Does Lithotripsy Require a Stent for Kidney Stones?

Lithotripsy does not automatically require a stent, and guidelines have discouraged routine stenting for both major forms of the procedure for over two decades. Whether you end up with one depends on the type of lithotripsy performed, the size and location of your stone, and what your surgeon encounters during the procedure. The reality, though, is more complicated than a simple yes-or-no: a significant number of patients still receive stents despite guideline recommendations against routine use, and there are specific scenarios where a stent genuinely helps.

Two Kinds of Lithotripsy, Two Different Stenting Stories

The stent question plays out differently depending on whether you are having shock wave lithotripsy (ESWL) or ureteroscopic lithotripsy (URS), because the two procedures work in fundamentally different ways. ESWL breaks stones apart from outside the body using focused sound waves; the fragments then have to pass on their own through the ureter. URS involves threading a small scope up through the urinary tract and breaking the stone with a laser at close range, often allowing fragments to be pulled out during the procedure itself.

For ESWL, a systematic review and meta-analysis pooling multiple trials found no difference in stone-free rates between patients who received a stent and those who did not. Patients with stents did, however, report significantly more lower urinary tract symptoms, at roughly four times the rate of the stentless group.¹ That finding is the main reason guidelines have long recommended against routine stenting before or during ESWL.

For URS, the European Association of Urology’s updated guidance states plainly that a postoperative stent is not needed in uncomplicated cases.² Randomized trials back that up: in one, stone-free rates were 100% in both the stented and non-stented groups, while the stented patients had significantly more flank pain, abdominal pain, dysuria, and urinary frequency during the first week.³ Another randomized controlled trial found the same pattern: identical clearance rates, but the stented group had significantly worse symptoms at one week.⁴ A separate prospective trial concluded that stenting after uncomplicated ureteroscopic laser lithotripsy increased pain and urinary symptoms without preventing complications like postoperative infection or unplanned emergency visits.⁵

Yet despite all this evidence, a substantial number of patients treated with ESWL still receive a stent, a practice one study described as significantly discordant with clinical guidelines stretching back two decades.⁶ Surgeons may stent out of habit, defensive practice, or concern about an individual patient’s anatomy. That gap between guidelines and practice is worth knowing about, because it means you can and should ask your urologist whether a stent is truly necessary in your case.

When a Stent Actually Helps

The word “uncomplicated” in the guidelines is doing heavy lifting. When a case is complicated, the calculus shifts. The clearest scenario where stenting earns its keep is large stones treated with ESWL. When shock waves shatter a big stone, a column of fragments can stack up in the ureter like cars in a traffic jam, a complication called steinstrasse. One study found that the overall incidence of steinstrasse was about 6%, but it was significantly linked to stone size and was reduced in patients with stones larger than 20 mm who had a stent placed beforehand. In those patients, the risk of acute symptoms from steinstrasse also dropped, and treatment could continue safely in the vast majority of cases.⁷

A more recent trial comparing stented and non-stented patients undergoing ESWL for 1-to-2-centimeter stones found that complete clearance was higher in the stented group (about 83% versus 68%), and steinstrasse occurred less often with a stent in place (roughly 4% versus 13%).⁸ That same study, though, showed a tradeoff: hematuria was about twice as common in the stented group, and about a quarter of stented patients reported stent-related symptoms. So even within this size range, the decision involves weighing better fragment clearance against the certainty of more discomfort.

Not all studies agree on the steinstrasse benefit. A retrospective analysis of over 1,300 ESWL patients found no significant difference in steinstrasse rates between stented and non-stented groups across stone size categories.⁹ And an older randomized trial specifically looking at large kidney stones found that stents did not reduce post-ESWL complications, were clearly associated with their own morbidity (including bladder discomfort in nearly half of stented patients), and did not markedly improve stone passage.¹⁰ The evidence, in other words, is genuinely mixed once you get past the small-stone cases where everyone agrees stents are unnecessary.

Beyond stone size, your surgeon may also place a stent if the ureter was injured or swelled during ureteroscopy, if there is significant residual stone burden, if there is an active infection that needs drainage, or if the kidney was severely obstructed before the procedure. These are judgment calls made in the operating room based on what the surgeon sees, and they are harder to study in randomized trials because every case is a little different.

What Living With a Stent Actually Feels Like

If you do end up with a stent, it helps to know what you are in for. The medical literature on stent symptoms is unusually blunt for a clinical field. In one widely cited survey, about 78% of patients reported bothersome urinary symptoms including urgency, frequency, and incontinence. More than 80% experienced pain that affected their daily activities, nearly a third reported sexual dysfunction, and close to 60% said the stent reduced their capacity to work.¹¹

A daily-survey study tracking patients after ureteroscopy captured the time course in detail. Pain was worst during the first two days, and while it lessened over the following days, it stayed above baseline for the duration of the stent. Urinary symptoms spiked the day after surgery and remained elevated until stent removal, without substantial improvement while the stent was in place. The researchers noted wide variation between individuals: some people tolerated stents reasonably well, while others were miserable the entire time.¹² The critical takeaway is that the symptoms generally do not resolve until the stent comes out. Waiting it out with a stent in place is a matter of enduring, not healing.

A qualitative study that interviewed 39 patients in depth after ureteroscopy found that all of them experienced pain, though descriptions ranged widely from sharp and stabbing to a dull ache or pressure. Almost all also experienced urinary symptoms. Many felt unprepared for the intensity of these symptoms, suggesting that better counseling beforehand could help patients manage expectations and cope more effectively.¹³

Medications That Take the Edge Off

If a stent is necessary, there are drugs that can reduce its impact. Tamsulosin, originally prescribed for prostate symptoms, relaxes smooth muscle in the ureter and bladder neck. A meta-analysis of randomized controlled trials found that tamsulosin significantly decreased urinary symptoms and body pain in stented patients and also improved sexual function compared with placebo or no treatment.¹⁴ A prospective study confirmed that stent-related urinary symptoms and overall quality-of-life scores were significantly better in patients taking tamsulosin compared to those without it, particularly during the first week after placement.¹⁵

Interestingly, adding a second medication on top of tamsulosin does not seem to help much. A prospective placebo-controlled study found that tamsulosin reduced analgesic use and urinary symptom scores, but combining it with another bladder-relaxing drug did not offer additional benefit for most symptom categories.¹⁶ So if your surgeon prescribes tamsulosin alongside your stent, take it. But don’t expect miracles: it makes symptoms more manageable, not invisible.

Stents on Strings and Self-Removal

One of the biggest hassles of stenting after ureteroscopy is the removal process. Traditionally, you need a second office visit, sometimes involving a brief cystoscopy, to pull the stent out. That adds cost, time, and another round of discomfort. An increasingly popular alternative is a stent with an extraction string attached, which trails from the stent through the urethra and is taped to the patient’s body. When the stent has done its job, you pull the string at home.

A systematic review of stents with extraction strings found that self-removal reduces stent dwell time, which in turn reduces the total duration of symptoms and the financial burden of a return visit. The main risk is that the string can cause the stent to dislodge prematurely, making strings a poor choice for certain patients who need the stent to stay put for a specific duration.¹⁷ A prospective study implementing routine string use found that self-removal was successful in about 79% of patients, the stent dislodgement rate was about 3%, and 90% of patients said they would choose to self-remove again. Most described the process as “very easy.”¹⁸

Complication rates were essentially the same whether or not the stent had a string. One study found complications in about 13% of the string group versus 14% in the no-string group, with emergency department return rates that were also statistically identical.¹⁹ If your surgeon plans to place a stent, it is worth asking whether a string is an option. It will not change the stent symptoms while it is in, but it can shorten how long you deal with them and eliminate the return visit.

Why Stent Dwell Time Matters

How long a stent stays in place is not just about comfort. Infection risk rises with duration. One study found that only about 4% of patients had a urinary tract infection when the stent had been in for less than a month, compared with over 26% when the stent stayed longer than a month.²⁰ Stents also tend to develop a biofilm over time, and mineral encrustation becomes more likely the longer they sit. This is one reason urologists want stents out as soon as they have served their purpose, and it is another argument against routine stenting when a procedure was straightforward.

If you have a stent and your follow-up appointment for removal gets delayed, it is worth pushing to reschedule promptly rather than letting it slide. Forgotten stents, though uncommon, can cause serious problems including obstruction, infection, and stone formation on the stent itself.

The Cost of Routine Stenting

Avoiding an unnecessary stent is not just a quality-of-life decision; it is a financial one. A decision analysis comparing stented and stentless ureteroscopy with laser lithotripsy estimated the average cost at roughly $11,300 per procedure with a stent versus about $8,300 without one, a difference of nearly $3,000 per case. The cost gap was driven largely by stent removal: the need for a follow-up cystoscopy adds facility fees, physician fees, and the patient’s time off work.²¹ The analysis found that using string-based self-removal narrowed the gap but did not eliminate it. Across a healthcare system treating thousands of patients a year, routinely skipping stents in uncomplicated cases would represent substantial savings.

Stenting During Pregnancy

Pregnant patients with obstructing kidney stones face a unique situation. The traditional approach has been to place a ureteral stent or a percutaneous nephrostomy tube to relieve the obstruction and wait until after delivery to deal with the stone definitively. More recently, ureteroscopy itself has been studied as a safe option during pregnancy when performed by an experienced surgeon. A review of the literature concluded that URS is appropriate for pregnant patients with kidney stones, provided patient selection and surgical expertise are adequate.²² The choice between a temporizing stent and definitive stone removal during pregnancy involves weighing the discomfort and infection risk of a stent that might need to stay in for months against the procedural risks of ureteroscopy. There is no one-size-fits-all answer, and this is a conversation best had with both your urologist and obstetrician.

Biodegradable Stents on the Horizon

Much of the stent problem boils down to two facts: stents cause symptoms for as long as they are in, and removing them requires either a second procedure or a string. Biodegradable stents aim to solve both issues by dissolving on their own over a set period. Research into materials and coatings for these devices is accelerating, with designs being explored that could also incorporate antibacterial, anti-inflammatory, or even anti-encrustation properties.²³ These are not yet standard in clinical practice, but they represent the direction the field is heading. A stent that supports healing for a week and then dissolves without a removal visit would fundamentally change the risk-benefit conversation for cases where short-term stenting is helpful but long-term placement is unnecessary.

How to Talk to Your Surgeon About It

If you are scheduled for lithotripsy, the single most useful question you can ask your urologist is: “Do I specifically need a stent, or would you be placing one routinely?” That distinction matters. A surgeon who says “your ureter was tight and I had to dilate it, so I’m placing a stent to keep it open while it heals” is making a clinical judgment specific to your case. A surgeon who says “we always place stents after this procedure” may be following habit rather than evidence.

Questions worth raising before the procedure include whether a stent would be placed only if complications arise during surgery (a common reasonable approach), whether a string could be attached if a stent proves necessary, and what medication you would be prescribed to manage symptoms. Some surgeons discuss stenting as part of informed consent; others mention it only if asked. The evidence is clear that patients who feel prepared for stent symptoms cope better than those who are caught off guard.¹³ Even if the answer is “yes, you need one,” knowing what to expect and having a plan for symptom management makes the experience considerably less distressing.