For decades, extracorporeal shockwave lithotripsy (ESWL) has been considered a first-line and non-invasive treatment for kidney stones, especially small and medium-sized stones located in the upper pole and renal pelvis. However, this procedure is not without collateral damage to kidney tissue, with both acute and chronic side effects. Shear stress and cavitation forces generated by shockwaves to fragment stones do not discriminate between stones and renal parenchyma. When they release their energy into the renal parenchyma, shockwaves cause microvascular damage, vasospasm, ischemia-reperfusion injury, oxidative stress, and an inflammatory cascade that might end with fibrosis and nephron loss. These detrimental side effects would be more evident in patients requiring multiple treatment sessions and those with solitary or pre-damaged kidneys.

Although population-level data on long-term systemic effects like hypertension and diabetes are equivocal, imaging, biomarkers, and histopathology consistently demonstrate ESWL-related subclinical renal injury, questioning the traditional “treat and assess” trend.​

Given the clear pathophysiological rationale and growing supportive evidence, reno-protective protocols should be an integral component of modern ESWL practice, at least for high-risk groups such as patients with solitary kidneys, pre-existing renal damage, children, and patients with recurrent stones requiring repeated treatment sessions.