Extracorporeal Shock Wave Lithottrypsy (ESWL) for Urinary System Stone Disease

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive medical procedure used to treat kidney Stones and other types of stones in the urinary tract (urolithiasis). Instead of surgery, ESWL utilizes shock waves generated outside the body to break down the stones into smaller fragments, which can then be passed naturally through the urine.

During the procedure, the patient lies on a table while a machine delivers shock waves targeted at the location of the stones. These shock waves are focused and controlled to minimize damage to surrounding tissues. ESWL is typically performed under sedation or anesthesia to ensure patient comfort.

One of the key benefits of ESWL is its minimal invasiveness, as it avoids the need for surgical incisions. It also offers a shorter recovery time compared to traditional surgical methods. However, not all types and sizes of stones are suitable for treatment with ESWL, and it may not be effective for particularly large or hard stones.

Overall, ESWL has become a widely used and effective option for managing kidney stones and urinary tract stones, offering patients a less invasive alternative to surgery with favorable outcomes.

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What is extracorporeal shock wave lithottrypsy?

Extracorporeal shock wave lithotripsy (ESWL) is a medical procedure used to break down kidney stones and other types of stones in the urinary tract without the need for surgery. During ESWL, shock waves are generated outside the body and focused onto the stone using specialized equipment. These shock waves pass harmlessly through the body tissues but are powerful enough to fragment the stone into smaller pieces. The smaller stone fragments can then be naturally passed out of the body through the urinary system.

ESWL is typically performed on an outpatient basis and does not require general anesthesia, although some form of sedation or pain management may be used to ensure patient comfort. The procedure is guided by imaging techniques such as ultrasound or fluoroscopy to precisely target the stone.

Overall, ESWL offers a non-invasive and effective treatment option for kidney stones and urinary tract stones, with lower risks and shorter recovery times compared to surgical alternatives. However, not all types and sizes of stones are suitable for ESWL, and the effectiveness of the treatment may vary depending on factors such as the composition and location of the stone.

Indications of ESWL

Extracorporeal shock wave lithotripsy (ESW) is primarily indicated for the treatment of kidney stones (renal calculi) and other stones in the urinary tract. The specific indications for ESWT include:

Kidney stones (renal calculi): ESWL is commonly used to treat kidney stones that are smaller in size (typically less than 2 centimeters) and located within the kidney or upper urinary tract.
Ureteral stones: Stones that have passed from the kidney into the ureter (the tube connecting the kidney to the bladder) can also be treated with ESWT, particularly if they are smaller in size and not causing severe obstruction.
Other urinary tract stones: ESWL can be used to treat stones located in other parts of the urinary tract, such as the bladder or urethra, although this is less common compared to kidney and ureteral stones.
High surgical risk: ESWL may be recommended for patients who are not suitable candidates for surgery due to factors such as advanced age, significant medical comorbidities, or an increased risk of complications associated with surgical procedures.
Patient preference: In some cases, patients may prefer ESWL over surgical interventions due to its non-invasive nature, shorter recovery time, and reduced risk of complications.

It’s important to note that the suitability of ESWL for treating urinary stones depends on various factors, including the size, location, composition, and number of stones, as well as the overall health and preferences of the patient. Therefore, a thorough evaluation by a Urologist is necessary to determine the most appropriate treatment approach for each individual case.

Contrindications of ESWL

Extracorporeal shock wave lithotripsy (ESWL) may not be suitable for all patients, and there are several contraindications to consider before undergoing this procedure. Some of the contraindications include:

Pregnancy: ESWL is contraindicated during pregnancy due to the potential risk to the fetus from exposure to shock waves.
Bleeding disorders: Patients with bleeding disorders or those taking anticoagulant medications may have an increased risk of bleeding complications during or after ESWL.
Severe obesity: Severe obesity may limit the effectiveness of ESWL due to difficulties in targeting the shock waves accurately and achieving adequate stone fragmentation.
Severe kidney impairment: ESWL may not be recommended for patients with severely impaired kidney function, as they may be at an increased risk of complications such as kidney damage or decreased efficacy of the treatment.
Uncontrolled urinary tract infection: Active urinary tract infections increase the risk of complications from ESWL, and the procedure is typically deferred until the infection is adequately treated.
Large stone size: ESWL may not be effective for treating large stones (greater than 2 centimeters) or stones with a particularly hard composition, such as certain types of calcium oxalate stones.
Anatomical abnormalities: Patients with anatomical abnormalities of the kidney or urinary tract that may interfere with the delivery of shock waves or increase the risk of complications may not be suitable candidates for ESWL.
Implanted devices: Certain implanted devices, such as pacemakers or metal implants in the treatment area, may interfere with the delivery of shock waves and pose a risk to the patient during ESWL.
Prior radiation therapy: Previous radiation therapy to the kidney area may increase the risk of complications from ESWL, and alternative treatment options should be considered.

It’s important for healthcare providers to carefully assess each patient’s medical history, overall health status, and individual risk factors before recommending ESWL for the treatment of urinary stones. Alternative treatment options may be considered for patients with contraindications to ESWL.

Complications of extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is generally considered a safe procedure for the treatment of kidney stones and urinary tract stones. However, like any medical intervention, it carries some risk of complications. Some potential complications of ESWL include:

Pain or discomfort: After ESWL, patients may experience discomfort or pain in the treatment area, which can usually be managed with pain medications prescribed by the healthcare provider.
Bruising or skin injury: In some cases, the shock waves used during ESWL may cause bruising or minor skin injuries at the treatment site. These effects are typically temporary and resolve on their own.
Bleeding: ESWT may cause minor bleeding in the urinary tract, particularly in patients with pre-existing bleeding disorders or those taking anticoagulant medications. In rare cases, significant bleeding requiring medical intervention may occur.
Fragmentation of stones: While the primary goal of ESWL is to break down kidney stones and urinary tract stones into smaller pieces, there is a risk that the stone fragments may not pass easily or completely out of the body, leading to obstruction or other complications.
Kidney injury: In rare cases, ESWL may cause damage to the kidney tissue, resulting in kidney injury. This risk is higher in patients with pre-existing kidney disease or other risk factors for kidney damage.
Hypertension: Some studies have suggested a possible association between ESWL and temporary increases in blood pressure (hypertension) immediately following the procedure, particularly in patients with pre-existing hypertension or cardiovascular conditions.
Infection: Although uncommon, ESWL may increase the risk of urinary tract infections, especially if there is residual stone material or if the procedure is performed in patients with pre-existing urinary tract infections.
Stone migration: Following ESWL, there is a risk that small stone fragments may migrate and become lodged in other parts of the urinary tract, leading to obstruction or other complications.
Failure to fragment stones: In some cases, ESWL may not effectively break down the stones, necessitating additional treatment options such as surgery or other minimally invasive procedures.

Which urinary system stones are resistent to ESWL

While Extracorporeal Shock Wave Lithotripsy (ESWL) is effective for many types of urinary system stones, there are certain types of stones that may be more resistant to this treatment. These include:

Cystine Stones: Cystine stones are composed of the amino acid cystine and are relatively rare, but they can be particularly challenging to treat with ESWL. Cystine stones tend to be hard and resistant to fragmentation with shock waves.
Large Stones: Stones that are larger in size, typically greater than 2 centimeters in diameter, may be more resistant to fragmentation with ESWL. Larger stones require more energy to break apart, and there may be limitations to the amount of energy that can be safely delivered during the procedure.
Staghorn Calculi: Staghorn calculi are large, branching stones that fill a significant portion of the renal pelvis and/or calyces. These stones may be more difficult to effectively fragment with ESWL due to their size, shape, and complexity.
Hard Stones: Stones with a high density or hardness, such as certain types of calcium oxalate stones or stones containing uric acid, may be more resistant to fragmentation with shock waves. These stones may require higher energy levels or alternative treatment methods for successful removal.
Anatomical Factors: Stones located in areas that are difficult to access or target with shock waves may be more challenging to treat with ESWL. This includes stones located in the lower pole of the kidney or stones within calyceal diverticula.
Obesity: In patients with obesity, the increased distance from the skin to the stone can make it more difficult to effectively deliver shock waves to the target area, reducing the efficacy of ESWL.
Certain Uric Acid Stones: While some uric acid stones may respond well to ESWL, others may be more resistant, particularly if they are densely packed or have a crystalline structure.

Preperation before extracorporeal shock wave lithottrypsy

Before undergoing Extracorporeal Shock Wave Lithotripsy (ESWL), patients typically undergo several preparations to ensure the procedure’s success and minimize potential risks. Here’s a general outline of the preparation process:

Medical Evaluation: Patients will undergo a thorough medical evaluation by their healthcare provider. This evaluation may include a review of medical history, physical examination, and diagnostic tests such as imaging studies (X-rays, ultrasound, CT scan) to assess the size, location, and composition of the stones.
Laboratory Tests: Blood and urine tests may be performed to assess kidney function, screen for urinary tract infections, and evaluate for any underlying medical conditions that may affect the procedure or recovery.
Medication Review: Patients should inform their healthcare provider of all medications they are currently taking, including prescription medications, over-the-counter drugs, supplements, and herbal remedies. Some medications may need to be adjusted or temporarily stopped before the procedure, particularly anticoagulants or medications that affect blood clotting.
Fasting: Patients may be instructed to fast for a certain period before the procedure, typically for several hours. This helps reduce the risk of aspiration if sedation or anesthesia is used during the procedure.
Hydration: Adequate hydration is essential before ESWL to ensure optimal shock wave transmission and improve the effectiveness of the procedure. Patients may be advised to drink plenty of fluids in the hours leading up to the procedure.
Bowel Preparation: In some cases, patients may be instructed to undergo bowel preparation before ESWL, particularly if the stones are located in the lower urinary tract or if the procedure involves general anesthesia. Bowel preparation may involve dietary restrictions and/or the use of laxatives to empty the bowels.
Clothing: Patients should wear comfortable, loose-fitting clothing on the day of the procedure, as well as flat shoes. Avoid wearing jewelry or metal objects that may interfere with the shock wave equipment.
Arrangements: Patients should arrange for transportation to and from the medical facility on the day of the procedure, as they may not be able to drive themselves home afterward, especially if sedation or anesthesia is used.
Informed Consent: Before the procedure, patients will be asked to sign a consent form indicating that they understand the risks, benefits, and potential complications of ESWL.
Follow Instructions: Patients should carefully follow any additional instructions provided by their healthcare provider, such as specific dietary restrictions, medication adjustments, or pre-procedure hygiene measures.

ESWL for kidney stones: indications, conraindications

Certainly, here are the indications and contraindications for Extracorporeal Shock Wave Lithotripsy (ESWL) for kidney stones:

Indications:

Stone Size: ESWL is typically indicated for kidney stones less than 2 centimeters (20 mm) in diameter. Stones larger than this may require alternative treatments such as percutaneous nephrolithotomy (PCNL) or ureteroscopy.
Stone Composition: ESWL is most effective for treating certain types of kidney stones, including calcium-based stones (calcium oxalate or calcium phosphate). Stones composed of other materials, such as cystine or certain types of uric acid stones, may be less responsive to shock wave therapy.
Stone Location: ESWL is generally suitable for kidney stones located in the kidney or upper ureter. Stones in the lower pole of the kidney may be more challenging to effectively treat with shock waves due to their location.
Number of Stones: ESWL may be used for treating solitary kidney stones or multiple stones in the kidney, depending on their size and location.
Patient Factors: ESWL may be preferred for patients who are poor candidates for more invasive procedures due to factors such as advanced age, significant comorbidities, or patient preference for non-invasive treatment options.
Absence of Obstruction: ESWL is typically indicated for kidney stones without significant urinary tract obstruction. Stones causing obstruction may require urgent intervention to relieve the blockage before considering ESWL.

Contraindications:

Stone Size: Very large kidney stones (greater than 2 centimeters) may not be effectively treated with ESWL and may require alternative treatments such as PCNL.
Pregnancy: ESWL is generally contraindicated during pregnancy due to the potential risks to the fetus from exposure to shock waves.
Coagulopathy: Patients with bleeding disorders or who are taking anticoagulant medications may be at increased risk of bleeding complications with ESWL.
Severe Obesity: In patients with severe obesity, it may be challenging to adequately target and treat kidney stones with shock waves due to the increased distance from the skin to the stone.
Anatomic Abnormalities: Certain anatomical factors, such as abnormal kidney anatomy or the presence of urinary tract anomalies, may limit the effectiveness or safety of ESWL.
Urinary Tract Infection: Active urinary tract infection may increase the risk of complications with ESWL and should be treated before considering the procedure.
Uncontrolled Hypertension: Patients with uncontrolled high blood pressure may be at increased risk of complications during ESWL due to the potential effects of shock waves on blood pressure.
Kidney Function: Patients with severely impaired kidney function may not be suitable candidates for ESWL due to the risk of acute kidney injury.

It’s essential for healthcare providers to carefully evaluate each patient’s individual circumstances and consider both the indications and contraindications before recommending ESWL for kidney stones.

ESWL for renal pelvis stones: indications, conraindications

Extracorporeal Shock Wave Lithotripsy (ESWL) can be used for renal pelvis stones in certain cases. Here are the indications and contraindications

Indications:

Stone Size: ESWL is generally effective for renal pelvis stones smaller than 2 centimeters (20 mm) in diameter. Larger stones may require alternative treatments such as percutaneous nephrolithotomy (PCNL).
Stone Composition: ESWL is most successful for treating certain types of stones, particularly calcium-based stones (calcium oxalate or calcium phosphate), which are commonly found in the renal pelvis. Stones composed of other materials, such as cystine or certain types of uric acid stones, may be less responsive to shock wave therapy.
Stone Location: Renal pelvis stones that are well-positioned and accessible for shock wave treatment are suitable candidates for ESWL. Stones located in areas that are difficult to target with shock waves may not be suitable for this treatment.
Number of Stones: ESWL may be used for solitary renal pelvis stones or for multiple stones in the renal pelvis, depending on their size and composition.
Patient Factors: ESWL may be preferred for patients who are not good candidates for more invasive procedures due to factors such as advanced age, significant comorbidities, or patient preference for non-invasive treatment options.
Absence of Obstruction: ESWL is typically indicated for renal pelvis stones without significant urinary tract obstruction. Stones causing obstruction may require urgent intervention to relieve the blockage before considering ESWL.

Contraindications:

Large Stone Size: Renal pelvis stones larger than 2 centimeters may not be effectively treated with ESWL and may require alternative treatments such as PCNL.
Pregnancy: ESWL is generally contraindicated during pregnancy due to the potential risks to the fetus from exposure to shock waves.
Coagulopathy: Patients with bleeding disorders or who are taking anticoagulant medications may be at increased risk of bleeding complications with ESWL.
Severe Obesity: In patients with severe obesity, it may be challenging to adequately target and treat renal pelvis stones with shock waves due to the increased distance from the skin to the stone.
Anatomic Abnormalities: Certain anatomical factors, such as abnormal kidney anatomy or the presence of urinary tract anomalies, may limit the effectiveness or safety of ESWL.
Urinary Tract Infection: Active urinary tract infection may increase the risk of complications with ESWL and should be treated before considering the procedure.
Uncontrolled Hypertension: Patients with uncontrolled high blood pressure may be at increased risk of complications during ESWL due to the potential effects of shock waves on blood pressure.
Kidney Function: Patients with severely impaired kidney function may not be suitable candidates for ESWL due to the risk of acute kidney injury.

Extracorporeal Shock Wave Lithottrypsy for ureteral stones: indications, conraindications

Certainly, here are both the indications and contraindications for Extracorporeal Shock Wave Lithotripsy (ESWL) for ureteral stones:

Indications:

Stone Size: Ureteral stones less than 10 mm in diameter are generally considered suitable for ESWL. Larger stones may be more difficult to effectively fragment with shock waves alone.
Stone Location: Ureteral stones located in the upper or mid-ureter are often suitable for ESWL. Stones in the lower ureter may be more challenging to target accurately with shock waves due to anatomical considerations.
Composition of Stones: Certain types of ureteral stones, such as calcium-based stones (calcium oxalate or calcium phosphate), are more responsive to shock wave therapy. However, stones composed of other materials, such as cystine or certain types of uric acid stones, may be less effectively treated with ESWL.
Patient Factors: ESWL may be preferred for patients who are poor candidates for more invasive procedures due to factors such as advanced age, significant comorbidities, or patient preference for non-invasive treatment options.
Absence of Obstruction: ESWL is typically indicated for ureteral stones without significant urinary tract obstruction. Stones causing obstruction may require urgent intervention to relieve the blockage before considering ESWL.
Stone Density: Stones with higher density may respond better to shock wave therapy. However, overly dense stones may also be more challenging to fragment effectively with ESWL.
Prior Treatment History: ESWL may be considered as a first-line treatment option for ureteral stones or as a secondary option for patients who have failed other conservative measures such as hydration and pain management.

Contraindications:

Large Stone Size: Ureteral stones larger than 10 mm may not be effectively fragmented with ESWL and may require alternative treatments such as ureteroscopy or percutaneous nephrolithotomy.
Pregnancy: ESWL is generally contraindicated during pregnancy due to the potential risks to the fetus from exposure to shock waves.
Coagulopathy: Patients with bleeding disorders or who are taking anticoagulant medications may be at increased risk of bleeding complications with ESWL.
Severe Obesity: In patients with severe obesity, it may be challenging to adequately target and treat ureteral stones with shock waves due to the increased distance from the skin to the stone.
Anatomic Abnormalities: Certain anatomical factors, such as abnormal kidney or ureteral anatomy, may limit the effectiveness or safety of ESWL.
Urinary Tract Infection: Active urinary tract infection may increase the risk of complications with ESWL and should be treated before considering the procedure.
Uncontrolled Hypertension: Patients with uncontrolled high blood pressure may be at increased risk of complications during ESWL due to the potential effects of shock waves on blood pressure.
Kidney Function: Patients with severely impaired kidney function may not be suitable candidates for ESWL due to the risk of acute kidney injury.

Extracorporeal Shock Wave Lithottrypsy for urinary bladder stones: indications, conraindications

Extracorporeal Shock Wave Lithotripsy (ESWL) can also be used for urinary bladder stones in certain situations. Here are the indications and contraindications:

Indications:

Stone Size: ESWL is generally effective for urinary bladder stones less than 2 centimeters (20 mm) in diameter. Larger stones may be more challenging to treat with shock wave therapy.
Stone Composition: ESWL is most successful for treating certain types of stones, including calcium-based stones (calcium oxalate or calcium phosphate), which are commonly found in the urinary bladder. Stones composed of other materials, such as uric acid or struvite stones, may also be amenable to shock wave therapy.
Stone Location: Urinary bladder stones that are well-positioned and accessible for shock wave treatment are suitable candidates for ESWL. Stones located in areas that are difficult to target with shock waves may not be suitable for this treatment.
Number of Stones: ESWL may be used for solitary bladder stones or for multiple stones in the urinary bladder, depending on their size and composition.
Patient Factors: ESWL may be preferred for patients who are not good candidates for more invasive procedures due to factors such as advanced age, significant comorbidities, or patient preference for non-invasive treatment options.

Contraindications:

Large Stone Size: Urinary bladder stones larger than 2 centimeters may not be effectively treated with ESWL and may require alternative treatments such as cystolitholapaxy (transurethral stone removal) or open surgical removal.
Pregnancy: ESWL is generally contraindicated during pregnancy due to the potential risks to the fetus from exposure to shock waves.
Coagulopathy: Patients with bleeding disorders or who are taking anticoagulant medications may be at increased risk of bleeding complications with ESWL.
Urinary Tract Infection: Active urinary tract infection may increase the risk of complications with ESWL and should be treated before considering the procedure.
Bladder Outlet Obstruction: Patients with significant bladder outlet obstruction may not be suitable candidates for ESWL due to the risk of urinary retention or incomplete stone clearance.
Anatomic Abnormalities: Certain anatomical factors, such as bladder diverticula or bladder wall abnormalities, may limit the effectiveness or safety of ESWL.
Urinary Fistula: The presence of a urinary fistula or other urinary tract abnormalities may be a contraindication to ESWL due to the risk of complications.

Summary

Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive medical procedure used to treat kidney stones and other urinary tract stones. It involves the use of shock waves generated outside the body to break down the stones into smaller fragments, which can then be passed naturally through the urine. ESWL is typically performed on an outpatient basis and does not require surgery. While generally safe and effective, potential complications include pain, bruising, bleeding, kidney injury, and stone migration. ESWL offers a less invasive alternative to surgery with shorter recovery times and is commonly used for suitable candidates with smaller stones.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKEY