Should we say farewell to ESWL ?

HARRY WINKLER

Director, section of Endo-urology Kidney stone center

Dept. of Urology ‘Sheba’ medical center

Financial and Other Disclosures

2

I have the following financial interests or

relationships to disclose: Disclosure code

No financial relationships N

Off-label use of drugs, devices, or other agents: None

including our local regulatory agency

Data from IRB-approved human research is not presented

By the end of the 1980s, noninvasive SWL had become the predominant treatment modality, with URS utilized only for lower ureteral stones and PCNL used more sparingly.

Regression in the efficacy of SWL combined

with advances in endoscopic technology such as the introduction of holmium: YAG lasers has shifted these trends

Clinical parameters that may affect outcome of SWL

Body habitus: high body mass index (BMI) ,skin - to – stone

distance (SSD),

Stone burden /size

Stone composition : Stones of differing composition vary

widely with regard to their fragility

Density of the calculus - Hounsefield units ( HU) 0n NCCT.

Stone location / intrinsic renal anatomy

Contraindications for SWL. Pregnancy

Uncorrected coagulation disorders

Skeletal deformities might make SWL impossible

UPJ obstruction, ureteral strictures.

Large stone burden.

lower calyx stones with diameters exceeding 15 mm.

Hard stones -brushite ( CaPH) , cystine ,CaOX

monohydrate,

complications after SWL

Subcapsular hematoma

Other types of trauma to the kidney

Injuries to surrounding organs,

Infected urine or stones

Obstruction caused by stones and fragments

/steinstrasse

Endoscopic surgery

Holmium Laser

Holmium Laser Stone Dusting

Extracorporeal shock wave lithotripsy (ESWL) versus Ureteroscopic management for ureteric calculi (Review) Aboumarzouk OM et al, Cochrane Database of Systematic Reviews, 2012

Stone-free rate : Achievement of stone-free status favoured ureteroscopy (Analysis 1.1 (7 studies, 1205 participants)

Retreatment rate:, Higher re-treatment rate for SWL compared with ureteroscopy ( 6 studies, 1049 pts). RR 6.18, 95%CI 3.68 to 10.38; P < 0.00001)

Auxiliary procedures: additional treatments. meta-analysis indicated that ureteroscopy treated needed more auxiliary procedures (Analysis 1.3 (5 studies, 751 pts): RR 0.43, P=0.003. most patients required stents at the end of the procedure. (common practice)

Efficacy quotient (EQ): (The EQ takes stone free rate/ re-treatment/ auxiliary procedures.) favoured ureteroscopy (0.79 for ureteroscopy and 0.43 for ESWL in stones more than 1 cm diameter; 0.88 for ureteroscopy and 0.7 for ESWL in stones less than 1 cm diameter.

Health economics: ESWL was the more costly

by USD 1255 (for hospital cost) and USD 1792 (charged to patient) compared with ureteroscopy (Pearle 2001).

Systematic Review and Meta-analysis of the Clinical Effectiveness of Shock Wave Lithotripsy, Retrograde Intrarenal Surgery,and Percutaneous Nephrolithotomy for Lower-pole Renal Stones James F. Donaldson, EUR UROL 6 7 (2015 ) 612–616

5 RCTs comparing RIRS with SWL

RIRS over SWL (RR: 1.31; 95% CI, 1.08–1.59)

What is the future for ESWL?

Whilst the incidence of urolithiasis is increasing, the use of ESWL is not increasing at the same rate ,particularly for ureteric stones.

Kay Thomas . BJU International ,2014,636

Continued improvement in the optics,

miniaturisation of ureteroscopes and advent of holmium laser have contributed to a surge in the use of ureteroscopy.

Turk,C et al. EAU Guidelines on Urolithiasis,2014

Extracorporeal shock wave lithotripsy: An opinion on its future Rassweiler J et al : Indian J Urol , 2014 Jan-Mar; 30(1): 73–79

With significant improvement in technology endourological procedures became more attractive and effective

The main argument in favor of endourological techniques is that the stone can be removed in one session with minor sequelae

SWL has a 20-30% re-treatment rate and the problems associated with passage of fragments

primary treatment strategies for uroliothiasis at Department of Urology, SLK Kliniken Heilbronn

AUA guidelines Mid or distal ureteral stones should be treated with URS as first-line therapy North America - from 1991 to 2010 SWL decreased from 69% to 34% (p < 0.0001) URS use increased from 25% to 59% PCNL use remained relatively constant

Evidence from the UK published in 2016 showed an increase in endoscopic treatment over the previous 5 yr, along with a stable rate of SWL utilization for upper urinary tract stones. Heers H, Trends in urological stone disease: BJU Int 2016;118:785–9.

Australia too has experienced a rise in endoscopic interventions over the past two decades, from 33% of all procedures to nearly 70%. Between 2001 and 2015, URS increased by an average of 9.3% per year, while SWL decreased by 3.5% and PCNL by 6.4% per year. Perera M, et al. Urolithiasis treatment In Australia: the age of ureteroscopic intervention. J Endourol 2016;30:1194–9.

Trends in the cost of urolithiasis treatments Cost of primary treatment: In 2012, URS was compared with SWL and found to be approximately $2000 less for distal ureter stones and substantially less for all other stone locations. Matlaga BR, Economic outcomes of treatment for ureteral and renal stones: a systematic literature review. J Urol 2012;188:449–54.

An international survey also reported that SWL is generally more costly than URS in Turkey, Japan, and parts of Europe, mostly because of the high initial investment and maintenance of the lithotripter. Trinchieri A. The impact on health care of the recent global epidemiological trends in urolithiasisUrolithiasis: basic science and clinical practice. London, UK: Springer; 2012. p. 915–9.

Costs for re-treatment

Patients undergoing URS had fewer unplanned ED or hospital visits than those receiving SWL.

SWL required more procedures and expense on

average to clear a stone Scales CD. The impact of unplanned post-procedure visits in the management of patients with urinary stones. Surgery 2014;155:769–75

Extracorporeal Shockwave Lithotripsy Falling Out of Favor Debate at the AUA 2015.

Olivier Traxer -University Pierre et Marie Curie in Paris

Since ESWL was introduced in the early 1980s, "the stone-free rate in 2015 is the same" as it was 30 years ago.

Dramatic advances in Endourology, including in

visualization, laser technology, and miniaturization. Endourology is slowly replacing SWL.

"Shockwave lithotripsy is slowly dying," Dr Traxer said. "If shockwave lithotripsy technology doesn't improve in terms of stone treatment,“. ..“it will be completely retire very soon and replaced with endourology."

Debate at the AUA 2015- Cont.

Glenn Preminger- Duke University in Durham, North Carolina.

The technologic advances in endoscopic equipment have made lithotripsy practically obsolete

With SWL , the stone-free rate depends on stone parameters and the procedure is reliant on renal anatomy for effective stone elimination. endoscopy has a lower re-treatment rate and is more cost-effective.

"Shockwave lithotripsy is a lot like sex; it might feel good and it might be a lot of fun, but is it right?"

Ralph Clayman - University of California, Irvine

Currently, about 30% of procedures involve extracorporeal shockwave lithotripsy, down from 70%. that could decline further.

"The future is going to be very much dependent upon the reinvention of shockwave lithotripsy and the training of our future urologists,"

in few years, even in developing countries This process is already ongoing and probably is irreversible

So, ESWL will die?

In will not, and nor should die. But certainly its’ use will decrease a lot, until stabilize around 10 to 20% of all stone treatments.

Flexible ureteroscopy will probably replace almost completely the use of ESWL in the clinical practice in the coming years.

THANK YOU !