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).

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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)

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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

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THE URINARY TRACT

An additional procedure may be required beforeorafteryourvisittoLithotripsy.Referredtoasauxiliaryprocedures,theyincludecystoscopy,basketextraction,ureteralcatheterizationorstenting,ureteroscopywithorwithoutstonemanipulation,andultrasonicorlaserlithotripsy.(Seeglossary).

AuxiliaryProcedures

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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

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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.

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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

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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

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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.

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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.

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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)

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3779 PIEDMONT

3772 HOWE

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Parking:ParkingisavailableintheHoweStreetvisitors’parkinggarage,locatedacrossfromtheEmergencyentranceofthemedicalcenter.

REMEMBER: You musthavesomeonegiveyouaridehomeafterlitho-tripsy.Youarenottodrivefor24hoursaftertheprocedure.

Getting to theOakland Medical Center

1. OaklandMedicalCenter2. EmergencyEntrance3. EastEntrance4. Parking5. ParkingEntrance

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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

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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

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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

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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

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07303-000 (REV. 5-08)

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medical care. If you have persistent health problems orif you have further questions, please consult

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Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.

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