European European Urology 43 (2003) 552–555

Urology

Emergency Extracorporeal Shock Wave Lithotripsy (ESWL)

for Obstructing Ureteral Stones
M. Tligui*, M.R. El Khadime, K. Tchala, F. Haab, O. Traxer, B. Gattegno,
P. Thibault
Service d’Urologie, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
Accepted 6 February 2003

Abstract
Objective: To evaluate emergency treatment of obstructing ureteral stones by in situ extracorporeal shock wave
lithotripsy (ESWL) during acute renal colic.
Patients and Methods: From January 1994 to February 2000, 200 patients (mean age: 42 years) were treated by
ESWL (EDAP LT-02) for obstructing ureteral stones causing acute renal colic refractory to medical treatment or
recurring within 24 hours of such treatment. Stones were visualised by fluoroscopic imaging and/or ultrasound.
Follow-up included radiological and/or ultrasound examinations and lasted three months.
Results: Mean stone size was 7 mm (3–20 mm). At three months, 164/200 (82%) patients were stone-free.
This rate ranged from 79% to 83% according to the location of the stone, and from 75% to 86% according
to the size of the stone. These differences in rate were not significant. Two or three ESWL sessions were
required in 79 patients. ESWL was well tolerated in 90% of patients. The only complication was a case of
pyelonephritis requiring the placement of a JJ stent, administration of antibiotics, and distant ureteroscopy. The
36 patients, in whom ESWL failed, underwent ureteroscopy (n ¼ 23) or lithotripsy with a Dornier1 machine
(n ¼ 13).
Conclusion: Non-deferred ESWL for acute renal colic secondary to obstructing ureteral stones has a satisfactory
success rate and very low morbidity.
# 2003 Elsevier Science B.V. All rights reserved.

Keywords: Kidney diseases; Colic; Ureteral calculi; Lithotripsy

1. Introduction The success rate of ESWL in the treatment of

The usual treatment for acute renal colic caused by
obstructing ureteral stones is medical relief of symptoms
with the exception of cases of pyelonephritis and/or
acute kidney failure. Management of the stone tends to
be deferred as the stone is eliminated spontaneously in
16–98% of cases, depending upon its size and location
[1–4]. Besides expectant management, the standard
treatments are extracorporeal shock wave lithotripsy
(ESWL) or ureteroscopy [5–10]. Open surgery is rarely
used [11].
*
Corresponding author. Tel.: þ33-6-81-06-68-46.
E-mail address: radouaneelkhadime@hotmail.com (M. Tligui).
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0302-2838(03)00086-1
ureteral stones is about 80% [4,12]. The main prog-
nostic factors for success are stone size, and the extent
and nature of the obstruction. Failure is most common
for stones larger than 10 mm [13,14]. The efficacy and
very low mortality of ESWL justify its use in the
treatment of ever smaller symptomatic ureteral stones,
often in response to patient demand [11,14–16].
We have shown that ESWL can be successfully used,
without anaesthesia, in patients with early recurrence of
renal colic [17]. Other teams have used ESWL within
14 days of the onset of acute renal colic but under
anaesthesia [15] or even during acute renal colic [18] or
acute renal failure [19]. Moreover, a comparative retro-
spective analysis has shown that, in emergency situa-
tions, ESWL is more effective than nephrostomy or a JJ
 M. Tligui et al. / European Urology 43 (2003) 552–555
stent and has very low morbidity [20]. All but one of
these studies [21] have concerned rather small numbers
of patients.
We have investigated the efficacy of the latest gen-
eration piezo-electric lithotriptor in the treatment,
without anaesthesia, of 200 outpatients with obstruct-
ing ureteral stones during acute renal colic resistant to
medical treatment.
2. Patients and methods
Between January 1994 and February 2000, 200 patients (125
women, 75 men) were admitted to our department for acute renal
colic that proved to be resistant to anti-inflammatory agents
(100 mg ketoprofen i.v.) or that recurred within 24 hours of such
treatment. They underwent emergency extracorporeal shock wave
lithotripsy (ESWL) after standard kidney, blood and urine tests had
been performed. Patients with an urine infection or blood coagula-
tion disorders, who were pregnant, or had heart deficiency were
excluded. All patients underwent an abdominal X-ray and ultra-
sound examination. An intravenous pyelogram was only indicated
when there was doubt as to the diagnosis.
Stones were fragmented with an EDAP LT-02 piezo-electric
lithotriptor (EDAP-Technomed Group, Marne-la-Vallée, France)
with dual ultrasound/fluoroscopic detection. All patients received
a dextropropoxyphene suppository (60 mg) and paracetamol
(800 mg) 20 minutes before the session. They were given no
anaesthesia but, when tolerance to ESWL was poor, they were
administered an injection of 100 mg ketoprofen during the session.
Fig. 1. Distribution of ureteral stones as a function of their size and location.
553
Lumbar ureteral stones were fragmented with the patient in the
prone position, iliac and pelvic stones in the supine position. At the
end of the session, patients completed a visual pain scale (0–10).
Follow-up over three months comprised evaluation of pain, tem-
perature and fragment elimination, and radiologic check-ups
(abdominal X-ray and/or ultrasound).
Patients in whom ESWL failed to completely disintegrate the
stone during a first session underwent repeat sittings. Patients in
whom ESWL had no impact on the stone during the first session, as
evidenced by abdominal X-ray, underwent either lithotripsy with a
Dornier1 lithotriptor (Dornier Medical Systems, Marietta, Georgia)
or ureteroscopy.
Results were compared by the Chi-square test. A 0.05 signifi-
cance level was used. A mean energy requirement was calculated as
follows: (number of shock waves per second  power  time)/480.
A mean efficiency quotient (EQ) was calculated according to the
formula of Denstedt and co-workers [22]: 100% stone-free/(100%
þ percent retreatment þ percent auxiliary procedures).
3. Results
The mean age of the patients was 42 years (20–83
years). Overall, 145 patients were treated as outpatients
and 55 were kept in hospital overnight. All the stones
were radioopaque. Their mean size was 7.2 mm (3–
20 mm). They were located in the pelvic (n ¼ 102), iliac
(n ¼ 54) or lumbar (n ¼ 44) region (Fig. 1). Detection
of the stones by fluoroscopy and/or ultrasound required
opacification of the excretory route in four patients.
554 M. Tligui et al. / European Urology 43 (2003) 552–555
Table 1
Results of ESWL at three months as a function of stone location and
size
n Success rate
Location
Lumbar 44 36 (81.8%)
Iliac 54 43 (79.6%)
Pelvic 102 85 (83.3%)
Size
3 to <6 mm 44 34 (77.3%)
6 to <10 mm 136 117 (86.0%)
10–20 mm 20 15 (75.0%)
ESWL treatment lasted on average 50 minutes
(18–112 minutes). Mean maximum power was 94%
(50–100%). The number of shock waves per second
ranged from 4 to 8. The mean number of sessions per
patient was 1.3 (1–3). Tolerance was either excellent
(50%), good (40%), average (8%) or poor (2%). No
treatment was interrupted because of poor tolerance.
After ESWL treatment, pain resolved in 48% of
patients, persisted in 40%, and required administration
of supplementary anti-inflammatory agents or opioids in
12%. Fragmentation after a single session was complete
in 121 patients (60.5%), incomplete in 49 (24.5%), and
absent in 30 (15%). Patients presenting incomplete
fragmentation underwent a second (n ¼ 49) or even
third session (n ¼ 30). Five patients with remnants after
two sessions underwent ureteroscopy. One patient
developed acute obstructive pyelonephritis proximal
to a pelvic ureteral stone which was successfully treated
by a JJ stent, antibiotics and distant ureteroscopy. Of the
30 patients in whom ESWL had no impact on the stone,
13 underwent lithotripsy with a Dornier1 machine and
17 ureteroscopy.
The stone-free success rate for ESWL (fragmenta-
tion þ elimination) was 35% (n ¼ 70) on day 2, 42%
(n ¼ 84) on day 15, 71% (n ¼ 142) on day 30, and 82%
(n ¼ 164) on day 90. The efficiency quotient was 53.2.
Results as a function of stone location and size are
given in Table 1; neither location nor size was a
prognostic factor. The mean size of stones that were
completely fragmented at a single session (n ¼ 121)
was 6.6 mm, of those requiring a second session
(n ¼ 49) was 8.3 mm (4–11 mm), and of those resis-
tant to ESWL (n ¼ 30) was 7.6 mm.
4. Discussion
Use of an EDAP LT-02 piezo-electric lithotriptor
enabled us to provide emergency treatment, without
anaesthesia and on an outpatient basis, to patients
suffering from acute renal colic caused by obstructing
ureteral stones. Treatment at a mean maximum
Failures generator power of 94% was well tolerated. The
stone-free success rate was 82% at three months
8 which compares favourably with the average 80%
11
17
rate obtained on deferred ESWL treatment. Our effi-
ciency quotient (EQ ¼ 53:2) was lower than that in
10
published studies using a Lithostar1 Siemens litho-
19 triptor (EQ ¼ 66:7) [23] or a Dornier1 lithotriptor
5 (EQ ¼ 70–80) [6].
Although expectant management is common for
small stones that are most likely to be eliminated
spontaneously, we treated small stones (3 mm to
<6 mm) by ESWL because the patients complained
of persistent pain despite appropriate medical treat-
ment. In fact, ESWL proved to be a treatment modality
for acute renal colic in 48% of the patients. Only one
patient in our series developed complications (a case of
pyelonephritis). Our complication rate of 0.5% thus
compares favourably with the 6% complication rate
recorded by Kumar et al. [24].
Overall, 21 patients in our series of 200 patients
successfully underwent ureteroscopy, with no compli-
cations, after failure of ESWL. Ureteroscopy has a
reported success rate of 90–100% and a complication
rate of 0.5–10% which has decreased considerably
with technological advances (miniature devices). The
success rate is lower and morbidity is higher for stones
located in the upper third of the ureter, especially in
men. Ureteroscopy necessitates hospitalisation, anaes-
thesia and sometimes deferred removal of a JJ stent. It
is sometimes offered as a first option for whewellite
stones [25] but, unlike ESWL, cannot be used in an
emergency setting.
In conclusion, we suggest that emergency ESWL
treatment of ureteral stones during acute renal colic
could be more widespread. It presents medical
advantages, i.e. no need for prolonged anti-inflam-
matory treatment, and also possible economic
advantages, i.e. no need for pyelography (because
diagnosis is based also on KUB, echography and
helical CT only when necessary), anaesthesia and
systematic hospitalisation; fewer absences from
work. However, it has a failure rate of 10–20%
(18% in this study), it requires appropriate lithotriptor
facilities for emergency use (and the machine is
expensive) and a follow-up period of up to three
months. Ultimately, the chosen treatment option
(medical treatment, ESWL, or ureteroscopy) is a
matter of a joint decision between the physician
and the informed patient.
 M. Tligui et al. / European Urology 43 (2003) 552–555
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