1. ESWL Treatment Result with DiREX Integra
Kumamoto Urological HP
Yasuhiro Yamamoto,　Yasufumi Nabekura, Hidetaka Ih, Akihiro Nojiri
Kengun Kumamoto Urological　Clinic
Hitoshi Sakiyama

2. Background
About 700cases/year of urolithiasis were treated in our hospital. (ESWL/TUL/f-TUL/PNL/Vesical Lithotomy)
The number of ESWL treatments was about 600cases/year and we expect that the number of patients will increase still more in the future.
We have started to use a new ESWL device (DiREX Integra) since April of 2009, in parallel to the use of Storz Modulith SL20, which has been used for a long time in our hospital.
We report here the results of ESWL treatment with Direx Integra during April January 2010.

3. DiREX Integra Electromagnetic SWL System (3rd generation ESWL)
Supine position is the standard, but prone position is also possible.
Compact　body(1×2m)
Stone localization is made by X-ray fluoroscopy. (Echo is not mounted.)
This hospital is the 2nd user of Integra in Japan.

4. Case Report 305cases were treated with Direx Integra.
（Term）　10months during April 2009-January 2010
（Sex）　Male：213cases、　Female：92cases
（Age）　19～102y.o　[Average：56.2y.o]
（Details）
・Number of shocks : Max shocks/session
（Renal stones : Max 3500 shocks/session）
・Level : 1～20　（Max Power：300Bar）
・Evaluate the overall success rate (stone free cases & cases with residual fragments less than 4mm) within 3months after treatment.

5. Stone information Stone Location Stone maximal diameter 8cases 89cases
≦1cm
1cm＜、≦2cm
2cm＜
R1・・・0case
R2・・・23cases
R3・・・34cases
U1・・・153cases
U2・・・36cases
U3・・・59cases

6. Treatment Result according to stone location（Average number of sessions）
0.2
0.4
0.6
0.8 1
1.2
1.4
1.6
1.8 2 R1 R2 R3 U1 U2 U3
［Stone location］
［Average number of sessions］
The average number of sessions for urinary stones was1.4.(R2:1.9, R3:1.7, U1:1.3, U2:1.3, U3:1.5) It can be said that this is good result for ureteral stones. The number of sessions for renal stones was more than ureteral stones, because the particle of fragmentation remained in calix in many cases. In such a case, the re-treatment was often necessary. And, the percentage of more than 1cm stones in R3 was higher than other stone locations. The number of sessions in U3 was more than U1,U2, because the power might be reduced by pelvis.

7. Treatment Result according to stone location（Overall success rate）10 20 30 40 50 60 70 80 90
100 R1 R2 R3 U1 U2 U3
［Overall success rate（％）］
［stone location］
Stone-free rate including overall success rate (less than 4mm) within 3months was 93.4% in urinary stones. (R2:52.2%, R3:76.4%, U1, U2:100%, U3:98.3%) Only in U3, we had 1TUL treatment after ESWL.

8. Treatment Result according to maximal diameter (Average number of sessions)
3.5 2＜ 3
2.5
≦1cm
1cm＜,≦2cm
2cm＜ 2
1.5 1
The average number of sessions according to stone maximal diameter was as follows. :1.3 for less than 1cm stones, 1.6 for 1-2cm, 3.1 for more than 2cm. We basically applied ESWL for less than 2cm stones, but sometimes we applied it for partial staghorn calculus at the request of the patients.
0.5
［Stone maximal diameter（cm）］ ≦1
1＜,≦2

9. Treatment Result according to maximal diameter (Overall success rate)10 20 30 40 50 60 70 80 90
100
≦1cm
1cm＜,≦2cm
2cm＜
［Overall success rate（％）］
［Stone maximal diameter（cm）］ ≦1
1＜,≦2 2＜
Overall success rate according to stone maximal diameter was as follows. : 97.1% for less than 1cm, 87.6% for 1cm-2cm, 62.5% for more than 2cm. We recognized that stone size was relevant to overall success rate.

10. Complication ・Mild complication・・・Gross hematuria（Almost all cases）
　　　　　　 Subcutaneous hematoma
　　　　　　 Colic attack（pain・nausea・vomiting）
・Serious complication・・・Renal subcapsular hematoma
（2cases）
　　　　　　　 Pyelonephritis（3cases）

11. 2009 ESWL number of treatments and the graph of fragmentation results
ＳＬ２０ 80
ＳＬＸ
Integra
BOTH 70
TOTAL
[Number of treatments] 60 50 40 30
This is a bar graph of 2009 ESWL number of treatments in order to see the change of ESWL treatment results since installation of Integra. As you see, the number of treatments has been increasing gradually since installation of Integra on April. 20 10
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec/2009

12. Installation of Integra
2009　ESWL number of treatments and the graph of fragmentation results
ＳＬ２０ 80
ＳＬＸ
Integra
Installation of Integra
BOTH 70
TOTAL
[Number of treatments] 60 50 40 30 20 10
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec/2009

13. Installation of Integra
2009　ESWL number of treatments and the graph of fragmentation results
Ratio of number of treatments (single/multiple) 10 20 30 40 50
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec/2009 0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 60 70 80
ＳＬ２０
ＳＬＸ
Integra
BOTH
TOTAL
Full fragmentation at first session
More than 2sessions to achieve full fragmentation
Installation of Integra
［number of treatments］
This is a line graph of the ratio of single treatment and multiple treatments in order to see the change of fragmentation results. As you see, number of single treatment has been increasing greatly since installation of Integra.

14. Summary ・This is a report of ESWL treatment results with Integra.
・We confirmed that ESWL treatments with Integra were effective for urinary stones with less side effect.
・The treatment results for renal stones were little worse than for ureteral stones. The cause might be the setting up the restriction of number of shocks and HV level for the safety, because we are still the second user of this machine in Japan.
・We are going to treat still more patients in order to conduct further examination of this machine.