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Extracorporeal Shockwave Lithotripsy (ESWL): As Minimally Invasive as It Gets!

ESWL — who needs it? If you’re having pain from a kidney stone, maybe YOU do. If Dr. Bevan-Thomas has recommended ESWL, you’re surely wondering, “What exactly does that mean?”

LET US HELP WITH THAT

ESWL stands for extracorporeal shockwave lithotripsy. Interestingly, extracorporeal soundwave lithotripsy would be a more accurate name because it is technically soundwaves, not shockwaves, that are used in the procedure. A shock of energy produces the soundwaves, thus the shockwave name. The kidney stones absorb the soundwaves and begin to break up, like a small earthquake within the stone.

GOOD TO KNOW! SO WHAT IS THE ESWL PROCEDURE?

For starters, ESWL is noninvasive; extracorporeal means “outside the body.” So it’s not an invasive surgery, and you won’t have an incision.

The lithotripsy part means “the breaking of stones.” Dr. B-T will use fluoroscopy (x-rays) to locate the stone(s) and a machine called a lithotripter to target your kidney stone with soundwaves. The soundwaves break the stone into small particles that will pass with your urine.

WHO SHOULD HAVE ESWL?

You’re a candidate for ESWL if:

• Your stone is causing persistent pain and/or pain medication is not working.
• Your stone is causing recurrent infections.
• Your stone is smaller and blocking the kidney but has not passed by itself.
• You are worried about a stone passing in the future and want to save yourself the pain and anguish of passing the stone on your way to Mexico or during your PhD dissertation.

IT IS EASY TO PASS THESE STONE FRAGMENTS?

Unfortunately, kidney stones are rarely easy. Sure there are times when a patient has a very small stone that passes into the bladder and urinates it out. But that is far less common than the usual routine. The ESWL procedure tries to make passing the fragments as painless as possible, and as you can imagine, the smaller the fragments, the less the pain.

Kidney stones are all made within the kidneys and then at some point pass down the long tube called the ureter. The ureter is the tube that connects the kidneys to the bladder. Each kidney routinely has only one ureter. Some people can be born with two ureters per kidney, but this is rare and a topic for another day.

As the stones travel down the ureter, this is routinely where the pain starts. Think about a small pea traveling down a straw that opens and closes but then gets stuck in the straw. OK, that’s very similar to what happens to stones. So, the smaller the size of the pea fragments, the less pain involved.

ESWL is the least invasive approach, but in order for it to be successful, the patient needs to drink plenty of fluids afterward to pass the fragments. Occasionally, these fragments can get stuck in the ureter, causing more pain. The more fluids a patient drinks, the more the ureter stays open and the better chance for the fragments to pass into the bladder. Once in the bladder, the fragments will pass during normal urination.

Bladder stones are a completely different animal and primarily occur because the bladder can’t empty completely, not because the kidney stones get stuck in the bladder.

ARE THERE OTHER OPTIONS?

Besides ESWL, the other options include placing a ureteral stent, using a laser to destroy the stone, or placing a small hole through the back into the kidney (PCNL). Dr. B-T will discuss these options with you in more detail during your office visit, and his recommendations will depend on the location, size, and hardness of your stone(s).

The ureteral stent merely opens the ureter so urine and potentially stones and stone fragments can pass alongside the stent. Stents are routinely placed for patients who have a bad infection and the kidney needs help draining the urine, or because the stone(s) are larger and Dr. B-T is worried that the fragments could block the ureter.

Fortunately, unless the stent has already been placed prior to the ESWL, it is done under anesthesia at the time of your procedure. Ureteral stents are temporary and must be either removed or exchanged every four to six months to prevent calcifications building up like barnacles on a boat. Stents are routinely removed in the office as a two- to three-minute procedure.

I'M IN! SO WHAT CAN I EXPECT DURING THE ESWL PROCEDURE?

ESWL is usually done as an outpatient procedure. Dr. Bevan-Thomas will use general anesthesia to make you comfortable and because you must remain still throughout the procedure. During the procedure, you should not feel anything as you will be under anesthesia and happy as a clam at high tide.
You will lie on a procedure table with a cushion of warm water under you. The lithotripter will be positioned on your body over the region of the stone and will direct a series of soundwaves to the precise location.

Dr. Bevan-Thomas only uses the Dornier 3 currently, which has excellent results in breaking kidney stones. In some cases, Dr. Bevan-Thomas will insert a stent. A stent is a thin, flexible tube that is inserted to hold a ureter open (see above).

Following your procedure, you will probably spend a few hours in recovery before being sent home the same day.

WHAT HAPPENS AFTER THE LITHROTRIPSY PROCEDURE?

• It may take a few weeks for your stone fragments to pass. Rarely, it can take a month or two.
• Drink plenty of fluids to help the fragments pass. Aim for at least eight glasses a day.
• Dr. Bevan-Thomas may ask you to strain your urine and save the stone fragments so they can be analyzed in the lab.
• Expect blood in your urine for a few days.
• You may have bruising at the site of treatment.
• You can resume normal activities after 24 hours. Walking and other light exercise may help the stone fragments to pass more quickly.
• On your follow-up visit, you should stop by to get a KUB (x-ray) so we can see if the fragments have passed.

WHAT ARE THE RISKS AND SIDE EFFECTS OF ESWL?

• The most common side effect is pain as the fragments pass. Dr. B-T will send you home with pain medication.
• Urinary blockage if fragments get stuck in the ureter.
• Incomplete breakage and passage of stone fragments.
• Bleeding around the kidney. (It is very important to stop blood thinners prior to ESWL.)

HOW EFFECTIVE IS ESWL?

Numerous studies have documented the efficacy of ESWL in the 90% range or higher for kidney stones. It could be slightly lower for stones in the ureter depending on the size, location, and hardness of the stone(s).

Ureteroscopy with Laser Lithotripsy: Oh, Say Can You See? (Yes, We Really Can See Inside the Kidney!)

If you are suffering from kidney stone pain, Dr. Bevan-Thomas may recommend Holmium laser lithotripsy to break the stone into small fragments that will pass with your urine.

HOW IS THE URETEROSCOPY WITH LITHOTRIPSY PERFORMED?

Holmium laser lithotripsy can usually be done as an outpatient procedure, but sometimes it can involve a short hospital stay. You will receive general anesthesia, so you’ll snooze right through it.

Dr. B-T will pass the scope through the urine channel to the bladder and then into the ureter (the tube that carries urine from the kidney to the bladder). Occasionally, such as with a persistent stone that has failed ESWL), he will continue up into the kidney.

When he finds a stone, the blasting begins! Dr. B-T will use the laser to blast the stone into tiny bits, exactly like the video game Asteroids. (Remember that one?)

The length of the procedure varies depending on the location and number of stones. You will spend a few hours in recovery, and then most patients go home the same day.

I'VE HEARD THAT I MIGHT NEED A STENT. WHAT'S A STENT?

A ureteral stent is a thin tube that Dr. Bevan-Thomas will place in the ureter — the tube from the kidney to the bladder — during your procedure. Think of it as a tiny straw that keeps the ureter open and allows urine and stone fragments to pass into the bladder more easily.

And yes, you will go home with one. Your ureter is likely to be irritated and can swell after the procedure, making urinating difficult and uncomfortable. Trust us on this one — you’ll be a lot more comfortable with the stent.

OK, YOU'VE CONVINCED ME! SO, WHAT HAPPENS AFTER THE PROCEDURES?

• It can take anywhere from a few weeks to a month or two for the stone fragments to pass.
• Hydration is critical! Sometimes the fragments can get stuck in the ureter, which causes more pain. The more fluid you drink, the more the ureter stays open, which increases the chance of fragments passing into the bladder. Once in the bladder, the particles will pass with your urine. Drink plenty of fluids to help them along. Aim for at least eight glasses a day.
• Dr. Bevan-Thomas may ask you to strain your urine and save the stone fragments so they can be analyzed in the lab.
• Expect blood in your urine for a few days.
• You can get back to your regular activities after 24 hours. Walking and other light exercise can help the stone particles pass more quickly.
• Your stent may have a string attached, like dental floss, dangling from your urethra. Dr. B-T uses this when he thinks that the stent only needs to stay for a few days. The bonus is that you can remove the stent easily at home without a followup appointment. If the stent needs to stay longer, it is routinely removed in the office after an x-ray is done to ensure the stone fragments have passed. Remember: The ureteral stent is a temporary tube and should either be removed or changed every few months. Most stents are removed within the first few weeks after the procedure, but sometimes patients need stents for a longer period of time. These longer stents will need changing every four to six months because minerals in your urine will calcify and cause encrustation, like barnacles on a boat. Let’s keep you and your stent barnacle-free!
• On your follow-up visit, stop by to get a KUB (x-ray) so we can see if the fragments have passed.

WHAT ARE THE RISKS OF URETEROSCOPIC LITHOTRIPSY?

All surgical procedures have risks, but complications are rare for this procedure. The most common side effects (but not all) are:

• Pain when the stone particles pass. Dr. B-T will give you pain medication to go home with.
• Blood in your urine.
• Urinary blockage if particles get stuck in the ureter. (The stent should prevent this.)
• Incomplete breakage and passage of stone fragments.