Extracorporeal shock wave lithotripsy

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Extracorporeal shock wave lithotripsy
Kidney stone fragments.png
Some of the passed fragments of a 1-cm calcium oxalate stone that was smashed using lithotripsy.
ICD-9-CM 98.5
MeSH D008096

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive treatment of kidney stones[1] (urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) using an acoustic pulse. It is also reported to be used for salivary stones.[2] and pancreatic stones [1]

It is estimated that more than one million patients are treated annually with ESWL in the USA alone.[citation needed]


It was first used by physicians from the university hospital Großhadern (Munich, Germany) and technicians from Dornier System (Friedrichshafen, Germany) in 1980. The device used is now displayed in the Deutsches Medizinhistorischen Museum in Ingolstadt.[citation needed]

Non-invasive treatment[edit]

The lithotriptor attempts to break up the stone with minimal collateral damage by using an externally applied, focused, high-intensity acoustic pulse. The sedated or anesthetized patient lies down in the apparatus' bed, with the back supported by a water-filled coupling device placed at the level of kidneys. A fluoroscopic x-ray imaging system or an ultrasound imaging system is used to locate the stone and aim the treatment. The first generation lithotriptor known as the Dornier HM3 (Human Model 3), has a half ellipsoid-shaped piece that opens toward the patient. The acoustic pulse is generated at the ellipsoidal focal point that is furthest from the patient and the stone positioned at the opposite focal point receives the focused shock wave. The treatment usually starts at the equipment's lowest power level, with a long gap between pulses, in order to accustom the patient to the sensation. The length of gap between pulses is also controlled to allow cavitation bubbles to disperse minimizing tissue damage. Second and later generation machines use an acoustic lens to focus the shock wave. This functions much like an optical lens, focusing the shock wave at the desired loci. The frequency of pulses are currently left at a slow rate for more effective comminution of the stone and to minimize morbidity while the power levels are then gradually increased, so as to break up the stone. The final power level usually depends on the patient's pain threshold and the observed success of stone breakage. If the stone is positioned near a bone (usually a rib in the case of kidney stones), this treatment may be more uncomfortable because the shock waves can cause a mild resonance in the bone which can be felt by the patient. The sensation of the treatment is likened to an elastic band twanging off the skin. Alternatively the patient may be sedated during the procedure. This allows the power levels to be brought up more quickly and a much higher pulse frequency, often up to 120 shocks per minute.

The successive shock wave pressure pulses result in direct shearing forces, as well as cavitation bubbles surrounding the stone, which fragment the stones into smaller pieces that then can easily pass through the ureters or the cystic duct. The process takes about an hour. A ureteral stent (a kind of expandable hollow tube) may be used at the discretion of the urologist. The stent allows for easier passage of the stone by relieving obstruction and through passive dilatation of the ureter.

Extracorporeal lithotripsy works best with stones between 4 mm and 20 mm (0.4 cm and 2.0 cm) in diameter that are still located in the kidney. ESWL can be used to break up stones located in ureters as well, but with a lower rate of success.

The patients undergoing this procedure can, in some cases, see for themselves the progress of their treatment. If allowed to view the ultrasound or x-ray monitor, they may be able to see their stones change from a distinct bright point (or dark spot depending on whether the fluoro unit is set up in native or bones white) to a fuzzy cloud as the stone is disintegrated into a fine powder.

ESWL is the least invasive of the commonplace modalities for definitive stone treatment, but provides a lower stone-free rate than other more invasive treatment methods, such as ureteroscopic manipulation with laser lithotripsy or percutaneous nephrolithotomy (PCNL) or retrogade intrarenal surgery (RIRS).[1] The passage of stone fragments may take a few days or a week and may cause mild to extreme pain depending on the patient and the success of the operation. Patients may be instructed to drink as much water as practical during this time. Patients are also advised to void through a stone screen in order to capture stone fragments for analysis.

ESWL is not without risks. The shock waves themselves, as well as cavitation bubbles formed by the agitation of the urine medium, can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. This can lead to long-term consequences such as renal failure and hypertension. Overall complication rates of ESWL range from 5–20%. Occasionally, patients have experienced infections and thus are advised by medical professionals to obtain medical help as soon as possible if they develop a fever.


  1. ^ a b Srisubat, A; Potisat1, S; Lojanapiwat, B; Setthawong, V; Laopaiboon, M (24 November 2014). "Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones". The Cochrane Library. doi:10.1002/14651858.CD007044.pub3. PMID 25418417. Retrieved 2 April 2015. 
  2. ^ Salivary duct stones

Further reading[edit]

  • Abe T, Akakura K, Kawaguchi M, Ueda T, Ichikawa T, Ito H, et al. Outcomes of shockwave lithotripsy for upper urinary-tract stones: a large-scale study at a single institution. J Endourol. Sep 2005;19(7):768-73.
  • Albala DM, Assimos DG, Clayman RV, Denstedt JD, Grasso M, Gutierrez-Aceves J, Kahn RI, Leveillee RJ, Lingeman JE, Macaluso JN, Munch LC, Nakada SY, Newman RC, Pearle MS, Preminger GM, Teichman J, and Woods JR: Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. The Journal of Urology 166(6):2072–80 2001 Dec
  • Anagnostou T, Tolley D. Management of ureteric stones. Eur Urol. Jun 2004;45(6):714-21.
  • Auge BK, Preminger GM. Update on shock wave lithotripsy technology. Curr Opin Urol. Jul 2002;12(4):287-90.
  • Chacko J, Moore M, Sankey N, Chandhoke PS. Does a slower treatment rate impact the efficacy of extracorporeal shock wave lithotripsy for solitary kidney or ureteral stones?. J Urol. Apr 2006;175(4):1370-3; discussion 1373-4.
  • Chaussy CG, Fuchs GJ. Current state and future developments of noninvasive treatment of human urinary stones with extracorporeal shock wave lithotripsy. J Urol. Mar 1989;141(3 Pt 2):782-9.
  • Collins JW, Keeley FX. Is there a role for prophylactic shock wave lithotripsy for asymptomatic calyceal stones? Curr Opin Urol. Jul 2002;12(4):281-6.
  • Delius M. This month in Investigative Urology: effect of extracorporeal shock waves on the kidney. J Urol. Aug 1988;140(2):390.
  • Hayes, J, Ding, S. Pancreatic stone and treatment using ERCP and ESWL procedures: a case study and review. NZMJ. 7th September 2012, Volume 125 Number 1361
  • Joshi HB, Obadeyi OO, Rao PN. A comparative analysis of nephrostomy, JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones. BJU Int. Aug 1999;84(3):264-9.
  • Kim FJ, Rice KR. Prediction of shockwave failure in patients with urinary tract stones. Curr Opin Urol. Mar 2006;16(2):88–92.
  • Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE, Segura JW. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup. J Urol. May 2006;175(5):1742-7.
  • Lee C, Ugarte R, Best S, Monga M. Impact of renal function on efficacy of extracorporeal shockwave lithotripsy. J Endourol. May 2007;21(5):490-3.
  • Lee YH, Tsai JY, Jiaan BP, Wu T, Yu CC. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopic lithotripsy for management of large upper third ureteral stones. Urology. Mar 2006;67(3):480-4; discussion 484.
  • Lindqvist K, Holmberg G, Peeker R, Grenabo L. Extracorporeal shock-wave lithotripsy or ureteroscopy as primary treatment for ureteric stones: a retrospective study comparing two different treatment strategies. Scand J Urol Nephrol. 2006;40(2):113-8.
  • Lingeman JE, Zafar FS. Lithotripsy systems. In: Smith AD, Badlani GH, Bagley DH, et al. Smith's Textbook of Endourology. St Louis, Mo: Quality Medical Publishing; 1996:553–89.
  • Lingeman JE, Kim SC, Kuo RL, McAteer JA, Evan AP. Shockwave lithotripsy: anecdotes and insights. J Endourol. Nov 2003;17(9):687-93.
  • Liou LS, Streem SB. Long-term renal functional effects of shock wave lithotripsy, percutaneous nephrolithotomy and combination therapy: a comparative study of patients with solitary kidney. J Urol. Jul 2001;166(1):36; discussion 36-7.
  • Macaluso JN and Thomas R: Extracorporeal shock wave lithotripsy: an outpatient procedure. The Journal of urology 146(3):714-7 1991 Sep
  • Macaluso JN: Management of stone disease—bearing the burden. The Journal of urology 156(5):1579–80 1996 Nov
  • Macaluso JN: Shock Wave Lithotripsy for Stones in the Ureter. Business Briefing: North America Pharmacotherapy; 85–88, April 2004
  • Macaluso JN: Editorial Comment: re Incorporation of patient preferences in the treatment of upper urinary tract calculi: a decision analytical view. Journal of Urology, Vol 162, 1913–1919, December 1999
  • Madaan S, Joyce AD. Limitations of extracorporeal shock wave lithotripsy. Curr Opin Urol. Mar 2007;17(2):109-13.
  • Martin TV, Sosa RE. Shock-wave lithotripsy. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ. Campbell's Urology. Vol 3. 7th ed. Philadelphia, Pa: WB Saunders; 1998:2735-52.
  • Micali S, Grande M, Sighinolfi MC, De Stefani S, Bianchi G. Efficacy of expulsive therapy using nifedipine or tamsulosin, both associated with ketoprofene, after shock wave lithotripsy of ureteral stones. Urol Res. Jun 2007;35(3):133-7.
  • Moody JA, Evans AP, Lingeman JE. Extracorporeal shockwave lithotripsy. In: Weiss RM, George NJR, O'Reilly PH, eds. Comprehensive Urology. Mosby International Limited; 2001:623-36.
  • Pareek G, Armenakas NA, Fracchia JA. Hounsfield units on computerized tomography predict stone-free rates after extracorporeal shock wave lithotripsy. J Urol. May 2003;169(5):1679–81.
  • Pearle MS, Lingeman JE, Leveillee R, Kuo R, Preminger GM, Nadler RB, Macaluso JN, Monga M, Kumar U, Dushinski J, Albala DM, Wolf JS, Assimos D, Fabrizio M, Munch LC, Nakada SY, Auge B, Honey J, Ogan K, Pattaras J, McDougall EM, Averch TD, Turk T, Pietrow P, and Watkins S: Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. The Journal of urology 173(6):2005-9 2005 Jun
  • Putman SS, Hamilton BD, Johnson DB. The use of shock wave lithotripsy for renal calculi. Curr Opin Urol. Mar 2004;14(2):117-21.
  • Sayed MA, el-Taher AM, Aboul-Ella HA, Shaker SE. Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJU Int. Nov 2001;88(7):675-8.
  • Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, Macaluso JN, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol. Jun 1994;151(6):1648–51.
  • Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, and Macaluso JN: Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. The Journal of urology 158(5):1915–21 1997 Nov
  • Sheir KZ, Madbouly K, Elsobky E, Abdelkhalek M. Extracorporeal shock wave lithotripsy in anomalous kidneys: 11-year experience with two second-generation lithotripters. Urology. Jul 2003;62(1):10-5; discussion 15-6.
  • Sheir KZ, El-Diasty TA, Ismail AM. Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: the first prospective clinical study. BJU Int. Feb 2005;95(3):389-93.
  • Skolarikos A, Alivizatos G, de la Rosette J. Extracorporeal shock wave lithotripsy 25 years later: complications and their prevention. Eur Urol. Nov 2006;50(5):981-90; discussion 990.
  • Tan EC, Tung KH, Foo KT. Comparative studies of extracorporeal shock wave lithotripsy by Dornier HM3, EDAP LT 01 and Sonolith 2000 devices. J Urol. Aug 1991;146(2):294-7.
  • Thomas R, Macaluso JN, Vandenberg T, Salvatore F: An innovative approach to management of lower third ureteral calculi. Journal of Urology, Volume 149, #6, 1427–1430, June 1993.
  • Unal B, Kara S, Bilgili Y, Basar H, Yilmaz E, Batislam E. Giant abdominal wall abscess dissecting into thorax as a complication of ESWL. Urology. Feb 2005;65(2):389.
  • Weiland D, Lee C, Ugarte R, Monga M. Impact of shockwave coupling on efficacy of extracorporeal shockwave lithotripsy. J Endourol. Feb 2007;21(2):137-40.
  • Winters JC, Macaluso JN: Ungated Medstone Outpatient Lithotripsy. Journal of Urology, Volume 153, #3 part 1, 593–595, March 1995

External links[edit]