Difference of opinion--In the era of flexible ureteroscopy is there still a place for Shock-wave lithotripsy? Opinion: NO.

Flexible ureteroscopy will replace almost completely ESWL for the treatment of renal stones in few years, even in developing countries. This process is already ongoing and probably is irreversible. Let ́s try to understand how and why this phenomenon is happening. Since the development of the External Shockwave Lithotripsy (ESWL) in the late 70’s (1), it has been the standard treatment for small renal stones (2). However, recent years have seen a significant shift towards endoscopic therapies (3). This can be attributed to the evolving surgical experience in the use of these techniques, but even more to major improvement in the technical equipment. The question of if the flexible ureteroscopy will substitute ESWL as the choice therapy for renal stones is controversial. First of all, they are not totally comparable, since ESWL is a non-invasive method. If ESWL is not an option no more, we lose a noninvasive method of treatment of renal stones. Otherwise, a non-invasive method doesn’t means that it is not harmful, because its association with late development of diabetes and hypertension is still controversial, while a link between ESWL and phosphate calcium stones is possible (4). However, as flexible ureteroscopy has higher success rates, it can be justified, since the complications rates are low. Regarding the cost, in some services the flexible ureteroscopy is cost effective compared to ESWL (5). If we see this issue from a current point of view only, it sounds almost absurd to state that ESWL will disappear. Almost 60% of renal stones today are treatment by ESWL, at low cost and low complications rates. No one should close an ESWL service that is established and working properly. The urological guidelines support the use of ESWL for renal and ureteral stones (2, 6). However, we are discussing the future of renal stones treatment, what includes search for better treatments, with lower costs, higher success rates and low complications rates, with a high acceptance and satisfaction of the patients. Vol. 41 (1): 203-206, January February, 2015