ESWL: Shock Wave Lithotripsy from Outside the Body
Breaking the stone with sound waves delivered from outside, with nothing entering the body. It is non-invasive, but it does not suit every stone and a result in one session cannot be guaranteed.
Last medically reviewed: October 4, 2026 — Assoc. Prof. Dr. Müslüm Ergün
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- Procedure time
- 30–60 minutes
- Anesthesia
- Painkillers or light sedation
- Hospital stay
- None — day case
- Stay in Türkiye
- 3–5 days (for one session)
- Return to work
- 1–2 days
- Flight clearance
- 1–2 days
About the condition
ESWL (extracorporeal shock wave lithotripsy) uses sound waves delivered from a head in contact with the skin, focused on the stone so as to break it into small pieces. No instrument is passed into the body and no incision is made. The patient usually goes home a few hours after the procedure.
IMPORTANT: THE STONE DOES NOT COME OUT DURING THE PROCEDURE. ESWL breaks the stone; the fragments then pass out on their own with the urine over the following days and weeks. Colicky pain can occur while they pass. So the point at which you can say "the stone has gone" is not the day of treatment but the follow-up imaging.
IT DOES NOT SUIT EVERY STONE, AND THAT IS NOT A DETAIL BUT THE DECIDING FACTOR. Three things govern success: the hardness of the stone, its size and its distance from the skin. If the density measured on CT (the Hounsfield value) is high, the stone is hard and more difficult to break with sound waves. In heavier patients the distance between skin and stone increases and the energy reaching it falls. Stones in the lower pole of the kidney may also be hard to clear because gravity works against the fragments.
MORE THAN ONE SESSION MAY BE NEEDED. Where a single session does not fully clear the stone, the procedure is repeated, usually after a gap of a few weeks. That is not a failure but a known feature of the method. Be wary of anyone who tells you it will be finished in one session.
A urine culture before the procedure is compulsory. Breaking a stone while an untreated infection is present can allow bacteria to enter the bloodstream. The schedule for blood-thinning medication must also be arranged in advance, because ESWL carries a bleeding risk.
Who is it suitable for?
May be suitable
- Patients with a small to moderately sized stone in the kidney or upper ureter
- Patients whose stone is of low density on CT, that is softer
- Patients who are not very overweight, where the skin-to-stone distance is favourable
- Patients who do not want, or for whom it is risky to have, an anaesthetic
- Patients whose kidney anatomy allows the fragments to clear
- Children — in selected cases it is among the preferred methods
May not be suitable
- Pregnant women — it is absolutely not performed
- Patients with an untreated urinary tract infection — the infection is treated first
- Patients with a bleeding disorder, or whose blood thinners cannot be stopped
- Patients with a narrowing below the stone obstructing urine flow — the fragments cannot pass
- Patients with a very hard (high-density) or very large stone
- Patients with uncontrolled high blood pressure
- Patients in whom the distance to the skin means the waves cannot reach the stone adequately
Technology used
- Lithotripter — a focused shock wave generator
- Targeting the stone with fluoroscopy and/or ultrasound
- Measuring stone density (Hounsfield) and skin-to-stone distance on non-contrast CT
- Confirming stone clearance with follow-up imaging
- Stone analysis and assessment aimed at preventing recurrence
Surgeon's experience
Verifiable information
- Surgeon's experience
- Assoc. Prof. Dr. Müslüm Ergün121270
Step-by-step journey
- Step 1
Assessing suitability
Non-contrast CT measures the size, density and skin distance of the stone. These three figures largely indicate whether ESWL will work.
- Step 2
Screening for infection
A urine culture is taken. If there is infection the procedure is postponed and the infection treated first; this step cannot be skipped.
- Day of the procedure
Delivering the shock waves
The patient lies on the table, the stone is targeted using imaging and focused waves are delivered. The procedure takes 30–60 minutes; painkillers or light sedation are enough.
- First days
The fragments pass
The broken pieces begin to pass with the urine. Colicky pain and blood in the urine can occur during this time; plenty of fluids are advised.
- Weeks 2–4
Follow-up imaging
Clearance is assessed with imaging. If fragments remain, a second session or a different method is planned.
- Afterwards
Prevention plan
If a passed fragment can be collected it is analysed chemically, and a fluid and diet plan is drawn up to prevent recurrence.
Method comparison
| Criterion | ESWL | RIRS |
|---|---|---|
| Entering the body | None — entirely from outside | Through the urinary passage, no incision |
| Anaesthesia | Painkillers or light sedation | General anaesthesia |
| Effect of stone hardness | Decisive — success falls with hard stones | Less affected by hardness |
| When the result appears | Over weeks, as fragments pass | During the procedure |
| Number of sessions | May be more than one | Usually a single session |
| JJ stent | Usually not needed | Usually placed |
| Return to work | 1–2 days | 3–7 days |
ESWL is less invasive but its result is less predictable. It is an excellent option for a suitable stone and a waste of time for an unsuitable one. The decision rests on the density and distance measurements from the CT.
Risks
- NOT CLEARING IN ONE SESSION: the most frequent outcome to allow for. More than one session may be needed; this is not a complication but a known feature of the method
- Severe colicky pain as the fragments pass
- STEINSTRASSE ("stone street"): fragments lining up in the ureter and causing obstruction; this may require a further procedure
- Blood in the urine — expected for a few days after the procedure
- Bleeding or a haematoma around the kidney — uncommon
- Infection and blood poisoning — which is why a urine culture beforehand is compulsory
- Fragments not clearing completely, leaving stone behind
- Recurrence of the stone — if no preventive measures are taken
Alternatives
- Surveillance and a trial of medical expulsive therapy — for small stones that have moved down
- RIRS (laser fragmentation with a flexible endoscope) — gives a more predictable result for hard stones and lower pole stones
- PCNL — for large and staghorn stones
- Ureteroscopy — for stones in the ureter
- Going straight to an endoscopic method where stone density is very high — to avoid a futile ESWL session
Recovery
First 24 hours
Tenderness in the flank and a pink tinge to the urine are expected. Plenty of fluids help the fragments to pass.
Days 2–7
The fragments begin to pass; colicky pain can occur. Take the painkiller your doctor advises. Fever, shivering or inability to pass urine require prompt medical attention.
Weeks 2–4
Passage of the fragments is largely complete. Follow-up imaging is carried out during this period.
Afterwards
If fragments remain, a second session or an endoscopic method is planned. A preventive plan is applied according to the stone analysis.
Frequently asked questions
Will the stone come out during the procedure?
No. ESWL breaks the stone, it does not remove it. The fragments pass out on their own with the urine over the following days and weeks. For that reason we judge the result not on the day of treatment but on follow-up imaging at 2–4 weeks.
Will one session be enough?
It cannot be guaranteed. In some patients one session is enough; in others a second or even a third is needed. That is a known feature of the method and is not counted as a failure. Be wary of anyone guaranteeing a single session.
Is my stone suitable for ESWL?
Three measurements decide it: the density (hardness) of the stone on CT, its size and its distance from the skin. For hard, very large or deeply placed stones the chance that ESWL will work falls, and going straight to an endoscopic method saves you time.
Is it painful?
There is a tapping sensation where the waves pass. Most patients are comfortable with painkillers or light sedation; a general anaesthetic is usually not needed. The real discomfort is not during the procedure but in the days afterwards, as the fragments pass.
What is steinstrasse?
It is when the fragments line up in the ureter and cause an obstruction; the name means "stone street". It causes pain and blocks the flow of urine. It often clears on its own, but sometimes a JJ stent or an endoscopic procedure is needed.
Why is a urine culture requested before the procedure?
Because breaking a stone while an untreated infection is present can allow bacteria to enter the bloodstream. That is a serious situation and it is preventable. Taking a culture and, where needed, treating the infection first is therefore a step that cannot be skipped.
I take blood thinners — can I have it?
Because ESWL carries a bleeding risk, blood-thinning medication must be assessed beforehand. If the drug cannot be stopped, ESWL may not be suitable, and RIRS then comes into consideration as a safer option.
When can I fly?
Usually after 1–2 days. Bear in mind, though, that colicky pain can occur as the fragments pass, which may be unpleasant on a long flight. A stay of 3–5 days is planned for patients travelling from abroad.
Will my stone come back?
Stone disease can recur if no preventive measures are taken. If you can collect a passed fragment, keep it; its chemical analysis forms the basis of the plan to prevent recurrence.
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This page is for general information only and is not a substitute for medical advice.
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