Contraindications of Extracorporeal Shock Wave Lithotripsy (ESWL)
ESWL is absolutely contraindicated in pregnancy, bleeding disorders, uncontrolled urinary tract infection, arterial aneurysm near the stone, and anatomic obstruction distal to the stone. 1
Absolute Contraindications
The following conditions represent absolute contraindications where ESWL must not be performed:
- Pregnancy: ESWL is strictly contraindicated due to potential fetal harm from shock wave exposure 1, 2
- Bleeding disorders: Uncorrected coagulopathy significantly increases hemorrhagic risk and represents an absolute contraindication 1, 2
- Uncontrolled urinary tract infection: Active, untreated UTI must be resolved before proceeding with ESWL 1, 2
- Arterial aneurysm near the stone: Shock waves can rupture vascular aneurysms in the treatment field 1, 2
- Anatomic obstruction distal to the stone: Downstream obstruction prevents fragment passage and increases complication risk 1, 2
Relative Contraindications and High-Risk Scenarios
Anticoagulation and Antiplatelet Therapy
Patients on antithrombotic therapy require careful pre-procedural management, as ESWL is classified as a high bleeding-risk procedure. 1, 2
- Patients with low thromboembolic risk (e.g., previous myocardial infarction on aspirin alone): Discontinue antiplatelet therapy 8 days prior to ESWL to allow platelet function recovery 3
- Patients with high thromboembolic risk (e.g., aortocoronary bypass, atrial fibrillation, cerebrovascular disease): Suspend antiplatelet therapy and bridge with unfractionated heparin 5000 IU three times daily for 8 days prior to ESWL, then perform procedure on day 9 3
- Resume antithrombotic therapy within 10-14 days post-procedure once bleeding risk has subsided 3
- Refer all patients on anticoagulation to internal medicine or hematology for risk stratification before deciding on ESWL versus alternative treatment 1, 2
Severe Obesity and Skeletal Malformations
- Severe obesity limits shock wave penetration and stone targeting, making ESWL technically difficult or impossible 1
- Skeletal malformations may prevent proper patient positioning or shock wave delivery 1
Cardiac Device Considerations
- Patients with pacemakers or defibrillators: ESWL is feasible with technical precautions; newer lithotripters may eliminate the need for device reprogramming, though coordination with cardiology is prudent 1
- Monitor for cardiac dysrhythmias, which occur in 11-29% of patients during ESWL 1, 2
Clinical Scenarios Where ESWL Should Not Be First-Line
While not absolute contraindications, the following scenarios warrant alternative treatment approaches:
- Renal stones >20 mm: PCNL offers superior stone-free rates and should be first-line therapy 1, 2
- Lower pole stones >10 mm: Poor drainage and gravity-dependent fragment clearance make ESWL suboptimal 2, 4
- Obstructing stones with suspected infection: Urgent drainage via nephrostomy or ureteral stent must precede definitive stone treatment to prevent sepsis 1
Critical Management Pitfalls to Avoid
- Never perform ESWL in the setting of active infection and obstruction without first establishing drainage, as this can precipitate life-threatening sepsis 1
- Do not proceed with ESWL in patients with uncorrected bleeding disorders; consider ureteroscopy as an alternative, though this recommendation is based on low-quality evidence 5
- Avoid routine pre-stenting, as it does not improve stone-free rates but may reduce steinstrasse formation in select cases 1
- Ensure proper acoustic coupling between the treatment head and skin, as air pockets deflect shock waves and reduce efficacy 1
Special Populations Requiring Modified Approach
Hypertensive Patients
- Hypertension is a risk factor for post-ESWL renal hematoma (46% of hematoma cases were hypertensive) 6
- While the link between ESWL and new-onset hypertension remains unclear with no conclusive evidence of long-term adverse effects, monitor blood pressure closely in hypertensive patients 1