Stenting Around ESWL: Guideline Recommendations
Routine stenting before ESWL should not be performed, as it does not improve stone-free rates and may increase patient morbidity. 1
Pre-ESWL Stenting
The most recent 2025 European Association of Urology guidelines are unequivocal on this matter:
Routine prestenting before ESWL does not improve stone-free rates but may reduce steinstrasse (stone street formation). 1
The American Urological Association/Endourological Society guidelines similarly state that routine stenting should not be performed in patients undergoing SWL (Strong Recommendation; Evidence Strength: Grade B). 1
Nuanced Exception for Renal Stones
While routine prestenting is not recommended, the EAU guidelines note that prestenting may improve treatment outcomes specifically for renal stones (not ureteral stones). 1 This is a selective consideration, not a blanket recommendation.
Evidence Supporting No Routine Prestenting
Multiple research studies support the guideline position:
A 2012 prospective randomized study found that pre-treatment stenting significantly lowered stone-free rates (68.6% vs 83.7%, p=0.026) and was associated with increased post-treatment lower urinary tract symptoms, need for more ESWL sessions, and higher operation rates due to ESWL failure. 2
A 2010 study of impacted upper ureteral stones showed no significant difference in stone-free rates between stented (90%) and non-stented (86.7%) groups (p=0.346), while stented patients experienced significantly more dysuria, urgency, frequency, and suprapubic pain. 3
A 1991 randomized trial of large renal calculi found that ureteral stents did not reduce post-ESWL complications and were clearly associated with morbidity including stent calcification (in stents left longer), migration, and bladder discomfort in almost half of patients. 4
Even in pediatric populations, a 2025 study of 277 renal units showed no significant difference in stone-free rates (60.6% vs 68.4%, p=0.36) or complication rates (15.2% vs 14.3%, p=0.79) between stented and non-stented groups. 5
Post-ESWL Stenting
Post-ESWL stenting is not addressed separately in the guidelines, as the stenting recommendations provided apply to the context of URS (ureteroscopy), not ESWL. 1
For URS procedures, the guidelines specify:
- Routine post-URS stenting is unnecessary after uncomplicated procedures and may increase morbidity. 1
- Stenting is advised in cases with trauma, residual fragments, bleeding, perforation, UTI, or pregnancy. 1
Clinical Algorithm for Stenting Decisions with ESWL
For most patients undergoing ESWL:
- Proceed without prestenting 1
Consider selective prestenting only if:
- Large renal stones (>200 mm² stone burden) where improved outcomes may justify the morbidity trade-off 1
- Anatomic obstruction distal to the stone (which is actually a contraindication to ESWL itself) 1
Accept that prestenting may reduce steinstrasse risk but:
- This benefit does not outweigh the decreased stone-free rates and increased patient morbidity 1, 2
- Steinstrasse occurs in only 4% of ESWL cases overall 1
Common Pitfalls to Avoid
Do not routinely stent "just to be safe" – the evidence shows this approach worsens outcomes and increases patient suffering. 1, 3, 2
Do not confuse URS stenting recommendations with ESWL stenting – these are different procedures with different evidence bases. 1
If a stent is placed, remove it promptly – prolonged stenting leads to calcification and migration complications. 4
Use alpha-blockers to improve stent tolerability if stenting is deemed necessary for specific clinical reasons. 1