Extracorporeal Shock Wave Lithotripsy

in a Nutshell
Christian Chaussy, Geert Tailly, Bernd Forssmann, Christian
Bohris, Andreas Lutz, Martine Tailly-Cusse, Thomas Tailly

Edited by Christian Chaussy and Geert Tailly

Extracorporeal Shock Wave Lithotripsy

in a Nutshell
Christian Chaussy
Geert Tailly
Bernd Forssmann
Christian Bohris
Andreas Lutz
Martine Tailly-Cusse
Thomas Tailly

Christian Chaussy
Prof. of Urology
University of Regensburg, Germany
cgchaussy@gmail.com
Geert G. Tailly, MD, FEBU
Head of the Department of Urology
AZ Klina, Brasschaat, Belgium
geert.tailly@klina.be
Bernd Forssmann, Dr.
Herrsching, Germany
Christian Bohris, Dr.
Project Leader, Dornier MedTech Systems GmbH,
Wessling, Germany
Andreas Lutz, Dr.
Program Manager, Dornier MedTech Systems GmbH,
Wessling, Germany
Martine Tailly-Cusse
Specialty nurse Endourology & ESWL
AZ Klina, Brasschaat, Belgium
Thomas Tailly, MD
Department of Urology, UZ KU Leuven, Belgium

Dornier MedTech Europe GmbH

Published by
Dornier MedTech Europe GmbH
Argelsrieder Feld 7
82234 Wessling
Germany
http://www.dornier.com
Printed by
Dinauer GmbH, Munich, Germany
4th edition, 2014

Contents
1 Introduction

2
2.1
2.2
2.3
2.4

Lithotripter design
Shock wave generator
Localization system
Patient positioning
Integrated endourology concept

3
3.1

Basics of shock wave physics

13
Shock wave generation
14
14
3.1.1 Electromagnetic
3.1.2 Electrohydraulic
14
3.1.3 Piezoelectric
14
Shock wave parameters
15
3.2.1 Pressure P+
15
16
3.2.2 Focus size
3.2.3 Penetration depth
16
3.2.4 Effective energy E12mm 17
3.2.5 Energy flux density
17
Energy dose concept
18
Stone breaking mechanisms
19
3.4.1 Hopkinson effect
19
3.4.2 Shear forces
20
3.4.3 Squeezing effect
20
3.4.4 Cavitation
21
Tissue effects
22

3.2

3.3
3.4

3.5

9
9
10
10
11

4 Indications
4.1 Renal stone treatment
4.1.1 General recommendation
4.1.2 Special recommendation for lower pole stones
4.2 Ureteral stones
4.3 Special indications
4.3.1 Paediatric urolithiasis
4.3.2 Obesity
4.3.3 Renal anomalies
4.4 Stone composition

23
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23
23
24
24
25
25
26
26

5 Contraindications

27

VI
Contents
6
How to perform ESWL?
6.1 Device preparation
6.2 Pain management
6.3 Patient preparation
6.4 Positioning
6.5 Stone targeting
6.5.1 X-ray guided ESWL
6.5.2 Ultrasound guided ESWL
6.6 Coupling
6.7 Shock wave application treatment parameters
6.7.1 Kidney stones
6.7.2 Ureteral stones
6.8 Paediatric urolithiasis
6.8.1 Anesthesia
6.8.2 Paediatric positioning aid
6.8.3 Lung protection
6.8.4 Imaging
6.8.5 Adapted shock wave parameters

29
29
30
31
32
33
34
35
38
40
40
42
42
42
43
43
43
44

7 Follow-up
7.1 Stone clearance
7.2 Stone analysis prevention of new stone formation
7.3 Complications
7.3.1 Subcapsular haematoma
7.3.2 Septicaemia
7.4 Long-term complications

45
45
46
46
46
47
48

8 Summary

48

9 Literature

49

1 Introduction
Following extensive research that started as early as in 1974, the first
extracorporeal shockwave lithotripsy (ESWL) treatment of a human was
performed on February 07, 1980 by Christian Chaussy, Dieter Jocham and
Bernd Forssmann using a prototype Dornier HM1 (Dornier Human Model1,
see Fig. 1-1) lithotripter [1]. The first serial Dornier HM3 (Dornier Human
Model 3) was installed in 1983 at the Katharinen Hospital in Stuttgart and in
March 1984 the first Dornier HM3 in the US was installed at the Methodist
Hospital in Indianapolis. The results with this new treatment modality were
so successful, that it thoroughly revolutionized modern stone management.
A rapid expansion of indications encompassing urinary stones of all sizes at
all levels of the urinary tract made ESWL the treatment of choice for almost
any urolithiasis.

Fig. 1-1: HM1 at the Munich University Hospital Grosshadern

1 Introduction

Primarily due to the high capital investment for a Dornier HM3 ESWL
originally remained the privilege of high volume stone centers with urologists
heavily trained in the practice of ESWL. With the introduction of less
expensive second and third generation lithotripters the practice of ESWL
became available to more and also smaller centers. This rapid propagation
of extracorporeal shockwave lithotripsy in ever smaller centers inevitably
resulted in dilution of experience and poorer results with ESWL. As the newer
lithotripters also proved easier to operate than the Dornier HM3, they were
considered plug and play and proper training in ESWL more often than not
was neglected leading to a further deterioration in results. As a consequence
the pendulum swung in favour of endoscopic techniques (URS, RIRS, PNL).
Although these techniques demand a high level of skill and expertise, these
were and still are provided in extensive and intensive training programs. This
is in sharp contrast to the often substandard training in ESWL, still the least
invasive treatment modality for any urinary stone. With proper equipment, an
understanding of the basic physics of shock waves and adequate training in
the safe application of shock wave energy, results are excellent with minimal
complications. In order to achieve optimal treatment results with ESWL,
an understanding of the underlying physical mechanisms and a knowledge
of the necessary treatment protocols are therefore essential. The purpose of
this brochure is to inform the user about the physical principles behind the
technology and to offer practical guidance on performing ESWL.

2 Lithotripter design
All lithotripters basically consist of three components: a shock wave generating
system, a localization system for identifying and localizing the stone and a
positioning system used to position the stone in the shock wave focus, where
the shock wave intensity is the highest. When the three components are used
in the right combination, the stone can be fragmented. Next to these three
essential systems, additional components for controlling, monitoring and
documentation (See Fig. 2-1) are incorporated in most models.
2.1 Shock wave generator
The shock wave generator, the most important component of any lithotripter,
generates the shock waves and aims them at the focus by means of a focussing
unit, such as a lens. Water is necessary to efficiently transfer the shock waves
into the patient as it has acoustic properties similar to those of tissue. In the
HM3, coupling between the generator and the tissue is achieved directly by
means of a water bath in which the patient is placed. This coupling is ideal
because there are no disturbing structures to inhibit the propagation of shock
waves. In the new units, the shock waves are transferred into the patient via
a coupling cushion. For ESWL to be successful the coupling must be lossfree. Shock wave energy is a key parameter in stone disintegration, while
energy flux density relates to the cause of renal side effects. Therefore, the
new systems are optimized for high energy in order to deliver the maximum
level of energy to the stone with minimal tissue trauma. The penetration
depths have been extended to 17 cm, which makes it possible to treat obese
patients. Today, most lithotripters are equipped with electromagnetic shock
wave systems (detailed information is provided in chapter 3).

10

2.2 Localization system

2.2 Localization system

Precise three-dimensional localization of the stone is essential for successful

ESWL. Fluoroscopy is the preferred method for locating radiopaque stones in
the upper urinary tract and is easily learned. However, it has the disadvantage
that continuous observation is not possible because of the associated radiation
exposure. Therefore, fragmentation cannot be monitored continuously. In the
case of radio-lucent stones, additional measures, such as the use of contrast
agents, are necessary. The fluoroscopy is performed using an isocentric
C-arm containing a high-powered tube and the imaging system, such as a
flat-panel detector. This C-arm can be pivoted longitudinally or orbitally
around the shock wave focus in order to view the stone in two planes. The
position of the stone can be accurately determined in three dimensions using
this information.
Ultrasound is a method that allows the stones to be localized without ionizing
radiation, regardless of their composition. The position of the stone in
relation to the focus can be monitored and evaluated continuously. However,
ultrasound is only satisfactory with stones located in the kidney and in the
proximal and distal area of the ureter. It requires a relatively long training
period in order to achieve the experience that is needed for successful
ultrasound guided ESWL. Both imaging methods can be used simultaneously
in most modern lithotripters. In outline localization, the ultrasonic transducer
can be moved isocentrically about the focal point in order to set the optimal
window for the image. When the ultrasonic transducer is localized in-line, it
is located within the shock wave generator along the shock wave propagation
axis.
2.3 Patient positioning
In order to achieve sufficient disintegration, the stone must first be positioned
precisely in the shock wave focus. This is accomplished by using an x-raytransparent table on which the patient can be moved in all spatial axes. The
table contains openings that make it possible to couple the shock wave
generator to the patient.

2 Lithotripter design

11

Fig. 2-1: Modern urological workstation for ESWL and endourology (Dornier Gemini).
Shock wave unit (a), patient positioning system (b), X-ray localization system with C-arm (c),
Flat Panel Detector (FPD) (d) and X-ray tube (e), isocentric ultrasonic localization arm (f).

2.4 Integrated endourology concept

Modern stone management is based on a judicious combination and
integration of ESWL and endoscopic techniques: the Integrated Endourology
Concept. Therefore, modern lithotripters are designed as multifunctional
urological workstations that provide optimal conditions for both ESWL and
endourolgical procedures, such as URS, PNL, RIRS [2].

12

13

3 Basics of shock wave physics

Shock waves are acoustic waves. These waves consist of pressure and density
variations, which propagate at medium-specific velocities in media like water
and soft tissue as well as in solid bodies such as bones and metals.
In the simplest case, an acoustic wave is a periodic sinusoidal oscillation
(See Fig. 3-1).

Fig. 3-1: Schematic illustration of a longitudinal wave. The curve represents pressure or
density as a function of space. In a homogeneous medium the waves produce areas of periodic
compression and decompression. This is illustrated by the distribution of volume elements
showing dense and expanded regions.

When the oscillation is limited to a short duration comprising only a few

signal periods, it is called an acoustic pulse. Typical examples are diagnostic
ultrasound pulses.
Shock waves are very short acoustic pulses with very short rise times and a
high peak pressure.
For details on shock wave physics we recommend literature [3, 4].

14

3.1 Shock wave generation

3.1 Shock wave generation

Fig. 3-2: Principles of shock wave generators used in lithotripters (See text for description).
Left: Electro-Magnetic Shock wave Emitter (EMSE). Centre: Electrohydraulic shock wave
emitter. Right: Piezoelectric shock wave emitter.

3.1.1 Electromagnetic
The main component of an electromagnetic shock wave source is the ElectroMagnetic Shock wave Emitter (EMSE). The EMSE is driven by a high voltage
electric pulse that causes a rapid movement of the EMSEs membrane. This
rapid forward movement of the membrane creates a planar acoustic pulse
that is focused by an acoustic lens and transmitted to the patient through a
water-filled bellow.
3.1.2 Electrohydraulic
The main components of an electrohydraulic shock wave generator are the
electrode, which is also referred to as spark plug, and an ellipsoidal reflector.
The underwater spark gap discharge between the tips of the electrode causes
rapid local vaporization to occur in the water, which generates a high-amplitude
pressure pulse. To focus the initial radial wave, the electrode is located at the
focal point F1 of the ellipsoidal reflector. The shock wave is reflected by the
walls of the ellipsoid creating a focused shock wave in the focal zone F2.
3.1.3 Piezoelectric
Piezoelectric crystals expand rapidly when a high voltage electrical pulse is
applied to them. In piezoelectric shock wave generators, a large number of
piezoelectric crystals are synchronously excited, which creates a pressure
wave. Focusing is accomplished by arranging the piezoelectric crystals in a
spherical shape.

3 Basics of shock wave physics

15

3.2 Shock wave parameters

Fig. 3-3 and Fig. 3-4 illustrate the pressure signal in the focus of a shock wave
source. A shock wave is characterized by a very short rise time and short
pulse duration followed by a negative pressure phase. A set of parameters is
used to characterize a shock wave field.
3.2.1 Pressure P+
The maximum positive pressure is referred to as the positive peak pressure
P+ and is measured in MPa. Typically the focal value varies between 30 and
120 MPa. The rise time ranges between 1 and 200 ns. The minimum negative
pressure of the succeeding tensile phase is typically between -4 MPa and
-15MPa.

Fig. 3-3: Shock wave pressure pulse as function of time measured in the shock wave focal
zone F2.

16

3.2 Shock wave parameters

3.2.2 Focus size

The focus size is the Full Width at Half Maximum (FWHM) of the spatial
pressure distribution, also referred to as the -6 dB focus. The FWHM is
the width of the spatial pressure distribution at 50% of the peak pressure
(maximum of the curve). While this definition makes sense in physical terms,
considering it as the precise region at which stone disintegration is possible
can be misleading. From Fig. 3-4 it is obvious that significant pressure is still
present outside of the area defined by the focus size and that this pressure may
also contribute to stone disintegration.

Fig. 3-4: Curve illustrating the focus width (showing the -6 dB focus).

3.2.3 Penetration depth

This is the distance between the coupling surface and the focal spot of the
shock waves. The maximum penetration depth of lithotripters may vary.

3 Basics of shock wave physics

17

3.2.4 Effective energy E12mm

The effective energy E12mm (also referred to as Eeff) is a measure of the
energy per shock wave pulse in mJ that is transmitted through a circular area
of 12 mm in diameter within the focus spot. (See Fig. 3-5).

Fig. 3-5: Effective Energy E12mm.

The blue circle represents the diameter of the cross section of a typical stone. The green arrow
indicates the direction in which the shock wave travels. The total energy that passes through
the circle is referred to as the effective energy.

3.2.5 Energy flux density

The energy flux density ED is a measure of the energy concentration. It is
measured in mJ/mm2, i.e. energy per unit area.
In focussed shock wave systems, the energy remains the same as the wave
travels through a decreasing area on its way to the focal zone. Thus the energy
flux density increases and reaches its maximum at the focus (See Fig. 3-6).

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3.3 Energy dose concept

Fig. 3-6: Energy flux density.

The lower part of the illustration shows the lens (light red) of an EMSE system. The yellow
cone indicates the shock wave path. Green circles indicate the area the shock wave passes
through while travelling from the lens surface to the focal region. As the distance from the lens
increases, the area traversed by the shock wave gets smaller. Conservation of energy dictates
that the energy density must increase and reach its maximum at the focal point.

3.3 Energy dose concept

With each shock wave pulse a certain amount of effective energy Eeff is
applied. The energy dose then is the sum of applied effective energy for all
shock wave pulses during the course of a stone treatment.
Assuming that ramping is applied, the treatment starts at low energy level
with Eeff1. After a given number of pulses n1, the energy is increased in steps,
e.g. with n2 pulses of Eeff2, n3 pulses of Eeff3, a.s.o. Then energy dose is
calculated as follows:
Edose(12mm) = n1 Eeff1 + n2 Eeff2 + n3 Eeff3 +
Within a certain acceptable range the same effect on treatment outcome and
side effects can be expected provided that the applied energy dose is the same.

3 Basics of shock wave physics

19

3.4 Stone breaking mechanisms

Stone-breaking mechanisms have been investigated since the early days of
medical shock wave research. Four major effects that contribute to stone
disintegration have been identified:
Hopkinson effect
Shear forces
Quasistatic squeezing
Cavitation
Cavitation mainly contributes to the surface erosion of stones and fragments.
Its other effects contribute to the cracking that breaks the stone into pieces.
The Hopkinson effect, shear forces and quasistatic squeezing are caused by
the differences in the speed of sound in tissue and in stones. Some basic
information about the Hopkinson effect, shear forces and cavitation is
provided in the following subsections.
3.4.1 Hopkinson effect
The Hopkinson effect occurs because of a reflection of the shock wave at
the rear surface of the stone. It causes the stone to break into large pieces. In
analogy to light, acoustic waves are reflected and diffracted at the transition
from one medium to another. When a shock wave is passing through a stone,
it is partially reflected at the stone front and rear surfaces. However, at the
rear surface of the stone, i.e. the transition from the more dense to the less
dense medium, the reflected pulse component is associated with a reversal of
the peak amplitude of the shock wave. Therefore, a high amplitude negative
pressure wave travels in the direction opposite to that of the original wave,
inducing high tensile forces in the stone. (See Fig. 3-7 for illustration).

20

3.4 Stone breaking mechanisms

3
Fig. 3-7: Hopkinson effect.
The grey circle represents a stone. The incoming shock wave (1), travelling from left to right,
is split at the front stone surface into a reflected (2) and transmitted (3) component. At the rear
stone surface, the shock wave (3) is again partially reflected, resulting in a high-amplitude
negative pressure wave (4).

3.4.2 Shear forces

Shear forces are another effect caused by the different speeds of sound in stone
and tissue. Inside the stone a shock wave travels faster than in surrounding
tissue. A convergent wave is produced inside the stone, but outside the stone
a divergent wave is created. This creates strong tensile forces in the stone,
which contribute to crack formation within the stone.
3.4.3 Squeezing effect
Quasistatic squeezing was postulated by Eisenmenger in 2001. Quasistatic
squeezing is believed to occur as an effect of the faster speed of sound
inside the stone versus that outside the stone. When the shock wave enters
the stone it moves faster than the wave outside the stone. This would create
circumferential compressive forces outside the stone and tensile stress inside
the stone, which might contribute to stone fragmentation.

3 Basics of shock wave physics

21

3.4.4 Cavitation
Every shock wave pulse has a trailing negative pressure phase. Its tensile
forces create microbubbles in liquids like urine or blood. These cavitation
bubbles are unstable and collapse with a rapid implosion (See Fig. 3-8).
The associated liquid jets cause a pitting of adjacent structures like stones.
Cavitation increases with shock wave frequency and intensity.

Fig. 3-8: Image sequence of a solid target exposed to a shock wave propagating from left to
right. The second frame shows individual cavitation bubbles within the water and a bubble
cluster on the face of the target. Whereas the single cavitation bubbles collapse quite early,
the cluster grows further until it collapses, revealing an intermediate mushroom-like shape
(680s).

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3.5 Tissue effects

3.5 Tissue effects

Basically all effects that contribute to stone disintegration may also contribute
to tissue damage. Two major effects are discussed in this section.

Cavitation, which may occur for example inside blood vessels or in the urinefilled collecting system of the kidney, can cause vessel and parenchymal
damage resulting in bleeding and haematomas. Recent literature shows that
the risk of cavitation-induced renal damage increases with high shock wave
frequencies and excessive intensities. When a shock wave passes through
tissue it may strike cavitation bubbles created by a previous shock wave
pulse. This has two effects:
The shock wave energy is partly blocked by the cavitation bubbles so
that the stone is exposed to reduced shock wave energy (SeeFig.3-9).
The shock wave interfering with cavitation bubbles can create forced
bubble collapse, which increases the risk of side effects.
As a result, stone disintegration is impaired and the risk of side effects is
increased.
Gas-filled organs, particularly the lung, are at high risk of severe tissue
damage when exposed to shock waves. When shock waves reach the tissue/
gas interface, they are reflected, and the reflected shock wave is reversed
in polarity (See also Hopkinson Effect). The resulting tensile forces at the
interface can cause organ rupture (See Fig. 3-9).

Fig. 3-9: Left: Blocking effect of a cavitation bubble field. Cavitation bubbles within the shock
wave path cause an attenuation of the shock wave. Compared to the undisturbed situation, the
shock wave pressure amplitudes are lowered (See blue curves). Right: Reflection at a tissue/
air interface. The incoming shock wave (blue) is fully reflected. Due to the transition from the
positive pulse into a negative pulse this region is exposed to strong tensile forces.

23

4 Indications
ESWL is a non-invasive treatment modality for stones in the entire urinary
tract. With modern lithotripters all portions of the urinary tract are accessible.
Major advantages of ESWL over other procedures are: It is the least invasive
treatment modality for urolithiasis. In the majority of cases it does not require
anaesthesia. Generally, analgosedation is used for pain management. ESWL
is very safe with a very low risk of side effects and serious complications.
Despite ESWLs potential as a universal method for stone treatment, selecting
the right patients and stone locations is a prerequisite for success. For patients
with normal renal anatomy and stones located in the renal pelvis and the
upper and middle calyx up to a size of 20 mm, shock wave lithotripsy is the
preferred treatment modality.
4.1 Renal stone treatment
4.1.1 General recommendation
With the introduction of the Dornier HM3 in the 1980s, ESWL became the
treatment of choice for kidney stones. This is reflected in current EAU and
AUA Guidelines [5, 6]. For the removal of radiopaque (calcium) and cystine
stones with a maximum diameter of 20 mm, ESWL is recommended as the
first-line therapy.
4.1.2 Special recommendation for lower pole stones
For lower calyx stones there is an ongoing debate about the efficacy of ESWL.
Several clinical trials have shown that the stone-free rate after ESWL of lower
calyx stones is worse than for stones in other parts of the renal system. In 1992,
Sampaio et al. already reported that an acute lower pole infundibulopelvic
angle, a narrow infundibular width, and a long infundibular length may
predict a decreased stone-free rate. However, Danuser et al. (2007) could not
find any significant anatomical influence on the clearance of disintegrated
stones from the lower calyx. In the lower pole study 1 by Albala et al. (2001)
a cumulative stone-free rate of 37% for ESWL versus 95% for percutaneous
nephrostolithotomy (PNL) was reported.

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4.2 Ureteral stones

On the other hand, Obek et al. (2001) and Riedler et al. (2003) reported
cumulative stone-free rates of 63% and 65.5% for lower pole calculi treated
with second- and third-generation lithotripters. Obek could not find significant
differences in treatment outcomes for stones in lower, middle or upper calices.
Pearle et al. (2005) compared ESWL and ureteroscopic lithotripsy (URS) for
treatment of small lower pole stones. In a randomized multicenter study they
could not find a significant difference in stone-free rates. ESWL, however,
was associated with greater patient acceptance and shorter convalescence.

Modern lithotripters with electromagnetic or piezoelectric shock wave

sources may result in stone-free rates that are superior to the 37% stonefree rate reported in the lower pole study 1 if higher retreatment rates are
accepted. Several studies have demonstrated that the most important factor
influencing the treatment outcome is stone size. Therefore, ESWL should be
the preferred treatment modality for lower pole renal stones up to a diameter
of 10 mm. For lower pole stones 11-20 mm in size ESWL outcome is inferior
to endoscopic stone removal. However, ESWL might be an option because of
its non-invasive nature and the low risk of complications.
Though clinical trials indicate that the anatomy of the lower pole collecting
system might play a role in stone clearance and thus stone-free rate, it remains
unclear which parameter is the best predictor for treatment success.
4.2 Ureteral stones
While URS has gained significant importance for the management of
ureteral stones, the advantage of ESWL for stones smaller than 10 mm is
its non-invasiveness, avoidance of general or regional anaesthesia, and the
low incidence of significant complications. In a series of 598 ureteral stone
patients treated with ESWL, Tiselius et al. (2008) achieved a stone-free rate
of more than 97% with an average number of 1.3 treatment sessions, a result
that is comparable to the outcome of endoscopic stone removal.
4.3 Special indications
Special attention is needed in paediatric and obese patients as well as in
patients with renal abnormalities.

4 Indications

25

4.3.1 Paediatric urolithiasis

For paediatric patients ESWL is a safe and effective treatment method. In
spite of its small diameter, the ureter has a high transport capacity for stone
fragments, which explains why stone-free rates for children are superior to
those in adults. There is no evidence that ESWL causes irreversible functional
or morphological changes.
Therefore, ESWL remains the treatment of choice for stones in children.
However, it is important to adapt the ESWL protocol to the smaller
anatomical dimensions. The following recommendations may be helpful:
A paediatric positioning device should be used to assure safe patient
positioning.
Lungs have to be protected against shock wave exposure to avoid
tissue damage.
Radiation exposure should be minimized; if possible, ultrasound
localization should be used.
Shock wave energy should be as low as possible.
See section 6.8 for details.
4.3.2 Obesity
Overall, ESWL is challenging in morbidly obese patients due to difficulties
with stone visualization and positioning. The coincidence of obesity with
large and hard stones is likely to result in poor stone clearance. However, in
experienced hands, ESWL is a reasonable therapy option for obese patients
with stones < 20 mm. Shock wave devices having a deeper penetration depth
can also be expected to improve outcomes.
Pareek et al. (2005) found that a skin-to-stone-distance (SSD) exceeding
10cm was associated with ESWL treatment failure. In contrast, Muoz et
al. (2003) reported a 3-months stone-free rate of 72% and concluded that
lithotripter properties and operator experience were the secret of success.
Similar results were found by Mezentsev et al. (2005). In morbidly obese
patients (BMI > 40 kg/m) an overall 3-months stone-free rate after ESWL of
73% was achieved.

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4.4 Stone composition

In obese patients the main problem is the proper targeting and focussing
of the stones. Therefore lithotripters with high resolution imaging systems,
versatile coupling of the therapy head above and under table, and above all
a SW-source with a penetration depth of up to 17 cm are expected to yield
better results.
Experienced operators also use simple positioning tricks to improve targeting
in obese patients.
4.3.3 Renal anomalies

Renal anomalies are often associated with an impaired drainage and

consequently a reduced clearance of stone fragments. In their review Sheir
et al. (2003) reported a 72.2% stone-free rate after 3 months in patients
with anomalous kidneys. Turna et al. (2007) concluded from a retrospective
analysis of management of calyceal diverticular stones that ESWL is suitable
to render most patients symptom-free with minimal complications despite a
low stonefree rate of 21%.
For patients with renal anomalies the treatment procedure should be chosen
individually considering kidney function and location, stone size, availability
of appropriate equipment and expertise of the performing urologist and even
accepting multiple treatment.
4.4 Stone composition
It is known that stone composition and internal stone structure are important
characteristics that determine the hardness of urinary calculi and therefore the
responsiveness to shock waves. There have been numerous attempts to use
non-contrast computed tomography (NCCT) to predict ESWL success rate
based on Hounsfield unit (HU) measurements. There is no consensus, though,
as to which HU values will predict ESWL success or failure.
Even hard concretions like brushite and cystine stones are not a contraindication
for ESWL if the stone burden is small and the patient prefers a non-invasive
therapy.

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5 Contraindications
Since ESWL was first introduced in 1980, its range of indications rapidly
expanded to include most stones at all levels of the urinary tract. International
EUA / AUA Guidelines [5, 6] consider ESWL to be the primary treatment
modality for most stone types.
The following conditions are absolute contraindications, and patients who
have them should be considered for alternative treatment modalities:
Pregnancy
Untreated coagulation abnormalities
Continued use of anticoagulants prior to ESWL
Pulmonary tissue in the shock wave path
Tumour in the shock wave path
Aneurysms in the shock wave path
Pathological changes in the shock wave path
Active pyelonephritis
Pregnancy remains an absolute contraindication due to the possible use of
fluoroscopy but above all due to the possible adverse effects of the shock
wave on the foetus.
Given that untreated coagulation abnormalities dramatically increase the
risk of large perirenal and subcapsular haematomas, they are an absolute
contraindication for ESWL. The influence of medications containing
acetylsalicylic acid is under discussion. Most of the available publications
recommend a break of four to seven days.
Untreated hypertension is considered a relative contraindication and should
be regulated before treatment.

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6 How to perform ESWL?

This section provides general practical guidelines for ESWL. The order of
the various activities device preparation, pain therapy, patient preparation,
positioning, stone targeting, coupling and shock wave application is based
on the workflow of the ESWL treatment. This will facilitate implementation
of the clinical process. All of these activities contribute in one way or another
to good stone disintegration combined with low tissue injury and patient
safety. This chapter is the result of long lasting experience of the authors
and others [7-10]. Most points are also applicable when treating children.
However, special aspects of paediatric ESWL are summarized in a separate
section.
6.1 Device preparation
When treating a patient, it is important to be sure that the lithotripter is in
proper working order. The alignment of the imaging systems (X-ray and
ultrasound) is especially critical and must be checked daily after the system is
initially started. The target mark superimposed on the image must not deviate
from the actual lithotripter focus. This would cause incorrect stone alignment
and thus reduced disintegration and possible tissue injury. Manufacturers
provide special test equipment and phantoms for these tests (See lithotripter
user manual). The images obtained with the tests should be stored or printed
out in order to document correct alignment.
The coupling cushion and patient table must be clean in order to avoid crosscontaminations between patients.
The lithotripter coupling cushion needs to be checked for possible air bubble
inclusions. Any air that is present needs to be evacuated as described in the
user manual.
Check the status of the lithotripter.
Check the alignment of the ultrasound and
X-ray imaging systems.

30

6.2 Pain management

6.2 Pain management

ESWL is a potentially painful procedure and sufficient analgesia is mandatory
for good treatment results. Pain arising during ESWL is a multifactorial event.
On the one hand cutaneous superficial skin nociceptors are stimulated, on
the other hand visceral nociceptors in the renal capsule, periosteum, pleura,
peritoneum and muscles are involved.
Patients who experience pain tend to move voluntarily or involuntarily and
show increased respiratory motion. Consequently, the target moves out of the
shock wave focus and the hit rate decreases. This correlates with impaired
stone fragmentation and a subsequent impaired stone clearance. Additionally,
pain can prevent the planned shock wave dose from being applied, i.e. the
shock wave energy level and the number of pulses. It may also cause a rise in
blood pressure, which may lead to more complications like a higher rate of
kidney haematomas.
The pain is highly dependent on the shock wave energy level applied. It is
also increased if the skin is close to the shock wave focus, as is the case
in thin patients. There are also patient-related factors like age, gender and
body habitus. In particular, young female patients and anxious or depressed
patients experience more pain during ESWL.

In routine clinical practice, there is a rather broad spectrum of protocols for

pain treatment in ESWL. They may range between the extremes of general
anaesthesia and simple oral medication.
General anaesthesia for ESWL treatment is an option. General anaesthesia is
safe and morbidity is low, with the obvious exception of high-risk patients.
It is associated with a higher overall cost and a longer overall procedure time
due to the need for post-operative recovery. It may entail practical problems,
in particular with outpatient procedures. However, in young children or in
extremely anxious patients, general anaesthesia is the method of choice.
Intravenous analgosedation is possibly the most widely used protocol
for ESWL treatment. It is suitable for most patients and overall costs are
significantly lower than general anaesthesia. The administration of alfentanil
with or without propofol, which can be intermittently repeated when
necessary, has a long history of effective use.

6 How to perform ESWL?

31

For adaptive dosage during the treatment, the use of a patient-controlled

medication pump is a well-proven option. ECG, blood pressure and oxygen
monitoring are obligatory when administering opioids. Possible side effects
are nausea, vomiting and respiratory depression.
Effective pain management is mandatory for good treatment
results.
The need for pain treatment depends on shock wave energy
level, skin-to-stone distance and patient-related factors.
Intravenous analgosedation, which can be intermittently
repeated when necessary, is the most common therapy to
manage ESWL-induced pain.

6.3 Patient preparation

Any necessary monitoring sensors, such as ECG electrodes, should be
attached to the patient before stone targeting in order to avoid delays once the
stone has been located and positioned in the shock wave focus. Likewise, the
monitors which are required for the specific protocol and patient-related risks
should be started. RR blood pressure should be monitored, since increasing
blood pressure (RR > 160/95 mm Hg) caused by pain, stress or insufficient
control of pre-existing hypertension may increase the risk of inducing kidney
haematomas.
The complete urinary tract needs to be examined immediately prior to ESWL
in order to confirm the actual position of the stone and compare the findings
with pre-treatment diagnosis. The concretion may have changed its position,
which may require an updated treatment strategy.
Briefly but fully explaining the treatment procedure to the patient can
significantly improve the patients relaxation and cooperation.
Start the monitoring instruments (ECG, O2 saturation, RR).
Urinary tract examination immediately before ESWL.
Confirm the position of the stone.

32

6.4 Positioning

6.4 Positioning
Patient movements during shock wave application and respiration cause
the stone to move out of the shock wave focus and are detrimental to stone
disintegration. Therefore, a stable patient position is essential for good disinte
gration results. Since the treatment typically takes about 30 to 45 minutes,
the patient requires a comfortable position. A neck roll, knee roll, a wedge
or arm rests are accessories that help to stabilize the patients position. If
possible, the supine patient position is preferred, since it is more comfortable
for the patient and offers better access to the patient for the anaesthetist when
doing general anaesthesia.
With a lithotripter offering both under-table and over-table therapy head
positions, the patient can be treated in a supine position for all stone locations
(See Fig. 6-1). Stones in the kidney and upper ureters down to the iliac crest
are treated with the therapy head coupled in the dorsal or dorsolateral location.
Since the iliac crest blocks the shock waves, stones in the distal ureter require
a ventral or ventrolateral therapy head position. If the lithotripter only permits
under-table therapy head positions, the patient needs to be positioned prone
for ureteral stones distal to the iliac crest.

Fig. 6-1: Dornier Gemini lithotripter. Left: Set-up for stone treatment in left kidney. The
therapy head (indicated by an arrow) is coupled from dorsolateral. Right: Setup for stone
treatment in right lower ureter. The therapy head is coupled from the ventrolateral position.

It is advisable to pre-position the patient in such a way that the stone is already
in close proximity to the focus. This will avoid time-consuming moves later
in the procedure.

6 How to perform ESWL?

33

Abdominal compression by a belt reduces respiration-induced stone movements

and thus increases the efficacy of the ESWL treatment. The belt should press
on the abdomen and not on the thorax.
A stable patient position is essential.
Stones in the kidney and proximal ureter down to the iliac crest
therapy head dorsal.
Stones in the distal ureter therapy head ventral.
Abdominal compression suppresses respiratory motion.

6.5 Stone targeting

Most modern lithotripters offer both X-ray and B-mode ultrasound for stone
visualization (See Fig. 6-2).

Fig. 6-2: Left: Native X-ray image with radiopaque stone within the crosshairs. The
lithotripter coupling cushion of the therapy head is shading the right side. Right: Ultrasound
image of a kidney stone. Within the crosshairs it is displayed by its bright stone reflection. It is
accompanied by an acoustic shadow behind the reflection.

Calcium oxalate and calcium phosphate stones are radiopaque and have a
high density. Struvite, mixed and cystine stones have a lower density but are
still visible on native X-ray images. Uric acid stones are radio-translucent and
can only indirectly be visualized by X-ray using a contrast agent.

34

6.5 Stone targeting

With ultrasound stones are visualized by a bright echo marking the stone
surface regardless of the stones chemical composition. The characteristic
acoustic shadow behind the bright stone reflection distinguishes a stone
from other bright structures such as blood vessels or a stent. Ultrasound is
unsuitable for visualization of ureteral stones unless they are very proximal
in a dilated system or pre-vesical where the bladder serves as an acoustic
window. In the middle section of the ureter, ultrasound scanning cannot be
used to locate stones, since anatomical landmarks are missing and intestinal
gas and bone interfere (See Fig. 6-3).

Fig. 6-3: Ultrasound imaging is appropriate for kidney stones, proximal and distal ureteral
stones.

6.5.1 X-ray guided ESWL

X-ray is the first-line modality for imaging in ESWL, especially in the United
States. In order to target the stone in three dimensions, the stone has to be
aligned in two different X-ray projection planes. If the patient is in supine
position, the stone is typically localized in the coronal plane by the vertical
C-arm position (PA projection). The stone is adjusted in the craniocaudal
(X-axis) and laterolateral axis (Y-axis). In the angled C-arm position (CC
projection), the stone is adjusted along the frontal axis (Z-axis). The targeting
of the stone is supported by software functions specific to the lithotripter
model (e.g. image-oriented movement, auto-positioning).

6 How to perform ESWL?

35

Initially, the full image area is used to confirm the position of the stone taking
into account visible landmarks like the spine and ribs. Once the stone has
been identified and is located in the shockwave focus, the imaged region
of interest has to be reduced in size by closing the X-ray collimator. This
effectively reduces the patients radiation exposure.
Since the target may get out of the shock wave focus due to patient movement
or stone movement within the patient, stone positioning must be reconfirmed
at regular intervals. If there is an apparent patient movement, stone targeting
must be checked immediately after the patient has returned to a stable
position. Otherwise imaging may be repeated, for example: every 300-500
shock waves. Even though stone movements are more likely within the
coronal plane, imaging should not rely solely on the vertical C-arm position.
Especially in the beginning of the treatment and if the position was corrected
in the coronal plane, the ventrodorsal axis should be checked with the angled
C-arm position.
During ESWL treatment, the degree of stone disintegration may be assessed
by direct signs (cracks in the stone, visualisation of multiple fragments) or
indirect signs (loss of density, softening of the margins).
Target the stone in both image projection planes (PA and CC).
Stone targeting must be reconfirmed at regular intervals.
Reduce the image size for monitoring (reduction of radiation
exposure).

6.5.2 Ultrasound guided ESWL

Even though most urologists routinely use ultrasound imaging for
examinations of the urinary tract and for stone diagnosis, ultrasound guided
ESWL is considered more difficult. This may be explained by the fact that
the transducer is typically located either within the bulky therapy head or
fixed in a holder. Thus, the scanning of the patient is quite different from the
normal procedure in ultrasound examinations where the ultrasound scanner
can be moved freely over the target organ. Instead of making small manual
angular movements, the operator now has to move the patient by means of
table movements.

36

6.5 Stone targeting

Therefore, it can sometimes prove more difficult to find a good acoustic

window in rib gaps. Consequently, image quality is often inferior to standard
freehand scanning. With inline ultrasound, image quality may suffer from
additional artefacts caused by the coupling cushion and air bubbles in the
coupling interface.
However, ultrasound guided ESWL is a procedure which can be learnt with
some training and is not more demanding than other standard procedures
performed by urologists. The use of ultrasound has some relevant advantages
over X-ray guidance:
There is no radiation exposure to the patient or personnel. Therefore,
ultrasound can be used in continuous mode (real time) during the
complete session.
Real-time imaging allows better monitoring of the entire
procedure: movements of the targeted stone or the patient are
detected immediately.
Smaller renal stones might be easier to detect.
Uric acid stones can be visualized without the use of a contrast agent.
During shock wave application a stone which is hit by shock waves
seems to slightly jump, which is also sometimes described as pixel
flickering. This may be used to monitor hits/misses.

With inline ultrasound it is also possible to check the acoustic path

of the shock waves, especially the coupling quality (See Fig. 6-4 and
section 6.6).
Given these advantages, we recommend that ultrasound be used whenever
possible.

6 How to perform ESWL?

37

Fig. 6-4: Ultrasound monitoring of the contact zone with an inline transducer.
Left: A bubble is revealed by its bright echo (white arrow) and posterior shadow (black arrows).
Right: Image after removal of the bubble by wiping the cushion.

Achieving prompt and reliable stone localization by ultrasound is highly

dependent on the actual lithotripter being used. However, we like to stress that
there are possible advantages to initial scanning with a freehand transducer.
In this way it is possible to confirm that the stone planned for treatment can
be adequately visualized by ultrasound. Also the suitable acoustic window
which could be used later by the outline or inline transducer may be selected.
A pre-positioning of the patient such that only minor corrections are needed
in the succeeding targeting is advisable.
Use ultrasound imaging whenever possible.
Pre-scanning with freehand ultrasound (-> selection of acoustic
window for imaging, pre-positioning of the patient).
Check for posterior stone shadow.

38

6.6 Coupling

6.6 Coupling
With most modern lithotripters, the shock waves are transmitted from the
shock wave source to the patient via a water-filled cushion. To achieve a good
transmission into the body, typically ultrasound gel is applied.
Various studies have shown that even a few air bubbles trapped in the gel
considerably reduce the effectiveness of the shock waves (See Fig. 6-5). In
particular, incomplete coupling or a cushion which does not fit snugly against
the body surface but has an air-filled wrinkle inevitably leads to ineffective
treatment.

6
Fig. 6-5: Reduction of disintegration capability by air trapped within the coupling zone. Results
from in vitro model stone tests (for details see Bohris et al. 2012). Test results are the number
of shock waves required for complete disintegration of the stone. Test was performed under
various coupling conditions. When 20% of the coupling area was blocked by air bubbles, about
three times the number of shock waves was needed as compared to the bubble-free condition.

Some tips help to obtain a bubble-free coupling and avoid poor coupling
conditions (See table).

6 How to perform ESWL?

39

Remove hair at the shock wave entry area.

Store the gel bottle head down and do not shake it before use.
A large opening instead of a small diameter nozzle should be
used when dispensing gel.
Apply a sufficient amount (3050 ml) of low viscous ultrasound
gel on the therapy head as a mound (See Fig. 6-6).
Contact between the cushion and the patient should be achieved
by inflating the bellow or slowly lowering the patient onto the
inflated bellow. Typically the gel spreads radially without air
entrapment.
Once good coupling is attained, the contact between cushion
and patient must not be lost during treatment. If contact is lost,
the coupling procedure needs to be restarted.
Coupling can be improved by manually wiping the cushion (See
Fig. 6-6). Wiping is recommended after decoupling or frequent
patient repositioning steps.
If available, employ inline ultrasound or surveillance video to
monitor coupling.

Fig. 6-6: Left: Applying gel to the cushion. Right: Improving coupling by manually wiping the
cushion. During this procedure the inflation pressure and patient position should be maintained
so that the contact between bellows and skin is not lost.

40

6.7 Shock wave application treatment parameters

If the lithotripter therapy head is equipped with an inline ultrasound unit, the
quality of coupling may be monitored (Fig. 6-4) and improved as needed.
Even more convenient is the use of a surveillance camera which is integrated
into the therapy head (See Fig. 6-7).

Fig. 6-7: Video monitoring of the coupling area. Left: Numerous bubbles (dark) are located
within the gel layer (bright). Right: Area after removal of the disturbances by wiping the
cushion.

6.7 Shock wave application treatment parameters

The aim of ESWL is to disintegrate a stone into fragments that can pass
through the urinary tract system spontaneously. The disintegration improves
as the shock wave energy dose, which is the total shock wave energy applied
during one treatment, increases (See section 3.3). The energy dose must be
sufficient to achieve adequate stone fragmentation and clearance so that the
need for further procedures (re-ESWL, URS, PNL) is reduced. On the other
hand, overtreatment must be avoided since the risk of side effects is also
directly related to energy dose.
6.7.1 Kidney stones
Within a certain range the accumulated shock wave dose may be applied
using different energy settings. If a lower energy is chosen, though, this must
be compensated by applying a larger number of shock waves. It is generally
recommended to adjust the total dose and energy level to the individual
patient (obesity, risk factors) and stone characteristics (stone size, chemical
composition). Patient risk factors that require a lower shock wave dose are:

6 How to perform ESWL?

41

Untreated hypertension
Diabetes mellitus
Age > 65 years
Impaired renal function, hydronephrosis
Paediatric patients
Renal tissue damage and resulting haematoma can be caused by cavitation
(See section 3.4.4). The tensile stress of the shock wave may induce small
vapour bubbles in the blood. These bubbles are not stable but collapse after a
sub-second lifetime. Both bubble expansion and collapse are accompanied by
forceful stress to the proximity of the bubble which can damage the capillary
walls.
The risk of inducing cavitation within the renal parenchyma increases with
the energy level used. Various recent publications have indicated that the
occurrence of cavitation is strongly related to the pulse repetition frequency.
Lowering the pulse repetition frequency (PRF) is thus an effective way to
avoid renal vascular damage. In addition, a slower PRF will also improve
stone disintegration, since a blocking effect by cavitation is avoided (See
section 3.5).
A pre-treatment (100-500 shock waves) at low energy levels is recommended
to activate a protective effect in the kidney. Animal studies have shown that
shock waves reduce the glomerular filtration rate and the renal plasma flow in
the area exposed to the shock waves and even in the contralateral kidney due
to induced vasoconstriction.
If ESWL is performed with intravenous analgesia, it is a common practice in
any event to increase the energy stepwise in order to adapt the patient to the
shock waves. Operators who apply ESWL under full anaesthesia and start
immediately with high-power shock wave levels should switch their strategy
to a gradual energy increase in order to achieve better results.

42

6.8 Paediatric urolithiasis

6.7.2 Ureteral stones

If the stone is located in the ureter instead of the kidney, the dose required
for complete stone disintegration is generally higher. On the other hand, a
somewhat higher energy level and shock wave frequency may be used if the
kidney is not within the shock wave path. If the kidney is within the shock
wave path, the same shock wave parameters as for kidney stones should be
employed. This is of importance when treating upper ureteral stones.
Adjust the shock wave parameters to the individual case.
A low shock wave repetition frequency provides less renal
vascular damage and better stone fragmentation. Use 60 shocks
per minute.
Activate vasoconstriction by a pre-treatment of low energy
shocks combined with ramping up the energy slowly.
When treating upper ureteral stones, check if the kidney is
within the shock wave path. Adjust shock wave parameters
accordingly.

6.8 Paediatric urolithiasis

This section addresses some aspects specific to ESWL in the paediatric

population [11]. Especially in this group the shock wave energy dose and
radiation dose must be adapted to avoid the risk of long-term adverse effects,
especially if patients need to undergo repeated ESWL. Also the smaller
anatomy requires some adaptations in the procedure and settings.
6.8.1 Anesthesia
Whereas ESWL can be administered without general anaesthesia to most
adults, this is different with children. The need differs considerably depending
on the age of the child and the shock wave energy applied. Older children
often tolerate ESWL under intravenous sedation, but with younger children
general anaesthesia is the first choice.

6 How to perform ESWL?

43

6.8.2 Paediatric positioning aid

The table cut-out may be too wide for the treatment of infants. Some manu
facturers provide special positioning aids like an acoustically transparent sheet
that supports the body as shown in Fig. 6-8. Bubblefree acoustic coupling
must be provided between the coupling cushion and the sheet and between
the sheet and the body.

Fig. 6-8: Positioning aid which supports the body at a table cut-out.

6.8.3 Lung protection

Because the lungs in children are in closer proximity to the kidneys, special
care needs to be taken to protect lung parenchyma from the shock waves,
particularly when treating upper pole stones. The lung needs to be shielded
with shock wave-absorbing materials, such as sheets of polystyrene or foam.
6.8.4 Imaging
Image quality in children is generally better due to the smaller penetration
depth. To avoid radiation exposure, ultrasound is the preferred imaging
modality. It also permits continuous and close monitoring (real-time imaging).

44

6.8 Paediatric urolithiasis

6.8.5 Adapted shock wave parameters

The necessary energy dose as defined by shock wave energy level and
number of shocks is generally lower in children than in adults. This may be
attributed to the smaller skin-to-stone distance and the good ability of the
paediatric ureters to pass stones. However, an adequate dose must be selected
by balancing safe stone clearance with avoiding auxilliary procedures which
are related with potential additional risks.
Paediatric positioning aid.
Lung protection for children (e.g. polystyrene between
the chest and coupling bellow).
Minimizing radiation exposure: preferably ultrasound
localization.
Adapt shock wave parameters.

45

7 Follow-up
Stone clearance is monitored in follow-up examinations. Success is verified,
or auxiliary procedures are specified. Even though severe complications
induced by ESWL are rare, subcapsular haematomas or septicaemia can lead
to life-threatening conditions. Such complications must be identified and
properly treated.
7.1 Stone clearance
After stone disintegration by ESWL, episodes of ureteral colic during passage
of fragments are common (8-10%). Renal colic should be dealt with lege
artis. In case of (rapid onset) massive pain, an ultrasound exam is indicated to
rule out renal haematoma (See section 7.3.1).
In the treatment of kidney stones, colicky pain may be reduced and obstruction
may be avoided by stenting. The insertion of a stent prior to ESWL is advised
when the largest stone diameter exceeds 20 mm. However, routine stenting,
especially in the case of ureteral stones, is not recommended [5].
Pharmacological facilitation of fragment passage or medical expulsion
therapy (MET) can be accomplished by administering -receptor antagonists.
Tamsulosin is the commonly used compound, but other -blocking agents
appear to be similarly effective. MET is not recommended for the paediatric
population due to the limited data for that group.
Mechanical percussion and inversion therapy may enhance passage of
fragments, especially originating from the lower pole calyces.
In most cases, a plain X-ray (KUB) is taken to define the status of stone
clearance.
Stone-free rates are typically high in ureteral stones, even though repeated
ESWL treatment sessions are occasionally required.
In kidney stones, however, a substantial number of patients show residual
fragments. When those fragments are small and are without symptoms,
they are referred to as clinically insignificant residual fragments (CIRF) or
asymptomatic residual fragments (ARF). The number of patients who are
stone-free typically increases with time.

46

7.2 Stone analysis prevention of new stone formation

Therefore, most clinical reports do not report stone-free rates until after
3months. Final evacuation of CIRF or ARF from the lower pole calyx may
take up to 24 months. However, it must be noted that the management of
patients with residuals after ESWL is an area that is still broadly debated.
7.2 Stone analysis prevention of new stone formation
Measures to prevent new stone formation or to avoid growth of rest fragments
are mainly dependent of stone composition.
In order to provide the patients with advice regarding preventive measures to
avoid new stone episodes, it is therefore advisable to obtain a stone analysis
on the evacuated fragments if and whenever possible.
The full extent of medical therapy of different stone types is a vast chapter
and is beyond the scope of this booklet on the good practice of ESWL. We
refer to the literature [12].
7.3 Complications
Generally and especially in comparison with endoscopic techniques
complication rate following ESWL is extremely low.
Severe complications are extremely rare. Appropriate precautions need to be
taken to avoid them.
7.3.1 Subcapsular haematoma

The current EAU Guidelines [5] list the risk of symptomatic haematoma as
less than 1% and the risk of asymptotic haematoma as 4%. Diagnosis is based
on ultrasound or CT imaging. Clinical signs are abnormal pain following
SW treatment, bulging and/or tenderness of the flank region, tachycardia,
hypotension or signs of acute anaemia. The majority of manifested
haematomas can be treated with a conservative approach, including blood
transfusion in rare cases. Resorption may take 6 weeks to 6 months.
Although the risk of an induced haematoma cannot completely be eliminated,
it can be minimized when the ESWL is competently performed and patientspecific risk factors are identified and addressed.

7 Follow-up

47

Adequate ESWL treatment was described in detail in Chapter 6 of this

booklet. In short, blood pressure monitoring (See section 6.3), precise
shock wave targeting (See section 6.5) and careful selection of the treatment
parameters (See section 6.7) are essential. In addition, it is recommended that
ESWL treatments not be repeated within overly short intervals. There is no
consensus as to the minimum interval, and this interval may also depend on
the acoustic doses administered. However, we suggest waiting at least two
weeks before performing a re-ESWL.
Patient related risk-factors are:
Treatment with anticoagulants (acetyl salicylic acid, coumarins,
warfarin, etc.)
Coagulation disorders
Hypertension or history of hypertension
Diabetes mellitus
High age (> 65-70)
Patients who take anticoagulants like aspirin, warfarin or similar agents
should not be treated unless the medication is temporarily discontinued or
substituted. For details, it is referred to Alsaikhan et al. (2011).
ESWL should not be performed on patients with coagulation disorders or
hypertension unless they have been medicinally corrected.
In all patients with risk factors the ESWL treatment parameters should be
adapted to the specific case.
7.3.2 Septicaemia
In order to anticipate eventual infectious problems it is wise to perform a
urine culture prior to ESWL in all patients, especially those with larger stones.
Any urinary tract infection diagnosed prior to ESWL should be adequately
treated with antibiotics before scheduling the treatment. In the case of large,
potentially infected stones, antibiotic coverage should continue during and
after ESWL.

48

8 Summary

In cases of urosepsis the highest priority must immediately be given to

removing any obstruction caused by a stone or a fragment that might be
present. Further medical treatment of the septic problems cannot be successful
until a possible obstruction has been removed.
7.4 Long-term complications
An initial study by Krambeck et al. (2006) identified a higher risk of
developing hypertension or diabetes mellitus in patients treated by ESWL.
Krambeck et al. (2011) and Chew et al. (2012) both refuted these findings
with large cohort studies. They were unable to identify an association between
ESWL and the long-life risk of developing hypertension or diabetes mellitus.
It is now suggested that lithiasis per se and the metabolic disorders associated
with it may be responsible for changes in blood pressure and the higher
incidence of diabetes mellitus regardless of any stone treatment modality.

8 Summary
ESWL is an excellent first-line treatment for the majority of patients with
urinary tract calculi, provided that the technique is appropriately applied.
Therefore, operators must be properly educated and trained to ensure
the success of ESWL. This booklet focusses on the basic principles and
practical aspects of ESWL and is intended to serve as an aid to any urologist
performing ESWL. The literature section lists various review articles that are
recommended for further reading.

9 Literature

49

9 Literature
[1] C. Chaussy, W. Brendel et al. Extracorporeally induced destruction
of kidney stones by shockwaves. Lancet 316: 1265-8, 1980.
[2] G.G. Tailly. Lithotripsy Systems. In A.D. Smith, G.H. Badlani et
al. (Eds.) Smiths textbook of Endourology (3rd Edition). WileyBlackwell, 2012, pp 559-575.
[3] A.M. Loske. Shock wave physics for urologists. Mexico: Universidad
Nacional Autnoma de Mxico. ISBN: 978-970-32-4377-8.
[4] R.O. Cleveland, J.A. McAteer. Physics of shock-wave lithotripsy.
In A.D. Smith, G.H. Badlani et al. (Eds.) Smiths textbook of
Endourology (3rd Edition). Wiley-Blackwell, 2012, pp 529-558.
[5] C. Trk, T. Knoll et al. Guidelines on Urolithiasis. European
Association of Urology, 2011.
[6] G.M. Preminger, H.G. Tiselius et al. EAU/AUA Nephrolithiasis
Guideline Panel. 2007 guideline for the management of ureteral
calculi. J Urol 178: 2418-34, 2007.
[7] H.-G. Tiselius, C.G. Chaussy. Aspects on how extracorporeal
shockwave lithotripsy should be carried out in order to be
maximally effective. Urol Res 40: 433-46, 2012.
[8] J.J. Rassweiler, H.-M. Fritsche et al. Extracorporeal shock wave
lithotripsy in the year 2012. In T. Knoll, M.S. Pearle. Clinical
Management of Urolithiasis. Springer, 2013, pp 51-76.
[9] C. Bach, N. Buchholz. Shock wave lithotripsy for renal and ureteric
stones. Eur Urol Suppl. 10: 423-432, 2011.
[10] M.J. Semins, B.R. Matlaga. How to improve results with extra
corporeal shock wave lithotripsy. Ther Adv Urol 1: 99-105, 2009.
[11] A. DAddessi, L. Bongiovanni et al. Extracorporeal shockwave
lithotripsy in pediatrics. J Endourol 22: 1-22, 2008.
[12] A. Hesse, H.G. Tiselius et al. Urinary stones. Diagnosis, treatment
and prevention of recurrence. 3rd Edition. Karger, 2009.

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Some of the product names, patents, and registered designs referred to in this book are in
fact registered trademarks or proprietary names even though specific reference to this fact
is not always made in the text. Therefore, the appearance of a name without designation as
proprietary is not to be construed as a representation by the publisher that it is in the public
domain.

HM1 at the Munich University Hospital Grohadern

The first extracorporeal shockwave lithotripsy (ESWL) treatment

of a human was performed on February 07, 1980 by Christian
Chaussy, Dieter Jocham, and Bernd Forssmann using a prototype
Dornier HM1 (Dornier Human Model 1). The results with this
new treatment modality were so successful, that it thoroughly
revolutionized modern stone management.
The purpose of this brochure is to inform the user about the physical
principles behind the technology and to offer practical guidance on
performing ESWL.