BERKELEY, CA (UroToday.com) - Caveat emptor! Upper urinary tract calculi in patients with a urinary diversion remain problematic. In this manuscript, ESWL with a Dornier MFL 5000 was used as the primary mode of therapy to treat upper urinary tract calculi which on average were 8 x 11 mm. Of note, the "success" rate was 81%; to achieve this outcome, 44% required retreatment, 7% developed obstruction, and 18% required secondary nonESWL procedures. The overall chance of "success" (i.e. fragments < 4mm) with only one treatment would have been 50%. As the authors report, half of their patients had a positive urine culture; they also note that the goal of therapy is a "stone free" state in order to best eliminate the possibility of recurrent infection and further stone formation. To my mind, in order to achieve these goals, in most of these patients, a percutaneous stone removal may well be needed. While ESWL is tempting due to its ease of delivery; it would appear that the effect (i.e. the stone) and not the cause (i.e. the infection) are addressed. As many investigators have documented, the "insignificant fragment" is not often insignificant?bottom line, stone free (on CT) is best.

Urology 66: 510-513, September, 2005