Saudi Journal of Kidney Diseases and Transplantation

: 2008  |  Volume : 19  |  Issue : 3  |  Page : 397--400

Effect of Diuretics on Ureteral Stone Therapy with Extracorporeal Shock Wave Lithotripsy

A Zomorrodi, J Golivandan, J Samady 
 Imam Hospital, Tabriz Medical Science University, Tabriz, Iran

Correspondence Address:
A Zomorrodi
Associate Professor of Urology, Imam Hospital, Tabriz Medical University, Science, Tabriz


To evaluate the effect of diuretics on ureteral stone fragmentation and clearance during therapy with extra corporeal shock wave lithotripsy (ESWL), we studied 87 patients with ureteral stone at different levels and treated with ESWL. The patients were randomized into two groups treated by standard ESWL; the treatment protocol included 3500 shock wave per patient in each session, energy of the shock in two groups was 13 to 9 kv per patient, and the number of sessions was 3 per patient. The first group included 43 patients who received only ESWL, while the second group of 44 patients received as well 40 mg of furosemide. Stone fragmentation rate was 81% and 93.1% and stone clearance rate was 68.2% and 88.4% for the first and the second groups, respectively. With diuretics, fragmentation was18.8% more in the middle ureteral stones, 16.9% more in the upper tract stones, and 5.4% more in the distal stones. Moreover, clearance of fragmented stones was 38%, 28%, 15.4% more at middle and upper and distal ureteral stone, respectively. We conclude that the stone fragmentation and clearance were higher with ESWL and diuretics than without diuresis. Diuresis is safe and has some advantage at increasing the effect of ESWL on ureteral stones especially the middle ureteral calculi.

How to cite this article:
Zomorrodi A, Golivandan J, Samady J. Effect of Diuretics on Ureteral Stone Therapy with Extracorporeal Shock Wave Lithotripsy.Saudi J Kidney Dis Transpl 2008;19:397-400

How to cite this URL:
Zomorrodi A, Golivandan J, Samady J. Effect of Diuretics on Ureteral Stone Therapy with Extracorporeal Shock Wave Lithotripsy. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Aug 11 ];19:397-400
Available from:

Full Text


Management of ureteral stone includes open surgery, laparoscopic surgery, ureteroscopic extraction, ureteroscopic lithotripsy and extra­corporeal shock wave lithotripsy (ESWL), which is the least invasive procedure. How­ever, some patients may require a repeat session of ESWL, or adjuvant surgical inter­vention in order to achieve a stone free status. Success rate of ureteral stone with ESWL depends on several factors that include stone size, degree of obstruction, impaction, and renal function.

The aim of this study is to investigate the role of diuretics during ESWL therapy on the outcome of the procedure in terms of frag­mentation and clearance of ureteral stones.

 Materials and Methods

The study included 87 patients with ureteral calculi at different ureteral levels. Patients were referred for ESWL at Urology Depart­ment of Imam Hospital. They were 56 male and 31 female and the range of age was from 12-52 years.

All patients had complete history, physical examination, and routine laboratory investi­gation including CBC, urinalysis, creatinine, BUN, prothrombine activity, and bleeding and coagulation time. All patients were exa­mined by ultrasound and plain x-ray com­plemented in some patients with x-ray intra­venous urography (IVU).

All the patients were treated by standard ESWL using Simons Lithostor plus machine. Patients with stones in the upper third of ureter were treated in supine position, while patients with middle or distal thirds of the ureter were treated in prone position. All the patients were advised to void before starting ESWL session. After exposing stones on monitor and targeting them, shock waves were administered at a rate of 90 shock per minute with energy started at range 13 that gradually increased according tolerance of patient till 19 kv. This gradual increase of energy is important at desensibilization of skin.

In every session, shock wave treatment was continued until stone disintegration or 3500 shock wave delivered. Follow-up plain x ray was obtained 2 weeks after treatment, and ESWL was repeated if a stone equal or more than 5mm was still evident. In evaluation of the results of ESWL, failure was defined as inability to fragment the targeted stones after three ESWL sessions, while success was defined as stone free-within three months after application of ESWL.

The patients were randomized into two groups. The groups were comparable as re­gards stone location, stone size, and asso­ciated hydronephrosis. All the stone were radiopaque. All the patients received 3500 shock every session in three sessions. The first group included 43 patients who were treated by standard ESWL without diuretics. In this group, upper stone was in 20 patient, middle ureteral stone in 6, and lower urinary stone in 17; stone size ranged from 8-16 mm. The second group included 44 patients who were treated by ESWL with addition of furosemide 40 mg before the start of the ESWL session.


In the first group, stone fragmentation was 81% and stone clearance 68.2%. In the second group, stone fragmentation was 93.1% and stone clearance was 88.4%. There were no complications following ESWL treatment. The results according to stone location are shown in [Table 1], while the results of fragmentation and clearance are shown in [Table 2].


ESWL is a perfect example of fruitful cooperation between the medical and Indus­trial world. Since its introduction into clinical practice in 1980 by Chaussy and associates, [1] It has revolutionized the management of urolithiasis and has become the first option for treatment of most upper urinary tract calculi, thus dramatically limiting the indi­cation of endourological procedure and even open surgery. [2] Since 1986, ESWL has pro­gressively acquired popularity as the gold standard treatment for upper urinary tract lithiasis in children as well as in adults. [3] Proximal ureteral stones and distal calculi in women past the childbearing age can be treated with in situ ESWL. [4]

To the treatment with ESWL is started at low power (11 kv) that is increased progre­ssively so that the initial shocks desensitize the skin nerve receptors with a transcuta­neous electrical nerve stimulator like effect. [5] Shock wave lithotripsy has four mechanisms of stone fragmentation that include compre­ssive fracture, spallation, acoustic cavitations, and dynamic fatigue. [6] Cavitation is an im­portant mechanism of ESWL action and has many roles in fragmentation. It is an acous­tic phenomena that every ESWL can induce in f2 point, which requires low viscosity fluid.

Cavitation phenomena induces another energy called pitting in foil. [7] Patients are prepared best for ESWL by proper hydra­tion and bowel cathertics one day before the procedure. Patients referred to ESWL depart­ment without preparation, i.e. dehydrated and/or constipated, will have less satisfactory results because dehydration reduces good flow of urine around the targeted stone especially if the treated kidney has reduced function due to obstruction. Diuretics can surmount this problem by increasing the urine flow around the stone, which im­proves the possibility for the cavitation phe­nomena to occur. [8]

In the actual disintegration of stones, the analysis of the high-speed films clearly de­monstrates the progress of stone fragmen­tation related to time. First cracks appear to be produced by shock wave. Then, after the surrounding liquid enters the cracks, the actual disintegration of stone material occur as a result of collapsing cavitation bubble. [6],[7]

In our study, the administration of diure­tics improved both the fragmentation and clearance as predicted in the patients who received the drug regardless of location of the ureteral stones.

In conclusion, diuretics seems to be safe adjunct to ESWL treatment of ureteral stone and coincide with better result.


1Chaussy C, Branded W, Schemidt E. Extra­corporeally induced destruction of kidney stone by shock wave. Lancet 1980;2(8207): 1265-8.
2Henrilottmann MT, Gagnadocer M. Dauclon urolithiasis in children GEARHART Rink­Mouriq and pediatric urology. Saunders company, 2001:839 chapt.52.
3Newman DM, Coury T, Lingeman JE, et al. Extracorporeal shockwave lithotripsy expe­rience in children. J Urol 1986;136(1.2): 238-40.
4Marshall L, Stoller MD, Damien M. Bothom, urinary stone diseases Smiths general urology Hamilton Printing Company, CE Milla, Tanagho, MD 2000:308.
5Shill-Cutman H, Jordan WR. Lithostar low pressure treatment of renal stone. Siemens Electro-melic.J Urol 1990;58:33.
6James E, Ligeman MD, David A, Lifshil MD, Andrew P. Even surgery management of urinary lithiasis. Walsh, Retik Vaughan Campbell's urology, Eight edition 2002:3406.
7Azm TA, Higazy H. Effect of diuresis on extracorporeal shockwave lithotripsy treat­ment of ureteric calculi. Scand J Urol Nephrol 2002;36(3):209-12.
8Wolf Gang sass martin Braunhick hans peter dreges ultrasound in med and biol, USA, 1991;3:230-43.