A simple position to provide better imaging of upper ureteral stones close to the crista iliaca during extracorporeal shock wave lithotripsy using the Siemens Lithostar.

Objective: The fluoroscopic image from the second plan (oblique) tube of an upper ureteral stone close to the crista iliaca may be superimposed on the pelvic bones during SWL using the Siemens Lithostar with the patient in the prone position. This creates difficulty in imaging and targeting of the stone and can necessitate using ureteral catheters before treatment and/or intravenous contrast injection during SWL. We describe a very simple, yet effective method for easier visualization of the stone under this circumstance.

Methods: Between March 1992 and February 2003, we treated 1561 patients with ureteral stones by SWL with the Siemens Lithostar. The stones were localized in the upper ureter in 841. The image of the stone from the second plan (oblique) tube was superimposed on the pelvic bones in 221 in whom visualization of the stone was hardly possible with the standard prone position. By simply rotating the patient 180 degrees on the table, the superimposition of the image of the stone on the pelvic bone was obviated. This resulted in easier and better imaging of the stone during SWL. It also allowed for a clear and superior image to the treating physician during SWL. The energy and shock waves, utilization of anesthesia, number of treatment sessions, auxiliary measures, and complications were noted. Stone load was recorded in square centimeters (cm(2)). Patients were evaluated by intravenous urogram or KUB and ultrasonography when stone-free or CIRF (nonobstructive and noninfectious insignificant fragments < or =4mm) status was noted at the fluoroscopic control 2 to 4 weeks after the last session. Final CIRF decision was made 10-12 weeks after the last session. SWL was regarded as failure if no fragmentation was noted after the 3rd session. Therapy was continued if fragmentation was noted.

Results: The median age was 40 (range 5-85). The mean stone burden was 0.8 (range 0.24-2.9) cm(2). No indwelling ureteral stents were placed in any patients before and during treatment. The mean number of shock waves and energy used for the entire patient population was 2007 and 17.5kV, respectively. The median and average treatment session was 1 and 1.7, respectively. A total of 196 patients (89%) were rendered stone-free. Clinically insignificant residual fragments were present in 18 (8%). SWL was unsuccessful in 7 (3%) patients. These stones were removed by ureterorenoscopy. Intravenous contrast administration was not used to facilitate stone targeting during SWL. Anesthesia, in the form of analgesic sedation, was used in 7 (3%) patients. We did not observe any complications and adverse effects.

Conclusions: The technique described hereby does not have an affect on coupling; it only provides a superior image of the stone to the treating physician. We advocate its application in all patients with upper ureteral stones close to the crista iliaca when the fluoroscopic image of the stone from the second plan (oblique) tube is superimposed on pelvic bones during SWL in prone position.