Abdelrasheed A. et al., 2025: Perinephric Hematoma Following Extracorporeal Shock Wave Lithotripsy: A Comprehensive Review of Four Decades of Evidence on Risk Factors, Prevention, and Management.

Ahmed Abdelrasheed, Muhammad Iqbal
Cureus. 2025 Oct 14;17(10):e94565. doi: 10.7759/cureus.94565

Abstract

Perinephric hematoma represents a significant complication following extracorporeal shock wave lithotripsy (ESWL), with reported incidence ranging from 0.1% to 30% depending on detection methodology. This comprehensive review examines four decades of evidence since the first clinical ESWL treatment in 1980, analyzing risk factors, prevention strategies, and management approaches. Following a systematic literature search, we identified 36 relevant studies encompassing 30,347 treated patients. Hypertension emerges as the dominant modifiable risk factor, increasing hematoma rates from a baseline of 0.66% to 3.8% in poorly controlled patients. Stepwise voltage ramping protocols demonstrate remarkable protective effects, reducing incidence by over 50%. Conservative management succeeds in over 95% of cases, with arterial embolization reserved for active bleeding. Paradoxically, the original Dornier HM3 lithotripter maintains superior safety profiles compared to modern devices despite technological advances. Long-term follow-up studies document complete renal function preservation following appropriate management. These findings inform evidence-based protocols optimizing safety while maintaining treatment efficacy.

Comment Hans-Göran Tiselius

Perinephric hematoma is the most serious complication encountered after SWL. It is uncommon but mostly associated with dramatic and painful symptoms.

Although several reports have been devoted to renal hematoma after SWL, this one is of particular interest because it gives a summary of perinephric hematoma that have been described in the literature during the past four decades.

It is of great clinical interest that hypertension was the most evident and modifiable risk factor. My personal experience in this regard was the clinical rule never to treat any stones in the kidney with SWL unless the hypertension was adequately treated and controlled. The experience also showed that great care was necessary in patients who had a clinical history of hypertension. Obviously, hypertension, also when adequately treated, caused vulnerable vessels and increased risk of bleeding. The ramping procedure was shown effective to counteract bleeding complications and the recommended early pause is described as a very useful protective measure.

The four risk factors mentioned were:

HYPERTENSION

PRIOR ANTICOAGULATION

HIGH STONE DENSITY

HIGH BMI

Other factors can be found in Table 1 in the report.

The importance of the focal size for risk of hematoma is shown in Table 3.

                                  Focal zone          Hematoma

Dornier HM3 (original)      60 x 10 mm       0.66-1.0%

Wolf Piezolith                      12 x 3 mm           1.8%

Storz Modulith SL               28 x 6 mm           3%

Dornier compact S              40 x 8 mm           2.5%

Siemens Lithoscope           28 x 8 mm           2.1%     

This information supports my own personal experience because using the Dornier HM3 device during more than twelve years no clinically evident and symptomatic hematoma was diagnosed. But shortly after starting SWL with the Dornier MFL 5000 (a lithotripter with a significantly smaller focal zone) the first hematoma appeared. The explanation is that with small sharp focal zones the risk of artery damage is increased.

To summarize the risk of hypertension, the author concluded that the risk was about six-fold. The highest risk was encountered in patients with anticoagulation and advanced age. The highest risk was seen when SWL was used to disintegrate particularly hard stones in the lower calyx.

Hans-Göran Tiselius