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Stone Management
Extracorporeal Shock-wave Lithotripsy
Hans-Göran Tiselius
Renal Stone Unit, Department of Urology, Karolinska University Hospital, and
Division of Urology, Department of Clinical Science, Intervention and Technology, Karolinska Institute
Abstract
Extracorporeal shock-wave lithotripsy (ESWL) has been available for active stone removal for more than 25 years. The efficiency and
usefulness of this method for removal of stones from the kidney as well as from the ureter have been continuously reported, and the
technique has stood the test of time. Modern lithotripters seem to be at least as powerful and efficient as the original unmodified ‘gold
standard’ Dornier HM3 lithotripter. Stone-free rates of over 95% for ureteral stones can be expected, and a similar percentage of renal
stones can be satisfactorily disintegrated. Whereas in almost all cases ureters become stone-free after ESWL, residual fragments are rather
common after ESWL of renal stones. The future course of these fragments is difficult to predict, but in more than 60% of patients with
residual fragments the situation was essentially unchanged during a four-year follow-up. Although more invasive treatments such as
ureterorenoscopy (URS) and percutaneous nephrolithotomy (PNL) may result in a higher rate of stone-free kidneys and ureters with fewer
treatment sessions, the advantage of ESWL is its non-invasive or extremely low-invasive character. Moreover, in almost all cases the
procedure can be completed without general or regional anaesthesia, on an outpatient basis and with a very low risk of complications. In
combination with currently available pharmacological tools and, hopefully, with future improvements, it is my opinion that ESWL will
continue to be the most attractive and least demanding method for active stone removal.
Keywords
Complications, extracorporeal shock-wave lithotripsy (ESWL), kidney stones, precautions, ureteral stones, pharmacological therapy, stone
treatment index (STI), treatment strategies
Disclosure: The author has no conflicts of interest to declare.
Received: 15 April 2009 Accepted: 17 July 2009
Correspondence: Hans-Göran Tiselius, Department of Urology, Karolinska University Hospital, SE-141 86 Stockholm, Sweden. E: hans.tiselius@karolinska.se
When extracorporeal shock-wave lithotripsy (ESWL) was invented Ureteral Stones
and introduced at the beginning of the 1980s, the principles for More than 20 years of experience with ESWL has convinced me that
active removal of urinary tract concrements were dramatically this technique is a superb method for treating patients with ureteral
changed. Owing to the outstanding achievements obtained with the stones. The prerequisite for success is a sufficiently powerful
Dornier HM3 lithotripter, this new method became enormously lithotripter that should be used with great care to maintain the stone
popular. In view of this success, several other lithotripter models in focus and to make sure that the shock wave hits the stone with
appeared on the market. These were much less expensive than the optimal disintegrating power. There are numerous recent reports in
original device, and the lower cost enabled the wide and rapid the literature in support of the above statement, but there is also
dissemination of ESWL. Unfortunately, many of the modified technical great variability in the reported results.
1,2
Several factors may explain
solutions resulted in lithotripters with poor disintegrating abilities. the less successful outcomes, such as the type of lithotripter, poor
When the initial results were accordingly difficult or impossible to transmission of the shock wave, limited operator experience and
repeat, ESWL gained a bad reputation, leading to a discussion of how limited interest or ambition in performing shock-wave lithotripsy.
to define the appropriate indications for ESWL. Arguments were
presented that the use of ESWL should be restricted to small stones In a recent analysis of around 600 unselected patients with ureteral
in the kidney. stones fulfilling the criteria for active stone removal for whom ESWL
was used as the primary treatment modality, a stone-free rate of
However, during recent years several much more competent and more than 97% was achieved.
3
The stone-free rates were almost the
efficient lithotripters have been developed, with results at the same same for stones located in the proximal, middle or distal ureter. In
level or even better than those reported with the ‘gold standard’ the debate on whether ureteral stones are best treated with ESWL
Dornier HM3 device. I have consistently and successfully used ESWL or ureterorenoscopy (URS), emphasis has been directed to the need
as the primary procedure for removal of stones from the kidney, as for repeated treatment sessions with ESWL. It is indisputable that a
well as from the ureter, over the past 24 years. This article provides a certain number of stones will require more than one treatment
review of what we can expect from ESWL today and how the session, and the mean number of sessions in the group of patients
technique should best be applied. referred to above was 1.3, which is similar to the overall
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