Treatment of Sialolithiasis: What Has Changed? An Update of the Treatment Algorithms and a Review of the Literature

Treatment for sialolithiasis has undergone significant changes since the 1990s. Following the development of new minimally invasive and gland-preserving treatment modalities, a 40–50% rate of gland resection was reduced to less than 5%. Extracorporeal shock-wave lithotripsy (ESWL), refinement and extension of methods of transoral duct surgery (TDS), and in particular diagnostic and interventional sialendoscopy (intSE) are substantial parts of the new treatment regimen. It has also become evident that combining the different treatment modalities further increases the effectiveness of therapy, as has been especially evident with the combined endoscopic–transcutaneous approach. In the wake of these remarkable developments, a treatment algorithm was published in 2009 including all the known relevant therapeutic tools. However, new developments have also taken place during the last 10 years. Intraductal shock-wave lithotripsy (ISWL) has led to remarkable improvements thanks to the introduction of new devices, instruments, materials, and techniques, after earlier applications had not been sufficiently effective. Techniques involving combined approaches have been refined and modified. TDS methods have been modified through the introduction of sialendoscopy-assisted TDS in submandibular stones and a retropapillary approach for distal parotid sialolithiasis. Recent trends have revealed a potential for significant changes in therapeutic strategies for both major salivary glands. For the submandibular gland, ISWL has replaced ESWL and TDS to some extent. For parotid stones, ISWL and modifications of TDS have led to reduced use of ESWL and the combined transcutaneous–sialendoscopic approach. To illustrate these changes, we are here providing an updated treatment algorithm, including tried and tested techniques as well as promising new treatment modalities. Prognostic factors (e.g., the size or location of the stones), which are well recognized as having a strong impact on the prognosis, are taken into account and supplemented by additional factors associated with the new applications (e.g., the visibility or accessibility of the stones relative to the anatomy of the duct system).

Prognostic Factors for the Effectiveness of Extracorporeal Shock Wave Lithotripsy in Patients with Ureterolithiasis

The purpose of the work was to study prognostic factors for the effectiveness of extracorporeal shock wave lithotripsy in patients with ureterolithiasis. Materials and methods. The study included 53 patients with ureteral stones up to 2 cm in size. All patients underwent extracorporeal shock wave lithotripsy under ultrasound control, with a pulse rate of 90 per minute and a maximum number of pulses of 2000 per session. The outcome of treatment was evaluated by ultrasound on day 5 after the extracorporeal shock wave lithotripsy session. If there were stone fragments larger than 5 mm, a second extracorporeal shock wave lithotripsy session was performed. Treatment was considered effective in the absence of stone fragments in the urinary tract 4 weeks after extracorporeal shock wave lithotripsy. Results and discussion. The data were analyzed to identify clinical and radiological factors associated with treatment failure. As a result of the treatment, 46 (86.4%) patients were found to have no stones in the urinary tract (the condition is “stone free”), 9 (13.6%) had stone fragments larger than 5 mm 4 weeks after extracorporeal shock wave lithotripsy, and therefore contact ureterolithotripsy was performed. As complications, 7 (13.2%) patients had an exacerbation of chronic pyelonephritis, which required percutaneous nephrostomy. As the results showed, age, gender, body mass index, and Hausfield units did not differ significantly in terms of extracorporeal shock wave lithotripsy results. Factors that significantly affected the prognosis of extracorporeal shock wave lithotripsy success were the size of the stone and skin-stone distance. Body mass index did not significantly affect the outcome of lithotripsy in this study. The stone density index according to computed tomography data is considered by many authors to be a predictor of the effectiveness of fragmentation, but in our study this indicator was not a significant predictor of the effectiveness of extracorporeal shock wave lithotripsy, which allows us to think that there are other factors, namely the features of the internal structure of the stone, which determine its compliance with the shock wave. Conclusion. The size of the stone and the skin-stone distance are prognostic factors that affect the effectiveness of extracorporeal shock wave lithotripsy in patients with ureterolithiasis. Body mass index and stone density in Hausfield units did not significantly affect extracorporeal shock wave lithotripsy outcome in this study

A Systematic Review on Comparative Analyses between Ureteroscopic Lithotripsy and Shock-Wave Lithotripsy for Ureter Stone According to Stone Size

Background and Objectives: This systematic review and meta-analysis was conducted to analyze the treatment outcomes of shock wave lithotripsy (SWL) and ureteroscopic lithotripsy (URSL) according to the ureteral stone size. Materials and Methods: In this systematic review, relevant articles that compared SWL and URSL for treatment of ureteral stones were identified. Articles were selected from four English databases including Ovid-Medline, Ovid-EMBASE, the Cochrane Central Register of controlled Trials (Central), and Google Scholar. A quality assessment was carried out by our researchers independently using the Scottish Intercollegiate Guidelines Network (SIGN). A total of 1325 studies were identified, but after removing duplicates, there remained 733 studies. Of these studies, 439 were excluded, 294 were screened, and 18 met the study eligibility criteria. Results: In randomized control trial (RCT) studies, URSL showed significantly higher SFR than SWL (p < 0.01, OR= 0.40, 95% CI 0.30–0.55, I² = 29%). The same results were shown in sub-group analysis according to the size of the stone (<1 cm: p < 0.01, OR = 0.40, 95% CI 0.25–0.63; >1 cm: p < 0.01, OR = 0.38, 95% CI 0.19–0.74, I² = 55%; not specified: p < 0.01, OR = 0.43, 95% CI 0.25–0.72, I² = 70%). In the non-RCT studies, the effectiveness of the URSL was significantly superior to that of SWL (p < 0.01, OR = 0.33, 95% CI 0.21–0.52, I² = 83%). Retreatment rate was significantly lower in URSL than in SWL regardless of stone size (p < 0.01, OR = 10.22, 95% CI 6.76–15.43, I² = 54%). Conclusions: Meta-analysis results show that SFR was higher than SWL in URSL and that URSL was superior to SWL in retreatment rate. However, more randomized trials are required to identify definitive conclusions.

METAPHYLAXIS OF UROLITHIASIS BY VEGETABLE MEDICINES

Мочекаменная болезнь является одной из главных проблем современной урологии как наиболее часто встречающаяся патология органов мочевой системы и составляющая 30 - 50% всех больных урологических стационаров. Целью настоящего исследования явилось изучение эффективности применения препарата «Фитолизин» у больных мочекаменной болезнью. В основу исследования положены результаты лечения 160 (85 женщин и 75 мужчин) пациентов, находившихся на стационарном лечение, средний возраст больных составил 42,2±12,4 года, длительность заболевания от 1-3 до 72 часов, размер конкрементов, в том числе и дезинтегрированных фрагментов после дистанционной ударно-волновой литотрипсии и контактно-лазерная литотрипсия варьировал от 0,4 до 0,8 см. Все больные были разделены на две группы. В основную группу вошли 70 больных, получавших помимо традиционной симптоматической терапии (спазмолитики и водная нагрузка) «Фитолизин» по 43 мл 3 раза в день. В контрольной группе (90 больных) проводилась только традиционная терапия. При включение в терапию препарата «Фитолизин» самостоятельное отхождение отмечено у 64(91,4%) больных, частота возникновения почечной колики имело место у 7(10%), лейкоцитурия - у 14(20%), бактериурия - у 10(15%). Применение фитопрепарата «Фитолизин» в составе комплексной терапии, является эффективным методом консервативного лечения больных мочекаменной болезнью и после после дистанционной ударно-волновой литотрипсии и контактно-лазерная литотрипсия в 90,9% случаев в отношении самостоятельного отхождения конкрементов. Urolithiasis is one of the main problems of modern urology as the most common pathology of the urinary system and makes up 30 - 50% of all patients in urological hospitals. The purpose of this study was to study the effectiveness of the use of the drug "Phytolysin" in patients with urolithiasis. The study is based on the treatment results of 160 (85 women and 75 men) patients who were hospitalized, the average age of the patients was 42.2 ± 12.4 years, the duration of the disease from 1-3 to 72 hours, the size of the stones and disintegrated fragments after remote shock wave lithotripsy and contact laser lithotripsy ranged from 0.4 to 0.8 cm. All patients were divided into two groups. The main group included 70 patients who received in addition to the traditional symptomatic therapy (antispasmodics and water load) "Phytolysin" 43 ml 3 times a day. In the control group (90 patients), only traditional therapy was performed. When "Phytolysin" was included in the therapy, independent discharge was observed in 64 (91.4%) patients, the incidence of renal colic occurred in 7 (10%), leukocyturia in 14 (20%), bacteriuria in 10 (15%). The use of the phytopreparation "Phytolysin" as a part of complex therapy is an effective method of conservative treatment of patients with urolithiasis and after remote shock-wave lithotripsy and contact laser lithotripsy in 90.9% of cases with regard to self-discharge of calculi.

A comparison of stone free rate between a diuretic and a control group of patients undergoing extracorporeal shock wave lithotripsy: a prospective, randomized, double-blind, placebo-controlled trial

Objectives: To compare the stone free rate and treatment success rate between a diuretic group of patients undergoing extracorporeal shock wave lithotripsy (ESWL) and a control placebo group (normal saline solution). Materials and Methods: One hundred and ninety-four patients with solitary renal calculi or ureteric calculi size of 5 mm or over were prospectively randomized into 2 groups. Ninety-seven patients in the first group (diuretic group) underwent ESWL after intravenous injection of furosemide 40 mg, and 97 patients in the second (control) group received normal saline solution 4 ml instead of furosemide prior to ESWL. The treatment protocol included 3,000 shockwaves per patient in each session with the energy beginning at 8 and progressing up to 15 kilovolts. A maximum of 3 ESWL sessions were permitted per patient. The primary outcome was stone free rate, and the secondary outcome was treatment success rate at 3 months after the first ESWL treatment. Results: The stone free rate was 48.5% compared to 50.5% for diuretic group and control group respectively and the treatment success rate was 81.4% compared to 64.9%. The difference in stone free rate was not statistically significantly different (p = 0.87), however the treatment success was, p = 0.01. Conclusion: A combination of diuretic therapy followed by ESWL improves the treatment success rate compared with standard ESWL therapy alone.

The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis

Pain is the most frequent symptom in chronic pancreatitis (CP) and has an important impact on quality of life. One of its major pathophysiological mechanisms is ductal hypertension, caused by main pancreatic duct stones and/or strictures. In this article, we focus on extracorporeal shock wave lithotripsy (ESWL) as a treatment for main pancreatic duct stones, which have been reported in >50% of CP patients. ESWL uses acoustic pulses to generate compressive stress on the stones, resulting in their gradual fragmentation. In patients with radiopaque obstructive main pancreatic duct (MPD) stones larger than 5 mm, located in the pancreas head or body, ESWL improves ductal clearance, thereby relieving pain and improving quality of life. In case of insufficient ductal clearance or the presence of an MPD stricture, ESWL can be followed by endoscopic retrograde cholangiopancreatography (ERCP) to increase success rate. Alternatively, direct pancreaticoscopy with intracorporeal lithotripsy or surgery can be performed