Is a 10mm radiopaque calculus in the left kidney with a double-J (double J ureteral) stent in place an indication for Extracorporeal Shock Wave Lithotripsy (ESWL)?

From the Guidelines

Extracorporeal Shock Wave Lithotripsy (ESWL) is a suitable treatment option for the multiple radiopaque calculi in the left kidney, with the largest measuring 10 mm, especially with a double-J stent already in place. The size of the stone, 10 mm, falls within the recommended range for ESWL, which is typically used for kidney stones between 4-20 mm in size 1. The presence of a double-J stent is beneficial as it helps with urinary drainage and can prevent complications like ureter obstruction from stone fragments after ESWL.

Key Considerations

• The procedure works by delivering focused shock waves that break the stones into smaller fragments, which can then pass naturally through the urinary tract.
• The stent facilitates this passage and reduces the risk of "steinstrasse" (stone street) formation, a known complication of ESWL, as indicated in the 2007 guideline for the management of ureteral calculi 1.
• For stones of this size, ESWL typically achieves a success rate of 70-90%, though multiple sessions might be needed depending on stone composition and location.
• Post-procedure, the patient will likely need to maintain adequate hydration and may require pain medication as fragments pass.
• Follow-up imaging will be necessary to confirm complete stone clearance.

Treatment Options

• Both SWL and URS are acceptable first-line treatments for patients requiring stone removal, according to the guideline 1.
• However, considering the specific case of a 10 mm stone with a double-J stent in place, ESWL is particularly suitable due to its non-invasive nature and the reduced risk of complications associated with the stent.
• The patient should be informed about the existing active treatment modalities, including the relative benefits and risks associated with each modality, as recommended by the guideline 1.

From the Research

Indications for ESWL

• The presence of a multiple radiopaque calculus shadow at the left kidney, with the largest measuring 10 mm, along with a double-J stent in place, may be considered for Extracorporeal Shock Wave Lithotripsy (ESWL) treatment.
• Studies have shown that ESWL can be effective in treating kidney stones, including those with a size similar to the one mentioned 2, 3.

Role of Double-J Stents

• Double-J stents are often used to reduce complications following ESWL, but their use is not without controversy 4, 5.
• Some studies suggest that double-J stents do not enhance stone passage or reduce complications following ESWL, and their use should be limited to specific conditions, such as patients with solitary kidneys 4.
• However, other studies recommend the use of double-J stents in patients with stones larger than 13 mm, as in the case of infants 2.

Treatment Outcomes

• The outcome of ESWL treatment for kidney stones, including those with a double-J stent in place, can be successful, with stone-free rates ranging from 88% to 91% 5, 2.
• However, complications can occur, including hematuria, pain, fever, and encrustation of the stone on the double-J stent 3, 6.

Specific Considerations

• The size of the stone, in this case, 10 mm, is considered relatively small, and ESWL may be a suitable treatment option 2, 3.
• The presence of a double-J stent may require additional consideration, as it can affect the treatment outcome and increase the risk of complications 4, 5, 6.