How the 4th Generation ESWL works?

Last updated: May 18, 2026

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Extracorporeal Shockwave Lithotripsy (ESWL) is a minimally invasive procedure for kidney stones. This article focuses on the 4th Generation ESWL, the most advanced technology currently available. For post-ESWL patient instructions and the history of all 4 ESWL generations, see the linked articles.

• Urology center Bangkok hospital Thailand Booking online 02-310-3009 bhquro@bdms.co.th
• Samitivej Sriracha hospital Chonburi 088-022-1445

How does ESWL work?

• ESWL technology originated as an incidental breakthrough during World War 2 and has been refined through 4 generations. Each generation offers better pain control and fewer complications
• The shockwave head is placed against the patient’s flank (the area where the kidney lies). The machine generates shockwave pulses that travel through the skin and break kidney stones into small fragments
• Once fragmented, the natural continuous flow of urine from the kidney flushes the stone fragments out through normal urination

Advantages of 4th Generation ESWL over previous generations

• Auto-tracking system — The 4th Generation machine uses an automated targeting system that continuously tracks and locks onto the stone like a precision targeting system. This ensures shockwaves hit the stone accurately, minimizing unnecessary energy delivery to surrounding kidney tissue
• Day-care procedure without anesthesia — Minimized perioperative pain means the procedure is completed as a day-care (outpatient) treatment, requiring only 3 hours total, with no anesthesia team needed. This reduces medical costs and eliminates post-anesthetic recovery time
• Higher accuracy rate — 98.5% hit rate for the 4th Generation vs. 82.6% for 3rd Generation machines
• Fewer complications — Higher targeting precision means less trauma to surrounding renal tissue

Success rates of 4th Generation ESWL (Bangkok Hospital data)

The European Association of Urology (EAU) 2020 guidelines recommend ESWL for kidney stones under 2 cm. Success is defined as stone fragments < 4 mm on follow-up imaging.

• Stone < 1 cm: 84% success rate
• Stone 1–2 cm: 77% success rate
• Stone > 2 cm: 60% success rate

For any questions about ESWL, discuss with your trusted urologist or contact me through the social links on this website.

Frequently Asked Questions About 4th Generation ESWL

What makes 4th Generation ESWL better than previous generations?

The defining advantage of 4th Generation ESWL is its auto-tracking system, which continuously locks onto the kidney stone and delivers shockwaves with 98.5% targeting accuracy (compared to 82.6% in 3rd Generation machines). This precision reduces energy delivery to surrounding tissue, minimizes pain, and allows the procedure to be performed as a day-care outpatient treatment without anesthesia. The total procedure time is approximately 3 hours with no hospitalization required.

What size kidney stones can ESWL treat?

The European Association of Urology (EAU) guidelines recommend ESWL for kidney stones under 2 cm. At Bangkok Hospital Headquarters, our 4th Generation ESWL data shows: 84% success for stones under 1 cm, 77% for 1–2 cm stones, and 60% for stones over 2 cm. Success is defined as residual stone fragments under 4 mm at follow-up. Stones larger than 2 cm may require additional sessions or alternative procedures such as ureteroscopy or percutaneous nephrolithotomy (PCNL).

Is ESWL painful and is anesthesia required?

With 4th Generation ESWL, the procedure is well-tolerated and does not require general anesthesia. The auto-tracking technology minimizes unintended shockwave delivery to surrounding tissue, significantly reducing perioperative pain compared to older generations. The procedure is completed as a day-care outpatient treatment in approximately 3 hours. Patients can typically return home the same day without post-anesthetic recovery concerns.

If you have been diagnosed with kidney stones and would like to discuss ESWL or other kidney stone treatment options, Dr. Soarawee Weerasopone offers specialist consultations at Bangkok Hospital Headquarters. Book a Consultation.

Disclaimer: This content is written and reviewed by Dr. Soarawee Weerasopone, a board-certified urologist at Bangkok Hospital Headquarters. It is intended for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional before starting any medical treatment.

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