Extracorporeal Shock Wave Lithotripsy

(ESWL)
Extracorporeal shock wave lithotripsy (ESWL) was introduced in the early 1980s as a
completely noninvasive therapy to break up stones within the kidney and ureter. The
Department of Urology at the University of Florida was one of six sites within the
United States to investigate the efficacy of ESWL lead by Dr. Birdwell Finlayson, a
world renowned expert in stone disease.

ESWL accomplishes stone fragmentation by utilizing shock waves generated by a

sophisticated spark plug electrode housed within a lithotripter device. These shock
waves are generated by the lithotripter outside of the human body and the energy
generated travels through the body converging onto the stone resulting in
fragmentation. The resulting tiny fragments then pass out of the urinary system
over the course of several weeks. This obviates the need for surgical incisions or
invasive devices required to break up and extract these stones. ESWL, however, is
only used in select stones in the kidney and ureter and therefore is not applicable for
all stone types or locations.

Prior To the Procedure:

What to expect during your initial consultation

It is important that prior to your initial clinic consultation that all Xray films and
their reports (e.g. CT scans, intravenous pyelogram or IVP, sonogram, or MRI)
are compiled and brought to your appointment for careful review by your surgeon.
These films can be requested along with the radiology report from the facility that
performed the Xray. A review of your medical history and a physical examination will
be performed along with blood and urine tests if needed. If your surgeon determines
that you are a candidate for ureteroscopy, you will then meet with a Surgery
Scheduling Coordinator to arrange for the date of your procedure.
What to expect prior to surgery
Depending on you age, medical history, medications and overall degree of health, the
following tests may need to be performed prior to your procedure:

 EKG (electrocardiogram)
 CBC (complete blood count)
 PT / PTT (blood coagulation profile)
 Comprehensive Metabolic Panel (blood chemistry profile)
 Urinalysis
 Urine culture

Preparation for procedure

Medications to Avoid Prior to Surgery

The following is a list of medications to avoid at least 7-10 days prior to surgery.
Many of these medications can alter platelet function or your body’s ability to clot
and therefore may contribute to unwanted bleeding during surgery. Please contact
your surgeon’s office if you are unsure about which medications to stop prior to
surgery. Do not stop any medication without contacting the prescribing doctor to get
their approval.

Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin,

Lovenox, Celebrex, Voltaren, Vioxx, Plavix

A formal list of these medications and others will be provided to you by our Surgery
Scheduling Coordinators.

Signs and Treatment of Urinary Tract Infection Prior to Surgery

It is very important that your urine remain free of infection prior to ESWL.
Therefore if you suspect that you may have a urinary tract infection (burning on
urination, blood in the urine, urinary frequency and urgency, fevers), please notify
your surgeon immediate so that proper cultures and treatment may be provided.
The Procedure
For the vast majority of patients, ESWL is performed on an out-patient basis with
no need for hospital admission following the procedure. ESWL procedures typically
last approximately one hour. ESWL can be performed either under general anesthesia
or under intravenous sedation. Once the patient is anesthetized, the lithotripter
machine is positioned in contact with the patient’s flank on the side of the stone. A
series of up to 2,000 shock waves are delivered to fragment the stone. ESWL is
performed under Xray guidance to accurately target the stone in efforts to maximize
stone fragmentation while minimizing adjacent organ injury. On occasions, a ureteral
stent may be required to dilate the ureter, avoid stone obstruction, and facilitate
stone passage down to the bladder.

Potential Risks and Complications

Although ESWL has proven to be very safe over decades of use and experience, there
are potential risks that patients must be aware of which include:

• Bleeding and Transfusion: A small amount of bleeding will occur as a result of

ESWL and often manifests by visible blood in the urine following the procedure.
Rarely, bleeding can occur in and around the kidney (called a hematoma) that
may require a transfusion. Nevertheless, transfusion rates for ESWL are
generally <1%.

• Infection: Although patients receive a dose of intravenous antibiotic

immediately prior to ESWL, occasional infections within the urinary system can
occur resulting in high fevers and chills. Although most infections are treated
successfully with oral antibiotics, in rare cases patients may require readmission
to the hospital for intravenous antibiotics.

• Adjacent Tissue / Organ Injury: Although uncommon, injury to surrounding

skin, tissue, nerves, muscles and organs (liver, spleen, small and large intestines,
pancreas, and kidney) may occur following ESWL. Most injuries are minor,
resolve spontaneously and require no further intervention.

• Ineffective/Incomplete Stone Fragmentation: Although ESWL has proven to

be an effective treatment for kidney and ureteral stones, the success of ESWL
is dependent upon many variables including the size and especially the
 composition of the stone. All stones are made of slightly different
composition, which may impact on the density of the stone and hence
responsiveness to ESWL fragmentation. Other factors that affect ESWL success
are the location of the stone within the urinary tract, function of the affected
kidney, medical condition of the patient, time since ESWL treatment and the
ability to accurately target the stone during ESWL treatment. For some
stones, multiple ESWL treatments may be required to adequately fragment the
stone. Unfortunately in some cases the stone may be resistant to
fragmentation with ESWL despite multiple attempts.

• Steinstrasse: Steinstrasse, or an accumulation of a large number of unpassable

stone fragments within the ureter, occurs in 1-4% of patients who undergo
SWL, increasing to 5-10% for stones >2 cm in size, and up to 40% in patients
with partial staghorn calculi.

• Diabetes/Hypertension: New onset hypertension, primarily diastolic, is a

potential consequence of SWL, with the development likely being dose
dependent. Despite multiple retrospective reports, three prospective randomized
trials in this area failed to demonstrate SWL-mediated changes in blood
pressure. In a recent retrospective, case-control study, development of diabetes
and hypertension was found to be higher in patients who underwent SWL in
1985 (odds ratio of 3.23 and 1.47 respectively) than in control patients who
were treated conservatively. Despite the study limitations and methodologic
biases, the results of this analysis must be viewed as significant potential long-
term complications of SWL, and patients should be counseled appropriately.

What to Expect After Surgery

 Flank Pain: Most patients experience some degree of discomfort for a day or
two after ESWL. The pain is usually described as a dull ache or soreness over
the kidney or flank area, and is typically at its worst the evening following
 surgery. The pain lessens over the following days.

 Blood in Urine: It is normal to see visible blood in the urine for days to
several weeks after surgery. It is important during this time of bleeding that
you avoid strenuous activity, blood thinning medications, and drink plenty of
fluid.

 Fevers: Low grade fevers are not uncommon following any surgical procedure and
anesthesia. If you have fevers >101o F, please notify your surgeon or call352-
265-0111 and ask to be connected to the urologist on call.

When to call your Doctor

Although adverse events are rare following ESWL, it is important for patients to
recognize these events and know when to contact their surgeon. You should contact
your surgeon or primary care doctor immediately if any of the following occur:

 Worsening pain over the ensuing days following ESWL procedure. If this pain
continues to escalate despite the use of oral pain medication, this may indicate
obstruction of the kidney from a large stone fragment lodged within the ureter,
hematoma around the kidney or infection of the kidney.

 Large amounts of blood clots in the urine that may lead to difficulty with
voiding and fully emptying the bladder.
o
 Fevers >101 F may indicate a serious infection within the urinary tract.

 Nausea and vomiting

 Chest pain or difficulty breathing

Frequently Asked Questions (FAQs)

What is the advantage of ESWL as compared to other stone

treatments?
The primary advantage of ESWL is that it is completely non-invasive in that there
are no skin incisions required or invasive instrumentations used to treat the stone.
Instead, the energy from shock waves is used to fragment the stone into smaller
pieces that will then pass down the ureter and out the bladder.

Are there disadvantages?

Unfortunately not all stones will fragment successfully with ESWL as the fragility of
the stone is dependent on many factors including size, location, and stone
composition. Therefore on theoretical disadvantage to ESWL as compared to more
invasive stone procedures is that more than one ESWL treatment may be required to
adequately fragment the stone to small enough fragments to allow for spontaneous
passage through the urinary tract. In addition, rare complications may occur following
ESWL as described above.

Which patients are good candidates for ESWL?

ESWL is well suited to patients with small kidney stones (generally < 1cm) that can
be easily seen by x-ray. Certain stones within the upper portion of the ureter may
be treated with ESWL as well. Those that are further down the ureter are often
approached by ureteroscopically.

What patients are not good candidates for ESWL?

Patients who are pregnant, have active urinary infection, obstruction of the kidney or
are on blood thinning medications that can not be discontinued are not ideal
candidates for ESWL treatment. Patients with particular known stone composition
including cystine and certain types of calcium phosphate stones are not ideal
candidates as these stone types may not fragment well with ESWL due to their
dense nature.

Can multiple stones be treated simultaneously with ESWL?

Multiple stones can be treated; however, the number of shock waves delivered may be
distributed amongst the stones therefore limiting the energy delivered to any one
stone for fragmentation. Your surgeon will determine if there are too many stones
for ESWL therapy and whether alternative treatments should be considered.

Will I need placement of an indwelling ureteral stent following

ESWL?
Not all patients who undergo ESWL will require a ureteral stent. Based upon stone
size, location, or presence of any abnormalities in the drainage system of the kidney,
placement of a ureteral stent may be required to aid in passive dilation of the ureter
to help facilitate passage of stone fragments following ESWL. This is usually placed
at the time of the ESWL while you are under anesthesia. Our surgeons will make this
decision with each patient prior to surgery based upon each individual’s case. For
stent related questions, please refer to Ureteroscopy FAQs.

What is the overall success rate with ESWL?

The success of ESWL is dependent on many factors such as stone composition, stone
location within the urinary tract, patient body habitus (obesity), kidney anatomy,
and type of ESWL machine used. Our surgeons carefully consider all of the
aforementioned variables and will discuss this with you in order to maximize success
and determine if ESWL is right for you. Overall stone free success rate is 67% at our
center.

How do I know if ESWL was successful?

Following ESWL, your surgeon will determine whether the treatment was successful
based upon X-ray findings. This may be in the form of either an abdominal Xray or
CT scan. With these Xray tests, the surgeon can determine the degree of stone
fragmentation and whether any fragments remain within the kidney or ureter. If
stone fragments remain within the urinary tract, more time may be required to allow
for spontaneous passage, which often takes several weeks. Alternatively your surgeon
may recommend further treatment with repeat ESWL, ureteroscopy, or percutaneous
nephrolithotomy.

Can ESWL be repeated?

Yes. Often due to stone density or size, fragments may at times remain in the
urinary tract that are too large to pass spontaneously. In such cases, repeat ESWL
may be considered.