When should stents be removed after lithotripsy (extracorporeal shock wave lithotripsy)?

Stent Removal Timing After Extracorporeal Shock Wave Lithotripsy (ESWL)

Routine stenting is not recommended after uncomplicated ESWL, and when stents are placed for specific indications (trauma, residual fragments, bleeding, perforation, or infection), they should be removed within 1-2 weeks. 1

Primary Recommendation: Avoid Routine Stenting

• The American Urological Association/Endourological Society provides a Strong Recommendation (Grade B evidence) that routine stenting should NOT be performed in patients undergoing ESWL. 1
• The European Association of Urology similarly recommends against routine prestenting before ESWL, as it does not improve stone-free rates and only marginally reduces steinstrasse formation. 1
• Prospective randomized trials demonstrate that patients with moderate stone burden (7-25 mm) who receive stents experience no reduction in symptomatic ureteral obstruction or improvement in final stone eradication rates compared to unstented patients. 2

When Stents Are Indicated

If stenting is necessary due to complications, the evidence supports removal within 1-2 weeks:

• For complex renal stones or staghorn calculi treated with combination therapy (percutaneous nephrolithotomy plus ESWL), stents may be left indwelling to maintain drainage while fragments pass, though specific duration is not standardized. 3
• In biliary stenting (analogous endoscopic procedure), short-term stenting of 1-2 weeks shows equivalent efficacy to longer durations (8-12 weeks) while avoiding stent clogging complications. 4
• Most urologists managing complex stones remove nephrostomy tubes or stents within 24-48 hours to 5-7 days, with complex stones requiring drainage for at least 24-48 hours. 4

Morbidity of Stent Placement

The evidence overwhelmingly demonstrates that stents cause significant patient morbidity:

• In randomized trials, 85-100% of stented patients experience urinary frequency, urgency, bladder pain, hematuria, and flank pain with urination. 2, 5
• 27% of stented patients require early stent removal due to severe irritation, early migration, or accidental removal. 2
• Stented patients have significantly greater flank pain, abdominal pain, dysuria, and frequency at 1 week post-procedure compared to unstented patients (p <0.005). 6
• Hospital readmission rates and emergency department visits are higher in stented groups in some studies. 7, 8

Clinical Algorithm for Stent Management After ESWL

For uncomplicated ESWL:

• Proceed without stenting. 1, 2, 5
• Stone-free rates of 88-91% are achieved without stenting. 5

For complicated ESWL (trauma, residual fragments >5mm, bleeding, perforation, UTI, pregnancy):

• Place stent intraoperatively. 1
• Remove at 1-2 weeks post-procedure. 4, 1
• Consider "stent-on-string" technique to avoid second anesthetic for removal, particularly in pediatric patients. 4

For large renal stones (>200 mm² stone burden):

• Selective prestenting may be considered as improved outcomes may justify the morbidity trade-off. 1
• Alpha-blockers can improve stent tolerability if stenting is deemed necessary. 1

Common Pitfalls to Avoid

• Do not routinely stent after uncomplicated ESWL - this increases patient morbidity without improving outcomes. 1, 2, 5
• Do not leave stents in place beyond 2 weeks - stents clog rapidly and cause persistent irritative symptoms without additional benefit. 4
• Do not assume stenting prevents steinstrasse - randomized trials show no difference in symptomatic obstruction rates between stented and unstented patients. 2
• Do not delay stent removal in symptomatic patients - up to 27% require early removal due to intolerable symptoms. 2