Lithotripsy is a medical procedure used to treat kidney stones and other urinary tract stones of all sizes through a variety of techniques: ESWL, Laser Lithotripsy, and PCNL. At SRMC, our urologist, Dr. Joshua Caldwell, is qualified to perform each of these procedures and has several years of experience.

Benefits:

• Non-invasive procedure (no surgery required).
• Effective for treating small- to medium-sized stones.
• Can be performed as an outpatient procedure.

How it Works:

• The patient lies on a table and the stone is located using ultrasound or X-ray imaging.
• A machine called a lithotripter generates shock waves that are focused on the stone.
• The shock waves break the stone into small fragments.
• The fragments are then passed out of the body in the urine.

Recovery:

• Most patients can return to their normal activities within a few hours after lithotripsy.
• Some may experience mild discomfort or bruising at the treatment site.
• It may take several weeks for all of the stone fragments to pass through the urinary system.

1) ESWL

Extracorporeal shock wave lithotripsy (ESWL) is the most common type of lithotripsy. ESWL treats kidney and ureter stones that are difficult to pass naturally. It is most effective for smaller stones seen on X-rays or ultrasound. During this procedure, high-energy shock waves guided by X-ray or ultrasound, will pass through your body until they hit the kidney stones. The waves will then break the stones into tiny pieces. This procedure should take about 45 minutes to 1 hour.

During ESWL:

• You will lie on a padded table on top of a water-filled cushion.
• Providers will use X-rays or ultrasound to pinpoint the stone’s location. These images help our urologist aim shock waves as precisely as possible at the stone.
• Your care team may move you slightly to line your body up with the energy beams.
• A shock wave lithotripsy machine sends powerful energy waves through the water and into your body. If you choose to be awake for the procedure, you may hear a popping sound or feel a tapping sensation along your side.
• Thousands of shock waves are then aimed at the kidney stone, breaking the stone into numerous pieces.

ESWL can be performed using different systems:

• Electrohydraulic: Creates shock waves by making a tiny spark underwater between two metal points. These shock waves are then directed at kidney stones to break them into smaller pieces. Imagine a little, controlled underwater firework that sends waves to crack the stones apart.
• Electromagnetic: Utilizes an electromagnetic coil to create shock waves. A magnetic field generates powerful shock waves when electricity flows through the coil. These waves are aimed at kidney stones to break them into smaller pieces by using robust and focused energy waves to shatter the stones.
• Piezoelectric: Unique crystals, like quartz or certain ceramics, change shape when electricity is applied. This change creates shock waves aimed at kidney stones to break them into smaller pieces. It’s similar to how quartz crystals in a watch vibrate to keep time, but in this case, the vibrations create waves that can crush the stones.
• Laser lithotripsy: Laser lithotripsy is a way to break up kidney stones using a laser. Dr. Caldwell uses a small, flexible tube that goes through the urethra (the tube that carries pee out of your body) and into the bladder to find the stones. Think of the laser as a powerful beam of light that smashes the stones, making them small enough to pass out of your body more easily or be removed by the doctor.

2) Laser Lithotripsy

Laser lithotripsy is a medical procedure designed to break up and eliminate stones located in the kidney, bladder, ureter, or urethra. This procedure involves the use of a laser, which is introduced through a scope (a long tube with a camera on it) within the urinary tract. Dr. Caldwell uses a small, flexible tube that goes through the urethra and into the bladder to find the stones.

Laser lithotripsy usually takes 1 to 2 hours. During a laser lithotripsy performed with ureteroscopy, you can expect the following:

1. You’ll be under general anesthesia, so you will be asleep during the procedure.
2. A scope will be inserted into your urethra.
3. A flexible fiber with a laser on the end will be placed through the scope.
4. The laser will break up the stones.
5. Dr. Caldwell will remove the pieces of stones.
6. The provider will place a temporary tube (ureteral stent) that allows pee and small pieces of the stone to leave your body.
7. Dr. Caldwell will remove the stent at a later date (usually days to weeks later).
8. After laser lithotripsy, providers will monitor you until it is safe for you to return home. You’ll need someone to drive you home. Your provider may prescribe pain medication, medications for stent discomfort, and a few days of antibiotics, if needed.

Advantages of laser lithotripsy over shock wave therapy:

• Higher success rates
• A lower chance of stone fragments blocking your ureter (steinstrasse)
• Less limited by location, hardness, or size of stones
• Effective on multiple stones
• Can be used if you’re on blood thinners or pregnant

The difference between laser and shock wave lithotripsy is how your provider breaks up stones. Laser lithotripsy breaks stones up more directly, from inside of your body, with a laser. ESWL breaks them up from outside of your body with shock waves.

Laser lithotripsy is generally more effective in fragmenting stones that ESWL may not be able to address due to factors such as size, location, or hardness. However, laser lithotripsy involves the insertion of a surgical device into the body, which carries certain risks that are not associated with shock wave lithotripsy.

3) PCNL

Percutaneous nephrolithotomy (PCNL) is a technique used to remove certain stones in the kidney or upper ureter (the tube that drains urine from the kidney to the bladder) that are too large to pass on their own or don’t respond to other forms of stone treatment such as ESWL or ureteroscopy. “Percutaneous” means that the procedure occurs through the skin. “Nephrolithotomy” means the removal of a calculus (kidney stone) from a kidney.

Dr. Caldwell will make a small incision (cut) in your back or side to access your kidneys and remove the kidney stone. Typically, the length of the surgery is 3 to 4 hours. This procedure has resulted in significantly less post-operative pain, a shorter hospital stay, and earlier return to work and daily activities when compared to open stone surgery.

What to expect?

• During most PCNL procedures, you’ll lie on your stomach, so Dr. Caldwell can access your kidney through your back. However, the physician may position you on your back.
• The anesthesiologist will sedate you with general anesthesia, so you won’t be awake, won’t move, and won’t feel any pain during the procedure.
• Once you’re asleep, Dr. Caldwell will make a small (approximately 1 cm or smaller) incision in the flank area.
• Next, he will insert a protective sleeve (sheath) through the incision and into your kidney and insert a small video camera (nephroscope) into the sheath to locate and remove the kidney stone.
• If necessary, Dr. Caldwell may use a laser or shock wave device (lithotripter) to break the stone into smaller pieces before removing it.
• After removing the kidney stone, Dr. Caldwell may install a drainage tube or a ureteral stent. These help drain urine and promote healing.
• He will then use stitches to close your skin incisions.
• Recovery typically takes 2 to 4 weeks.

This technique has a higher success rate for clearing all stones in one setting compared to other techniques, such as ESWL, which often requires several attempts. Percutaneous nephrolithotomy has a success rate of approximately 75% to 98%.

References:

1. MedlinePlus: https://medlineplus.gov/ency/article/007113.htm
2. National Kidney Foundation: https://www.kidney.org/kidney-topics/extracorporeal-shock-wave-lithotripsy-eswl
3. Cleveland Clinic: https://my.clevelandclinic.org/health/procedures/16285-holmium-laser-lithotripsy
4. Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/percutaneous-nephrolithonomy-pcnl
5. Cleveland Clinic: https://my.clevelandclinic.org/health/treatments/17349-percutaneous-nephrolithotomy