【纪念ESWL·41周年】EAU指南学习：体外冲击波碎石术
1980年2月7日，Christian G. Chaussy进行了首次ESWL治疗
2021年的今天，ESWL的现状如何呢？
今天，柳叶新潮与大家一起学习《EAU尿石症指南》中有关体外冲击波碎石的内容。
The success of SWL depends on the efficacy of the lithotripter and the following factors:
·size, location (ureteral, pelvic or calyceal), and composition (hardness) of the stones (Section 3.4.9.3);
·patient's habitus (Section 3.4.10.3);
·performance of SWL (best practice, see below).
SWL的成功取决于碎石机的功效和以下因素：
·结石的大小、位置（输尿管，肾盂或肾盏）和成分（硬度）（第3.4.9.3节）；
·患者的体质（3.4.10.3节）；
·SWL的性能（最佳实践，见下文）。
Each of these factors significantly influences the retreatment rate and final outcome of SWL.
这些因素均会严重影响SWL的再治疗率和最终结果。
Best clinical practice
最佳临床实践
Stenting 支架置入
Routine use of internal stents before SWL does not improve stone free rates (SFRs), nor lowers the number of auxiliary treatments. It may, however, reduce formation of steinstrasse.
在SWL之前常规置入支架不会提高结石清除率（SFR），也不会减少辅助治疗的次数。但是，它可以减少石街的形成。
Pacemaker 起搏器
Patients with a pacemaker can be treated with SWL, provided that appropriate technical precautions are taken. Patients with implanted cardioverter defibrillators must be managed with special care (firing mode temporarily reprogrammed during SWL treatment). However, this might not be necessary with new-generation lithotripters.
如果可以采取适当的技术预防措施，那么可以对带有起搏器的患者进行SWL治疗。对于植入心脏复律除颤器的患者，必须进行特别管理（在SWL治疗期间暂时对触发模式进行重新编程）。但是，这对于新一代碎石机可能不是必需的。
Shock wave rate 冲击波频率
Lowering shock wave frequency from 120 to 60-90 shock waves/min improves SFRs. Tissue damage increases with shock wave frequency.
将冲击波频率从120 SW/min降低到60-90 SW/min，可提高SFR。冲击波频率越高，组织损伤越严重。
Number of shock waves, energy setting and repeat treatment sessions
冲击波冲击数量，能量设定和重复治疗次数
The number of shock waves that can be delivered at each session depends on the type of lithotripter and shock wave power. There is no consensus on the maximum number of shock waves. Starting SWL on a lower energy setting with stepwise power (and SWL sequence) ramping can achieve vasoconstriction during treatment, which prevents renal injury. Animal studies and a prospective randomised study have shown better SFRs (96% vs. 72%) using stepwise power ramping, but no difference has been found for fragmentation or evidence of complications after SWL, irrespective of whether ramping was used.
每次冲击波的冲击数量取决于碎石机的类型和冲击波功率。目前关于冲击波的最大冲击数量尚无共识。在SWL开始治疗时，采用低能量，然后逐渐增加功率（和SWL sequence*），可以在治疗过程中实现血管收缩，从而防止肾脏损伤。动物研究和一项前瞻性随机研究显示，逐渐增加功率可以提高SFR（96％vs72％），但是使用和不使用“逐渐增加功率”在碎石效果和SWL后并发症证据方面没有差异。
*注：SWL sequence：指“timing and shock wave number at a given power level”。
There are no conclusive data on the intervals required between repeated SWL sessions. However, clinical experience indicates that repeat sessions are feasible (within 1 day for ureteral stones).
关于重复SWL治疗所需的治疗间隔，目前尚无确切数据。但是，临床经验表明，（对于输尿管结石在一天之内）重复治疗是可行的。
Improvement of acoustic coupling
改善耦合剂
Proper acoustic coupling between the cushion of the treatment head and the patient's skin is important. Defects (air pockets) in the coupling gel deflect 99% of shock waves. Ultrasound gel is probably the most widely-used agent available as a lithotripsy coupling agent.
在水囊和患者的皮肤之间涂抹适当的耦合剂很重要。耦合剂中的缺陷（气泡）会偏转99％的冲击波。超声凝胶可能是目前碎石时使用最为广泛的耦合剂。
Procedural control 过程控制
Results of treatment are operator dependent, and experienced clinicians obtain better results. During the procedure, careful imaging control of localisation contributes to outcome quality.
治疗结果取决于操作员，有经验的临床医生会获得更好的结果。在操作过程中，利用影像学进行仔细的结石定位有助于改善治疗效果。
Pain control 疼痛控制
Careful control of pain during treatment is necessary to limit pain-induced movements and excessive respiratory excursions.
治疗期间必须注意控制疼痛，这对于减少疼痛引起的体位移动和过度的呼吸运动十分必要。
Antibiotic prophylaxis 抗生素预防
No standard antibiotic prophylaxis before SWL is recommended. However, prophylaxis is recommended in the case of internal stent placement ahead of anticipated treatments and in the presence of increased bacterial burden (e.g., indwelling catheter, nephrostomy tube, or infectious stones).
建议在SWL之前不进行标准的抗生素预防。但是，如果在治疗之前置入了内部支架，或者细菌负担增加（例如，留置导管、肾造瘘管或感染性结石），建议进行预防。
Medical therapy after extracorporeal shock wave lithotripsy
体外冲击波碎石术后的药物治疗
In spite of conflicting results, most RCTs and several MAs support MET after SWL for ureteral or renal stones as adjunct to expedite expulsion and to increase SFRs. Medical expulsion therapy might also reduce analgesic requirements.
虽然研究结果不一致，但大多数RCT和几项MA都支持，对于输尿管或肾结石，在SWL后进行药物排石治疗（MET），以辅助排石并提高SFR。药物排石治疗可能也会减少患者的止痛需要。
Post treatment management 治疗后的管理
Mechanical percussion and diuretic therapy can significantly improve SFRs and accelerate stone passage after SWL.
机械振动和利尿治疗可显著改善SFR，加速SWL后的排石。
Complications of extracorporeal shock wave lithotripsy
体外冲击波碎石术的并发症
Compared to PNL and ureteroscopy (URS), there are fewer overall complications with SWL (Table 3.5).
与PNL和输尿管镜治疗（URS）相比，SWL的总体并发症更少（表3.5）。
Table 3.5: Shock wave lithotripsy-related complications
表3.5：冲击波碎石术相关并发症
The relationship between SWL and hypertension or diabetes is unclear. Published data are contradictory; however, no evidence exists supporting the hypothesis that SWL may cause long-term adverse effects.
SWL与高血压或糖尿病之间的关系尚不清楚。目前已发布的数据相互矛盾；但是，关于SWL可能造成长期副作用，尚无证据支持这一假说。
Summary of evidence and guidelines for SWL
SWL的证据概述和建议