体外冲击波碎石术濒危？值得拯救！

    体外冲击波碎石术濒危？值得拯救！  （（EAU）（YAU）尿石症组的观点）

   饶有兴趣地阅读了 Herout教授等人最近的研究，研究聚焦于德国冲击波碎石术 (SWL) 的现状。研究结果展示，在尿结石的治疗的领域中，输尿管镜手术 (URS)正在兴起，而SWL术则走向衰弱。英美等世界多国也有类似情况。

    为此，Herout 等人在其研究文章的标题中选择了“灭绝”这个词。这份关于 SWL 走向“灭绝”的特别报告也许更令人深省，因为它来自于20世纪80年代首创该技术的国家--德国。这些结果就好似在不断的鞭挞冲击波碎石技术，也好似在讽刺！

      20世纪80年代，早期的SWL呈现的是“浴缸式”模式，然后，40年，经历了一系列的变革。但是，对其具有挑战的是URS，URS 技术能坚持不懈的进步，而且，尚无放缓的迹象。激光技术以及光纤和数字URS软镜的发展，无疑在URS 技术进步中发挥了关键作用。摩西技术以及近期出现的铥激光（TFL）等概念，则进一步推动了这一进程。确实，输尿管镜技术就似“糖果店”一样，手术医师都想光顾，即便是在儿童结石患者中。鉴于URS 的高效性，儿童结石SWL也受到质疑。 

  “We are what we eat”，换一名话来说, 如果SWL是日常所吃的食品, 那么对于住院医师来说，SWL可能是在学术会议的菜单上没有能得到很好体现的食品。虽然，不能要求,在学术会当天的“菜谱”中，一定有“新鲜的SWL”，但它不应该仅仅是“菜谱”中的一个配菜而已。

近期一项多中心随机对照非劣效性试验，比较了冲击波碎石术与输尿管镜手术治疗输尿管结石 (TISU) 的临床研究，该研究再次唤起了泌尿学界对 SWL优点的认识。然而，为了最大化发挥SWL的优势，不仅需要选择合适的患者，而且，也需要给予操作者更多机会的培训。Okada等人通过额外的培训，使得SWL 的总体成功率提高了20% 以上。有经验的操作者 (操作>150例) ，则有更好的治疗结果。

在新型冠状病毒（COVID-19）流行期间，在一些无法使用手术室的结石治疗中心，SWL则展示了其价值，而且，它还可以在麻醉风险很高的多种合并症患者中发挥作用。

因此，医生不应根据自我喜好，来选择何种结石治疗方法。的确，SWL 在尿结石的治疗领域中的作用正在减弱，Herout 等人的研究确是证实了此点。然而，今天我们不是正在面对SWL的渐进消亡，而是面对应该如何提高SWL治疗效率的艺术水准。

SWL 的故事尚未结束，还有时间来叙述这样的故事。

Letter to the Editor

Published: 17 November 2021

The art of shockwave lithotripsy is an endangered species and is worth saving: the perspective of the European Association of Urology (EAU) Young Academic Urology (YAU) Urolithiasis group

Patrick Juliebø-Jones, Etienne Xavier Keller, Thomas Tailly, 

Mathias Sørstrand Æsøy, Francesco Esperto, Ioannis Mykoniatis, 

Vincent de Coninck & Amelia Pietropaolo 

World Journal of Urology (2021)Cite this article

Dear Editor,

We read with great interest the recent study by Herout et al., which shines a spotlight on the current status of shockwave lithotripsy (SWL) in Germany [1]. The findings confirm the rise of ureteroscopy (URS) and fall of SWL as the endourological treatment of choice for urolithiasis. The results mirror those from many other countries including the United Kingdom and United States [2]. To this end, it seems fair, therefore, that Herout et al. chose the word ‘extinction’ in their title [1]. However, perhaps this particular report on SWL’s decline, is even more thought provoking given that it hails from the very country where the technology was first pioneered in the 1980s. For SWL, these results may, therefore, feel somewhat like an eviction notice placed on its front door.

While SWL has undergone modifications since its early ‘bathtub’ days in the 1980s, the constant advancements in URS are unremitting and show no signs of slowing down. The emergence of light amplification by stimulated emission of radiation (laser) for use in intra-corporeal lithotripsy as well as the development of fiberoptic and digital ureteroscopes have certainly played a key role in this [3]. Concepts such as Moses technology and more recently, Thulium fiber laser (TFL) have fueled this even further [4, 5]. Indeed, URS is the proverbial candy store all residents want to visit. Even in paediatric urolithiasis, SWL has been brought into question given the high efficacy of URS [6].

If “we are what we eat”, then perhaps for residents SWL is poorly represented on the menus of academic conferences. While we are not necessarily calling for the dish of the day to be ‘Live SWL sessions’, it should feature more than just as a side order.

The recent multicentre randomised controlled non-inferiority trial comparing Shockwave Lithotripsy Versus Ureteroscopic Treatment as Therapeutic Interventions for Stones of the Ureter (TISU) has re-awoken the urology community to the possible merits of SWL [7]. However, for its benefits to be maximised, patient selection is crucial. So too is the investment in time for training. Okada et al. improved their overall success rate with SWL by over 20% with additional training [8]. High frequency of cases by individual operators (> 150) has also been shown to deliver better outcomes [9]. During the COVID-19 pandemic, SWL also demonstrated its value in centres where operating theatres were not available to use [10]. It can also play a role in patients with multiple comorbidities where the anaesthetic risk may be high. We must, therefore, strive to not select treatment choices be dictated by the procedure we enjoy the most.

The role of SWL in urology is diminishing and the study by Herout et al. confirms this. However, we argue that it is not SWL itself that is facing extinction but rather, the art of delivering the service well. The story of SWL is not over yet and there is still time to change the narrative.