Fluoroscopic-Guided Versus Ultrasound-Assisted Extracorporeal Shock Wave Lithotripsy for Renal Stones: A Prospective Randomized Single-Centre Study

Background: Extracorporeal shock wave lithotripsy (ESWL) is an established non-invasive treatment for selected renal calculi. Accurate stone localization is essential for effective shock-wave delivery. Fluoroscopy has traditionally been used for targeting, while ultrasound offers real-time localization without ionizing radiation. Evidence comparing the two approaches remains heterogeneous. The objective is to compare the efficacy and safety of fluoroscopic (FS)-guided ESWL with ultrasound (USG)-guided ESWL for renal stones up to 20 mm. Material and Methods: This prospective randomized single-centre study was conducted at the Department of Urology, Pt. B.D. Sharma PGIMS, Rohtak, from January 2024 to December 2025. Adults with a single renal stone measuring 5–20 mm and eligible for ESWL were randomly allocated to FS-guided or USG-guided treatment (65 patients per group). Stone characteristics, shock frequency, energy, procedure duration, number of sessions, treatment outcome and post-procedural complications were assessed. Treatment success was defined as stone-free status or residual fragments <4 mm (clinically insignificant residual fragments). Results: The two groups were comparable at baseline with respect to age, sex, renal laterality, stone location, skin-to-stone distance, stone size and stone density. Treatment success was significantly higher with FS-guided ESWL than with USG-guided ESWL (83.1% vs 67.7%; p=0.042), with corresponding failure rates of 16.9% and 32.3%. Shock frequency, energy requirements and procedure duration did not differ significantly between groups across sessions. Overall pain intensity was similar (p=0.757), as was hematuria (3.1% vs 4.6%; p=0.999). No cases of urosepsis or steinstrasse were reported in either group. Up to three ESWL sessions were used, and the thesis reported no significant difference in the need for ancillary procedures. Conclusion: In this study population, FS-guided ESWL achieved a higher treatment success rate than USG-guided ESWL, while both approaches demonstrated comparable procedural parameters and short-term safety outcomes. USG-guided ESWL remains a clinically useful alternative when fluoroscopy is undesirable or unsuitable. Larger multicentre randomized studies with longer follow-up, radiation-dose assessment and cost-effectiveness analysis are warranted.

Keywords: renal calculi, extracorporeal shock wave lithotripsy, ESWL, fluoroscopy, ultrasonography, stone-free rate, urolithiasis.