Rumors of my death have been greatly exaggerated.

Mark Twain

Prior to the 1980s, open lithotomy was commonplace for treating both ureteric and renal stones. The advent of shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous surgery (PCNL) rapidly changed the field. Although technological improvements have led to stepwise improvements in URS and PCNL, with miniaturization and improved treatment modalities, SWL has remained largely unchanged. In fact, although SWL treatments became easier since the original Dornier HM3 lithotripter (Dornier MedTech), which required anesthesia and immersion in a water bath, this has been at the compromise of treatment efficacy. Modern machines are smaller and do not require anesthesia, but this has been at the cost of treatment power (Figure). Technological advancements in URS/PCNL continue, with recent developments in suction devices now offering potential for improved stone clearance.¹ Correspondingly, many countries have seen a decrease in SWL rates, while URS rates have significantly increased.^2,3

However, SWL is far from dead and arguably may see a renaissance. In the UK, the guidance from the National Institute for Clinical Excellence on Stone Disease (2019) has recommended SWL as first-line treatment for renal and ureteral stones up to 10 mm in size.⁴ This is based on evidence of efficacy and economic analysis in the UK National Health Service public system; this might not apply in other health systems, but the principle of a highly efficacious, inexpensive, and noninvasive treatment is attractive to public health systems and patients if truly offered an equitable choice. In our opinion, this does rely on SWL being delivered without general or spinal anesthesia, which is one of the key advantages. This is standard practice in many countries around the world. In the UK (as in many countries), SWL is only performed with patients awake with or without analgesia. This is not delivered in an operating theater and is typically delivered by highly trained technicians (usually radiographers or nurses) who run the daily service.

Key advantages and disadvantages are listed in the Table. Disadvantages include high initial capital cost (this is often not included in economic analyses, assuming the equipment is already in place) and greater uncertainty following treatment, given that not all stones fragment with SWL and the fragments do need to pass, with the risk of colic and emergency department visits. However, this is offset with the avoidance of a ureteral stent. This is expressly not recommended prior to SWL by international guidelines.^5,6

Table. Advantages and Disadvantages of Shock Wave Lithotripsy

In our opinion, keys to a successful SWL program are as follows: fixed-site lithotripter, dedicated team to deliver care, outpatient treatment without general anesthesia/sedation, and appropriate patient selection.

Patient selection is paramount to good outcomes, and care should be taken to look at both patient and stone factors. Not all patients will do well; not all stones will break. Although studies have shown high success rates for SWL of nearly 80% for all ureteral stones,⁷ success for renal stones is much more variable. For renal stones, lower pole anatomy is a factor and should be considered, although this does not preclude SWL.⁸ Choosing appropriate stone volumes/density is important, and careful patient selection will lead to good outcomes. Care must be taken to ramp up the power with close patient observation. Appropriate treatment breaks may be necessary depending on patient tolerance. We have a television on the ceiling for patients to watch, and this has been shown to improve tolerance,⁹ or patients may choose to listen to their own music.

Early trials in a new technology, burst wave lithotripsy, are promising and could revolutionize outpatient treatment with a simple handheld device to target stones.¹⁰ New alternative versions of lithotripsy with microbubble-enhanced acoustic cavitation may revitalize interest in lithotripsy as a concept.

It is always an interesting question in medicine: What would you do if it were you? Would you choose the no-anesthetic, noninvasive option? What is there to lose? SWL is alive and kicking.