title: Shock-wave lithotripsy in the elderly: Safety, efficacy and special considerations.
abstract: OBJECTIVE
  Shock-wave lithotripsy (SWL) for elderly patients can be challenging. Patients often have a long-standing complex stone burden and significant comorbidities. We report a cohort of patients aged ⩾70 years who were treated by SWL, with special attention to treatment outcomes, complications and the need for adjuvant procedures.
  
  
  METHODS
  Over a period of 4 years, 2311 patients were treated with SWL in a tertiary referral centre. Among these patients, 137 were aged ⩾70 years (5.9%). Patient and stone data were obtained from an electronic database and the patients' electronic medical records were reviewed.
  
  
  RESULTS
  During the pre-procedural assessment, 29 patients (21.2%) were considered to be at high anaesthetic risk, due their comorbidities (American Society of Anesthesiology score 3+). In terms of stone burden, 16 stones (11.7%) were located in the distal ureter (mean stone diameter 7.9 mm) and 28 (20.4%) were in the proximal ureter (mean diameter 10.1 mm). In the kidney, 54 stones (39.4%) were in the renal pelvis, upper or mid calyx (mean diameter 10.6 mm), while 39 stones (28.5%) were in the lower calyx (mean diameter 10.1 mm). The median (range) number of SWL sessions per patient was 2.0 (1-3). The overall stone-free rate achieved by SWL alone was 63.5% (65.9% for ureteric stones and 62.4% for renal stones). In total, 38 patients (27.7%) had an adjuvant procedure to achieve stone clearance (ureteroscopy in 23, PCNL in 14 and laparoscopic ureterolithotomy in one case). Apart from six cases (4.3%) of ureteric obstruction due to steinstrasse, there were no severe complications noted.
  
  
  CONCLUSIONS
  The management of elderly patients presenting with urolithiasis is challenging, due to the presence of significant comorbidities. Careful assessment of an integrated management plan for geriatric patients with urolithiasis is essential, and SWL still remains a safe and efficient first-line tool in well-selected cases.
authors.affiliation: Endourology and Stone Services, Barts and The London NHS Trust, London, UK.
authors.forename: Prodromos
authors.initials: P
authors.lastname: Philippou
authors.affiliation: Endourology and Stone Services, Barts and The London NHS Trust, London, UK.
authors.forename: D
authors.initials: D
authors.lastname: Lamrani
authors.affiliation: Endourology and Stone Services, Barts and The London NHS Trust, London, UK.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Moraitis
authors.affiliation: Endourology and Stone Services, Barts and The London NHS Trust, London, UK.
authors.forename: Hassan
authors.initials: H
authors.lastname: Wazait
authors.affiliation: Endourology and Stone Services, Barts and The London NHS Trust, London, UK.
authors.forename: Junaid
authors.initials: J
authors.lastname: Masood
authors.affiliation: Endourology and Stone Services, Barts and The London NHS Trust, London, UK.
authors.forename: Noor
authors.initials: N
authors.lastname: Buchholz
keywords: ASA, American Society of Anesthesiology; ECG, electrocardiography.; Elderly; PCNL, percutaneous nephrolithotripsy; Renal stones; SFR, stone-free rate; SWL, shock-wave lithotripsy; Shockwave lithotripsy