A 47-year-old male patient presented with bilateral hydronephrosis caused by large ureteral stones in both upper ureters. He initially visited the emergency department due to left flank and lower back pain, where hydronephrosis was detected. Imaging revealed a 10 mm stone in the right upper ureter, a 12 mm stone in the right mid-ureter, and a 10 mm stone in the left upper ureter, all contributing to bilateral obstruction. Surgical treatment was performed using a rigid ureteroscope. An N-Trap device was used to prevent upward migration of the stones, and a holmium laser was applied to fragment and remove them. Multiple large stones were completely cleared within approximately one hour without residual fragments, resulting in a highly satisfactory outcome for both the patient and the medical team.
Urinary stones are a common and often painful condition, and various treatment methods are available. Among them, extracorporeal shock wave lithotripsy (ESWL) is widely used due to its non-invasive nature, accounting for more than 70% of stone treatments. Understanding the different types of lithotripters, along with their advantages and limitations, is essential for selecting the most appropriate treatment.
ESWL is a non-invasive procedure that uses shock waves generated by specialized equipment to break urinary stones into smaller fragments. It is typically used for stones larger than 4 mm that are unlikely to pass spontaneously. Compared to open surgery, ESWL is more convenient for patients and allows for faster recovery.
Lithotripters are generally classified into two main types: spark-gap and electromagnetic (magnetic) systems. The spark-gap type generates shock waves by creating an էլectrical spark between electrodes in water, transmitting energy through the fluid to the stone. While powerful, this method tends to cause more discomfort and requires frequent replacement of electrode components, increasing maintenance costs. In contrast, electromagnetic systems generate high-voltage, high-frequency vibrations using an էլectromagnetic field. These systems typically cause less pain and require fewer consumable replacements, making them more cost-efficient over time. Although the initial purchase cost of electromagnetic devices is higher for medical facilities, they can provide economic benefits from the patient’s perspective.
Despite its advantages, ESWL is not suitable for all patients. Certain conditions require careful consideration before selecting this treatment.
First, patients taking anticoagulants such as aspirin must be managed cautiously. These medications increase the risk of bleeding, and undergoing ESWL while on anticoagulants may lead to persistent bleeding or renal hematoma. It is generally recommended to discontinue such medications at least one week before the procedure under medical guidance.
Second, patients with long-standing stones may develop complications such as urinary tract infection or hydronephrosis. In cases accompanied by high fever or severe infection, immediate ESWL may not be appropriate. Instead, restoring urinary drainage—such as by inserting a ureteral stent—should be prioritized before definitive stone treatment.
Third, large or complex stones may not respond effectively to ESWL. Stones larger than 1 cm or multiple stones often require a more direct and definitive approach using endoscopic surgery, such as ureteroscopy (URS) or retrograde intrarenal surgery (RIRS).
Urinary stones can cause not only severe pain but also serious complications such as infection and obstruction. Therefore, timely and appropriate treatment is essential. The optimal treatment strategy should be determined based on stone size, location, and the patient’s overall condition, with clinical expertise playing a critical role.
When choosing a treatment center for urinary stones, it is important to consider whether the facility has extensive clinical experience and offers a full range of treatment options—not only ESWL but also ureteroscopic and flexible endoscopic procedures such as URS and RIRS. If you are experiencing severe flank pain or suspect urinary stones, prompt evaluation by a urology specialist is strongly recommended.