Since its introduction in the late 1970s, shock wave lithotripsy (SWL) has been the gold standard for the treatment of small renal calculi.¹ However, in recent years there has been a significant shift towards the use of ureteroscopy (URS) for the treatment of stones that could be amenable to SWL. This shift can be attributed to improvements in surgical training and experience, as well as technological improvements of both the ureteroscopes themselves as well as the supporting equipment.²

Given the accelerated pace of development in endoscopic instruments and significant laser improvements, the role of SWL becomes questionable. One of the undisputed arguments in favor of URS over SWL is the higher stone-free rates (SFRs) achieved. However, is the stone-free rate the only measure of success when it comes to treating urolithiasis patients? We think not. Instead of writing off SWL in favor of URS, the choice between SWL and URS is a complex decision that depends on multiple factors, eg the number of treatments required to obtain a stone-free status, the duration of the hospital stay, the need for anesthesia and auxiliary procedures, and the experience and equipment of the center.

One of the important things for SWL is patient selection. In the properly selected patient, up to 91.5% of stones <10 mm in the kidney were successfully treated with SWL.³ One other consideration is the location of the stone. Current AUA guidelines recommend URS as primary management of distal ureteral stones and SWL as a secondary option.¹ Data from our center show that 78.8% of patients with distal ureteral stones treated with SWL were stone-free following 1 session of SWL and required no subsequent procedures.⁴ Similar SFRs have been reported by groups who conduct routine SWL on distal ureteral stones. SWL is still very relevant and effective for distal ureteral stones.

Patient quality of life (QOL) is an important factor to be considered. How often have you come across a patient with anxiety about undergoing URS and the subsequent ureteral stent placement? Such worries from patients are common when URS is proposed and can affect QOL. In a prospective longitudinal study by Hamamoto et al, SWL and URS patients were followed to assess their QOL over 6 months. The SWL group had higher physical function, role-physical function and social function, in addition to better emotional and mental health despite the stone-free rate being significantly lower in the SWL group (72.1 vs. 93%).⁵ Interestingly, this improved QOL was seen not only at 4 weeks postprocedure, but was also present at 6 months postoperatively, suggesting that there is more to QOL than the stone-free rate. Ureteral stent placements following URS are common practice but severely impact patient QOL in up to 80% of patients.⁶ This begs the question: Is treating the stone more important, or is treating the patient more important? These findings suggest that the higher SFR associated with URS compared to SWL comes with the cost of a lower QOL.

The World Health Organization states that climate change is the number one public health challenge of the 21st century. Canada’s health care system produces over 33 million tons of carbon dioxide equivalents each year, representing 4.6% of all greenhouse gas emissions in Canada. Health care waste is the second leading contributor in the U.S., with more than 6,600 tons/day and 4 billion pounds of waste annually.⁷ Operating rooms combined with labor and delivery suites account for approximately 70% of hospital waste. The manufacturing cost of a flexible ureteroscope was 11.49 kg of CO₂ per 1 kg of ureteroscope.⁸ Furthermore, the single-use nature of the materials used in the operating room for URS results in vast amounts of plastic, metal and paper waste. As stated by Dr. Bodo Knudsen, “Surgeons, as end-users of devices, play a critical yet often unaddressed role in waste prevention.”⁹ Although there have been no comparisons between SWL and URS in terms of carbon footprint generated, the idea that SWL produces much less waste is not far-fetched and can be agreed upon by many.

In our opinion, we do not believe SWL is dead. SWL remains an attractive, noninvasive procedure for the treatment of renal calculi, which has similar degrees of SFRs compared to URS, better patient QOL and can assist the world on a path towards net-zero emissions in health care. SWL is still relevant and should maintain a spot in the urologist’s armamentarium.