Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive medical procedure used to break down kidney stones, ureteral stones, and certain types of gallbladder or pancreatic stones. It employs high-energy shock waves that are generated outside the body and focused on the stone to fragment it into smaller pieces, which can then pass naturally through the urinary tract.
ESWL is widely preferred due to its minimally invasive nature, shorter recovery time, and reduced risk of complications compared to surgical interventions. The procedure is performed under imaging guidance, such as ultrasound or fluoroscopy, to precisely target the stone while minimizing damage to surrounding tissues.
Indications
Stone-Related Indications Kidney Stones (Nephrolithiasis): Most effective for stones ≤20 mm in the renal pelvis or calyces.
Ureteral Stones: Suitable for proximal ureteral stones ≤10 mm, though less effective for distal ureteral stones.
Multiple Small Stones: Can be used when multiple stones are present, but stone-free rates may be lower than with other interventions. Stone Composition Calcium Oxalate (Monohydrate & Dihydrate), Calcium Phosphate, Struvite Stones: These respond well to ESWL.
Uric Acid and Cystine Stones: Less effective due to their composition and density but may be considered in selected cases.
Patient-Related Factors
Patients Unable to Undergo Surgery: ESWL is a good option for those who are high-risk for invasive procedures.
Contraindications
Uncontrolled Bleeding Disorders
Patients with conditions such as hemophilia, thrombocytopenia, or those on anticoagulants (e.g., warfarin, heparin) are at high risk of hemorrhage.
Uncontrolled Hypertension
Severe hypertension increases the risk of vascular injury and complications like hematoma formation.
Aortic or Renal Artery Aneurysm
Shock waves can cause aneurysm rupture, leading to life-threatening bleeding.
Obstruction Distal to the Stone
If there is a significant urinary tract obstruction beyond the stone, ESWL may cause worsening hydronephrosis and damage to the kidney.
Non-visualized Stones
Stones that are not well visualized on imaging (X-ray or ultrasound) make targeting ineffective.
Poor Kidney Function (chronic kidney disease – CKD Stage 4 or 5)
Shock waves can cause further renal damage in patients with severely impaired kidney function.
Pediatric Patients
ESWL is generally avoided in young children due to concerns about kidney development, but it may be used in specialized cases.
Outcomes
Equipment’s
Lithotripsy machine
Extracorporeal shock wave ultrasound
Types of ESWL Machines
Electromagnetic Lithotripters
Electrohydraulic Lithotripters
Piezoelectric Lithotripters
Components
Shock Wave Generator
Focusing System
Imaging System
Patient Positioning Table
Control Console
Patient Preparation Pre-Procedure Evaluation Medical History & Assessment
Evaluate for conditions that may affect the procedure (e.g., bleeding disorders, pregnancy, obesity, or anatomical abnormalities).
Review medications, particularly blood thinners (aspirin, warfarin, clopidogrel, NSAIDs), as these may need to be stopped before the procedure.
Dietary Restrictions
Usually, patients are required to fast for 6–8 hours before the procedure, especially if sedation or anesthesia is planned.
Clear fluids may be allowed up to a few hours before, depending on institutional protocols.
Medication Adjustments
Blood thinners and NSAIDs are typically stopped 5–7 days prior, as directed by the physician.
Antihypertensive medications may need adjustments, particularly diuretics.
Hydration & Bladder Preparation
Patients are often encouraged to stay well-hydrated before the procedure unless otherwise instructed.
A bowel preparation (e.g., laxative) may be required in some cases to clear gas from the intestines, which can interfere with shock wave transmission.
Patient position Supine Position (Most Common)
Used for most kidney stones.
The patient lies on their back on the treatment table.
The shock wave generator is positioned against the flank or back.
Prone Position
Sometimes used for lower ureteral stones or specific kidney stone locations.
The patient lies on their stomach.
Step 1-Pre-Procedure Preparation: Patient Evaluation:
Medical history review, including any contraindications (pregnancy, bleeding disorders, infections, or severe obesity).
Imaging studies (X-ray, ultrasound, or CT scan) to determine the stone’s size, location, and composition.
Blood and urine tests to check kidney function and rule out infections.
Patient Positioning:
The patient is positioned on a specialized lithotripsy table, either lying supine or prone, depending on stone location.
Proper alignment ensures that shock waves are targeted directly at the stone.
Anesthesia and Sedation:
Typically, mild sedation or local anesthesia is used to keep the patient comfortable.
In some cases, general anesthesia may be required for pediatric patients or if higher shock energy is needed.
Step 2-Localization of the Stone:
Fluoroscopy or ultrasound is used to precisely locate the stone and adjust patient positioning accordingly.
A marking system may be used on the skin to maintain alignment.
Step 3-Shock Wave Generation and Application:
A gel-filled cushion or water bath is placed between the patient’s skin and the lithotripter to conduct the shock waves.
The lithotripter generates focused high-energy shock waves, which travel through the body and fragment the kidney stone.
Shock waves are delivered in gradually increasing intensity to minimize tissue damage and improve stone fragmentation.
Typically, 2,000 to 4,000 shock waves are administered over 30–60 minutes.
Step 4-Real-Time Monitoring and Adjustments:
The stone’s response is continuously monitored using fluoroscopy or ultrasound.
Adjustments may be made to optimize the alignment if the stone moves.
Step 5-Post-Procedure Care:
Observation and Recovery:
The patient is monitored for a short period to ensure stability.
Common post-procedure symptoms include hematuria (blood in urine), mild flank pain, and passage of stone fragments.
Hydration and Pain Management:
The patient is advised to drink plenty of fluids to aid stone passage.
Pain relievers may be prescribed if discomfort occurs during fragment passage.
Follow-Up:
Imaging follow-up (X-ray, ultrasound) after a few weeks to check for residual fragments.
If significant fragments remain, a second ESWL session or an alternative procedure (e.g., ureteroscopy or percutaneous nephrolithotomy) may be needed.
Complications
Hematuria (Blood in Urine): Common after ESWL due to trauma to renal tissue and small blood vessels. Usually resolves within a few days.
Renal Hematoma: Bleeding in or around the kidney due to shock wave impact on blood vessels, occurring in 0.6–8% of cases. Large hematomas may require intervention.
Renal Function Impairment: Temporary decline in kidney function can occur, especially in patients with pre-existing kidney disease.
Renal Infarction: Rarely, disruption of renal blood supply can lead to localized kidney tissue death.
Incomplete Stone Clearance: Some fragments may remain, requiring repeat ESWL or additional procedures like ureteroscopy.
Residual Stone Growth: Incomplete fragmentation may allow remaining pieces to grow over time, necessitating further treatment.
Ureteral Obstruction: Large stone fragments can block the ureter, leading to pain, infection, or hydronephrosis.
Urinary Tract Infection (UTI): Bacteria released from fragmented stones can cause infections, which may progress to pyelonephritis (kidney infection) or sepsis.
»
Home » Procedure » Extracorporeal Shock Wave Lithotripsy
Extracorporeal Shock Wave Lithotripsy
Updated :
August 21, 2025
Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive medical procedure used to break down kidney stones, ureteral stones, and certain types of gallbladder or pancreatic stones. It employs high-energy shock waves that are generated outside the body and focused on the stone to fragment it into smaller pieces, which can then pass naturally through the urinary tract.
ESWL is widely preferred due to its minimally invasive nature, shorter recovery time, and reduced risk of complications compared to surgical interventions. The procedure is performed under imaging guidance, such as ultrasound or fluoroscopy, to precisely target the stone while minimizing damage to surrounding tissues.
Stone-Related Indications Kidney Stones (Nephrolithiasis): Most effective for stones ≤20 mm in the renal pelvis or calyces.
Ureteral Stones: Suitable for proximal ureteral stones ≤10 mm, though less effective for distal ureteral stones.
Multiple Small Stones: Can be used when multiple stones are present, but stone-free rates may be lower than with other interventions. Stone Composition Calcium Oxalate (Monohydrate & Dihydrate), Calcium Phosphate, Struvite Stones: These respond well to ESWL.
Uric Acid and Cystine Stones: Less effective due to their composition and density but may be considered in selected cases.
Patient-Related Factors
Patients Unable to Undergo Surgery: ESWL is a good option for those who are high-risk for invasive procedures.
Uncontrolled Bleeding Disorders
Patients with conditions such as hemophilia, thrombocytopenia, or those on anticoagulants (e.g., warfarin, heparin) are at high risk of hemorrhage.
Uncontrolled Hypertension
Severe hypertension increases the risk of vascular injury and complications like hematoma formation.
Aortic or Renal Artery Aneurysm
Shock waves can cause aneurysm rupture, leading to life-threatening bleeding.
Obstruction Distal to the Stone
If there is a significant urinary tract obstruction beyond the stone, ESWL may cause worsening hydronephrosis and damage to the kidney.
Non-visualized Stones
Stones that are not well visualized on imaging (X-ray or ultrasound) make targeting ineffective.
Poor Kidney Function (chronic kidney disease – CKD Stage 4 or 5)
Shock waves can cause further renal damage in patients with severely impaired kidney function.
Pediatric Patients
ESWL is generally avoided in young children due to concerns about kidney development, but it may be used in specialized cases.
Lithotripsy machine
Extracorporeal shock wave ultrasound
Types of ESWL Machines
Electromagnetic Lithotripters
Electrohydraulic Lithotripters
Piezoelectric Lithotripters
Components
Shock Wave Generator
Focusing System
Imaging System
Patient Positioning Table
Control Console
Patient Preparation Pre-Procedure Evaluation Medical History & Assessment
Evaluate for conditions that may affect the procedure (e.g., bleeding disorders, pregnancy, obesity, or anatomical abnormalities).
Review medications, particularly blood thinners (aspirin, warfarin, clopidogrel, NSAIDs), as these may need to be stopped before the procedure.
Dietary Restrictions
Usually, patients are required to fast for 6–8 hours before the procedure, especially if sedation or anesthesia is planned.
Clear fluids may be allowed up to a few hours before, depending on institutional protocols.
Medication Adjustments
Blood thinners and NSAIDs are typically stopped 5–7 days prior, as directed by the physician.
Antihypertensive medications may need adjustments, particularly diuretics.
Hydration & Bladder Preparation
Patients are often encouraged to stay well-hydrated before the procedure unless otherwise instructed.
A bowel preparation (e.g., laxative) may be required in some cases to clear gas from the intestines, which can interfere with shock wave transmission.
Patient position Supine Position (Most Common)
Used for most kidney stones.
The patient lies on their back on the treatment table.
The shock wave generator is positioned against the flank or back.
Prone Position
Sometimes used for lower ureteral stones or specific kidney stone locations.
The patient lies on their stomach.
Step 1-Pre-Procedure Preparation: Patient Evaluation:
Medical history review, including any contraindications (pregnancy, bleeding disorders, infections, or severe obesity).
Imaging studies (X-ray, ultrasound, or CT scan) to determine the stone’s size, location, and composition.
Blood and urine tests to check kidney function and rule out infections.
Patient Positioning:
The patient is positioned on a specialized lithotripsy table, either lying supine or prone, depending on stone location.
Proper alignment ensures that shock waves are targeted directly at the stone.
Anesthesia and Sedation:
Typically, mild sedation or local anesthesia is used to keep the patient comfortable.
In some cases, general anesthesia may be required for pediatric patients or if higher shock energy is needed.
Step 2-Localization of the Stone:
Fluoroscopy or ultrasound is used to precisely locate the stone and adjust patient positioning accordingly.
A marking system may be used on the skin to maintain alignment.
Step 3-Shock Wave Generation and Application:
A gel-filled cushion or water bath is placed between the patient’s skin and the lithotripter to conduct the shock waves.
The lithotripter generates focused high-energy shock waves, which travel through the body and fragment the kidney stone.
Shock waves are delivered in gradually increasing intensity to minimize tissue damage and improve stone fragmentation.
Typically, 2,000 to 4,000 shock waves are administered over 30–60 minutes.
Step 4-Real-Time Monitoring and Adjustments:
The stone’s response is continuously monitored using fluoroscopy or ultrasound.
Adjustments may be made to optimize the alignment if the stone moves.
Step 5-Post-Procedure Care:
Observation and Recovery:
The patient is monitored for a short period to ensure stability.
Common post-procedure symptoms include hematuria (blood in urine), mild flank pain, and passage of stone fragments.
Hydration and Pain Management:
The patient is advised to drink plenty of fluids to aid stone passage.
Pain relievers may be prescribed if discomfort occurs during fragment passage.
Follow-Up:
Imaging follow-up (X-ray, ultrasound) after a few weeks to check for residual fragments.
If significant fragments remain, a second ESWL session or an alternative procedure (e.g., ureteroscopy or percutaneous nephrolithotomy) may be needed.
Complications
Hematuria (Blood in Urine): Common after ESWL due to trauma to renal tissue and small blood vessels. Usually resolves within a few days.
Renal Hematoma: Bleeding in or around the kidney due to shock wave impact on blood vessels, occurring in 0.6–8% of cases. Large hematomas may require intervention.
Renal Function Impairment: Temporary decline in kidney function can occur, especially in patients with pre-existing kidney disease.
Renal Infarction: Rarely, disruption of renal blood supply can lead to localized kidney tissue death.
Incomplete Stone Clearance: Some fragments may remain, requiring repeat ESWL or additional procedures like ureteroscopy.
Residual Stone Growth: Incomplete fragmentation may allow remaining pieces to grow over time, necessitating further treatment.
Ureteral Obstruction: Large stone fragments can block the ureter, leading to pain, infection, or hydronephrosis.
Urinary Tract Infection (UTI): Bacteria released from fragmented stones can cause infections, which may progress to pyelonephritis (kidney infection) or sepsis.
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