflammatory wrapping and polyp formation.
”2″ refers to two tablets.
After determining lithotripsy, take 2 tablets of fruit guide the night before to reduce the disturbance of intestinal gas during lithotripsy the next day. Same day enema if necessary. This necessary preparation is often not taken seriously and results in suboptimal lithotripsy.
”1″ refers to taking an abdominal X-ray.
There are two implications; one, to make the basic situation of the stone clear to the operator, to shorten the positioning time, to minimize X-ray injuries, and to strictly prohibit the examination and treatment in sequence on the lithotripter. Secondly, small stones are mobile in the urinary tract, even being discharged, and a film before shattering is the basis for treatment.
There are techniques in treatment.
Lithotripsy position, to be comfortable and satisfactorily positioned.
Retrograde ureteral intubation via cystoscopy to assist lithotripsy: to prevent stone formation in the ureter after lithotripsy of stones >2.0 cm in diameter causing urinary tract obstruction. For patients with urinary tract obstruction and fluid accumulation, implantation of ureteral stent tube before lithotripsy is beneficial to improve renal function and promote stone expulsion, and can assist in localization for negative stones.
Intravenous urography (IVU) to help locate and determine renal function and analyze stone expulsion rate.
Emphasis on operating techniques to achieve twice the result with half the effort. Just as we break a brick in our daily life, the overall observation and analysis of the brick before implementation, and then determine the way to break it, shock wave lithotripsy similarly requires observation and understanding of stone size, location, shape, hardness, and surrounding environment to determine the impact force, mode, and sequence. For single stones: first hit the adjacent or distal side (the adjacent side is easy to fragment because of the cavitation effect of the shock wave, and the distal side is preferred to the distal side of the urinary tract); for multiple stones: first easy then difficult, first small then large, first secondary then primary. In bilateral cases, release of obstruction and/or restoration of function comes first; in case of ipsilateral multiple stones, ureter first and then renal pelvis and calyces, or renal pelvis first and then renal calyces.
After treatment.
Do not discard water, activity and medication, and recurrent stones. Increasing urine volume by drinking more water to promote stone discharge is the best way to discharge stones in accordance with physiology. Urine is delivered intermittently and regularly in strands, which discharges stones while flushing the urinary tract, and also plays an important role in preventing urinary tract infection. Without sufficient urine volume, stones cannot be discharged, while increasing urine volume by drinking water to reduce the urine concentration of stone-forming components is the main method to prevent stone recurrence.
Increasing physical activity after lithotripsy induces stone displacement and promotes stones to enter the lower urinary tract to facilitate discharge. However, in contrast, stones in the lower renal calyces require knee-chest position and patting of the renal area to facilitate stone movement in the direction of the urinary outflow tract of the calyces.
Most of the stones are accompanied by varying degrees of pain during discharge after lithotripsy. Proper pain relief not only reduces the patient’s pain, but also facilitates the discharge of stones by reducing the local swelling. The currently accepted drugs are non-steroidal anti-inflammatory drugs, not narcotic painkillers. For the whole ureter has multiple stenosis, the stone is mostly embedded here, and induce ureteral spasm is not conducive to stone removal, the application of ureteral dilators is very necessary to shorten the stone removal time, the types of drugs applied in the past, such as atropine, 654-2, etc., this drug also produces inhibition of normal ureteral peristalsis, therefore, the current study confirmed that a receptor blocker is preferred, such as nepetal, Halle.
For recurrent stones must be well collected, through the analysis of stone composition, to prevent stone recurrence from the root, lithotripsy is the treatment of symptoms, prevention of stone recurrence is the root.