Shockwave Lithotripsy Use in the State of Michigan: American Urological Association Guideline Adherence and Clinical Implications

Published:December 13, 2019DOI:



      To understand how treatment of patients with urinary stones by shockwave lithotripsy (SWL) aligns with current published practice guidelines.


      We used the Michigan Urologic Surgery Improvement Collaborative Reducing Operative Complications for Kidney Stones registry to understand SWL use in the state of Michigan. This prospectively maintained clinical registry includes data from community and academic urology practices and contains clinical and operative data for patients undergoing SWL and ureteroscopy (URS). We identified patients undergoing SWL from 2016 to 2019. In accordance with AUA guidelines, we evaluated practice patterns in relation to recommendations for treatment selection for SWL as well as clinical implications of guideline nonadherence.


      Four thousand, two hundred and nine SWL procedures performed across 34 practices were analyzed. Perioperative antibiotics were administered to 61.3% of patients undergoing SWL. A ureteral stent was placed at the time of SWL in 2.7% of patients. For lower pole renal stones >1 cm or large (>2 cm) renal stones in the registry, 32.2% and 58.9% of patients, respectively, underwent SWL, while the remainder were treated with URS. In these instances, SWL was associated with inferior stone-free rate (SFR) relative to URS. In patients with residual stones after SWL, 34.6% were treated with repeat SWL with lower SFR than those treated with subsequent URS. Postoperatively, 42.1% of patients were prescribed alpha-blockers with no benefit seen in terms of SFR.


      Substantial variation exists among urology practices with regard to SWL use. These data serve to inform quality improvement efforts regarding appropriateness criteria for SWL in Michigan.
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        • Geraghty RM
        • Jones P
        • Somani BK
        Worldwide trends of urinary stone disease treatment over the last two decades: a systematic review.
        J Endourol. 2017; 31: 547-556
        • Aboumarzouk OM
        • Kata SG
        • Keeley FX
        • McClinton S
        • Nabi G
        Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopicmanagement for ureteric calculi.
        Cochrane Database Syst Rev. 2012; 16 (Cd006029)
        • Scales Jr., CD
        • Saigal CS
        • Hanley JM
        • Dick AW
        • Setodji CM
        • Litwin MS
        The impact of unplanned postprocedure visits in the management of patients with urinary stones.
        Surgery. 2014; 155: 769-775
        • Preminger GM
        • Tiselius HG
        • Assimos DG
        • et al.
        2007 Guideline for the management of ureteral calculi.
        Eur Urol. 2007; 52: 1610-1631
        • Srisubat A
        • Potisat S
        • Lojanapiwat B
        • Setthawong V
        • Laopaiboon M
        Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones.
        Cochrane Database Syst Rev. 2014; 24 (Cd007044)
        • Matlaga BR
        • Jansen JP
        • Meckley LM
        • Byrne TW
        • Lingeman JE
        Treatment of ureteral and renal stones: a systematic review and meta-analysis of randomized, controlled trials.
        J Urol. 2012; 188: 130-137
        • Assimos D
        • Krambeck A
        • Miller NL
        • et al.
        Surgical management of stones: American Urological Association/Endourological Society Guideline, PART I.
        J Urol. 2016; 196: 1153-1160
        • Lantz AG
        • McKay J
        • Ordon M
        • Pace KT
        • Monga M
        • Honey RJ
        Shockwave lithotripsy practice pattern variations among and between American and Canadian Urologists: in support of guidelines.
        J Endourol. 2016; 30: 918-922
        • Hurley P
        • Dhir A
        • Gao Y
        • et al.
        A statewide intervention improves appropriate imaging in localized prostate cancer.
        J Urol. 2017; 197: 1222-1228
        • Wolf Jr., JS
        • Bennett CJ
        • Dmochowski RR
        • Hollenbeck BK
        • Pearle MS
        • Schaeffer AJ
        Best practice policy statement on urologic surgery antimicrobial prophylaxis.
        J Urol. 2008; 179: 1379-1390
        • Charlson ME
        • Pompei P
        • Ales KL
        • MacKenzie CR
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Alexander CE
        • Gowland S
        • Cadwallader J
        • Hopkins D
        • Reynard JM
        • Turney BW
        Routine antibiotic prophylaxis is not required for patients undergoing shockwave lithotripsy: outcomes from a National Shockwave Lithotripsy Database in New Zealand.
        J Endourol. 2016; 30: 1233-1238
        • Shen P
        • Jiang M
        • Yang J
        • et al.
        Use of ureteral stent in extracorporeal shock wave lithotripsy for upper urinary calculi: a systematic review and meta-analysis.
        J Urol. 2011; 186: 1328-1335
        • Chen K
        • Mi H
        • Xu G
        • et al.
        The efficacy and safety of tamsulosin combined with extracorporeal shockwave lithotripsy for urolithiasis: a systematic review and meta-analysis of randomized controlled trials.
        J Endourol. 2015; 29: 1166-1176
        • Zhu Y
        • Duijvesz D
        • Rovers MM
        • Lock TM
        Alpha-blockers to assist stone clearance after extracorporeal shock wave lithotripsy: a meta-analysis.
        BJU Int. 2010; 106: 256-261
        • Lam HS
        • Lingeman JE
        • Barron M
        • et al.
        Staghorn calculi: analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area.
        J Urol. 1992; 147: 1219-1225
        • Albala DM
        • Assimos DG
        • Clayman RV
        • et al.
        Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results.
        J Urol. 2001; 166: 2072-2080
        • Scotland KB
        • Rudnick B
        • Healy KA
        • Hubosky SG
        • Bagley DH
        Retrograde ureteroscopic management of large renal calculi: a single institutional experience and concise literature review.
        J Endourol. 2018; 32: 603-607
        • Donaldson JF
        • Lardas M
        • Scrimgeour D
        • et al.
        Systematic review and meta-analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower-pole renal stones.
        Eur Urol. 2015; 67: 612-616
        • Tiselius HG
        • Chaussy CG
        Arguments for choosing extracorporeal shockwave lithotripsy for removal of urinary tract stones.
        Urolithiasis. 2015; 43: 387-396
        • Omar M
        • Tarplin S
        • Brown R
        • Sivalingam S
        • Monga M
        Shared decision making: why do patients choose ureteroscopy?.
        Urolithiasis. 2016; 44: 167-172
        • Ahn JS
        • Holt SK
        • May PC
        • Harper JD
        National imaging trends after ureteroscopic or shock wave lithotripsy for nephrolithiasis.
        J Urol. 2018; 199: 500-507
        • Ordon M
        • Urbach D
        • Mamdani M
        • Saskin R
        • D'A Honey RJ
        • Pace KT
        The surgical management of kidney stone disease: a population based time series analysis.
        J Urol. 2014; 192: 1450-1456
        • Oberlin DT
        • Flum AS
        • Bachrach L
        • Matulewicz RS
        • Flury SC
        Contemporary surgical trends in the management of upper tract calculi.
        J Urol. 2015; 193: 880-884