International Journal of Gerontology 11 (2017) 179e181

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International Journal of Gerontology

journal homepage: www.ijge-online.com

Original Article

Comparison of Electrohydraulic and Electromagnetic Shock Wave

Lithotripsy for Upper Urinary Tract Stones in Elderly Patients
Yi-Zhong Chen a, Wun-Rong Lin a, b, Chih-Chiao Lee a, b, Yung-Chiong Chow a, b,
Wei-Kung Tsai a, b, Pai-Kai Chiang a, b, Ting-Po Lin a, b, Marcelo Chen a, b, c *,
Allen W. Chiu a, d
a
Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan, b School of Medicine, MacKay Medical College, New Taipei City, Taiwan, c Department
of Cosmetic Applications and Management, MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan, d School of Medicine, National
Yang-Ming University, Taipei, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Backgrounds: In this study we compared the clinical outcomes of elderly patients with upper urinary
Received 8 June 2016 tract stones who underwent extracorporeal shock wave lithotripsy (ESWL) with two different machines,
Received in revised form an electrohydraulic (EH) and an electromagnetic (EM) lithotripter.
20 October 2016
Methods: A retrospective review of medical records was performed of 238 patients (EH 168, EM 70) aged
Accepted 7 November 2016
Available online 3 August 2017
65 years or older with upper urinary tract stones who underwent ESWL at two branches of the same
institution between 2007 and 2015. The demographic data, stone parameters, stone-free rate, retreat-
ment rate, and complication rate in both groups were analyzed.
Keywords:
elderly,
Results: There was no significant difference between the EH and EM groups in terms of stone free rate
electrohydraulic, (43.5% vs. 34.3%, p > 0.05) regardless of stone site or size. EM group had a higher retreatment rate than
electromagnetic, EH group (31.5% vs. 50.0%, p ¼ 0.007). Complication rates were similar (22.0% vs. 27.1%, p > 0.05). The
shock wave lithotripsy, most common complication was flank pain. Two EH group patients had subcapsular renal hematomas.
urolithiasis Conclusions: Our study showed that elderly patients with upper urinary tract stones undergoing ESWL
with EH and EM machines had comparable stone free rates and complication rates, but a higher
retreatment rate was seen with EM machines.
Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction 2. Patients and methods

Extracorporeal shock wave lithotripsy (ESWL) has been
commonly used in the treatment of non-infectious urolithiasis of
the upper urinary tract since the 1980s. The original ESWL machine
was an electrohydraulic (EH) lithotripter. As technology progressed,
novel machines were invented, including piezoelectric and elec-
tromagnetic (EM) lithotripters. Studies have shown that EH and EM
lithotripters are equally efficacious and have similar safety profiles
in the general population.1e3 However, data in elderly patients are
lacking. The aim of this study was to compare the efficacy and
safety of EH and EM lithotripsy in the elderly.
* Corresponding author. No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei,
104, Taiwan.
E-mail address: mchen4270@yahoo.com (M. Chen).
We retrospectively reviewed the medical records of 238 patients
aged 65 years or older with upper urinary tract stones who un-
derwent ESWL between March 2007 and December 2015. The EH
lithotripter (E3000) was located at the Taipei Branch and the EM
lithotripter (EM1000) at the Tamshui Branch of Mackay Memorial
Hospital. The use of data and the research protocol of the study
were permitted and approved by the Mackay Memorial Hospital
Institutional Review Board.
All procedures, however, were performed by the same two
technicians who had experience operating both machines. Patients
with congenital anomalies, urinary diversion, urosepsis, coagul-
opathy and those who had undergone surgical treatment with
another modality were excluded from this study. The energy level
was gradually increased from 14 to 22 KV, and shock waves were
delivered at a rate of 120 shocks per minute by both lithotripters.

http://dx.doi.org/10.1016/j.ijge.2016.11.005
1873-9598/Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
180 Y.-Z. Chen et al.

The number of shock waves in a session ranged from 3000 to 4,000, Table 3
depending on stone fragmentation and patient tolerance. Patients Comparison of retreatment rates by stone location and size.

in the EH group were placed under conscious monitored intrave- Electrohydraulic Electromagnetic P value
nous sedation with 100e150 mg of fentanyl and 2.5e3 ml of mid- Retreatment/total (%) Retreatment/total (%)
azolam depending on body weight, while those in EM group were Overall 53/168 (31.5%) 35/70 (50.0%) 0.007
treated without anesthesia. Kidney 31/95 (32.6%) 25/50 (50.0%) 0.041
All of the patients underwent physiological and laboratory ex- Ureter 22/73 (31.0%) 10/20 (50.0%) 0.098
Stone size <1 cm 15/87 (17.2%) 11/29 (37.9%) 0.021
aminations before ESWL. Stone size was measured on plain
Kidney 5/38 (13.2%) 6/19 (31.6%) 0.096
abdominal radiograph of kidney, ureter, and bladder (KUB) in one Ureter 10/49 (20.4%) 5/10 (50.0%) 0.050
dimension. Patients were evaluated within 4 weeks after ESWL by Stone size S1 cm 38/81 (46.9%) 24/41 (58.5%) 0.225
KUB and renal ultrasonography. Stone-free status was defined as Kidney 26/57 (45.6%) 19/31 (61.3%) 0.160
Ureter 12/24 (50.0%) 5/10 (50.0%) p > 0.999
the absence of stone on radiographic imaging, and retreatment was
defined as further surgical intervention for residual stone frag-
ments >5 mm. Complications were classified according to the
Clavien-Dindo classification. All data were compared using t-test Table 4
Comparison of complication rates by stone location and size.
and chi-square test. Statistical significance was set at p < 0.05.
Electrohydraulic Electromagnetic P value
Complications/total (%) Complications/total (%)
3. Results
Overall 37/168 (22.0%) 19/70 (27.1%) 0.396
Kidney 18/95 (18.9%) 15/50 (30.0%) 0.131
Of the 238 patients, 168 were treated by EH and 70 by EM Ureter 19/73 (26.0%) 4/20 (20.0%) 0.772
lithotripters. The mean age was 71.8 ± 5.4 years in the EH group and Stone size <1 cm 15/87 (17.2%) 9/29 (31.0%) 0.112
75.6 ± 6.3 years in the EM group. (p > 0.05) The EM group had a Kidney 5/38 (13.2%) 8/19 (42.1%) 0.021
Ureter 10/49 (20.4%) 1/10 (10.0%) 0.670
higher proportion of kidney stones (p < 0.05). The male-to-female
Stone size  1 cm 22/81 (27.2%) 10/41 (24.4%) 0.742
ratio was similar in both groups. Comparison between the two Kidney 13/57 (22.6%) 7/31 (22.8%) 0.981
groups showed similar kidney stone sizes (mean, 1.25 ± 0.72 cm in Ureter 9/24 (37.5%) 3/10 (30.0%) >0.999
EH group and 1.29 ± 0.65 cm in EM group, p ¼ 0.78) and ureteral
stone sizes (mean, 0.89 ± 0.44 cm in EH group and 1.03 ± 0.57 cm in
EM group, p ¼ 0.25) (Table 1). One patient from each group did not statistically significant differences in overall retreatment rates
have a follow-up KUB taken and did not receive further treatment. (31.5% in EH group vs. 50% in EM group, p ¼ 0.007), and in the
The overall stone free rates were similar (43.5% in EH group vs. retreatment rates for stone size <1 cm (EH 13.2% vs. EM 31.6%,
34.3% in EM group, p ¼ 0.262). Comparable stone free rates were p ¼ 0.021).
seen in the kidney (EH 33.7% vs. EM 32.0%, p > 0.99) and in the Thirty-seven patients (22.0%) in the EH group and 19 patients
ureter (EH 56.2% vs. EM 40%, p ¼ 0.20) (Table 2). Similar stone free (27.1%) in the EM group had complications (p ¼ 0.396). There were
rates were seen in both groups regardless of stone size (p ¼ 0.592 no significant differences in overall complication rates between the
for stones <1 cm, and p ¼ 0.378 for stones S1 cm). A higher two groups when compared by stone site (kidney, p ¼ 0.131; ureter,
retreatment rate was seen in the EM group (Table 3). There were p ¼ 0.772) and stone size (<1 cm, p ¼ 0.112; S1 cm, p > 0.742)
(Table 4). Analysis by gender revealed comparable complication
rates (males, EH 22.3% vs. EM 29.4%, p ¼ 0.400; females, EH 21.6%
Table 1
Patient demographics and stone characteristics. vs. EM 25.0%, p ¼ 0.690). The most common complication was post-
ESWL-related flank pain (grade I), which occurred in 33 (19.6%)
Electrohydraulic Electromagnetic P value
patients in the EH group and 19 (27.1%) patients in the EM group
(n ¼ 168) (n ¼ 70)
(p > 0.05). These cases were managed with intravenous non-
Patient age (mean ± SD) 71.79 ± 5.41 75.62 ± 6.26 0.14
steroidal anti-inflammatory drugs in all cases. In the EH group,
Patient gender
Male n (%) 94 (55.9) 34 (48.5) 0.29 one patient had a urinary tract infection and another one had
Female n (%) 74 (44.1) 36 (51.5) nausea post-operatively. There were two cases of subcapsular renal
Stone location hematoma (1.2%) in the EH group. One received blood transfusion
Kidney n (%) 95 (58.5) 50 (71.4) 0.032 (grade II), and the other received trans-arterial embolization at the
Ureter n (%) 73 (43.5) 20 (28.6)
intensive care unit (grade IV).
Stone size
Kidney (cm) 1.25 ± 0.72 1.29 ± 0.65 0.781
Ureter (cm) 0.89 ± 0.44 1.03 ± 0.57 0.252 4. Discussion

Results from this study showed that ESWL with EH and EM

Table 2 lithotripters was equally efficacious in elderly patients. Previous
Comparison of stone free rates by stone location and size.
comparative studies between EH and EM lithotripters yielded con-
Electrohydraulic Electromagnetic P value flicting results. While a study by Sheir et al showed a significant
Stone-free/total (%) Stone-free/total (%) advantage of EM over EH lithotripters4, most studies showed that
Overall 73/168 (43.5%) 24/70 (34.3%) 0.262 these two types of lithotripters were comparable13,5.To our
Kidney 32/95 (33.7%) 16/50 (32.0%) p > 0.999 knowledge, our study is the first one to compare the efficacy and
Ureter 41/73 (56.2%) 8/20 (40.0%) 0.200
safety of these lithotripters in elderly patients. This study is
Stone size <1 cm 47/87 (54%) 14/29 (48.2%) 0.592
Kidney 15/38 (39.5%) 10/19 (52.6%) 0.396 important because the elderly is a unique population, and urologists
Ureter 32/49 (65.3%) 4/10 (40.0%) 0.166 must decide which treatment modality is the most efficacious and
Stone size S1 cm 26/81 (32.0%) 10/41 (24.3%) 0.378 safest in this group of patients with higher inherent surgical risks.
Kidney 17/57 (29.8%) 6/31 (19.4%) 0.286 Our study is the first such comparative study in the elderly and
Ureter 9/24 (37.5%) 4/10 (40.0%) p > 0.999
comparison with previous studies in all age groups showed some
Comparison of shock wave lithotripsy in the elderly
different results. Previous studies by Wazir et al6, and Anila et al
reported similar stone free rates and retreatment rates5. Our study
showed comparable stone-free rates in the EH and EM groups
(43.5% vs. 34.3%) but a higher retreatment rate in the EM group
(31.5% vs. 50.0%). This higher retreatment rate in our EM group
could be due to bias, as decision for further surgical intervention
was based on patients' clinical symptoms, patient's willingness to
undergo further treatment and different urologist's clinical expe-
rience and practice.
When comparing the treatment outcomes of different litho-
tripters, the stratification of the results according to stone size and
stone site was recommended by Clayman et al7. In our study,
stratification analysis showed that EH and EM yielded comparable
outcomes when comparisons were made for different stone sizes
and stone sites.
The higher shockwave requirements may potentially induce
renal trauma5. In our study, two patients (1.6%) in the EH group
developed renal hematomas. One was an 82-year-old male with a
5 cm renal stone, who was hardly indicated for ESWL. He received a
blood transfusion. The other was a 70-year-old female with a 1 cm
renal stone, who also had coronary artery disease, diabetes mellitus
and hypertension, which could be precipitating factors for hema-
toma formation. She received trans-arterial embolization and was
admitted to the intensive care unit. Both patients recovered un-
eventfully. Dhar et al8 showed the incidence of renal hematoma
following EM lithotripsy for renal stones to be 4.1%, and the prob-
ability of hematoma increased significantly with increasing patient
age. Sheir et al4 reported an incidence of renal hematoma of 0.5%
(4/694) and an incidence of renal colic pain of 9.6%. Jamshaid et al5
reported an incidence of renal colic pain of 3.3% (4/112) in the EH
group and 3.7% (6/162) in the EM group (p < 0.05). Renal colic was
the most common complication in our study, and it occurred in
19.6% (33/168) of patients in the EH group and 27.1% (19/70) of
patients in the EM group. ESWL of kidney stones is more likely to
cause significant complications due to functional and anatomic
injury of kidney. The relatively higher incidence of renal colic pain
in EM group could be related to treatment without anesthesia and a
higher percentage of kidney stones in this group. Compared to
other studies in patients of all ages, our study in elderly patients
showed a relatively higher incidence of renal colic pain.
Comparison among studies is difficult, as the majority of the
studies are retrospective with many potential biases. These studies
may be single-center or multicenter, the shock wave machines,
treatment plans (frequency, rate, energy and operative time),
anesthesia protocol, peri-operative oral medication, follow-up
protocol and retreatment protocol may be different, and the
experience of the operating staffs may vary. These factors taken
together may affect the operative outcomes9,10. Single-center
studies are more likely to give a more conclusive result than
multicenter studies11. Our study was a retrospective single-center
181
study, ESWL treatments were performed by the same two experi-
enced operators who traveled back and forth between the two
hospital branches and operated both machines, and all the patient
data were reviewed by a single researcher. The consistency of our
data was relatively high and potential biases were minimized. The
limitations of this study were (1) its retrospective nature; (2) the
small case number, (3) the absence of guidelines for stent place-
ment before ESWL, (4) the lack of data regarding stone composi-
tion, and (5) the lack of computed tomography exams from which
the hardness of the stones could be calculated.
5. Conclusion
This study showed that treatment of upper urinary tract stones
in elderly patients with EH and EM lithotripters resulted in com-
parable stone free rates but a higher retreatment rate was seen with
EM lithotripters. The higher complication rates seen in the elderly
must be kept in mind and carefully explained before performing
these procedures.
Conflict of interest
There are no potential financial and non-financial conflicts of
interest.
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