Stepwise energy escalation ESWL showed higher stone-free rates than fixed-energy protocols in pediatric urolithiasis.

This retrospective cohort study evaluated 81 children treated with extracorporeal shock wave lithotripsy (ESWL) for pediatric urolithiasis at a single center. Participants were assigned to either a stepwise energy protocol, which began at 10 kV and increased by 1 kV every 250 shocks up to 13 kV with a maximum of 3,000 shocks per session, or a conventional fixed-energy protocol utilizing a constant 13 kV setting.

Primary analysis assessed 3-month stone-free status, defined as no visible stones on follow-up imaging excluding fragments less than or equal to 3 mm. Secondary outcomes included stone-free status after the first session, total number of sessions, and the need for auxiliary procedures. At three months, 95.1% (39/41) of patients in the stepwise group achieved stone-free status compared to 87.5% (35/40) in the conventional group. Stone clearance at three months, including fragments less than or equal to 3 mm, was 97.6% (40/41) versus 95.0% (38/40). Additionally, 30 children in the stepwise group achieved clearance in a single session compared to 22 in the conventional group.

Safety and tolerability were assessed through reported adverse events. Only minor, self-limited events such as hematuria and transient pain or colic were observed. One case of auxiliary ureteroscopy was required in the stepwise group versus two in the conventional group. No serious adverse events or discontinuations were reported.

Key limitations include the retrospective design, single-center setting, and limited pediatric evidence base. Statistical significance was not reported for the observed differences. While stepwise energy escalation was associated with numerically higher clearance and fewer sessions without added morbidity, causality cannot be inferred. Prospective multicenter studies are needed to confirm these findings before changing clinical practice.