Evidence: ESWL has been successfully performed in children of all ages, including premature infants. Studies have shown high success rates across pediatric age groups, with stone-free rates of 86-100% in infants younger than 12 months.
Turna et al. (2025), Akin & Yucel (2014)
McLorie et al. (2003), Griffin et al. (2010)
The FDA states: “The safety and effectiveness of this device in the treatment of urolithiasis in children have not been demonstrated.” However, extensive clinical experience supports its use with appropriate precautions.
FDA Guidance Document (2018)
| Stone Size | Recommendation | Expected Success Rate | Reference |
|---|---|---|---|
| <10 mm | Optimal for ESWL | 90–100% | Straub et al. (2010) |
| 10–20 mm | First-line treatment (EAU Guidelines) | 70–90% | Güven et al. (2024) |
| >20 mm | Consider combined treatment or alternative modalities | 57–75% | Mohamed et al. (2023) |
| Cystine stones >15 mm | Consider endoscopic approach | Variable | Straub et al. (2010) |
Renal Stones:
Lower Pole Anatomic Predictors: An infundibulopelvic angle <40° reduces clearance. Infundibular length also affects outcomes.
Tan et al. (cited in Straub 2010)
Ureteral Stones:
Garg et al. (2018)
| Stone Type | Hounsfield Units (HU) | ESWL Suitability | Success Rate |
|---|---|---|---|
| Calcium oxalate monohydrate | >1000 | Moderate | 44–70% |
| Calcium oxalate dihydrate | 500–1000 | Good | 95–96% |
| Uric acid | <500 | Excellent | >95% |
| Struvite | Variable | Good | 85–90% |
| Cystine | Variable | Poor if >15 mm | <60% |
Massoud et al. (2019), Ouzaid et al. (cited in Demir 2025)
Shear Wave Elastography (SWE): Cutoff 13.70 kPa predicts ESWL success (AUC 0.979). May serve as alternative to HU.
Demir et al. (2025)
FDA Guidance (2018), Streem et al. (1997), StatPearls (2024)
Streem et al. (1997), Knapp et al. 2018
Animal data show growth plate effects. No clinical evidence of growth issues in children.
FDA Guidance (2018)
Sampaio et al., Newman et al.
Consensus: Most pediatric cases need anesthesia to prevent movement and manage pain. Choose methods that keep exposure and risk low.
Xiao et al. 2023, Cevik et al. 2018
| Method | Agents | Advantages | Considerations |
|---|---|---|---|
| General anesthesia | Inhalational | Complete immobilization | Used in 7/26 cases in one series |
| IV sedation (preferred) | Ketamine + Midazolam | Effective, outpatient feasible | Age-based dosing; older kids need more |
| Regional | Epidural/spinal | Avoids systemic effects | Limited use |
Cevik et al. 2018; Abid et al. 2019
Ketamine–Midazolam: 251 children, 408 sessions. Effective and safe. Older children required higher doses. No severe complications.
Cevik et al. 2018
| Method | Success | Advantages | Disadvantages |
|---|---|---|---|
| Fluoroscopy | 80–92% | Familiar; excellent for radiopaque stones | Radiation; cannot localize radiolucent stones |
| Ultrasound | 84–86% | No radiation; real-time targeting | Operator dependent |
| Dual modality | 90%+ | Combines strengths | Some radiation; more complex |
Abdel-Kader 2025; Urolithiasis/Urol 2023
Low (<60) and intermediate (60–90) have similar success and fewer complications than high (≈120).
Xiao et al. 2023; Madbouly 2005; Yoon 2021
Vandeursen 1991
Dysrhythmias in ~58% of children. Continuous ECG is essential. Use ECG-gated mode if arrhythmias occur or in at-risk patients.
Mathers 2015; FDA 2018
| Timeline | Modality | Purpose | Action |
|---|---|---|---|
| 2 weeks | KUB + US | Clearance; steinstrasse | Plan next session if needed |
| 1 month | KUB + US | Stone-free status | Decide on repeat or observe |
| 3 months | US ± CT | Final clearance; hydronephrosis | Plan further treatment if needed |
| 6 months | US ± DMSA/DTPA | Function and scars | Long-term safety check |
Abdel-Kader 2023; Straub 2010
| Timeline | SFR | Reference |
|---|---|---|
| After 1st session | 41–82.4% | Burgos Lucena 2021; others |
| After 2nd session | 70–90% | Straub 2010 |
| After 3rd session | Up to 95% | Burgos Lucena 2021 |
| Overall | 57–92% | Meta-analyses |
| Mean 10 months | 81.9% | Kartal 2021 |
Studies show preserved function and no increase in scarring at follow-up up to several months.
Akin & Yucel 2014; Fayad 2010; Goel 1996
Overall: In 247 procedures, complications ~15%, mostly minor and related to obstruction. No renal hematomas or perforations reported in that series.
Dobrowiecka 2018
| Complication | Incidence | Features | Management |
|---|---|---|---|
| Steinstrasse | ~10.7% | Obstruction by fragments | Hydration, analgesia, α-blocker; URS/stent if needed |
| Hematuria | Common | Usually transient | Reassure, hydrate |
| Renal colic | ~12% | Severe pain | Analgesia, hydration, α-blocker |
| UTI | 3–7% | Fever, dysuria | Antibiotics; ensure drainage |
Renal hematoma overall ≈0.3–4.1%. Risk higher with uncontrolled HTN, coagulopathy, high stone density, obstruction.
Dysrhythmias in ~58%. Most benign. Use ECG-gated delivery if needed.
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| UTI | 3–7% | Bacteriuria, obstruction | Antibiotics, drainage |
| Urosepsis | <1% | Obstruction + infection | Urgent IV antibiotics + drainage |
Similar clearance overall. URS uses more general anesthesia sessions and has more complications in some series.
Last updated: October 2025
Lithotripsy Academy is an educational initiative of Endourology Academy, focused on advancing knowledge and training in Shock Wave Lithotripsy (SWL) through evidence-based learning and clinical expertise.
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