Zang M. et al., 2026: New advances in efficacy prediction of extracorporeal shock wave lithotripsy in pediatrics: a narrative review.

Zang M, Dong Y, Wang X, Han C, Jia J.
Front Pediatr. 2026 Jan 21;13:1681384. doi: 10.3389/fped.2025.1681384

Abstract

Extracorporeal Shock Wave Lithotripsy (ESWL) has been a cornerstone in treating pediatric urinary stones for nearly four decades, but requires tailored approaches due to anatomical and physiological differences from adults. This review synthesizes current evidence on ESWL efficacy predictors in children, integrating multicenter data and emerging technologies. Key traditional predictors include favorable stone characteristics [density ≤600 Hounsfield units [HU], size ≤15 mm, skin-to-stone distance [SSD] ≤6.6 cm, upper/middle calyx or ureteral location] and patient factors (age ≤3 years, male sex); conversely, urinary tract infections (UTIs), BMI >22, and multiple stones correlate with poorer outcomes. Innovations like dual-energy CT (DECT), AI-based models, shear wave elastography (SWE), and bioelectric impedance analysis (BIA) offer promising non-invasive preoperative assessment. We highlight the need for standardized multifactorial predictive models to optimize pediatric ESWL outcomes. Future directions emphasize AI, big data, and multidisciplinary collaboration to enhance personalized treatment and reduce complications. This analysis provides clinicians with evidence-based tools to refine pediatric ESWL protocols.

Comment Hans-Göran Tiselius

This report is recommended for those who encounter and must deal with stone problems in the pediatric population. With the aim of formulating factors associated with successful SWL, the authors searched the literature and extracted relevant information. The review resulted in NINE factors that were associated with success.

Age ≤ 3 years

Gender: male

UTI: no

Stone diameter ≤ 15 mm

Location of stone: Upper calyx, middle calyx, ureter

Stone density ≤ 600 HU

SSD ≤6.6 cm

BMI ≤ 22

Stone number: single.

It is of great interest that the authors found inverted drainage positions of value for elimination of fragments from the lower calyx! How this can be accomplished is shown in a Figure in the article. Indeed, very useful information that demonstrates the importance of a method for improved stone clearance. This fundamental information indicates that unsuccessful clearance of stone fragments does not depend on poor SWL, but on anatomical outflow problems. Astonishing good stone-free rates support the value of inverted positioning in this age group. The reader should particularly consider this finding.

Those of us who have followed the attitude to SWL in pediatric patients know that there was a time at which several centers decided to avoid SWL in all pediatric patients. The current report obviously shows an altered and alternative attitude.

Hans-Göran Tiselius