ESWL

Dr. Muhammad Abdul Rauf

TR Urology
SZH, Lahore
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 Introduction
 History  Preoperative
 Components considerations
 Indications  Intraoperative
considerations
 Contra-indications
 Postoperative care
 Work up and complications
 Recent advances
 References
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Introduction

 procedure in which renal and ureteral calculi are pulverized into smaller
fragments by shock waves.

 small fragments then can pass spontaneously.

 This noninvasive approach allows patients to be rendered stone-free

without surgical intervention or endoscopic procedures
 4 History

 Dornier,* rediscovered during the investigation of pitting on

supersonic aircraft that shock waves originating from passing
debris in the atmosphere can crack something that is hard.

 The first clinical application with successful

fragmentation of renal calculi was in 1980.
 Diagrammatic representation of a Dornier HM-3
5
lithotriptor
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Components

 an energy source
 an imaging or localization unit
 a coupling mechanism

 Newer machines contain a patient treatment table

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Energy Source
 They differ in generated pain and anesthetic or
anesthesiologist requirements, consumable components, size,
mobility, cost, and durability. Focal peak pressures (400–1500
bar), focal dimensions (6 × 28 mm to 50 × 15 mm), modular
design, varied distances (12–17.0 cm) between focus 1 (the
shock wave source) and focus 2 (the target), and purchase
price differentiate the various machines available today
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Shock wave Physics
 Ultrasonic wave have sinusoidal characteristics and longitudinal
mechanical properties

 Acoustic shock waves are not harmonic and have nonlinear pressure
characteristics.

 A steep rise in pressure amplitude that results in compressive forces

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 Types of Shockwave Sources
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Energy sources

 Supersonic emitters

 Finite amplitude emitters

 11 Supersonic Emitters

 Analogous to Thunderstorm

 release energy in a confined space, thereby

producing an expanding plasma and an acoustic
shock wave.
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 13
Finite Amplitude Emitters

 create pulsed acoustic shock waves by displacing a

surface activated by electrical discharge.

 Two major types

Piezo ceramic variety
Electromagnetic systems
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Piezo ceramic
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Electromagnetic systems
 similar in concept to a stereo speaker system
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Mechanism of stone disintegration

 Fragmentation occurs when the tensile strength of a stone is

overcome by the force of shock waves.

 Fragmentation is achieved by erosion and shattering

 Cavitational forces result in erosion at the entry and exit sites

of the shock wave.
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 Cavitation is caused by shock waves that produce gaseous

bubbles in a liquid medium. The bubbles collapse explosively,
creating microjets that fracture and erode the calculus.

 This process can be noted on real-time sonography during

treatment, and it appears as swirling fragments and liquid in the
focal zone.
 19 Image or Localizing unit. Fluoroscopy
 appropriate collimation, dimmed room lighting, and adequate bowel
preparation*
 Intermittent fluoroscopy reveals movement of calculi with
respiration and is helpful in locating and focusing on offending
calculi
 can identify both renal and ureteral calculi
 Disadvantages.. use of ionizing radiation and the inabilityto
visualize radiolucent or minimally radiopaque stones.
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Ultrasonic Imaging
 advantage of eliminating radiation exposure to the patient or
lithotripsy team
 two basic types: the coaxial unit, aligned with the shock wave
generator, and the articulating
arm unit with a mobile transduce
 can easily identify radiolucent or small calculi
 Difficult to identify ureteral, medially located stones in non
obstructive system and in Obese patients
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Coupling
 Needed to transmit the energy created by the shockwave generator
and pressure wave to the skin surface and through body tissues to
reach the stone

 Optimal systems should prevent pain, ecchymosis, hematomas, or

skin breakdown

 Interfaces between gas and tissue can result in tissue damage.*

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 water bath…profound hemodynamic changes

including peripheral venous compression resulting in increased
right atrial pressure, increased pulmonary capillary wedge
pressure, and increased cardiac index.*

 water cushion coupling …The volume of such water cushions

can frequently be adjusted to help focus calculi when patients are
either extremely thin (eg, children) or obese
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Indications for ESWL
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Factors for impair success of ESWL
 steep infundibular-pelvic angle

 long calyx
 long skin-to-stone distance

 narrow infundibulum

 Shock wave-resistant stones

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Proximal and Distal Ureteric Stones
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Contraindications of ESWL
 pregnancy
 bleeding diatheses
 untreated urinary tract infections
 severe skeletal malformations and severe obesity
 arterial aneurysm in the vicinity of the stone
 anatomical obstruction distal to the stone
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Work Up
 CBC
 Coagulation profile
 Urine C/S
 Imaging studies
 Others i-e ECG if age >50
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Preoperative Details
 Success rate of ESWL will depend upon
 size of stone
 location
 composition
 Patient habitus
 Efficacy of Lithotripter & Performance of
ESWL
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Size & Location
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 As stones increases in size, stone-free rates decreases*

 Overall, approximately 75% of patients with renal calculi

treated with SWL become stone free in 3 months.
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Stone composition
 calcium oxalate dihydrate, magnesium ammonium phosphate,
and uric acid fragment readily with ESWL.
 Calcium oxalate monohydrate and certain forms of calcium
phosphate stones (eg, brushite) are more difficult to fragment
with ESWL.
 Cystine stones often are resistant to ESWL
 ESWL is more effective against HU < 815.
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Intraoperative considerations
 Proper patient positioning is a prerequisite for successful
lithotripsy.*
 Anterior located kidneys, medial oriented portions of a horseshoe
kidney, or transplant kidneys are best treated in the prone position.
 Localization of stone with fluoro or Usg
 Small or poorly calcified calculi can be difficult to image with
fluoroscopy, irrespective of their location
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 Placing a ureteral catheter identifies known anatomy and supplies

an injection port for radiocontrast agents.
 A poorly calcified caliceal calculus can be identified by injecting
dilute contrast agents into the collecting system and then focusing
on the appropriate calyx or filling defect.
 In patients who cannot have retrograde stents placed, intravenous
contrast agents may be used to help localize and thus focus on
such stones.
 Best clinical practice (best performance) in SWL
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 Stenting prior to SWL

Routine use of internal stents before SWL does not improve
stone-free rates,
nor lowers the number of
auxiliary treatments.
 It may, however, reduce
formation of steinstrasse
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 Pacemaker
Patients with a pacemaker can be treated with SWL.
 Patients with implanted cardioverter defibrillators must be
managed with special care.*
 However, this might not be necessary with new-generation
lithotripters
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 Shock waves, energy setting and repeat treatment sessions

 The number of shock waves that can be delivered at each session
depends on the type of lithotripter and shock wave power.
 Starting SWL on a lower energy setting with step- wise power
ramping prevents renal injury.
 Optimal shock wave frequency is 1.0 to 1.5 Hz.
 Clinical experience has shown that repeat sessions are feasible.*
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Antibiotic Prophylaxis
 No standard prophylaxis prior to SWL is recommended
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Special considerations
 45 ESWL in Children
 The indications are similar to those in adults.

 Compared to adults, children pass fragments more rapidly after

ESWL

 Children with renal stones of a diameter up to 20 mm (~300

mm2) are ideal candidates for ESWL.
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Postoperative care & Complications
 Encourage pt to maintain an active ambulatory status to facilitate
stone passage.
 Fluid intake should be encouraged.
 Gross hematuria should resolve during the first
postoperative week.*
 Severe pain unresponsive to routine intravenous or oral
medications should alert the physician for possible rare (0.66%)
perirenal hematomas.*
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 SWL is not associated with the development of hypertension.

 Steinstrasse (stone street) or accumulation and back-up of stone
gravel in a ureter can be frustrating.*
 Severe pain or fever requires intervention.
 Asymptomatic individuals can be followed up with serial KUBs
and ultrasonography.
 Many studies support MET after SWL to increase SFR
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Future of ESWL
 Bi-directional synchronous twin pulse technique*

 Smaller focal zone and tabletop lithotripter design

require precise localization and lower anesthetic
requirement*
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 Recent Advances; Burst Waveform Lithotripsy
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 Shock wave; single pressure pulse with compressive spike

 Burst wave; Oscillating ultrasound pressure pulse*
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Acoustic energy focusing (AEF)
 devices have been developed that can attach to the kidney stones

 An external energy source with the appropriate resonant frequency

will allow the AEF device to expand and then cavitate, resulting in
stone fragmentation.

 Clinical trials are underway and may give an outpatient approach

to fragmentating urinary stones.
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References

 Smith & Tanagho_s General Urology 19th Ed

 EUA Guidelines 2020
 Medscape, WebMD
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ESWL IS
HIGH RISK BLEEDING
PROCEDURE

Thank you