Extracorporeal shock wave lithotripsy (ESWL)

Please follow this link https://urology.jhu.edu/kidney/stones.php for more information about kidney stone disease.

The introduction of ESWL in the early 1980s revolutionized the treatment of patients with kidney stone disease. Patients who once required major surgery to remove their stones could be treated with ESWL, and not even require an incision. As such, ESWL is the only non-invasive treatment for kidney stones, meaning no incision or internal telescopic device is required.

ESWL involves the administration of a series of shock waves to the targeted stone. The shock waves, which are generated by a machine called a lithotripter, are focused by x-ray onto the kidney stone. The shock waves travel into the body, through skin and tissue, reaching the stone where they break it into small fragments. For several weeks following treatment, those small fragments are passed out of the body in the urine.

In the two-plus decades since ESWL was first performed in the United States, we have learned a great deal about how different patients respond to this technology. It turns out that we can identify some patients who will be unlikely to experience a successful outcome following ESWL, whereas we may predict that other patients will be more likely to clear their stones. Although many of these parameters are beyond anyone's control, such as the stone size and location in the kidney, there are other maneuvers that can be done during ESWL treatment that may positively influence the outcome of the procedure. At the Brady Urological Institute, our surgeons have researched techniques to make lithotripsy safer and more effective, and we incorporate our own findings as well as those of other leading groups to provide a truly state of the art treatment.

Advantages of ESWL

The primary advantage of ESWL is that it is completely non-invasive.

Who should be treated with ESWL?

ESWL is well suited to patients with small kidney stones that can be easily seen by x-ray.

ESWL is NOT a particularly good treatment for:

Pregnant patients

Patients on "blood thinners" or patients with bleeding disorders. Aspirin or other blood thinners must be discontinued for at least 1 week prior to ESWL.

Patients with chronic kidney infection, as some fragments may not pass, so the bacteria will not be completely eliminated from the kidney.

Patients with obstruction or scar tissue in the ureter, which may prevent stone fragments from passing.

Patients who require immediate and/or complete clearance of stone material.

Patients with stones composed of cystine and certain types of calcium, as these stones do not fragment well with ESWL.

Our Surgeons

Justin Benabdallah, M.D.
Office: 202-660-5561
Email: jbenabd1@jhmi.edu

Brian Matlaga, M.D., M.P.H.
Appointments: 410 955-6100
Office: 443-287-3193
Prior To The Procedure

What to expect during you preoperative consultation

During your initial consultation with your surgeon, he will review your medical history as well as any outside reports, records, and outside Xray films (e.g. CT scan, MRI, sonogram). A brief physical examination will also be performed at the time of your visit. If your surgeon determines that you are a candidate for this procedure, you will then meet with a Patient Service Surgery Coordinator to arrange for the date of your procedure.

NOTE: It is very important that you gather and bring all of your Xray films and reports to your initial consultation with your surgeon.

What to expect prior to the procedure

Since insurance companies will not permit patients to be admitted to the hospital the day before surgery to have tests completed, you must make an appointment to have pre-operative testing done at your family doctor or primary care physician's office within 1 month prior to the date of surgery.

For Johns Hopkins Hospital Patients: These results need to be faxed by your doctor's office to the Pre-operative Evaluation Center at 443-287-9358 two weeks prior to your surgery. Please call The Documentation Center at 410-955-9453 two weeks before your surgery date to confirm that this information was received.

Once your surgical date is secured, you will receive a form along with a letter of explanation to take to your primary care physician or family doctor in order to have the following pre-operative testing done prior to your surgery.

  • Physical exam

  • EKG (electrocardiogram)

  • CBC (complete blood count)

  • PT / PTT (blood coagulation profile)

  • Comprehensive Metabolic Panel (blood chemistry profile)

  • Urinalysis

Preparation for the procedure

Medications to Avoid Prior to Surgery

Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix and some other arthritis medications can cause bleeding and should be avoided 1 week prior to the date of surgery (Please contact your surgeon's office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval).

It is very important that your last urine culture was negative prior to having this procedure. Please call the physician's office at least one week before this procedure to confirm your urine culture results. If you suspect that you may have a urinary tract infection, please call the physician office immediately so that proper antibiotics can be prescribed before your surgery.

The Procedure


Because ESWL is a completely non-invasive therapy, most ESWL treatments are performed on an outpatient basis.

Although the use of anesthesia does depend on patient and physician preference, recent data suggest that the results of ESWL may be improved with the administration of a mild anesthetic.

When the patient has been adequately anesthetized, a computerized x-ray machine is used to pinpoint the location of the stone within the kidney. A series of shock waves (several hundred to two thousand) is administered to the stone. Our treatment protocols incorporate the latest research findings which suggest that adjustments of both the shock wave power and the rate at which the shock waves are delivered can affect treatment outcome. Our goal when performing ESWL is to maximize the breakage of a patient's kidney stone while minimizing injury that the shock waves can cause to the kidney and surrounding organs.

Typically, an ESWL procedure lasts for approximately one hour.

What To Expect After Procedure

  • Pain: Most patients experience some degree of discomfort for a day or two after ESWL. The pain is usually described as a dull ache over the kidney, and is typically at its worst the evening following surgery. The pain lessens over the following days.

  • Bleeding: It is normal to see blood in the urine for several weeks after surgery.

  • How do I know if ESWL was successful?

    Several weeks following ESWL treatment, your urologist will perform a follow-up x-ray, to determine if the stone broke up into small pieces, and if those small pieces passed out of the kidney. If the stone has broken up into small fragments, but the fragments have not cleared, the x-rays may be repeated again following another several weeks.
    If the stone has not broken up into small fragments, your urologist will likely recommend further treatment. In most cases, if the stone does not break up following one ESWL treatment, more ESWL treatments are unlikely to be successful. In this situation, other treatments, such as ureteroscopy or percutaneous nephrolithotomy, may be recommended.

When To Call Your Doctor

Although ESWL is a safe treatment, it is important to note that adverse events, although uncommon, do occur. You should contact your doctor if any of the following occur:
  • Increasing pain, or pain that is getting worse instead of getting better. This may indicate either that there is bleeding around the kidney as a result of ESWL or that the kidney stone fragments have all fallen into the ureter and are blocking the drainage of urine from the kidney.

  • Large amounts of blood or blood clots in the urine, which may indicate that the kidney was injured by ESWL treatment.

  • Fever, which may indicate that there is a serious kidney infection.