Arab Journal of Urology (2016) 14, 108114

Arab Journal of Urology

(Official Journal of the Arab Association of Urology)
www.sciencedirect.com

STONES/ENDOUROLOGY
ORIGINAL ARTICLE

Does lithotripsy increase stone recurrence? A

comparative study between extracorporeal
shockwave lithotripsy and non-fragmenting
percutaneous nephrolithotomy
Ahmed El-Assmy *, Ahmed M. Harraz, Yasser Eldemerdash, Mohammed Elkhamesy,
Ahmed R. El-Nahas, Ahmed M. Elshal, Khaled Z. Sheir
Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
Received 21 December 2015, Received in revised form 30 January 2016, Accepted 21 February 2016
Available online 3 April 2016

KEYWORDS
Extracorporeal shockwave lithotripsy;
Stone recurrence;
Percutaneous
nephrolithotomy;
Fragmentation
ABBREVIATIONS
ESWL, extracorporeal
shockwave lithotripsy;
HR, hazards ratio;
KUB, plain abdominal
radiograph of the kidneys, ureters and bladder;

Abstract Objectives: To investigate the effect of stone fragmentation on late stone

recurrence by comparing the outcome of extracorporeal shockwave lithotripsy
(ESWL) and non-fragmenting percutaneous nephrolithotomy (PCNL), and to investigate factors contributing to recurrent calculi.
Patients and methods: We evaluated stone recurrence in 647 patients who initially
achieved a stone-free status after ESWL and compared the outcomes to 137 stonefree patients treated with PCNL without stone fragmentation. Patients were evaluated every 3 months during the first year and every 6 months thereafter to censorship
or time of first new stone formation. Stone recurrence rates were calculated using the
KaplanMeier method. The effects of demographics, stone characteristics, and intervention on the recurrence rate were studied using the log-rank test and the Coxregression analysis.
Results: For ESWL the recurrence rates were 0.8%, 35.8% and 60.1% after 1, 5
and 10 years, which were comparable to the 1.5%, 35.5% and 74.9%, respectively
found in the PCNL group (P = 0.57). Stone burden (>8 mm) and a previous
history of stone disease were significantly associated with higher recurrence rates
regardless of the method of stone intervention (P = 0.02 and P = 0.01,

* Corresponding author. Tel.: +20 (2050) 2262222; fax: +20 (2050) 2263717.
E-mail address: a_assmy@yahoo.com (A. El-Assmy).
Peer review under responsibility of Arab Association of Urology.

Production and hosting by Elsevier

http://dx.doi.org/10.1016/j.aju.2016.02.004
2090-598X 2016 Arab Association of Urology. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Lithotripsy and stone recurrence

NCCT, non-contrast
CT;
OSS, open stone surgery;
PCNL, percutaneous
nephrolithotomy;
US, ultrasonography

109

respectively). In the ESWL group, a stone length of >8 mm showed a higher recurrence rate (P = 0.007). In both the ESWL and PCNL groups, there was a significant
shift from baseline stone location, with an increased tendency for most new stones to
recur in the calyces as opposed to the pelvis.
Conclusions: In comparison with PCNL, ESWL does not increase long-term
stone recurrence in patients who become stone-free. The stone burden appears to
be the primary factor in predicting stone recurrence after ESWL.
2016 Arab Association of Urology. Production and hosting by Elsevier B.V. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Introduction
Since the introduction of extracorporeal shockwave
lithotripsy (ESWL) by Chaussy et al. [1] in the early
1980s, the management of renal calculi has changed
dramatically. Currently, ESWL is the recommended
primary treatment option for renal stones of <2 cm,
whereas percutaneous nephrolithotomy (PCNL) is
preferred for large, complex or staghorn calculi [2].
Although the efficacy of ESWL in treating urolithiasis in adults and children has been established [3,4],
there is concern about the increasing rate of new stone
formation after ESWL compared with other techniques.
Looking carefully at published data identifies marked
variability in reported recurrence rates after ESWL
ranging from 5% to 20.3% [58], and in one study the
recurrence rate was higher, reaching up to 70% after
9 years [9]. This might be attributable to the presence
of microscopic residual stone fragments left in the
collecting system that may act as nidi for stone recurrence [10]. If this hypothesis is true; this would question
the long-term efficiency of ESWL.
Previous reports have investigated the recurrence rate
after ESWL compared with PCNL to test this hypothesis
[1115]. However, most of those studies [1215] neglected
that stone fragmentation during PCNL might be a
contributing factor for stone recurrence exactly as for
ESWL. In addition, small sample sizes in some of the
publications [1113] is a hindering factor for adequate
interpretation of the results.
The previous controversy and limitations were the
trigger to address the issue of late stone recurrence after
ESWL. In the present study, a large number of patients
were included who initially were stone-free after ESWL
and compared the findings for stone-recurrence rates in
stone-free patients treated with PCNL without stone
fragmentation. Also, we investigated factors predicting
late stone recurrence.

3 months after the last session of ESWL (from January

1999 through December 2011), were retrospectively
reviewed. Another group of 278 adult patients who were
stone-free after PCNL using mechanical extraction only
(from January 1998 through December 2005) were also
retrospectively reviewed.
Patients were excluded if they had a ureteric stone or
if any type of intracorporeal disintegration (Lithoclast,
ultrasonic or laser) was used during PCNL. Patients
with a follow-up of <6 months or with inadequate
follow-up data were also excluded. Similarly, patients
with evident metabolic or anatomical disorders such as
cystinuria, hyperparathyroidism, and congenital renal
anomalies (e.g. horseshoe kidney and polycystic kidney)
were excluded because of the high rate of stone
recurrence.
Pretreatment evaluation included a careful medical
history; physical examination; routine blood tests; urine
analysis; urine culture; plain abdominal radiograph of
the kidneys, ureters and bladder (KUB); urinary
ultrasonography (US); and IVU or non-contrast CT
(NCCT). Stone length was defined as the largest crosssectional diameter in a single stone measured on KUB
or NCCT in a single stone or the sum of the largest
diameters for multiple stones
All patients underwent ESWL using a Dornier
Lithotriptor S (Dornier MedTech GmbH, Germering,
Germany). The technique of PCNL was previously
described in detail [16]. Briefly, a renal puncture was
made with the patient prone, using multidirectional
C-arm fluoroscopic guidance (BV Pulsera, Philips Medical Systems, Eindhoven, the Netherlands). The tract
was dilatated using Alkens coaxial dilators (Karl Storz
Endoskope, Tuttlingen, Germany) to 30 F. A 26-F rigid
nephroscope (Karl Storz Endoskope) was used through
an Amplatz sheath (Boston Scientific Corp., Natick,
MA, USA). The stone was removed using forceps. A
22-F nephrostomy tube was placed at the end of the
procedure and left in situ for 2448 h.

Patients and methods

Follow-up
After approval of the Institutional Review Board, the
computerised patients records of 2252 adult patients
(aged >18 years), who had a stone-free status at

After treatment, stone-free status was determined in an

outpatient clinic setting at 3 months postoperatively

110

for PCNL and after the last session of ESWL. Patients

were evaluated every 3 months during the first year
and every 6 months thereafter or when symptoms
developed by urine analysis, urine culture, KUB and
urinary US or NCCT, whenever indicated. The patients
were followed to censorship or time of first new stone
formation. During follow-up we advised patients to
maintain a high fluid intake and avoid excessive intake
of salt, oxalate containing foods and animal proteins,
together with adequate intake of citrate containing fruits.
Statistical analysis
Stone and patients characteristics were compared
between the ESWL and PCNL groups using the chisquare test for categorical data and t-tests for continuous data. KaplanMeier estimates of the probability of
stone recurrence were plotted. The effects of various
factors such as patient age, sex, stone side, site, size,
previous stone disease, radio-opacity, stone multiplicity,
and type of intervention on the recurrence rate were
studied using the log-rank test and Cox regression
analysis. A threshold value of 8 mm was used for stone
size; this value was of maximal sensitivity and specificity
for prediction of stone recurrence and was determined
using a receiver operating characteristic curve. Statistical
analysis was done using IBM SPSS software version
20 (IBM Corporation, Armonk, NY, USA) and statistical
significance was defined as a P < 0.05.
Results
The present study included 647 and 137 patients in the
ESWL and PCNL groups, respectively. The clinical
and radiographic findings were compared between the
groups and are summarised in Table 1. While there
were statistically significance differences in most of
the variables between the groups at baseline, they are
unlikely to be of clinical significance, as both groups
were stone free after treatment.
Stone recurrence rates at 1, 5 and 10 years after
ESWL and PCNL are summarised in Table 2. Our data
showed a comparable stone recurrence rate at 1 and
5 years after ESWL compared with PCNL. With longer
follow-up, at 10 years there was a trend towards higher
new stone formation rate in the PCNL group compared
with the ESWL group, but this did not reach statistical
significance. The KaplanMeier curve in Fig. 1 shows
stone recurrence over time in both groups.
Within the ESWL group, there were no patients or
stone characteristics associated with time-to-stone
recurrence except stone length (Table 2). The log-rank
test showed that the rate of stone recurrence was
significantly greater (P = 0.007) with stone lengths of
>8 mm compared with smaller stones. Within
the PCNL group stone recurrence was significantly
associated with stone multiplicity (P = 0.015; Table 2).

El-Assmy et al.
Table 1 The patients and stone characteristics at baseline in
the ESWL and PCNL groups.
Variable

ESWL

PCNL

Number of patients
Mean (SD) age, years,

647
40 (10)

137
47.6 (10)

<0.001

490 (75.7)
157 (24.3)

83 (60.5)
54 (39.5)

449 (69.4)
46 (7.1)
152 (23.5)

58 (42.3)
10 (6.3)
69 (50.4)

631 (97.5)
16 (2.5)
13.8 (6)

116 (84.6)
21 (25.4)
9.4 (1.3)

535 (82.7)
112 (17.3)

93 (67.9)
44 (32.1)

507 (78.4)
140 (21.6)

60 (43.8)
77 (56.2)

640 (98.9)
7 (1.1)

103 (75.2)
34 (24.8)

312 (48.2)
335 (51.8)

64 (46.8)
73 (53.2)

515 (79.6)
52 (8)
80 (12.4)

63 (46)
45 (32.9)
29 (21.1)

N (%):
Gender
Male
Female
Renal morphology
Normal
Pyelonephritis
Hydronephrotic
Solitary kidney
No
Yes
Mean (SD) stone size, mm
N (%):
Stone nature
De novo
Recurrent
Stone number
Single
Multiple
Stone opacity
Opaque
Lucent
Side
Right
Left
Stone site
Pelvis
Calyx
Multiple

<0.001

<0.001

<0.001

<0.001
<0.001

<0.001

<0.001

0.7

<0.001

When we combined patients who underwent ESWL

and PCNL as one group, the rate of stone recurrence
was significantly higher with a stone length of >8 mm
(P = 0.023) and a previous history of stone disease
(P = 0.01; Table 2, Figs 2 and 3). By Cox regression,
patients with a stone length of >8 mm were more likely
to develop stone recurrence with time [hazards ratio
(HR) 1.297, 95% CI 1.0151659; P = 0.038]. In addition, a history of stone disease was also found to be significant for time-dependent stone recurrence (HR 1.257,
95% CI 1.0411.562; P = 0.019).
The site of stone recurrence within the pelvis or
calyces was analysed for both groups and compared
with baseline site of the original stone (Table 3). In both
the ESWL and PCNL groups, there was a shift from
baseline stone location, with an increased tendency for
most new stones to recur in the calyces as opposed to
the pelvis.
Discussion
Several authors have reported long-term stone recurrence rates after ESWL, but their results have been

Lithotripsy and stone recurrence

Table 2

111

Factors significantly associated with time-dependent recurrence for patients who underwent PCNL and ESWL.
Time-to-recurrence, months

Recurrence-free status,%

Median (95% CI)

1 year

5 years

10 years

84 (75.592.4)
72 (61.882.1)

99
99.4

65
61

38.6
28

118 (95.5140.4)
72 (65.278.7)

99.2
99

75.6
62.3

48
38.5

Intervention
ESWL
PCNL

78 (70.985)
75 (6089)

99.2
98.5

64.2
64.5

38.9
25.1

ESWL group sub-analysis

Stone size, mm
68
>8

121 (93148)
72 (6578.8)

98.8
99.3

76.6
62.3

56.5
36.1

PCNL group sub-analysis

Stone number
Single
Multiple

109 (75.5142.4)
66 (57.674.3)

98
98.7

72.4
59

36.8
17.4

Overall
Stone nature
De novo
Recurrent
Stone size, mm
68
>8

Figure 1

0.01

0.023

0.058

0.007

0.015

KaplanMeier plot for stone recurrence in the ESWL (SWL) and PCNL (PNL) groups. Time, months.

contradictory, with stone recurrence rates ranging from

5% to 20.3% [68]. Some claim that the recurrence rate
after ESWL is similar to the natural recurrence rate and
that ESWL has particular effect on true stone recurrence
[6]. On the other hand, Sun et al. [9] reported the highest
recurrence rate of 51% in 436 patients at a mean followup of 7.1 years; also late recurrences were noted in up to
70% of their patients after 9 years. They concluded that
the frequent late recurrences support the speculation
that ESWL might lead to higher recurrence rates.

A problem when analysing long-term stone recurrence is the large number of patients who withdraw from
the study. The KaplanMeier method allowed us to
draw long-term conclusions from the data on the
remaining cases still being followed. In our present
study, the recurrence rates at 1, 5 and 10 years after
ESWL were 0.8%, 35.8% and 60.1% using Kaplan
Meier analyses. Other studies have also calculated
cumulative recurrence rates using the KaplanMeier
method [17,18]. In one study [17], the overall ipsilateral

112

Figure 2

El-Assmy et al.

KaplanMeier plot for stone recurrence in all 784 patients according to stone length (68 vs >8 mm). Time, months.

Figure 3 KaplanMeier plot for stone recurrence in all 784 patients according to previous history of stone disease (de novo vs recurrent).
Time, months.

recurrence rates were 3.5%, 21.2%, 34.7% after 1, 3 and

5 years, respectively; and the contralateral stone recurrence rates were 1.9%, 7.5%, 12.8%, respectively. In
another study, the cumulative recurrence rates were
2.0% at 1 year, 13.1% at 3 years, 23.9% at 5 years,
30.7% at 7 years, and 40.7% at 10 years [18].
The differences in recurrence rates between ESWL
and other methods of stone management remain
controversial. A single study noted a greater recurrence

rate after conventional open stone surgery (OSS) [19].

The recurrence rate was 31.8% within a mean of
40 months in the OSS group, whereas this figure was
13.9%, with a mean period of 46 months in the ESWL
group (P < 0.05). The mean periods of recurrence in
the ESWL and OSS groups were 20 and 11 months,
respectively (P < 0.05). However, for comparable
stone burdens, the recurrence rate was similar. The
results of that study show that stone burden may be

Lithotripsy and stone recurrence

Table 3

113

Distribution of site of stone recurrence in both the ESWL and PCNL groups.

Site

Upper calyx
Middle calyx
Lower calyx
Pelvis
Multiple sites

ESWL, n (%) (N = 469)

Baseline

Follow-up

43 (9.2)
42 (9)
113 (24.1)
213 (45.4)
58 (12.4)

58 (12.4)
71 (15.1)
131 (27.9)
136 (29)
73 (15.6)

the primary risk factor for stone recurrence after ESWL

and OSS.
Few studies have compared late stone recurrence
after ESWL and PCNL, and they also show conflicting
findings [1115]. Krambeck et al. [12] reported that at
19 years of follow-up stone recurrences were less frequent after PCNL compared with ESWL. A similar conclusion was reported by Carr et al. [11], who reported
that new stones formed in 22.2% of their patients after
ESWL and in 4.2% after PCNL at 1 year (P = 0.004),
and in 34.8% vs 22.6%, respectively, at 2 years
(P = 0.190). More recently in a study by Chongruksut
et al. [14] and during 3 years of follow-up, the overall
stone recurrence rates were 15.5% and 12.6% in the
ESWL and PCNL groups, respectively. Contrary to
these findings; Carlson et al. [15] reported that stone
recurrence rates in the first 2 years after ESWL and
PCNL were similar in both groups, and there was no
significant difference in stone recurrence for patients
treated with ESWL. In accordance with the findings of
Carlson et al. [15]; Trinchieri et al. [13] reported that
the overall recurrence rates for ESWL and PCNL were
very similar (37% and 39%, respectively).
A major concern about the findings of these previous
studies is that most of them [1215], except those of Carr
et al. [11], did not exclude patients with PCNL who
underwent intracorporeal lithotripsy. It is clearly obvious that intracorporeal lithotripsy may lead to formation of microscopic fragments similar to those that
occur in ESWL. Therefore, the previous findings should
be interpreted with caution. Another concern is the
small number of patients included [1113].
In our present study, a large number of patients who
were stone-free after ESWL were included, as well as
patients treated by PCNL without any attempt at intracorporeal lithotripsy. Our present data showed no significant difference in recurrence rates in patients
treated by ESWL and PCNL. The KaplanMeier analyses showed high recurrence rates following either
ESWL or PCNL after 5 and 10 years, respectively.
These findings confirm the significance of long-term
follow-up after stone removal and the need to find an
effective prophylactic therapy to prevent recurrence.
In the study by Carr et al. [11], the location of stone
recurrences for the ESWL group showed a shift from the

<0.001

PCNL, n (%) (N = 80)

Baseline

Follow-up

4 (5)
2 (2.5)
25 (31.2)
30 (37.5)
19 (23.8)

2 (2.5)
8 (10)
31 (38.8)
13 (16.2)
32.5 (22.5)

0.01

baseline location before treatment to a higher incidence

for recurrence within the calyces. In another study [5],
the distribution of the location of the original stone
was unrelated to recurrence but calculi predominantly
recurred in the lower calyx (68%). The explanation for
higher recurrence in the lower calyx after ESWL may
be due to microscopic stone debris remaining following
ESWL, which gravitate to dependent calyces and act as
nidi for new stone growth. In our present study, there
was a similar trend of higher new stone formation in
the lower calyx compared with the original sites.
Stone size, site, multiplicity and composition, a positive history of stone disease and UTI after ESWL were
identified previously as factors influencing stone recurrence [6,8,17,18]. In our present study, a stone size of
>8 mm was a significant predictor of stone recurrence
after ESWL. A positive history of urolithiasis was
another predictive factor among the patients included
in our present study.
Finally, we acknowledge some limitations in our present study. Firstly, a large number of patients were lost
to follow-up. Another source of bias within our study is
that patient demographics or risk factors for stone
recurrence were not possible to control for between
treatment groups. Metabolic evaluation or stone analysis was not done routinely for all patients; if these factors were not similar within the ESWL and PCNL
groups stone recurrence rates may have been changed.
Prospective trials are warranted to avoid these potential
risk factors.
Conclusions
The KaplanMeier recurrence rates following ESWL
were 0.8%, 35.8% and 60.1% after 1, 5 and 10 years,
respectively. The recurrence rates in the ESWL and
PCNL groups were comparable. Our present results
demonstrated that ESWL does not increase long-term
stone recurrence in patients who become stone free after
ESWL. The stone burden appears to be the primary factor in predicting stone recurrence after ESWL. The
recurrence rate in all patients was also influenced by
positive history of urolithiasis. More new stones
recurred in the calyces compared with baseline location
in the ESWL and PCNL groups. The high recurrence

114

rates at 5 and 10 years after ESWL and PCNL show the

importance of long-term follow-up and the need for an
effective prophylactic therapy to prevent recurrence.
Conflicts of interest
None.
Source of funding
None.
References
[1] Chaussy CH, Brendel W, Schmiedt E. Extracorporeally induced
destruction of kidney stones by shock waves. Lancet
1980;2:12658.
[2] Skolarikos A, Alivizatos G, Delarosette J. Percutaneous
Nephrolithotomy and its Legacy. Eur Urol 2005;47:228.
[3] Lu P, Wang Z, Song R, Wang X, Qi K, Dai Q, et al. The clinical
efficacy of extracorporeal shock wave lithotripsy in pediatric
urolithiasis: a systematic review and meta-analysis. Urolithiasis
2015;43:199206.
[4] Salem S, Mehrsai A, Zartab H, Shahdadi N, Pourmand G.
Complications and outcomes following extracorporeal shock
wave lithotripsy: a prospective study of 3,241 patients. Urol Res
2009;38:13542.
[5] Kamihira O, Ono Y, Katoh N, Yamada S, Mizutani K, Ohshima
S. Long-term stone recurrence rate after extracorporeal shock
wave lithotripsy. J Urol 1996;156:126771.
[6] Kohrmann KU, Rassweiler J, Alken P. The recurrence rate of
stones following ESWL. World J Urol 1993;11:2630.
[7] Miles SG, Kaude JV, Newman RC, Thomas WC, Williams CM.
Extracorporeal shock-wave lithotripsy: prevalence of renal stones
321 months after treatment. AJR Am J Roentgenol
1988;150:3079.
[8] Yu CC, Lee YH, Huang JK, Chen MT, Chen KK, Lin ATL, et al.
Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy. Br J Urol 1993;72:68891.

El-Assmy et al.
[9] Sun BY, Lee YH, Jiaan BP, Chen KK, Chang LS, Chen KT.
Recurrence rate and risk factors for urinary calculi after extracorporeal shock wave lithotripsy. J Urol 1996;156:9036.
[10] Mulley AG, Carlson KJ, Dretler SP. Extracorporeal shock-wave
lithotripsy: slam-bang effects, silent side effects? AJR Am J
Roentgenol 1988;150:3168.
[11] Carr LK, DAHoney JR, Jewett MAS, Ibanez D, Ryan M,
Bombardier C. New stone formation: a comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy.
J Urol 1996;155:15657.
[12] Krambeck AE, LeRoy AJ, Patterson DE, Gettman MT. Longterm outcomes of percutaneous nephrolithotomy compared to
shock wave lithotripsy and conservative management. J Urol
2008;179:22337.
[13] Trinchieri A, Mandressi A, Zanetti G, Montanari E, Dormia G,
Luongo P, et al. Recurrence of lithiasis after extracorporeal
lithotripsy, percutaneous surgery, and open surgery for calculi of
the upper urinary tract. Prog Urol 1992;2:396401.
[14] Chongruksut W, Lojanapiwat B, Tawichasri C, Paichitvichean S,
Euathrongchit J, Ayudhya VC, et al. Kidney stones recurrence
and regrowth after extracorporeal shock wave lithotripsy and
percutaneous
nephrolithotomy.
J
Med
Assoc
Thai
2011;94:107783.
[15] Carlson KJ, Dretler SP, Roth RA, Hatziandreu E, Gladstone K,
Mulley Jr AG. Extracorporeal shock wave lithotripsy and
percutaneous nephrostolithotomy for urinary calculi: comparison
of immediate and long-term effects. J Stone Dis 1993;5:818.
[16] El-Nahas AR, Eraky I, Shokeir AA, Shoma AM, El-Assmy AM,
El-Tabey NA, et al. Long-term results of percutaneous
nephrolithotomy for treatment of staghorn stones. BJU Int
2010;108:7504.
[17] Tashiro K, Iwamuro S, Nakajo H, Hatano T, Furuta A, Noda K.
Et al. [Stone recurrence after stone free status with extracorporeal
shock wave lithotripsy]. Nihon Hinyokika Gakkai Zasshi
1997;88:4348.
[18] Kato S, Tanda H, Ohnishi S, Nakajima H, Ujiie T, Nanbu A.
Recurrence of stones after extracorporeal shock wave lithotripsy.
Hinyokika Kiyo 1996;42:71722.
[19] Kosar A, Sarica K, Aydos K, Kupeli S, Turkolmez K, Gogus O.
Comparative study of long-term stone recurrence after extracorporeal shock wave lithotripsy and open stone surgery for kidney
stones. Int J Urol 1999;6:1259.