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

Post-Lithotripsy Protocol for ESWL

According to the most recent European Association of Urology guidelines, antimicrobial prophylaxis is not recommended for extracorporeal shock wave lithotripsy (ESWL), but post-procedure monitoring for complications and adjunctive therapies to enhance stone passage are essential components of care. 1

Post-ESWL Monitoring and Management

Immediate Post-Procedure Care

• Pain management: Non-opioid analgesics like diclofenac are effective for most patients undergoing ESWL 2
• Hydration: Encourage increased fluid intake to facilitate stone fragment passage
• Activity: Normal activity can be resumed, with no specific restrictions required

Adjunctive Therapies

• Medical expulsive therapy (MET): Alpha-blockers should be prescribed after ESWL to facilitate passage of stone fragments 1
• Mechanical percussion: Can be used as an adjunct to enhance stone passage 1
• Diuretics: May be considered to increase urine flow and aid fragment elimination 1

Monitoring for Complications

Common Complications to Monitor

• Steinstrasse (stone street): Occurs in approximately 4% of cases 1
• Macroscopic hematuria: Common (17.2%) and typically self-limiting 1
• Pain: Occurs in about 12.1% of patients 1
• Renal colic: Occurs in 2-4% of patients 1
• Infectious complications:
  • Bacteriuria in non-infection stones (7.7-23%)
  • Sepsis (0.15%) 1

Rare but Serious Complications

• Symptomatic hematoma: Occurs in 0.21% of cases 1
• Asymptomatic hematoma: Occurs in 1.2% of cases 1
• Cardiovascular effects: Dysrhythmias can occur in 11-29% of patients 1

Follow-up Protocol

Imaging Follow-up

• Imaging should be performed to assess stone clearance
• The timing depends on stone size and location, typically 2-4 weeks post-procedure

Indications for Additional Intervention

• Persistent obstruction
• Significant residual fragments (>4mm)
• Infection
• Intractable pain

Special Considerations

Antibiotic Prophylaxis

• According to the 2024 EAU guidelines, antimicrobial prophylaxis is not recommended for ESWL 1
• However, for patients with specific risk factors (positive preoperative urine culture, indwelling nephrostomy tube or stent, history of recurrent UTIs, or immunocompromised status), antibiotic prophylaxis should be considered 3

Stenting Considerations

• Routine stenting before ESWL is not recommended as it does not improve stone-free rates 1
• However, stenting may be beneficial in reducing steinstrasse formation 1

Clinical Pitfalls to Avoid

1. Failure to recognize steinstrasse: Monitor for signs of obstruction and intervene promptly
2. Inadequate pain management: Some patients may require stronger analgesia than initially anticipated
3. Missing infectious complications: Watch for fever, chills, or increasing pain which may indicate infection
4. Overlooking residual fragments: Fragments can lead to stone regrowth (21-59% of cases) 1
5. Ignoring cardiovascular symptoms: Especially in patients with pre-existing cardiac conditions

By following this protocol, clinicians can optimize outcomes after ESWL while minimizing complications and the need for additional interventions.