NEW ORLEANS, LA USA (UroToday.com) - In this session, the present and future status of extracorporeal shockwave lithotripsy (SWL) was examined through a debate-style format. The use of SWL has continued to fall throughout the United States from upwards of 70% of patients in the 1990s to only a third of patients in 2012. The advent of improved measures (i.e., skin-to-stone distance, Hounsfield units, and stone size – distance, density, and diameter respectively or the 3Ds as described by Dr. Lingeman) to determine the ideal candidate for SWL plus marked improvements in the technology for ureteroscopy (i.e., ureteral access sheaths, smaller and more maneuverable ureteroscopes, nitinol stone baskets, and holmium laser lithotripsy as described by Drs. Traxer and Preminger) have combined to vastly decrease the use of SWL.
As argued in favor of SWL, Dr. Denstedt noted that the stone-free rate for ureteroscopy, while higher than SWL, is associated with an increase in costs and complications; over 80% of patients after ureteroscopy still have an indwelling stent placed and suffer the stent-associated discomforts. Indeed, the European guidelines of 2013 continue to recommend SWL as first choice therapy for renal pelvic as well as upper or middle calyceal stones less than 2 cm.
Dr. Lingeman then emphasized the importance of patient selection (the 3Ds), use of general anesthesia, and meticulous attention to 100% coupling as keys to boosting SWL success to over 90%.
Drs. Preminger and Traxer countered these pro-SWL arguments by emphasizing the higher cost-effective success rate of ureteroscopy and PCNL in rendering patients stone free with one procedure and the fact that urologists were flocking to ureteroscopy while fleeing from SWL therapy. They noted that in the 2015 EAU guidelines for ureteral stones, only in the proximal ureter for stones < 10 mm was SWL a first-choice therapy. They also emphasized that in many ureteroscopy patients, a ureteral stent had been clearly shown to be unnecessary and that for percutaneous stone removal, nephrostomy tubes and totally tubeless scenarios are now common.
To be sure, at this time, SWL use continues to decrease and the arguments of Drs. Traxer and Denstedt were most compelling; however, in the rebuttal, Dr. Lingeman presented evolving advances in technology, such as ultrasonic propulsion to reposition stones from the lower pole into the renal pelvis and burst-wave lithotripsy, both of which could create a renewed interest in SWL. In sum, without reinvention and retraining, SWL may well be moving into retirement, housed in a few centers of excellence.
Debater - Pro: Glenn M. Preminger, MD
Debater - Pro: Olivier Traxer, MD
Debater - Con: John D. Denstedt, MD, FACS, FRCS(C)
Debater - Con: James E. Lingeman, MD
Moderated by Ralph V. Clayman, MD at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
