The 3rd Generation of ESWL’s patient instruction

Last updated: August 30, 2026

• WordPress
• LinkedIn
• Mail

Patients often ask how aftercare differs between 3^rd– and 4^th-generation ESWL. This article deals specifically with the 3^rd generation — which is the lithotripter used at Bangkok Hospital Headquarters.

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

For general post-ESWL aftercare, see post-ESWL patient instructions, and for background on how the generations of lithotripter differ, see how 4th-generation ESWL works.

The practical difference between the generations is respiratory gating: a 4^th generation machine synchronises its shocks with the patient’s breathing, so that it fires when the stone is in the focal zone, while a 3^rd generation machine does not and instead relies on repositioning and on the patient lying still. Correction, August 2026: this page previously quoted stone hit rates of 82.6% for the 3^rd generation and 98.5% for the 4^th. Those figures have been removed, because they are manufacturer-style specifications and I could find no independent published data supporting them. What the independent literature does report is sobering in a useful way: in conventional lithotripters, only around 30–50% of shock waves actually strike the stone at all. Two further points are worth having straight. First, targeting accuracy is not the same as the stone-free rate — the first describes how often the shock lands on the stone during treatment, the second is the outcome you actually care about, whether you need another procedure. Second, newer does not automatically mean better: independent comparative studies have found first-generation machines fragmenting stones more effectively than later-generation ones, with broadly similar stone-free rates at three months. The generation of the machine matters far less than stone size, stone density, its position and your body habitus — which is what the decision should actually rest on.

Before the procedure: what your team must be told

If you are reading this before your ESWL rather than after it, there are a few things that change whether the procedure goes ahead as planned, and they are easy to leave unmentioned:

• Any blood-thinning medication — warfarin, the newer oral anticoagulants, aspirin, clopidogrel and similar. ESWL breaks a stone with shockwaves that also bruise the kidney around it, so a blood thinner has to be planned for in advance rather than discovered on the day. Do not stop it yourself; the decision about pausing, bridging or postponing belongs with the doctor who prescribed it and your urologist together.
• Pregnancy, or the possibility of it. ESWL is not performed during pregnancy.
• Any untreated urinary infection, and any implanted device such as a pacemaker.
• Everything else you take, including supplements. A photograph of the boxes is more reliable than remembering names.

Post 3^rd Generation ESWL Patient Instructions

Right after the ESWL procedure

• You will be woken by the anesthesiologist once the sedation wears off.
• At Bangkok Hospital Headquarters, ESWL is a daycare procedure. After 1-2 hours of observation in the recovery room — checking for sedation side effects such as dizziness or nausea, confirming that you can pass urine, and making sure pain is controlled — you go home the same day. No overnight stay is required.
• Practice varies between hospitals: many centres routinely transfer the patient to the ward for overnight observation after sedation. An overnight stay may also be advised in individual cases at any hospital — for example if pain is not settling, if there is a fever, or if you have other medical conditions that warrant closer monitoring.
• Arrange for someone to take you home. You should not drive yourself on the day of the procedure.

The first several days after ESWL

• Almost 100% of patients experience bloody urination caused by the shockwave effect on surrounding kidney tissue. Drink 2-3 liters of water daily to flush out residual blood.
• The 2-3 litres a day applies to patients with normal heart and kidney function. If you have heart failure or kidney impairment, or have been told to limit your fluids, ask what target is right for you rather than following that figure.

Within 30 days after ESWL

1. Steinstrasse risk 4-7% — Shattered stone fragments may accumulate in the ureter, causing flank pain or remaining asymptomatic.
2. Residual stone risk 21-59% — Fragments under 4 mm are considered clinically insignificant and may pass spontaneously. Regular ultrasound follow-up is recommended.
3. Stone pain risk — Shattered fragments may trigger sudden pain. Maintain high fluid intake (2-3 liters/day). Oral medication can help reduce post-ESWL stone pain.
4. Blood stream infection risk 1-2.7% — Bacteria residing in stones may enter the bloodstream. Routine antibiotics are not prescribed; fever monitoring after the procedure is recommended, and fever needs prompt medical assessment.
5. Major kidney bleeding <1% — Severe kidney injury is rarely reported, as ESWL is the least invasive kidney stone procedure.

If a stent was placed

Some patients have a ureteral (DJ) stent placed before or after ESWL, particularly for a large stone. If that applies to you, one thing matters more than everything else on this page: write down the date it is due to come out, and put it in your phone. A stent left in and forgotten encrusts and can eventually obstruct the kidney it was placed to protect, turning a five-minute removal into several operations. Feeling perfectly well is not evidence that it can stay — the people who forget are usually the ones with no symptoms. If you are already past the date, contact a urology department now rather than waiting.

When to come back rather than wait

Most of what happens after ESWL is expected and settles on its own. These are the exceptions, and they should not wait for the routine follow-up appointment. Go to an emergency department the same day — in Thailand you can call 1669:

• Fever or shaking chills — the single most important one. Bacteria trapped inside a stone can be released into the bloodstream when the stone breaks, and that infection can become serious quickly. Fever after ESWL needs same-day assessment, not paracetamol and a wait.
• Pain that is severe or not controlled by the medication you were given, particularly with vomiting or an inability to keep fluids down.
• Not passing urine at all, or passing very little despite drinking normally.
• Heavy bleeding or blood clots in the urine, or bloody urine that is getting worse rather than fading over several days.
• Any of the above matters more if you have only one working kidney, are diabetic, take blood thinners, or have reduced immunity.

Tell whoever assesses you that you have recently had ESWL, on which side, and whether a stent is in place. It changes what they look for immediately, and it is easily missed if nobody says it.

Long-term complications

No existing evidence supports any long-term complications from ESWL, per EAU 2020 recommendations.

One thing worth planning for while you are still in the follow-up period: if you catch a fragment when it passes, keep it and bring it in. Stone analysis identifies what the stone was made of, and that is what determines which preventive measures actually apply to you — treatment of the stone you had is not the same as prevention of the next one. On that second point, see why kidney stones form.

If you have any questions about the 3^rd Generation ESWL procedure, please discuss them with your trusted urologist, or raise them at your consultation. Take care!

Frequently Asked Questions

Q1: What is 3rd generation ESWL and how is it different from 4th generation?

The difference is respiratory gating. A 4th generation machine synchronises its shockwaves with the patient’s breathing so that it fires when the stone is in the focal zone; a 3rd generation machine does not, and instead relies on careful positioning and on the patient staying still, which is one reason short-acting intravenous analgesia or light sedation is used. An earlier version of this page quoted hit rates of 82.6% and 98.5% for the two generations. Those figures have been removed, because they are manufacturer-style specifications with no independent published data behind them. Two things are worth knowing instead. Targeting accuracy is not the same as the stone-free rate: the first is how often a shock lands on the stone, the second is whether you end up needing another procedure, and it is the second that matters to you. And newer is not automatically better — independent comparisons have found first-generation machines fragmenting stones more effectively than later ones, with broadly similar stone-free rates at three months. Stone size, density, position and body habitus influence the result far more than the generation of the machine. Bangkok Hospital Headquarters performs ESWL with a 3rd generation lithotripter.

Q2: What must I tell my doctor before ESWL?

Any blood-thinning medication is the most important, including warfarin, the newer oral anticoagulants, aspirin and clopidogrel, because ESWL bruises the kidney as it breaks the stone and the treatment plan has to account for that in advance. Do not stop such medication yourself — that decision belongs with the doctor who prescribed it, together with your urologist. Also declare pregnancy or the possibility of it, since ESWL is not performed during pregnancy; any untreated urinary infection; any implanted device such as a pacemaker; and everything else you take, including supplements. A photograph of the boxes is more reliable than remembering names.

Q3: Is bloody urination normal after ESWL?

Yes. Bloody urination occurs in almost 100% of patients after ESWL due to the shockwave effect on surrounding kidney tissue. It is expected and not dangerous. Drinking 2-3 liters of water daily helps flush out residual blood and stone fragments. The bloody urination typically clears within a few days. Bleeding that is heavy, contains clots, or worsens rather than fades should be reported.

Q4: What is Steinstrasse and should I be worried?

Steinstrasse is a German term meaning stone street — a condition where shattered stone fragments accumulate in the ureter, forming a column of debris. It occurs in 4-7% of ESWL cases and can cause flank pain or remain asymptomatic. Your urologist will monitor for this with follow-up imaging and manage it appropriately if it develops.

Q5: I had a stent placed with my ESWL. What do I need to know?

Record the date it is due to be removed and set a reminder. A ureteral stent left in and forgotten encrusts over time and can obstruct the kidney it was placed to protect, turning a simple outpatient removal into several operations and, in severe cases, threatening that kidney. Feeling well is not evidence that it can safely stay, because the patients who forget are usually the ones with no symptoms. If you are already past the removal date, contact a urology department now rather than waiting. Stent-related urinary urgency, frequency and discomfort are common and settle once it is out.

Q6: How long does it take to know if ESWL was successful?

Follow-up imaging is typically performed 4-6 weeks after ESWL to assess stone clearance. Residual stone fragments of less than 4 mm are considered clinically insignificant and may pass spontaneously. For larger residual fragments, additional ESWL sessions or alternative stone treatment may be recommended. Regular follow-up ultrasound is advised long-term as residual stones have a 21% chance of regrowth over 5 years.

Q7: Does ESWL cause long-term kidney damage?

According to EAU (European Association of Urology) 2020 guidelines, no existing evidence supports long-term kidney damage from ESWL when performed appropriately. ESWL remains one of the safest and least invasive kidney stone treatments available. However, patients with a history of multiple ESWL sessions or pre-existing kidney disease should discuss long-term monitoring with their urologist.

Q8: Which symptoms after ESWL need urgent attention?

Fever or shaking chills is the most important one: bacteria trapped inside a stone can be released into the bloodstream when the stone fragments, and that infection can escalate quickly, so it needs same-day assessment at an emergency department — in Thailand you can call 1669. Also seek care the same day for pain that is severe or not controlled by the prescribed medication, vomiting that prevents you keeping fluids down, passing little or no urine, and heavy bleeding or clots in the urine. These matter more if you have a single functioning kidney, diabetes, reduced immunity, or take blood thinners. Say that you have recently had ESWL, on which side, and whether a stent is in place.

If you have kidney stones and would like to explore ESWL treatment options, Dr. Soarawee Weerasopone offers specialist consultations at Bangkok Hospital Headquarters. Book a Consultation. Appointments at Samitivej Sriracha Hospital can be arranged by calling the Urology department on 088-022-1445. Questions about the cost of consultation or the procedure should go to the hospital directly — for Bangkok Hospital, by email to bhquro@bdms.co.th.

Bangkok Hospital also runs a Telemedicine service, which works well for reviewing follow-up imaging results and planning what happens to any residual fragments — arrange it in advance by email to the Urology department at bhquro@bdms.co.th. Samitivej Sriracha is in-person only. Anything in the urgent list above should be assessed in person rather than by video.

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. Fever after ESWL needs same-day medical assessment. Do not stop any prescribed medication, including blood thinners, on the basis of this article. No medical advice, diagnosis or prescription is provided through personal messaging channels or social media. Always consult a qualified healthcare professional before starting any medical treatment. In an emergency, attend the nearest emergency department — in Thailand the emergency number is 1669.