What is lithotripsy

Lithotripsy is also known as extracorporeal shock wave lithotripsy, is a procedure that uses shock waves to break up stones in the kidney, bladder, or ureter (tube that carries urine from your kidneys to your bladder). After the lithotripsy procedure, the tiny pieces of stones pass out of your body in your urine.

Extracorporeal shock wave lithotripsy (ESWL) is the most common type of lithotripsy. “Extracorporeal” means outside the body. Extracorporeal shock wave lithotripsy is a technique for treating stones in the kidney and ureter that does not require surgery. Instead, high energy shock waves are passed through your body and used to break stones into pieces as small as grains of sand. Because of their small size, these pieces can pass from your body along with the urine.

There are two ways to remove stones using shock wave treatment:

1. In one method, the patient is placed in a tub of lukewarm water. Using x-rays or ultrasound to pinpoint the location of the stones, the body is positioned so that the stones are targeted precisely.
2. In the second, more common method, the patient lies on top of a soft cushion or membrane through which the waves pass. About 1-2 thousand shock waves are needed to crush the stones. The complete treatment takes about 45 to 60 minutes.

A stone is fragmented when the force of the shockwaves overcomes the tensile strength of the stone. Although incompletely understood, fragmentation is thought to occur through a combination of methods, including compressive and tensile forces, erosion, shearing, spalling, and cavitation. Of these various forces, the generation of compressive and tensile forces and cavitation are thought to be the most important.

When a shockwave is propagated through a medium (water), it loses very little energy until it crosses into a medium with a different density. If the medium is denser, compressive forces are produced on the new medium. Similarly, if the new medium is less dense, tensile stress is produced on the first medium. Upon hitting the anterior surface of a stone, the change in density creates compressive forces, causing fragmentation. As the wave proceeds through the stone to the posterior surface, the change from high to low density reflects part of the shockwave’s energy, producing tensile forces, which again disrupt and fragment the stone.

In cavitation, shockwave energy applied at a focal point leads to failure of the liquid with generation of water-vapor bubbles. These gaseous bubbles collapse explosively, creating microjets that fracture and erode the calculus. This process can be monitored with real-time ultrasonography during the treatment and appears as swirling fragments and liquid in the focal zone.

Lithotripsy is used to remove kidney stones that are causing:

• Bleeding
• Damage to your kidney
• Pain
• Urinary tract infections

Not all kidney stones can be removed using lithotripsy. The stone may also be removed with:

• A tube (endoscope) inserted into the kidney through a small surgical cut.
• A small lighted tube (ureteroscope) inserted through the bladder into ureters. Ureters are the tubes that connect the kidneys to the bladder.
• Open surgery (rarely needed).

Indications for extracorporeal shock wave lithotripsy (ESWL)

The American Urological Association Stone Guidelines Panel has classified extracorporeal shock wave lithotripsy as a potential first-line treatment for ureteral and renal stones smaller than 2 cm.

In the pediatric population, those with uncomplicated, non-infectious calculi can undergo extracorporeal shock wave lithotripsy (ESWL) with an age-dependent response ¹.

Indications for extracorporeal shock wave lithotripsy (ESWL) include the following:

• Individuals who work in professions in which unexpected symptoms of stone passage may prompt dangerous situations (eg, pilots, military personnel, physicians) (In such individuals, definitive management is preferred to prevent adverse outcomes.)
• Individuals with solitary kidneys in whom attempted conservative management and spontaneous passage of the stone may lead to an anuric state
• Patients with hypertension, diabetes, or other medical conditions that predispose to renal insufficiency.

Extracorporeal shock wave lithotripsy contraindications

Absolute contraindications to extracorporeal shockwave lithotripsy (ESWL) include the following:

• Acute urinary tract infection (UTI) or urosepsis
• Uncorrected bleeding disorders or coagulopathies
• Pregnancy
• Uncorrected obstruction distal to the stone

Relative contraindications include the following:

• Body habitus: Morbid obesity and orthopedic or spinal deformities may complicate or prevent proper positioning. In these situations, attempting to position the patient prior to anesthetic induction is useful to ensure the practicality of the approach.
• Renal ectopy or malformations (eg, horseshoe kidneys and pelvic kidneys)
• Complex intrarenal drainage (eg, infundibular stenosis)
• Poorly controlled hypertension (due to increased bleeding risk)
• Gastrointestinal disorders: In rare cases, these may be exacerbated after extracorporeal shock wave lithotripsy (ESWL) treatment.
• Renal insufficiency: Stone-free rates in patients with renal insufficiency (57%) (serum creatinine level of 2–2.9 mg/dL) were significantly lower than in patients with better renal function (66%) (serum creatinine level < 2 mg/dL).
• History of previous Open Renal Stone Surgery: Overall stone-free rates after extracorporeal shock wave lithotripsy (ESWL) treatment found to be significantly lower in patients with a history of open stone surgery, especially for those with stones in the lower calyx (48.4% vs. 64%) ²

Preexisting pulmonary and cardiac problems are not contraindications, provided they are appropriately addressed both preoperatively and intraoperatively. In patients with a history of cardiac arrhythmias, the shockwave can be linked to electrocardiography (ECG), thus firing only on the R wave in the cardiac cycle, coinciding with the refractory period of the cardiac cycle (ie, gated lithotripsy).

Ganem and Carson ³ retrospectively reviewed patients treated with gated and ungated lithotripsy. The study population included those with preexisting hypertension and cardiac disease and those taking cardiac medications. Of the patients in the ungated group, 20% developed arrhythmias, although they were universally benign, resolving with conversion to a gated procedure. Conversely, only 1 of 357 patients in the gated lithotripsy group developed any arrhythmia.

Eaton and Erturk ⁴ studied 51 patients who underwent ungated lithotripsy, including several patients with preexisting cardiac arrhythmias. The 21 patients who had more than 6 premature ventricular contractions (PVC) intraoperatively had troponin measured 24 hours postoperatively. A selected sample of patients who did not develop arrhythmias also had troponin measured as a control group and the troponin levels did not vary significantly between the 2 groups.

Investigators concluded that extracorporeal shock wave lithotripsy (ESWL)-induced ventricular ectopy was probably reflective of mechanical stimulation of the myocardium rather than myocardial injury. However, the authors caution that as rare reports exist of myocardial injury after extracorporeal shock wave lithotripsy (ESWL), one should exercise caution when treating patients with renal stones who may be at increased risk for cardiac damage.

Based on these studies, patients with preexisting cardiac disease, not including documented preoperative arrhythmia, can probably undergo ungated lithotripsy safely. Close monitoring is imperative as those who develop arrhythmias can be safely converted to gated lithotripsy.

Cardiac pacemakers are also not contraindicated, although seeking assistance from a cardiologist for possible changes to pacemaker settings would be prudent.

Oral anticoagulants (eg, clopidogrel [Plavix] and warfarin [Coumadin]) should be discontinued to allow normalization of clotting parameters. Platelet function is normalized by discontinuing aspirin-containing products and nonsteroidal anti-inflammatory drugs (NSAIDs) 7 days before treatment.

What are the advantages and disadvantages of shock wave lithotripsy?

The main advantage of shock wave lithotripsy is that many patients may be treated for kidney stones without surgery. As a result, complications, hospital stays, costs and recovery time are reduced. Unfortunately, not all types of kidney stones can be treated this way. In addition, stone fragments are occasionally left in the body and additional treatments are needed.

Factors that affect the outcome of extracorporeal shockwave lithotripsy

Several factors related to the stone, including stone burden (size and number), composition, and location, affect the outcome of extracorporeal shockwave lithotripsy (ESWL).

Stone size

As stone size approaches 2 cm, the likelihood of success with extracorporeal shock wave lithotripsy (ESWL) decreases, and the need for retreatment and adjunctive therapy increases. extracorporeal shock wave lithotripsy (ESWL) has also been found to be most efficacious in treating nonobstructing renal calculi. In patients with a large stone burden, pre-extracorporeal shock wave lithotripsy (ESWL) stenting may secure drainage and prevent obstructive urosepsis. A study where stone volume was calculated based on a 3D rendered image corroborated that smaller stones are more likely to fragment than larger stones, with 500 microL as the cutoff ⁵.

Stone composition

The density and ability of a stone to resist extracorporeal shock wave lithotripsy (ESWL) is based in part on the composition of the stone. Stones composed of calcium oxalate dihydrate, magnesium ammonium phosphate, or uric acid tend to be softer and to fragment more easily with extracorporeal shock wave lithotripsy (ESWL). Stones composed of calcium oxalate monohydrate or cystine, on the other hand, are less susceptible to extracorporeal shock wave lithotripsy (ESWL). To a degree, this can be predicted with CT scanning by measuring the radio-opacity of stones. A recent retrospective study showed that extracorporeal shock wave lithotripsy (ESWL) monotherapy is more likely to be effective against stones with a Hounsfield units [HU] < 815 Hounsfield units [HU]) than those with a higher radio-opacity ⁶.

In addition, certain radiolucent stones (uric acid, indinavir [Crixivan]) are difficult to visualize on fluoroscopy and therefore require either ultrasonography-guided localization or the addition of retrograde or intravenous contrast to localize a calculus.

Stone location

• Lower-pole calculi: Although extracorporeal shock wave lithotripsy (ESWL) can fragment stones in the lower pole of the kidney, the resulting stone-free rate is decreased because of the difficulty in passing stones from this location. Recent studies have delineated renal morphology associated with improved stone-free rates (eg, lower infundibular length–to–diameter ratio of < 7, lower-pole infundibular diameter of >4 mm, single minor calyx), as well as factors associated with decreased stone-free rates (infundibulopelvic angle of < 70°, an infundibular length of >3 cm, an infundibular width of < 5 mm). Regardless of anatomy, extracorporeal shock wave lithotripsy (ESWL) tends to yield better results in patients with smaller stone burdens.
• Calyceal diverticula with infundibular stenosis: In patients with diverticula caused by or related to infundibular stenosis, fragmented stones cannot easily bypass the obstruction, with resultant retained stone fragments. These patients are best served by more invasive techniques that allow the surgeon to address the obstruction and the stones simultaneously, either with retrograde ureteroscopy or in an antegrade percutaneous fashion.
• Ureteral calculi: Fragmentation of proximal stones is more effective than mid or distal stones. In addition, when associated with hydronephrosis, ureteroscopy yields better stone-free rates for stones larger than 15 mm.

Skin to stone distance

Skin to stone distance, which can be easily measured on CT scan, appears to predict the success of extracorporeal shock wave lithotripsy (ESWL). Distances reaching greater than 10cm appears to have a negative effect on successful stone treatment ⁷.

Preoperative and intraoperative stenting

In the modern setting, where access to extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy is readily available, the indications for stenting prior to definitive treatment are much fewer. These indications include (1) obstructed pyelonephritis or pyelitis and (2) newly onset renal insufficiency or renal failure. In these situations, the stent helps to ensure internal drainage and allows passive dilatation of the ureter, facilitating future endoscopic evaluation and treatment. With the advent of newer and smaller ureteroscopic equipment, the rates of endoscopic complications (ie, strictures) have subsequently declined. When preoperative stenting is required, the authors believe that ureteroscopy, especially for ureteral stones, may yield higher stone-free rates without a significant increase in morbidity, time, or cost.

The need for intraoperative manipulation of stones for extracorporeal shock wave lithotripsy (ESWL) (eg, stone pushback) or placement of a ureteral catheter to assist with stone visualization has decreased, as newer machines are capable of treating proximal ureteral stones or visualizing radiolucent stones with ultrasonography. That said, intraoperative ureteral stents should be considered in patients with larger stones, as the rate of steinstrasse (German for “stone street”) increases with stone burden (1-4% in general vs 10% for stones >2 cm).

Does the patient need anesthesia?

In general, some type of anesthesia–either local, regional or general–is used to help the patient remain still and to reduce any discomfort.

Is lithotripsy painful?

You will be given medicine for pain or to help you relax before the lithotripsy procedure starts. You will also be given antibiotics.

When you have the lithotripsy procedure, you may be given general anesthesia for the procedure. You will be asleep and pain-free.

Does the patient need to be hospitalized?

Usually, patients are hospitalized for a day or two. In some cases, lithotripsy may be done on an outpatient basis.

How long after lithotripsy to pass stones?

Most patients pass kidney stones immediately after treatment and may continue to pass smaller stones for 4 to 8 weeks.

Can all kidney stone patients have shock wave lithotripsy?

No. The size, number, location and composition of the stones are factors that must be taken into account when exploring treatment options. Patient size may limit use of the water bath method, but patients of many sizes can be treated with the water cushion method.

Also the stones must be clearly viewed by the x-ray monitor so the shock waves can be targeted accurately. If anatomical abnormalities prevent this, other methods of stone removal may have to be considered. Through examination, x-ray and other tests, the doctor can decide whether this is the best treatment for the patient. In some cases, extracorporeal shock wave lithotripsy may be combined with other forms of treatment.

What other kidney stones treatment choices are available?

About 90 percent of kidney stones pass through the urinary system without treatment. In cases where this does not occur, treatment to remove stones may be needed. Some stones may be dissolved by medicines. In other cases, one of the following methods of stone removal may be needed:

Percutaneous Stone Removal

When stones are quite large (more than 2 cm) or in a location that does not allow effective lithotripsy, a technique called percutaneous stone removal may be used. In this method, the surgeon makes a small incision in the back and creates a tunnel directly into the kidney. A tube is inserted and the stone is removed through this tube.

Ureteroscopic Stone Removal

For stones found in the lower part of the urinary tract, the doctor may pass a ureteroscope (a hollow tube-like device) up into the bladder and ureter. A basket-like device may be passed through the tube to grasp and withdraw the stone.

How successful is extracorporeal shock wave lithotripsy?

In those patients who are thought to be good candidates for this treatment, about 70 to 90 percent are found to be free of stones within three months of treatment. The highest success rates seem to be in those patients with mobile stones that are located in the upper portions of the urinary tract (kidney and upper ureter). After treatment, some patients may still have stone fragments that are too large to be passed. These can be treated again if symptoms persist.

What is laser lithotripsy?

Laser lithotripsy was first introduced commercially in the late 1980s with the pulsed-dye laser, which uses 504 nm of light delivered through optical quartz fibers ⁸. This was a nonthermal safe laser that produced plasma between the tip of the fiber and the calculus, fragmenting stone with a photo-acoustic effect. The small flexible probes complemented both the semirigid and flexible ureteroscopes and could fragment most urinary calculi, excluding cystine. However, this was not a solid-state laser, and it required frequent maintenance, including changing of the coumarin dye. The energy available at the tip of the fiber is proportional to the fiber diameter. The 200-µm fiber allows the most endoscopic deflection but can deliver only 80 mJ of energy, which is frequently insufficient to fragment calcium oxalate monohydrate calculi.

Advancing laser technology has led to the development of the holmium yttrium–aluminium–garnet laser (Ho:YAG) laser, which is a thermal laser that uses a 2150-nm wavelength of light. The energy is delivered in a pulsatile fashion through low–water-density quartz fibers. Johnson studied the soft-tissue effects of this laser and found that the thermal effect of this laser within a water-based medium was confined owing to a vaporization bubble formed at the tip of the fiber ⁹. In 1995, Matsuoka et al presented the first clinical series of endoscopic lithotripsy with this wavelength and found it to be safe and efficient in treating ureteral stones ¹⁰. As opposed to the coumarin pulsed-dye laser, holmium yttrium–aluminium–garnet laser (Ho:YAG) laser lithotripsy produces smaller fragments that can be, in part, irrigated from the collecting system during treatment.

The energy available at the tip of the holmium yttrium–aluminium–garnet laser (Ho:YAG) laser does not depend on the diameter of the fiber. Techniques used to increase treatment efficiency by varying fiber diameters with complementary endoscopes have been described. These techniques involve larger fibers complemented by increased stiffness, which decrease the flexibility of the endoscope.

The composition, location, and the size of urinary stones may direct the type of laser and fiber used, the method of approach (eg, retrograde or anterograde), pulsation mode, and power output. For lithotripsy (renal pelvis, ureter, and bladder stones), use Ho:YAG, FREDDY, pulsed dye, or alexandrite.

The frequency-doubled, double-pulse Nd:YAG (FREDDY) laser is a short-pulsed, double-frequency solid-state laser with wavelengths of 532 and 1064 nm. It is a low-power, low-cost laser developed for intracorporeal lithotripsy that has been a subject of recent investigation. Although the FREDDY laser is effective for lithotripsy, it is does not have a soft-tissue application.

Dye lasers

The lasing medium is an organic liquid dye that must be excited optically by another laser or flash lamp. The wavelength emitted depends on the type of dye used, which can be changed or adjusted. The emitted light, therefore, can be tuned to cover a wide spectrum of visible light. In the pulsed mode, this laser is used for lithotripsy and ablation of vascular lesions. The most common dye used is coumarin, which produces a wavelength of 504 nm when excited by a flashlamp. As opposed to a solid-state laser, the dye in the lasing chamber requires replacement, which may be inconvenient and expensive compared with the maintenance of newer laser systems.

Alexandrite laser

This is another tunable laser composed of a chromium-doped mineral known as alexandrite (BeAl2 04). The wavelength range is from 380-830 nm and is strongest at 700-830 nm. This light is absorbed well by melanin; therefore, it can be used for cutaneous lesions. In a 1-ms pulsed mode delivered with an optical fiber, it is used for lithotripsy of pigmented stones. Combined with indocyanine green dye applied to tissues, this laser can also be used for tissue welding.

Holmium:yttrium-aluminum-garnet (Ho:YAG) laser

Holmium:YAG (Ho:YAG) is a somewhat recent addition. It consists of the rare earth element holmium doped in a YAG crystal that emits a beam of 2150 nm. This laser energy is delivered most commonly in a pulsatile manner, using a thermomechanical mechanism of action. It superheats water, which heavily absorbs light energy at this wavelength. This creates a vaporization bubble at the tip of a low–water density quartz or silica fiber used for delivery. This vapor bubble expands rapidly and destabilizes the molecules it contacts. This is ideal for lithotripsy of all stone types ¹¹. The absorption depth in tissue is 1-2 mm, as long as it is used in a water-based medium. This specific light energy provides good hemostasis when used in a pulsed mode of 250 ms duration and at low pulse repetition rate. At higher repetition rates, it may also be used for incisions.

Eye protection is required for the operators of the Ho:YAG laser, although at the energy levels used for the fragmentation of calculi the operator’s cornea would be damaged only if it was positioned <10 cm from the laser fibre ¹². Furthermore, laser fibres frequently damage flexible ureteroscope components, e.g. the working channel, flexible component cable system, wires and fibre optical systems, during routine flexible URS ¹³. The fracture of a laser fibre inside the ureteroscope can destroy the ureteroscope’s fibre-optic bundles that transmit images and light.

The clinical use of the protective FlexGuard sheath (LISA Laser Products, Germany) has been studied ¹⁴. It significantly reduced the amount of force required to insert the laser fibre through the working channel. This reduction in force was protective against mechanical damage caused by laser fibre insertion. However, deployment of the sheath significantly diminished the rate of irrigant flow and the maximal deflection of the flexible ureteroscope.

A novel endoscope-protection system against direct laser energy damage during ureteroscopy has been developed. Xavier et al. ¹⁵ evaluated in vivo a novel endoscope-protection system prototype that uses optical feedback from the sensor of a digital flexible ureteroscope to terminate the laser energy on retraction of the fiber. The endoscope-protection system was highly effective and reliable, as no energy-based ureteroscope damage was recorded with slow and rapid retractions of the activated laser into the ureteroscope.

Laser lithotripsy complications

The only true contraindication to laser lithotripsy is the presence of untreated UTI (urinary tract infection), because of the risk of urosepsis ¹². The laser is one of the safest intracorporeal lithotripters and the most significant complication of its use is the injury of the urothelial tissue adjacent to the treated stone. Well-known complications include a lost stone, ureteric perforation, extravasation and avulsion ¹⁶. As the depth of tissue penetration of the holmium yttrium–aluminium–garnet laser (Ho:YAG) laser is 0.4 mm, in the vast majority, injuries can be managed conservatively, although a ureteric stricture can be a chronic event ¹⁶.

The rate of development of subcapsular renal hematoma after ureteroscopy with the holmium yttrium–aluminium–garnet laser (Ho:YAG) laser is low. In a prospective study of 2848 consecutive patients who underwent laser ureteroscopy, 11 (0.4%) developed subcapsular renal haematoma after the operation ¹⁷. All these patients were successfully treated conservatively. Chang et al. ¹⁸ described a case of a fatal gas embolism that occurred during ureteroscopy with Ho:YAG laser lithotripsy under spinal anesthesia. Although the correct crisis resolution protocols took place (reduction in the volume of air entrained, hydration, cardiopulmonary resuscitation) the patient died. Another extremely rare complication after Ho:YAG lithotripsy was the development of an intrarenal arteriovenous bleeding fistula, which was embolised ¹⁹.

In case of accidental laser fiber breakage, the detection of the radiolucent fibre remnants might become troublesome. A recent study evaluated a prototype of a radio-opaque laser fiber that was designed for lithotripsy with a Ho:YAG laser ²⁰. An optical-core gold-clad fibre prototype offered comparable performance to the commercially available fiber of the same optical core diameter. The radio-opaque property was confirmed in vitro and intracorporeally, thereby adding an additional safety feature to the laser treatment.

Lithotripsy procedure

Before the lithotripsy procedure

Always tell your health care provider:

• If you are or could be pregnant
• What drugs you are taking, even drugs, supplements, or herbs you bought without a prescription

During the days before the lithotripsy:

• You will be asked to stop taking blood thinners such as aspirin, ibuprofen (Advil, Motrin), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot. Ask your provider when to stop taking them.
• Ask your provider which drugs you should still take on the day of the surgery.

On the day of your lithotripsy procedure:

• You may not be allowed to drink or eat anything for several hours before the procedure.
• Take the drugs you have been told to take with a small sip of water.
• You will be told when to arrive at the hospital.

During the lithotripsy procedure

Lithotripsy procedure is available at many hospitals, outpatient centers and sometimes even in mobile units. For information about where to have lithotripsy done in your area, contact your doctor, local hospital or health care facility.

To get ready for the lithotripsy procedure, you will put on a hospital gown and lie on an exam table on top of a soft, water-filled cushion. You will not get wet.

You will be given medicine for pain or to help you relax before the lithotripsy procedure starts. You will also be given antibiotics.

When you have the lithotripsy procedure, you may be given general anesthesia for the procedure. You will be asleep and pain-free.

High-energy shock waves, also called sound waves, guided by x-ray or ultrasound, will pass through your body until they hit the kidney stones. If you are awake, you may feel a tapping feeling when this starts. The shock waves break the stones into tiny pieces.

The lithotripsy procedure should take about 45 minutes to 1 hour.

A tube called a stent may be placed through your back or bladder into your kidney. This tube will drain urine from your kidney until all the small pieces of stone pass out of your body. This may be done before or after your lithotripsy treatment.

Lithotripsy recovery

After the lithotripsy procedure, you will stay in the recovery room for up to about 2 hours. After treatment is complete, the patient can move about almost at once. Most people are able to go home the day of their lithotripsy procedure. Have someone drive you home from the hospital.

You will be given a urine strainer to catch the bits of stone passed in your urine. Your doctor will tell you how to do this. Any stones you find can be sent to a medical lab to be examined.

Many people can fully resume daily activities within one to two days. Special diets are not required, but drinking plenty of water helps the stone fragments pass. Some pain may occur when the fragments pass, which begins soon after treatment and may last for up to four to eight weeks. Oral pain medication and drinking lots of water will help relieve symptoms.

It is normal to have a small amount of blood in your urine for a few days to a few weeks after this procedure.

You may have pain and nausea when the stone pieces pass. This can happen soon after treatment and may last for 4 to 8 weeks.

Drink a lot of water in the weeks after your lithotripsy procedure. This helps pass any pieces of stone that still remain. Your health care provider may give you a medicine called an alpha blocker (Tamsulosin) to make it easier to pass the pieces of stone. The efficacy of the tamsulosin (oral 0.4 mg/d for 1 month) as an adjuvant therapy to extracorporeal shock wave lithotripsy for the expulsion of ureteral and renal stones was studied in 186 patients (77 ureteral and 109 renal stones) ²¹. It was found that adjuvant treatment with tamsulosin, in addition to standard treatment with steroids and analgesics, significantly improved the stone clearance rate. In addition, Tamsulosin treatment was also associated with a significantly lower interval to the elimination of stone fragments, a significantly lower re-hospitalization rate, and a significantly lower proportion of patients with acute renal colic.

You may have some bruising on your back or side where the stone was treated if sound waves were used. You may also have some pain over the treatment area.

Take the pain medicine your provider has told you to take and drink a lot of water if you have pain. You may need to take antibiotics and anti-inflammatory medicines for a few days.

You will need to see your doctor for a follow-up appointment in the weeks after your lithotripsy.

You may have a nephrostomy drainage tube or an indwelling stent. You will be taught how to take care of it.

Lithotripsy prognosis

How well you do depends on the number of stones you have, their size, and where in your urinary system they are. Most of the time, lithotripsy removes all the stones.

In a study involving 225 patients who underwent extracorporeal shock wave lithotripsy, 192 (85%) had renal stones and 33 (15%) had ureteric stones ²². The mean stone size was 11.3±4.5 mm, while the mean age of the patients was 39.9±12.8 years with 68.5% males. The mean renal stone size was 11.6±4.7 mm; a mean of 1.3 sessions was required. The mean ureteric stone size was 9.9±3 mm; and a mean of 1.3 sessions was required. Treatment success (defined as complete clearance of ureteric stones, stone-free or clinically insignificant residual fragments of <4 mm for renal stones) was 74% for renal stones and 88% for ureteric stones. Additional extracorporeal shock wave lithotripsy and ureteroscopy were the most adjunctive procedures used for stone clearance. Complications occurred in 74 patients (38.5%) with renal stones and 13 patients (39.4%) with uretetric stones. The most common complication was loin pain (experienced by 16.7% with renal stones and 21% with ureteric stones). Severe renal colic mandating admission occurred in 2% of patients with renal stones and 6% of patients with ureteric stones. In patients with renal stone, steinstrasse occurred in 3.6% and infection post extracorporeal shock wave lithotripsy in 0.5%. Using Multivariate Logistic Regression analysis, factors found to have significant effect on complete stone clearance were serum creatinine and the number of shockwaves.

Lithotripsy complications

Most patients have some blood in the urine for a few days. The shattered stone fragments may cause discomfort as they pass through the urinary tract. Sometimes, the stone is not completely shattered, and additional treatments may be needed. However, in other studies, acute renal failure has been reported after extracorporeal shock wave lithotripsy ²³. Massive retroperitoneal hemorrhage after extracorporeal shock wave lithotripsy (ESWL) leading to patient death has also been reported ²⁴. Besides renal injury ²⁵, extracorporeal shock wave lithotripsy is not completely free from other serious complications, such as gastrointestinal injury in 1.8% of cases, including colonic perforation or duodenal erosions ²⁶. However, there was no association between extracorporeal shock wave lithotripsy and the subsequent long-term risk of hypertension ²⁷.

Lithotripsy side effects

Lithotripsy is safe most of the time. Talk to your health care provider about possible complications such as:

• Bleeding around your kidney, which may require you to get a blood transfusion
• Kidney infection
• Pieces of the stone block urine flow from your kidney (this may cause severe pain or damage to your kidney)
• Pieces of stone are left in your body (you may need more treatments)
• Ulcers in your stomach or small intestine
• Problems with kidney function after the procedure.

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