What is the recommended post lithotripsy (extracorporeal shock wave lithotripsy) protocol for patients?

Post-Lithotripsy Protocol

According to the most recent European Association of Urology guidelines, antimicrobial prophylaxis is not recommended for extracorporeal shock wave lithotripsy (ESWL) procedures. 1

Pre-Procedure Considerations

Antibiotic Prophylaxis

• Antimicrobial prophylaxis is not recommended for ESWL according to the 2024 EAU guidelines 1
• However, prophylaxis should be considered in special circumstances:
  • Patients with positive preoperative urine culture
  • Patients with indwelling nephrostomy tubes or stents
  • History of recurrent UTIs
  • Immunocompromised patients 2

Contraindications for ESWL

ESWL should not be performed in patients with:

• Pregnancy 1
• Bleeding disorders 1
• Uncontrolled urinary tract infection 1
• Severe obesity 1
• Skeletal malformations 1
• Arterial aneurysm near the stone 1
• Anatomic obstruction distal to the stone 1

Post-Procedure Protocol

Monitoring for Complications

1. Stone Fragment Complications

   • Steinstrasse (stone street) occurs in approximately 4% of cases 1
   • Macroscopic hematuria (17.2%) 1
   • Pain (12.1%) 1
   • Renal colic (2-4%) 1

2. Infectious Complications

   • Bacteriuria in non-infection stones (7.7-23%) 1
   • Sepsis (0.15%) 1

3. Tissue Complications

   • Symptomatic hematoma (0.21%) 1
   • Asymptomatic hematoma (1.2%) 1
   • Cardiovascular dysrhythmias (11-29%) 1

Pain Management

• Non-opioid analgesics like diclofenac are effective for most patients undergoing lithotripsy 3
• Reserve stronger analgesia for patients with more severe pain

Adjunctive Therapies

The following adjunctive therapies can enhance stone passage after ESWL:

• Medical expulsive therapy (MET) using alpha-blockers 1
• Mechanical percussion 1
• Diuretics 1

Follow-up Imaging

• Follow-up imaging is essential to assess stone clearance
• Monitor for residual fragments, which may regrow (21-59% of cases) 1
• Additional procedures may be required in 6-9% of cases 1

Special Considerations

Stenting

• Routine stenting before ESWL is not recommended as it does not improve stone-free rates 1
• However, stenting may reduce the risk of steinstrasse formation 1
• Alpha-blockers can improve stent tolerability if stenting is required 1

Technical Factors Affecting Outcomes

• Decreasing shockwave frequency (60-90/min instead of 120/min) improves stone-free rates and reduces tissue damage 1
• Proper acoustic coupling between the treatment head and skin is crucial 1
• Stepwise energy ramping minimizes renal injury 1

Common Pitfalls to Avoid

1. Failing to identify high-risk patients who might need additional monitoring
2. Inadequate pain management leading to poor patient experience
3. Missing signs of complications such as infection or significant hematuria
4. Not providing appropriate follow-up to ensure stone clearance
5. Overlooking the potential for stone regrowth in patients with residual fragments

By following this protocol, clinicians can optimize outcomes and minimize complications following ESWL procedures.