1. بنام خدا به نام خدا

2. Extracorporeal Shock-wave lithotripsy (ESWL)

3. Nephrolithiasis with a lifetime prevalence  13% in men and 7% in women 80-85%  Ca- based 20%  uric acid,struvite,cystine,……

4. For uric acid,struvite,cystine stones are predictable For calcium stone formation is multifactorial: hypercalciuria hyperoxaluria hyperuricosuria hypocitraturia dietary factors

5. ESWL Ureteroscopy PCNL Open surgery SWL has been the most commonly used approach  49-54% of procedures to treat renal stones

16. Active UTI Distal obstruction Pregnancy coagulopathy

17. D/C of anticoagulants Documentation of a negative U/C R/O of pregnancy Bowel prep Antibiotic CBC Renal function test

18. Lower pole stones Morbid obes Hounsfield unite>1000 SSD>10 cm Cystine and brushite are the most resistant to SWL Small diameter of lower pole infundibula Lower pole with multiple infundibula the angle formed between the lower infundibulum and the renal pelvis

22. Supine Prone transplant kidney ectopic kidney lower ureter stones

23. Prevent patient’s movement

25. Antibiotic Analgesic KUB+SONO  2-4 wk after the procedure In several trrials the use of potassium citrate or tamsulosin with or without methylprednisolone has resulted in superior stone- free rates as compared with placebo For PT with stones that failed to fragment repeat SWL may be considered 2 weeks or more

26. Passage of fragmens may continue for up to 3 months

31. Obstruction steinstrasse(stone street)  6-20% Hematoma risk factors: older age HTN DM IHD obesity

34. Trauma to organs such as the liver and skeletal muscle, as evidenced by elevated levels of bilirubin, lactate dehydrogenase, serum aspartate transaminase, and creatine phosphokinase within 24 hours of treatment Parameters begin to fall within 3 to 7 days of SWL treatment and Are normal at 3 months.

35. Perforation of the colon Hepatic hematoma Splenic rupture Pancreatitis Abdominal wall abscess

36. Hematuria Hematoma Shockwaves rupture blood vessels and can damage surrounding renal tubules

37. It is well accepted that shockwaves damage blood vessels, and the resulting hemorrhage initiates an inflammatory response that ultimately leads to scar formation. Rise in systemic blood pressure Decrease in renal function Increase in the rate of stone recurrence

38. Number of shocks Accelerating voltage Kidney size—juvenile vs. adult Preexisting renal impairment Treatment at a slow rate of shockwave delivery (60 shocks/min or less)