European Urology

50th Volume Editorials

Traditionally, urologists have embraced technologies in their speciality, which may be explained by the anatomy of the organs they treat and the conditions demanding treatment. Obviously urologic organs are very suitable for technologic treatments, and urologists increasingly appreciate the challenges to advance their profession from the “stone age” towards the “new age.”

The modern treatment of stone disease has been dominated for decades by open surgical stone removal, since Sir Henry Morris first described in 1880 the pyelotomy for treatment of renal stones. More recently, however, stone management was transformed into a pure minimally invasive treatment. Percutaneous stone surgery revolutionized the treatment of renal stones and, through the advances of endoscopic ureteric stone surgery, the open approach has fallen by the wayside [1].

With the introduction of extracorporeal shock wave lithotripsy (EWSL), the “end of the stone age” was announced. Professors Christian Chaussy and Ferdinand Eisenberger were amongst the pioneers taking the lead in the research for a truly nonsurgical approach to stone management [2]. In the search for the Holy Grail in stone treatment during the past 25 yr, the urologic community learned about the indications and limitations of ESWL. In the already classic paper of Fuchs et al. [3], the distribution of treatment modalities is presented as well as the complications and auxiliary measures after ESWL.

At this time it may be interesting to reflect on the impact of ESWL as a treatment for urolithiasis and the future treatment of urolithiasis in the new age. It is beyond any discussion that the urologic community has witnessed significant changes in the management of stone disease. Most importantly, with the introduction of multimodality approaches, the treatment of patients can now be tailored to the needs and the local situation. However, if ESWL changed completely the treatment approach for urinary stones, ESWL also changed the epidemiology of urolithiasis. With the introduction of ESWL, smaller-sized (asymptomatic) stones are treated that would otherwise receive a watchful waiting strategy. Moreover the advances in technology in combination with an increased use of imaging modalities have resulted in downsizing of urinary stones at diagnosis. Staghorn calculi are rarely presented, and loss of renal function can be prevented in the majority of cases.

Second, the ESWL units have evolved from big “bath cup” type models requiring anaesthesia during treatment into mobile units with a treatment performed without anaesthesia. However, the efficacy of the first device (HM3 of Dornier) is still regarded as the highest amongst all the other ESWL machines. The decrease of morbidity attributed to the latest generation ESWL devices may have resulted in a decrease of efficacy as well [4].

Last but not least, one has to keep in mind that minimal invasive treatments, such as ESWL, may have short- and/or long-term morbidity. In the case of ESWL, morbidity is related mostly to residual stone fragments, infections, and effects on tissues such as urinary, gastrointestinal, cardiovascular, genital, and reproductive systems [5]. One may conclude that there is a minimal risk for these complications. On the other hand a recent report on possible long-term side-effects has drawn our attention to the fact that continued critical evaluation of any technology is mandatory, even if this is regarded as virtually harmless and in spite of the long-term follow up [6].

What is the position of ESWL in the armamentarium of a modern stone centre [7]? The initial excitement and overwhelming use of ESWL 2 decades ago is balanced by the significant improvements in endoscopic instruments used for percutaneous nephrostolithotomy (PCNL) and ureteroscopy (URS). The introduction of miniscopes and flexible instruments especially has gained popularity amongst the urologic community [8]. Consequently the indications for ESWL have decreased, and the next step in modern stone management is progress towards stone prevention. That should be the logical evolution to come closer to a real end of the stone age. But how real is this goal? The answer to this question may be best given and illustrated by the example of how the management of lower urinary tract symptoms caused by so-called benign prostatic hyperplasia (BPH) has evolved during the very same period.

Throughout the past decades the management of BPH has shifted from open adenomectomy to transurethral resection of the prostate and transurethral microwave treatment (TUMT) towards medical treatment and, even more recently, to medical prevention. Consequently at present the majority of patients are treated conservatively. Furthermore, since there is no longer any “disease,” there is a limited need for instrumental treatment of the prostate gland. Can one in this context position ESWL for stone disease in the same category as TUMT for BPH treatment? On the one hand the answer may be “yes,” since the initial enthusiasm for TUMT also was not confirmed in daily clinical practice. Moreover advances in other technologies have resulted in a shift towards these technologies such as HoLEP (holmium laser enucleation of the prostate) and KTP (potassium-titanyl-phosphate) laser treatments (read mini-PCNL and flexible URS in stone disease). However, ESWL has stood the test of time and, once applied in the right indication, results in a very satisfactory outcome. The indications, however, have become stricter and are for renal stone disease limited by stone size and renal anatomy [9]. For active treatment of ureteric stones, advances in semirigid ureteroscopes have resulted in an increased use of URS over ESWL. The availability of an ESWL unit, however, is a prerequisite for every esteemed stone centre and contributes to a well-balanced choice in the different situations for stone treatment [10]. Recognition of ESWL limitations and improvement of ESWL efficacy have resulted in minimization of possible complications. Decrease of the shock wave number, rate, and energy; the use of two shock wave tubes simultaneously; and the delivery of two shock waves at carefully timed close intervals have resulted in improvements in ESWL efficacy and safety.