european urology 52 (2007) 1223–1228

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Stone Disease

Rapid Extracorporeal Shock Wave Lithotripsy for Proximal

Ureteral Calculi in Colic versus Noncolic Patients

Christian Seitz a,*, Enis Tanovic a, Zeljko Kikic a, Mazda Memarsadeghi b, Harun Fajkovic c
a
Medical University of Vienna, Vienna, Austria
b
Department of Radiology, Medical University of Vienna, Vienna, Austria
c
Military Hospital Vienna, Austria

Article info Abstract

Article history: Objectives: In delayed extracorporeal shock wave lithotripsy (ESWL)

Accepted February 5, 2007 treatment, increasing stone impaction is associated with delayed stone
Published online ahead of clearance. Whether colic patients treated by rapid ESWL have the same
print on February 12, 2007 time to stone clearance as noncolic patients, which supports the thesis
that stones in both groups are nonimpacted, has not been investigated
Keywords: yet, and was the objective of this study.
Colic Methods: A total of 82 patients were prospectively enrolled and treated
ESWL with piezoelectric ESWL for a solitary proximal ureteral stone. Of these,
Noncolic 56 patients experienced at least one colic episode compared with 26
Proximal ureter noncolic patients. Hydronephrosis has been assessed with the use of
Stone clearance ultrasound and intravenous urography (IVU). Time to stone clearance
after the first ESWL and stone-free rates after a follow-up period of 3 mo
were recorded.
Results: In colic and noncolic patients, mean stone size was 7.8 mm
( p = 0.7). Ultrasound-detected hydronephrosis was present in 88% versus
39% ( p < 0.0001), whereas IVU-detected hydronephrosis was present in
60% versus 7.7% ( p = 0.0001). Mean number of impulses applied was
8000  4000 versus 6700  3400 ( p = 0.1). Mean time to stone clearance
was 9.5  12.1 d versus 4.6  3.8 d ( p = 0.1). Colic and noncolic patients
were considered as treatment success in 83% and 81% after 3 mo of
follow-up ( p = 0.9).
Conclusions: Treatment outcome and time to stone clearance after rapid
ESWL in colic patients compared with noncolic patients is comparable
and independent of concomitant hydronephrosis. This finding suggests
an absence of significant impaction in proximal ureteral stones treated
within 24 h after a first colic episode, enforcing the concept of performing
rapid ESWL in patients harbouring proximal ureteral stones.
# 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna,
Austria. Tel. +43 (1) 40 400 2616; Fax: +43 (1) 40 400 2332.
E-mail address: drseitz@gmx.at (C. Seitz).
0302-2838/$ – see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2007.02.001
1224 european urology 52 (2007) 1223–1228

1. Introduction ESWL in colic patients was performed within 24 h after their

Extracorporeal shock wave lithotripsy (ESWL) is
currently recommended as first-line therapy for
proximal ureteral stones of any size [1]. The litera-
ture comprises numerous reports with variable suc-
cess rates. This lack of consistency of success rates
is related to stone size, degree of impaction, extent
to which shock wave sessions are repeated, and the
type of lithotripter used. The main purpose of
treatment is to achieve a stone-free status as soon
and as safely as possible, reducing treatment fail-
ures necessitating auxiliary measures. The influ-
ence of symptoms and obstruction on time to stone
clearance remain controversial.
As recently shown, colic patients harbouring
proximal ureteral stones profit from rapid ESWL
(24 h) in terms of a decreased time to stone
clearance and an increased treatment success [2–4].
One explanation is that symptomatic ureteral stones
treated with rapid ESWL are unlikely to be impacted
because they did not have enough time to develop a
surrounding edema. This study investigated rapid
ESWL in proximal ureteral stones in colic patients
compared with noncolic patients on the basis of the
assumption that stones in both groups are not
impacted yet and, therefore, have a favourable time
to stone clearance compared with colic patients
treated with delayed ESWL.
2. Material and methods
A total of 82 patients with a solitary proximal ureteral stone
and either at least one episode of acute renal colic and no
previous active treatment (n = 56), or no colic episode (n = 26)
were prospectively, nonrandomly enrolled in the study at a
single institution between March 2003 and May 2006. Rapid
first colic episode. Noncolic patients were scheduled as soon
as possible, usually within a 5-d period after presentation.
Stones were detected by either noncontrast computerised
tomography (NCCT) when symptomatic or by intravenous
urography (IVU) in the asymptomatic interval. Noncolic
patients harbouring proximal ureteral stones never experi-
enced an episode of colic pain. They were detected inciden-
tally in radiologic or ultrasound investigations of concomitant
diseases or haematuria, or after routine follow-up of prior
urolithiasis. Patients with ureteric strictures or clotting disor-
ders were excluded. Laboratory investigations included
urinalysis, urinary culture, coagulation profile, and serum
creatinine determination. All patients were afebrile, but
urinary cultures were positive in seven individuals (9%) who
received appropriate antimicrobial drugs prior to ESWL.
Stone size was measured by using urinary tract plain X-ray
(KUB). Stents were not routinely placed because they do not
decrease the incidence of steinstrasse in moderate-sized
stones [5].
The presence and degree of a hydronephrosis were
assessed with the use of ultrasound at initial presentation
of the patient. The degree of hydronephrosis was defined as
mild if the renal pelvis only was dilated, and as moderate if the
renal pelvis and calices were dilated. Patients with severe
hydronephrosis and rarefaction of the renal parenchyma were
not observed. The presence of a hydronephrosis was addi-
tionally assessed by performing an IVU (Table 1). Images were
routinely taken 7, 15, 25, and 30 min (postmicturition) after
contrast application. When necessary, further images for up to
5 h were taken. The time for the contrast material to advance
beyond the ureteral stone was recorded prior to ESWL treat-
ment. Results were stratified into three groups: group 1:
excretion within 7 min; group 2: between 7 and 30 min; and
group 3: after 30 min for up to 5 h. Initial ESWL treatment was
performed as an inpatient procedure with the newest Piezolith
3000 (Richard Wolf, Knittlingen, Germany) with dual ultra-
sound/fluoroscopic stone detection. Opacification of the
excretory route was never required. All stones were located
in the proximal ureter, and were radiographically defined as
between the ureteropelvic junction and the pelvic brim. The

Table 1 – Differences between colic patients undergoing rapid ESWL and noncolic patients

N = 82 Age Stone size Creatinine Hydronephrosis

(yr) (mm) (mg/dl)
IVU Sonography

Colic 56 46.4  12.6 7.8  2.4 1.13  0.3 59% 88%

Noncolic 26 47.3  14.8 7.8  3.2 1.06  0.3 7.7% 39%
p value 0.7¥ 0.7¥ 0.1¥ <0.0001 * <0.002 *

IVU excretion IVU excretion Impulses Therapy Therapy success after ESWL (d)
at 7 min (%) at 30 min (%) (103) successz (%)
Colic 48 72 84 83 9.5  12.1 (median: 5.5)
Noncolic 82 88 6.7  3.4 81 4.6  3.8 (median: 3)
p value 0.08 * 0.1¥ 0.7 * 0.1¥

IVU = intravenous urography; ESWL = extracorporeal shock wave lithotripsy.

¥
Wilcoxon test.
*
Fisher exact test.
z
After 3 mo.
 european urology 52 (2007) 1223–1228
urologists performing ESWL were not aware of the study
objective. Routine pain control, when necessary during ESWL,
was intravenous metamizol 2.5 g on demand. Stents were not
inserted prior to ESWL. The time between the first onset of
colic pain and ESWL treatment in colic patients, and the time
between the first ESWL session and stone clearance in colic
and noncolic patients were recorded.
Patients in whom ESWL failed to completely disintegrate
the stone during the first treatment underwent retreatment
the next day. Those in whom ESWL had no impact on the stone
at all during the first session, as evidenced by KUB, underwent
ureterorenoscopy (URS) or percutaneous nephrolitholapaxy
(PNL). Stone-free status was established by KUB and IVU as
well as by NCCT in cases for which residual fragments could
not be excluded. Therapy-refractory colic pain or persistence
of fragments >3 mm after repeated ESWL sessions necessitat-
ing auxiliary procedures was considered indicative of treatment
failure. Patients with stones 3 mm in diameter without the
need for auxiliary measures within a 3-mo follow-up period
were defined as a treatment success. Patients were reviewed 1 d
after each ESWL session with KUB and renal ultrasound to
assess stone fragmentation and hydronephrosis. Incomplete
fragmentation after a maximum of four sessions was con-
sidered an ESWL failure. Follow-up continued for a maximum of
3 mo using KUB and renal ultrasound every 2 wk or after each
stone passage until complete clearance was achieved. Stone
analysis to determine the crystalline structure was carried out
with the use of X-ray diffraction.
Primary and secondary end points were time to stone
clearance and failure rates after ESWL treatment in colic and
noncolic patients.
JMP version 3.2.2 1989–97 software (SAS Institute, Inc, Cary,
NC, USA) was used for statistical analysis. Wilcoxon, Pearson
correlations, and Fisher exact tests were used for comparison
between continuous variables and linear regression.
3. Results
Mean patient age in colic patients was 46.4  12.6 yr
(range: 21–81) and 47.3  14.8 yr in noncolic patients
(range: 29–81; p = 0.7). The maximum stone diameter
in colic compared with noncolic patients was
7.8  2.4 (range: 4–15 mm) versus 7.8  3.2 mm
(range: 4–18 mm).There were no significant differ-
ences in the gender distribution between both
groups ( p = 0.06). Of 82 patients, 56 experienced at
least one colic episode prior to admission and
underwent rapid ESWL. Mean time to ESWL after
a first colic episode was 17.9  6.9 h (range: 4.0–24).
Of colic patients 52% (n = 29) required one session
only, 25% (n = 14) a second, 20% (n = 11) a third, and
4% (n = 2) a fourth session. In the noncolic group 62%
(n = 16) of patients required one session only, 19%
(n = 5) a second, and 19% (n = 5) a third session for
complete stone fragmentation ( p = 0.4). The mean
number of impulses applied to achieve treatment
success per patient in both groups was insignificantly
1225
higher in colic patients (8000  4000 vs. 6700  3.400;
p = 0.1). No difference in impulse intensity was noted
(18.5  1.4 vs. 18.5  1.5; p > 0.9). Colic patients in 74%
( p = 40) were stone-free and 9% (n = 5) harboured
residual fragments 3 mm after 3-mo follow-up;
hence, 83% (n = 45) were considered a treatment
success. Of the 26 noncolic patients, 73% (n = 19) were
stone-free, and 7.7% (n = 2) harboured residual frag-
ments 3 mm, with 81% (n = 21) considered a treat-
ment success.
At initial presentation of the patient, hydrone-
phrosis detected by ultrasound was observed in 88%
(n = 49) of colic patients. In noncolic patients hydro-
nephrosis was present in 39% (n = 10). Although
differences in the presence and degree of hydrone-
phrosis in both groups were significant ( p = 0.002),
neither the presence nor the degree of hydrone-
phrosis had an impact on the time to stone
clearance or on treatment success. An IVU was per-
formed prior to ESWL treatment in a colic-free
interval. IVU detected hydronephrosis in colic and
noncolic patients was present in 59% (n = 33) versus
7.7% ( p < 0.0001). Again, the proportion of hydrone-
phrosis was significantly greater in colic patients but
again had no significant influence on time to stone
clearance or on treatment success. In colic versus
noncolic patients, immediate excretion of contrast
material beyond the stone within 7 min was found
in 48% versus 82%, within 30 min in 72% versus 88%,
and in 100% up to 5 hours thereafter. The overall
mean time to stone clearance in colic versus
noncolic patients was 9.5  12.1 d (median: 5.5 d)
versus 4.6  3.8 d (median: 3 d) ( p = 0.1) (Table 1).
Serum creatinine levels between colic and non-
colic patients were not significantly different.
(1.13  0.3 vs. 1.06  0.3 mg/dl; p = 0.1). A steinstrasse
with the need for an auxiliary procedure was
observed in one patient in each group, and 93% of
stones were radioopaque. There was no difference in
radioopacity or the proportion of calcium oxalate
monohydrate/dehydrate. Insufficient material for
analysis was collected in nine patients.
4. Discussion
Spontaneous stone passage can be expected in up
to 80% in patients with stones <4 mm in diameter.
For stones with a diameter >5 mm, the chance
of spontaneous passage declines [6–9]. A variety of
influential factors for spontaneous passage of
ureteral stones consisting of hydrostatic pressure
proximal to the calculus, edema, inflammation, and
spasm of the ureter at the site of the stone are
described [10,11]. Relaxation of the ureter appears to
1226 european urology 52 (2007) 1223–1228
facilitate ueteral stone passage in the region of the
stone [10]. With respect to the potential facilita-
tive effect of ureteral relaxation on stone passage,
a-blocker and b-agonists have been shown to relax
the ureteral wall at the level of an artificial stone,
permitting fluid flow beyond the stone [12]. Recently
a-blockade has indeed been shown to be beneficial
in reducing the time of stone expulsion and number
of colic events, and in increasing the number of
stone passages, either without interventional ther-
apy or after ESWL treatment [13–16].
It has been assumed that ureteral edema forma-
tion over time caused by a symptomatic impacted
ureteral calculus impairs stone clearance after ESWL
[17]. This assumption is supported by the fact that
rapid ESWL after a first onset of colic pain led to an
accelerated stone clearance in proximal ureteral
stones [1,2] and that a gradual increase of the time
after a first colic episode until ESWL treatment
significantly correlated with a delayed stone clear-
ance [4]. Our finding of a nonsignificant difference in
time to stone clearance between colic patients
undergoing rapid ESWL and noncolic patients is
compatible with the assumption that a significant
ureteral edema formation does not occur within 24 h
after a first colic episode. Nevertheless, within 1 d,
the presence of colic pain seemed to be associated
with hydronephrosis and a slightly delayed excre-
tion of contrast material, possibly caused by a
beginning ureteral edema; hence, ureteral stones
in colic patients treated within 24 h seemed not to be
impacted yet. This observation is supported by the
finding that colic patients undergoing delayed ESWL
demonstrated a significant prolonged time to IVU
contrast excretion and time to stone clearance
(unpublished data). Clinically significant changes
occur only after 24 h, with gradual impaction impai-
ring stone clearance. The correlation is explained by
the development of mucosal edema within days,
with impacted stones in the ureter [17]. Histologic
studies of the mucosa in the stone bed have indeed
revealed a hyperplastic appearance with increased
mitotic activity [18]. Therefore, it is beneficial for
colic patients to undergo ESWL as soon as possible
before such morphologic changes occur. Cummings
et al [19] reported identification of the pretreatment
duration of symptoms in ureteral stones as being the
most important factor for prediction of treatment
outcome and spontaneous stone passage in an
artificial neural network; stone position also ranked
highly, but the relative weight assigned by the
artificial neural network was 10-fold less than that
of symptom duration. It could be anticipated that
time to stone clearance is hampered by concomi-
tant impaired renal function. Srivastava et al [20]
recently assessed the efficiency of ESWL for stones
in renal units with impaired function as determined
by split glomerular filtration rate, IVU, and a renal
dynamic scan. Clearance rates for ureteral stones
were not influenced by the impairment of renal
function. Accordingly, we did not find a decline in
treatment success with rising creatinine levels.
Ultrasound-detected hydronephrosis influenced
neither the time to stone clearance nor the treat-
ment outcome; this finding has been reported in a
recent study including colic and noncolic patients
and in other studies showing no correlation of
ureteral stone-induced hydronephrosis with treat-
ment success after ESWL [21–23]. We confirmed
these results by assessing IVU-detected nonhydro-
nephrotic and hydronephrotic colic patients, which
demonstrated insignificant differences in time to
stone clearance ( p = 0.7).
The number of impulses applied was not sig-
nificantly different in both groups. Our finding was
in accordance with a recent finding that demon-
strated a significant higher number of impulses
applied in colic patients treated after 24 h compared
with colic patients treated with rapid ESWL [4]. This
difference might well be explained by an increasing
ureteral edema, and a subsequent lack of an expan-
sion chamber and liquid interface, which reduced
initial ESWL fragmentation rates. No evidence so far
supports a beneficial effect of rapid ESWL for noncolic
patients.
5. Conclusions
Treatment outcome and time to stone clearance
after rapid ESWL in colic patients are comparable to
those of noncolic patients and are independent of
concomitant hydronephrosis. This finding suggests
an absence of significant impaction in proximal
ureteral stones treated within 24 h after a first colic
episode, thus enforcing the concept of rapid ESWL
treatment in patients harbouring symptomatic
proximal ureteral stones.
Conflicts of interest
The authors have nothing to disclose.
References
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[2] Tombal B, Mawlawi H, Feyaerts A, et al. Prospective ran-
domized evaluation of emergency extracorporeal shock
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of symptomatic ureteral stones. Eur Urol 2005;47:855–9.
Corrigendum. Eur Urol 2005;48:876.
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Editorial Comment on: Rapid Extracorporeal
Shock Wave Lithotripsy for Proximal Ureteral
Calculi in Colic versus Noncolic Patients
Roberto Miano
Division of Urology, Policlinico Tor Vergata,
University of Tor Vergata, Rome, Italy
mianor@virgilio.it
‘‘Rapid’’ extracorporeal shock wave lithotripsy
(ESWL) is an emerging management strategy for
patients with proximal ureteral calculi, based on
the hypothesis that stone impaction could influ-
ence treatment outcome. Impaction is defined as
adhesion of the stone to the ureteric wall because
of fibrin bounds. Although we can assume that
stone impaction takes time to develop and
‘‘delayed’’ ESWL can give enough time for the
stone to adhere to the ureteric wall, we cannot
exclude that stones are already impacted when
1227
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treatment of patients with steinstrasse developing after
extracorporeal shock wave lithotripsy. Urology 2005;66:
945–8.
[15] Porpiglia F, Vaccino D, Billia M, et al. Corticosteroids and
tamsulosin in the medical expulsive therapy for sympto-
matic distal ureter stones: single drug or association? Eur
Urol 2006;50:339–44.
[16] De Sio M, Autorino R, Di Lorenzo G, et al. Medical
expulsive treatment of distal-ureteral stones using tam-
sulosin: a single center experience. J Endourol 2006;20:
12–6.
[17] Mueller SC, Wilbert D, Thueroff JW. Extracorporeal shock
wave lithotripsy of ureteral stones: clinical experience
and experimental findings. J Urol 1986;135:831–4.
[18] Kim HL, Labay PC, Boyarsky S, et al. An experimental
model of ureteral colic. J Urol 1970;104:390–4.
[19] Cummings JM, Boullier JA, Izenberg SD, et al. Prediction of
spontaneous ureteral calculous passage by an artificial
neural network. J Urol 2000;164:326–8.
[20] Srivastava A, Sinha T, Karan SC, et al. Assessing the
efficiency of extracorporeal shockwave lithotripsy for
stones in renal units with impaired function: a prospec-
tive controlled study. Urol Res 2006;34:283–7.
[21] Cass AS. In situ extracorporeal shock wave lithotripsy for
obstructing ureteral stones with acute renal colic. J Urol
1992;148:1786–7.
[22] Seitz C, Fajkovic H, Waldert M, et al. Extracorporeal shock
wave lithotripsy in the treatment of proximal ureteral
stones: does the presence and degree of hydronephrosis
affect success? Eur Urol 2006;49:378–83.
[23] Demirbas M, Kose AC, Samli M, et al. Extracorporeal shock
wave lithotripsy for solitary distal ureteral stones: does
the degree of ureteral obstruction affect success?
J Endourol 2004;18:237–40.
patients present to the emergency room. From a
clinical standpoint, stone impaction is frequently
associated with upper urinary tract dilatation.
Therefore, patients with no hydronephrosis can
be considered as patients with no stone impaction.
Symptoms related to ureteral stones are not
necessarily associated with dilation because renal
colic may develop in the absence of a demonstrable
hydronephrosis. Patients with ureteral stones, no
upper urinary tract dilatation, and negative history
for stone-related pain are rare, but they can be
considered as patients with no stone impaction
and constitute a good model for nonimpacted
ureteral stones.
Analysis of previously published peer-reviewed
literature suggests that ‘‘rapid’’ ESWL offers good
clinical outcome and provides preliminary data
showing accelerated stone clearance compared to
‘‘delayed’’ treatment [1–4]. Looking at the patient
1228 european urology 52 (2007) 1223–1228
population of the cited manuscripts, enrolled
patients were symptomatic so that the absence
of stone impaction could not be ruled out. In the
current study, the authors should be congratulated
for providing additional information on this sub-
ject and for reporting data on patients with the
lowest possible risk of stone impaction [5].
In conclusion, the present manuscript provides
new evidence for ‘‘early’’ ESWL treatment of
proximal ureteric stones based on the hypothesis
that extracorporeal treatment of nonimpacted
stones offers the best chance for rapid stone clear-
ance. The question remains open as to the
definition of ‘‘early’’ versus ‘‘delayed’’ ESWL.
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[2] Tombal B, Mawlawi H, Feyaerts A, Wese FX, Opsomer R,
Van Cangh PJ. Prospective randomized evaluation of
emergency extracorporeal shock wave lithotripsy
(ESWL) on the short-time outcome of symptomatic uret-
eral stones. Eur Urol 2005;47:855–9. Corrigendum. Eur
Urol 2005;48:876.
[3] Kravchick S, Bunkin I, Stepnov E, Peled R, Agulansky L,
Cytron S. Emergency extracorporeal shock wave litho-
tripsy (ESWL) for acute renal colic caused by upper
urinary-tract stones. J Endourol 2005;19:1–4.
[4] Seitz C, Fajcovic H, Remzi M, et al. Rapid extracorporeal
shock wave lithotripsy treatment after a first colic epi-
sode correlates with accelerated ureteral stone clear-
ance. Eur Urol 2006;49:1099–106.
[5] Seitz C, Tanovic E, Kikic Z, Memarsadeghi M, Fajcovic H.
Rapid extracorporeal shock wave lithotripsy for proxi-
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Eur Urol 2007;52:1223–8.
DOI: 10.1016/j.eururo.2007.02.002
DOI of original article: 10.1016/j.eururo.2007.02.001