There are many guidelines for the diagnosis and treatment of urinary stones, such as AUA and EUA guidelines, whose main feature is principles. The "Shockwave Lithography Guide" compiled by the International Urolithia Alliance mainly does some details. Under the guidance of Profes

There are many guidelines for the diagnosis and treatment of urinary stones, such as AUA and EUA guidelines, the main feature is principles. The "Shockwave Lithography Guide" compiled by the International Urolithia Alliance mainly does some details. Under the guidance of Professor Ye Zhangqun, Dean Zeng Guohua and organized the preparation of the guide. The writing team of the "Shockwave Lithography Guide" invited 16 countries and 27 well-known domestic and foreign experts to participate in the preparation.

Urolithia is one of the most common diseases in urology, and advice about management is a valuable tool for clinicians. Different international associations, including the American Urology Association, the European Urology Association and the Chinese Urology Association, have proposed their own urolithia guidelines. However, the focus is mainly on outlining the treatment principles of urolithiasis. The step-by-step technical details of this program will be more practical for urologists to guide best clinical practice .

International Urolithiasis Alliance (IAU) recently released a series of urolithia management guidelines, including percutaneous nephroscopic lithography (PCNL) and retrograde intrarenal surgery (RIRS). Shockwave lithotripsy (SWL) Guide is the third guide in the IAU urolithia management series, including preoperative evaluation, procedural tips and techniques, and follow-up strategies, designed to provide a clinical framework for surgeons and technicians who perform SWL.

For the IAU guidelines on SWL, all recommendations are organized, evaluated and summarized through structured evaluation of studies with high levels of evidence and published in English between January 1, 1984 and January 1, 2022. A comprehensive literature search covering all aspects of SWL was performed using the PubMed database. Search terms include "shock wave lithotripsy", "shock wave lithotripsy", "ESWL" and "SWL"). Grade recommendations (GR) were assigned using the improved GRADE method, where the evidence subjects were rated A (high-quality evidence; high-quality evidence), B (moderate-quality evidence; medium-quality evidence), or C (low-quality evidence; low-quality evidence). Levels of evidence (LE) were graded based on the nature and homogeneity of the study using the classification system modified by Oxford Evidence-Based Medicine Center [6]; Level 1 is the highest level and Level 5 is the lowest level.

indications

• kidney stones or ureteral stones or 15 mm diameter lesion stones (LE: 1, GR: A).

Kidney stones or ureteral stones are greater than 20 mm, and are suitable for cases where endoscopic lithotripsy is not possible or contraindicated. However, duplicate SWL and JJ scaffolds (LE:2, GR:B) may be required.

•SWL is an effective minimally invasive treatment option for urinary calculi of bladder or urethral stones (LE: 2, GR: B).

Contraindications

• •Pregnancy (LE: 4, GR: B).

• •Unt-treated coagulation abnormalities (LE: 4, GR: B).

• •Other important organs in tumors, aneurysms or shockwave paths (LE: 4, GR: B).

• •Uncontrolled urinary tract infection (UTI) (LE: 3, GR: B).

• •Distal anatomical obstruction of stones (LE: 4, GR: B).

• •Unt-treated or severe hypertension (LE: 4, GR: B).

2.2. Preoperative patient evaluation

2.2.1. Urine analysis and urine culture sensitivity test

• •Uricular analysis and urine culture sensitivity test is recommended before SWL (LE: 3, GR: B).

2.2.2. Imaging before SWL

• •Non-enhanced computed tomography (NCCT) before SWL (LE: 3, GR: B).

.3. Preoperative medication

2.3.1. antibiotic prevention and urinary tract infection treatment

• • Patients with sterile urine do not need to use antibiotics prophylactically (LE: 1, GR: A).

• •For patients with positive urine culture, antibiotics should be given based on the results of the culture-anti-bacterial spectrum detection (LE: 5, GR: A).

2.3.2. Antithrombotic therapy management

• •Anti-thrombotic therapy needs to be interrupted in consultation with the patient's primary care physician to minimize the risk of perioperative bleeding and hematoma formation in patients receiving SWL (LE: 4, GR: A).

• •Temporary suspension or transitional antithrombotic treatment should be discussed with the appropriate specialist (LE: 5, GR: A).

Table 1. Common time to stop anticoagulant before surgery











Drug category	Parameters	Time to interrupt anticoagulant before surgery
Direct oral anticoagulant	Renal function
Davigatran	CrCl 50 ml/min	4 days
CrCl 50–79 ml/min	3 day
CrCl ≥80 ml/min	2 day
rivaroxaban, apixaban , edoxaban	CrCl 15–30 ml/min	3 day
CrCl ≥ 30 ml/min	2 Tian
Vitamin K antagonist	International standardization ratio
6 Acetonikomarin	2	2 Tian
2–3	3 Tian
2–3	3 Tian
3	4 Tian
2	4 Tian
2–3	+ κ
3	6 Tian

CrCl = Creatinine clearance. 2.3.3. Perioperative rehydration

• diuretics and rehydration are recommended for SWL of kidney stones (LE: 2, GR: B).

2.4. Preset

• It is not routinely recommended to perform placement preset for patients receiving SWL (LE: 1, GR: A).

2.5. Intraoperative analgesia and anesthesia

• • During SWL treatment, sufficient analgesia and pain relief must be provided (LE: 1, GR: A).

• •Nonsteroidal anti-inflammatory drugs (NSAID), opioids and simple analgesics can all provide adequate or reasonable analgesic effects during SWL (LE: 2, GR: B).

• should be recorded and oxygen inhaled using electrocardiogram (ECG) during SW (LE: 5, GR: C).

2.6. Patient position, stone positioning and monitoring

2.6.1. Patient position

• If the shock wave generator under the stage and on the stage is available, a stable supine position is preferred regardless of the location of the stone (LE: 3, GR: A).

• If there is no on-stage shock wave generator, prone bits are applied to distal ureteral stones and stones in the pelvis (LE: 1, GR: A).

2.6.2. Stone positioning and shock wave positioning

• perspective or ultrasound is used to monitor stone positioning (LE: 2, GR: A). The position of the shock wave head should be positioned according to the location of the stone and the imaging method (LE: 3, GR: A).

• During the entire treatment process, the stone localization should be reconfirmed regularly (LE: 3, GR: A).

2.6.3. Radiation exposure management

• • Fluoroscopy time, distance, mode setting and shielding should be considered during treatment to reduce radiation exposure to patients (LE: 3, GR: A).

• •Precautions should be taken when using fluoroscopy to reduce radiation exposure (LE: 3, GR: A).

2.7. Machine and energy settings

• • Adjust shock wave parameters according to the characteristics of individual cases (LE: 3, GR: A).

• •Start with a low energy shock wave and then slowly rise to the required energy level (LE: 1, GR: A).

• • Low shock wave frequency is recommended to reduce renal blood vessel and tissue damage and improve stone fragmentation (LE: 1, GR: A).

2.8. Intraoperative lithotripsy strategy

• bubble-free coupled region is very important for achieving good and efficient energy transmission (LE: 2, GR: A).

• should avoid intestinal gas accumulation in the target path (LE: 5, GR: C).

2.9.Adjustment treatment after SWL

2.9.1. Drug expulsion therapy

• •Using alpha blockers (such as tamsolosin) can improve stone excretion after SWL (LE: 1, GR: A).

.9.2. Position stone removal therapy

• •Mechanical percussion and diuretic treatment help the discharge of stone fragments after SWL and improve SFR (LE:

2.9.3. SWL retardation

• Retardation SWL is another way to treat upper urinary tract stones (LE: 3, GR: B).

• The time interval between two SWL courses should not be less than 1-2 weeks. For ureteral stones, one day may be enough (LE: 5, GR: B).

2.9.4. Ureteroscopy Continuous Obstruction Fragments

• ureteroscopy can be considered as a treatment option for persistent obstruction fragments after SWL (LE: 5, GR: B).

2.10. Stone net rate evaluation

• KUB X-ray and ultrasound were sufficient to evaluate the clearance of stone after SWL , while low-dose CT provided the most accurate stone-free status information (LE: 2, GR:A). The time point for evaluating stone clearance after

• should be 2-3 months (LE:3, GR:A).

2.11. The incidence of complications after

SWL is determined by three main factors: formation and discharge of stone fragments; infection; and the effect on renal and non-renal tissues [109]. , the incidence of complications after Claveen I-II SWL was 18.4%, and the incidence of complications in Claveen III-IV was 2.5% [110].

2.11.1. Hematoma

• Risk factors for hematoma formation after SWL include the use of antiplatelet drugs, uncontrolled hypertension and diabetes [26], [111] (LE: 4, GR: A).

2.11.2. Bleeding

• •Use low-frequency shock waves can reduce bleeding complications after SWL (LE: 2, GR: A).

2.11.3. Fever

• •Positive urine culture and urinary tract obstruction are associated with a higher risk of infection and fever after SWL (LE: 4, GR: A).

2.11.4. Pain

• •The combined use of nonsteroidal anti-inflammatory drugs and alpha receptor antagonists can alleviate the pain caused by SWL caused by small fragments of stones (LE: 2, GR: A).

• •PDI and EPVL may actively discharge stone fragments, thereby minimizing pain after SWL (LE: 2, GR: B).

2.11.5.Stone Street Formation

• •The burden of large stones is a risk factor for the occurrence of oil street after SWL (LE: 1, GR:A).

• • For stones with size 20 mm (LE:2, GR:A), no internal stent is required to prevent stone street

• For patients with anatomical or functionally isolated renal stones 20 mm, stent placement should be considered (LE:2, GR:A).

2.11.6. Long-term adverse reactions

• almost no high level of evidence to support the hypothesis of long-term adverse reactions after SWL (LE:1, GR:A).

2.12.Quantity of life after SWL (QOL)

• treatment time is shorter, less pain is needed, and noninvasive removal of stones without systemic or regional anesthesia, resulting in higher QOL in patients after SWL (LE: 2, GR: A).

• . Conclusion

  SWL is a mature method for treating stones of 20 mm size. The suggestions, tips and tips for SWL summarized here should provide important guidance for urologists and technicians who undergo SWL.