THE SCOPE AND PLACE OF ULTRASOUND-MONITORED EXTRACORPOREAL SHOCK-WAVELITHOTRIPSY IN A MULTIMODALITY SETTING AND THE EFFECTS OF EXPERIENTIAL, AUDIT-EVOKED CHANGES ON THE MANAGEMENT OF URETERAL CALCULI

Objective To assess the results from ultrasound-monitored extracorpore al shock wave lithotripsy (ESWL) for ureteric stones, to compare the r esults with other treatment modalities and to evaluate experiential au dit-evoked gains. Patients and methods A review of the records of 109 patients with ureteric stones who were treated during 1990 (Group I) a nd 69 patients treated by ESWL during the first 10 months of 1991 (Gro up II), was carried out. All patients with a steinstrasse or fragments secondary to ESWL were excluded from the study. Results Of the 109 pa tients in Group I, 63 were treated with ESWL, nine underwent ureterosc opic push-up of the stone and 11 underwent catheter push-up prior to E SWL, 28 underwent ureteroscopic extraction/ fragmentation, five underw ent post-ESWL ureteroscopy and 29 underwent open ureterolithotomy (nin e after failed ureteroscopy). Ureteroscopy was successful in fragmenta tion/extraction of 19 of 28 (68%) stones and 95% of patients were ston e-free at 3 months. All patients who underwent ureterolithotomy and 84 % who underwent ESWL (and post-ESWL ancillary procedures) were stone-f ree at 3 months. All patients who underwent ureterolithotomy, 51% of t hose who underwent ureteroscopy and 56% of patients who underwent ESWL needed only one treatment. The mean stone burdens of patients in Grou ps I and II were comparable but more patients presented with larger st ones (> 15 mm length, > 100 mm(2) surface area) in Group II, The stone -free rates for ESWL monotherapy with ESWL increased from 84% in 1990 to 92% in 1991. A higher proportion of stones were treated in situ in 1991 and a stent was used less frequently in obstructed ureters. Post- ESWL procedures fell from 8% in 1990 to 6% in 1991 and the proportion of patients who required more than one treatment fell from 44% in 1990 to 14% in 1991. Conclusions The choice of treatment for patients with ureteric stones is critical but will vary depending on the individual 's circumstances, the availability of equipment, costs and time requir ed to perform the procedure. The results obtained using ESWL for urete ric stones improved considerably over the course of the study as a res ult of experience and refinement of the technique. Stones located in m ore difficult systems such as in kidneys with a thin cortex and those located above the ischial spine were no longer subjected to ESWL. Audi t of the results obtained following treatment allows identification of problem areas, alerts physicians to alternative methods of treatment and gives an objective quantification of experience, assisting rationa l decision malting with consequent improved success.