Abstract
Objective: To evaluate SSD and other factors related to the characteristics of the patient and renal stone to predict the ESWL outcomes in patients with renal stones.
Methods: A cross-sectional study was conducted on 90 patients undergoing ESWL for renal calculi. Pre-procedural CT scans were used to measure SSD, stone size, and CT attenuation values. Patients were followed post-ESWL by ultrasound and X-ray KUB to assess stone-free status. Correlation analysis, independent samples t-tests, chi-square tests, and binary logistic regression were used to assess associations between variables and treatment outcomes.
Results: The mean value of SSD in our cases was 10 ± 0.72 cm, and 57.8% of patients had SSD ≤10 cm. A statistically significant difference in mean SSD was found between the group that was stone-free vs. the group with residual stones (p < 0.0001). Logistic regression confirmed SSD as an independent predictor of ESWL success (p < 0.00001), with increasing SSD significantly reducing the odds of being stone-free. Stratified analysis showed that 90% of patients with SSD ≤10 cm achieved stone-free status versus only 37.5% with SSD >10 cm (p < 0.0001).
Conclusion: SSD is a statistically and clinically significant predictor of ESWL success. An SSD ≤10 cm is strongly associated with favorable outcomes. Given its simplicity, non-invasiveness, and predictive value, SSD should be incorporated into routine pre-ESWL evaluation to guide treatment planning and improve patient selection.
References
He M, Dong Y, Cai W, Cai J, Xie Y, Yu M, et al. Recent advances in the treatment of renal stones using flexible ureteroscopy. International Journal of Surgery. 2024 Jul 1;110(7):4320-8. https://doi.org/10.1097/JS9.0000000000001345.
Manzoor H, Leslie SW, Saikali SW. Extracorporeal shockwave lithotripsy. In Stat Pearls 2024 Oct 18. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560887/.
Leslie SW, Sajjad H, Murphy PB. Renal calculi, nephrolithiasis. In Stat Pearls 2024 Apr 20. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK442014/
Waqas M, Khan MA, Iqbal MW, Akbar MK, Akhter S. Non-contrast computed tomography scan-based parameters of ureteric stones affecting the outcome of extracorporeal shock wave lithotripsy. Cureus. 2017 May 5;9(5). https://doi.org/10.7759/cureus.1227.
Cho KS, Jung HD, Ham WS, Chung DY, Kang YJ, Jang WS, et al. Optimal skin-to-stone distance is a positive predictor for successful outcomes in upper ureter calculi following extracorporeal shock wave lithotripsy: a Bayesian model averaging approach. PloS one. 2015 Dec 14;10(12):e0144912. https://doi.org/10.1371/journal.pone.0144912.
Elmansy HE, Lingeman JE. Recent advances in lithotripsy technology and treatment strategies: A systematic review update. International Journal of Surgery. 2016 Dec 1;36:676-80. https://doi.org/10.1016/j.ijsu.2016.11.097.
Yoon JH, Park S, Kim SC, Park S, Moon KH, Cheon SH, et al. Outcomes of extracorporeal shock wave lithotripsy for ureteral stones according to ESWL intensity. Translational andrology and urology. 2021 Apr;10(4):1588. https://doi.org/10.21037/tau-20-1397.
Ng CF, Luke S, Chiu PK, Teoh JY, Wong KT, Hou SS. The effect of renal cortical thickness on the treatment outcomes of kidney stones treated with shockwave lithotripsy. Korean Journal of Urology. 2015 Apr 28;56(5):379. https://doi.org/10.4111/kju.2015.56.5.379.
Ergani B, Karabıçak M, Türk H, Yoldaş M, İşoğlu CS, Süelözgen T, et al. Does Increased Stone-skin Distance Due to Obesity Affect Outcomes of Percutaneous Nephrolithotomy? https://doi.org/10.4274/jus.galenos.2019.2660.
Dede O, Şener NC, Baş O, Dede G, Bağbancı MŞ. Does morbid obesity influence the success and complication rates of extracorporeal shockwave lithotripsy for upper ureteral stones? Turk J Urol. 2015;41(1):20-23. https://doi.org/10.5152/tud.2015.94824.
Miah ML, Islam MF, Alam SS, Naser MF, Alam MS, Enayetullah I. Stone Attenuation and Skin-to-Stone Distance on Computed Tomography Predict the Performance of Shock Wave Lithotripsy. Bangladesh Journal of Urology. 2023 Jan 30;26(1):9-13. https://doi.org/10.3329/bju.v26i1.69853.
Ma RH, Luo XB, Li Q, Zhong HQ. Systemic analysis of urinary stones from the Northern, Eastern, Central, Southern and Southwest China by a multi-center study. BMC urology. 2018 Dec 13;18(1):114. https://doi.org/10.1186/s12894-018-0428-2.
Shinde S, Al Balushi Y, Hossny M, Jose S, Al Busaidy S. Factors Affecting the Outcome of Extracorporeal Shockwave Lithotripsy in Urinary Stone Treatment. Oman Med J. 2018;33(3):209-17. https://doi.org/10.5001/omj.2018.39.
Akkaş F, Culha MG, Ayten A, Danacıoğlu YO, Yildiz Ö, İnci E, et al. A novel model using computed tomography parameters to predict shock wave lithotripsy success in ureteral stones at different locations. Actas Urológicas Españolas (English Edition). 2022 Mar 1;46(2):114-21. https://doi.org/10.1016/j.acuroe.2021.01.011.
Ordon M, Andonian S, Blew B, Schuler T, Chew B, Pace KT. CUA Guideline: Management of ureteral calculi. Can Urol Assoc J. 2015;9(11-12):E837-E851. https://doi.org/10.5489/cuaj.3483.
Erdoğan E, Özçelik F, Kahraman G, Şimşek M, Sarıca K. Effect of Stone Density, Skin-Stone Distance and Stone Size on Extracorporeal Shock Wave Lithotripsy Success of Ureter Stones: A Clinical Investigation. The New Journal of Urology. 2025 Feb 1;20(1):1-2. https://doi.org/10.33719/nju1560480.
Islam K, Shah SA, Minallah N, Dad N, Ullah F, Naz S. Evaluation of Skin to Stone Distance by Non-Contrast Computed Tomography as an Independent Predictor of Stone-Free Rate of Extra-Corporeal Shockwave Lithotripsy for Renal Pelvic Stones. Pakistan Journal of Medical & Health Sciences. 2023;17(03):655. https://doi.org/10.53350/pjmhs2023173655.
Iqbal N, Hasan A, Iqbal S, Noureen S, Akhter S. Role of variation coefficient of stone density in determining success of shock wave lithotripsy in urinary calculi. World J Nephrol 2025; 14(1): 96946. https://doi.org/10.5527/wjn.v14.i1.96946.
El-Abd AS, Tawfeek AM, El-Abd SA, Gameel TA, El-Tatawy HH, El-Sabaa MA, et al. The effect of stone size on the results of extracorporeal shockwave lithotripsy versus semi-rigid ureteroscopic lithotripsy in the management of upper ureteric stones. Arab J Urol. 2021 Nov 26;20(1):30-35. https://doi.org/10.1080/2090598X.2021.1996820.
Ahmadullah SK, Malik MI, Memon MA, Ali S, Lashari MK. Effect of skin to stone distance on non-contrast computed tomography and mean attenuation value on the performance of shock wave lithotripsy in kidney stone. Rawal Medical Journal. 2022 Apr;47(2). https://www.rmj.org.pk/fulltext/27-1631688848.pdf.
Kayra MV, Mehmet Resit Goren MR, Ozer C, Kilinc F. The factors that affecting shockwave lithotripsy treatment outcome of kidney stones. Authorea. June 25, 2021. https://doi.org/10.22541/au.162465128.81321037/v1.
Bajaj M, Smith R, Rice M, Zargar-Shoshtari K. Predictors of success following extracorporeal shock-wave lithotripsy in a contemporary cohort. Urol Ann. 2021;13(3):282-287. https://doi.org/10.4103/UA.UA_155_19.
Muhammad Nazim S. Advancements in Shock Wave Lithotripsy: Pushing Boundaries with Innovative Technology and Techniques Lithotripsy - Novel Technologies, Innovations and Contemporary Applications. Intech Open; 2023. http://dx.doi.org/10.5772/intechopen.1003654.
Chaussy CG, Tiselius HG. How can and should we optimize extracorporeal shockwave lithotripsy? Urolithiasis. 2018 Feb; 46:3-17. https://doi.org/10.1007/s00240-017-1020-z.

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