Journal of Clinical Medicine Commentary Bowel Perforation after Extracorporeal Wave Lithotripsy: A Review of the Literature Sofia Fontanet 1,† , Alba Farré 1,† , Oriol Angerri 1 , Andrés Kanashiro 1 , Edgar Suquilanda 1 , Jesús Bollo 2 , Maria Gallego 2 , Francisco Maria Sánchez-Martín 1 , Félix Millán 1 , Joan Palou 1 , Diana Bonnin 3 and Esteban Emiliani 1, * 1 Department of Urology, Fundación Puigvert, Autonomous University of Barcelona, 08025 Barcelona, Spain 2 Department of General Surgery, Sant Pau Hospital, Autonomous University of Barcelona, 08025 Barcelona, Spain 3 Department of Radiology, Fundación Puigvert, Autonomous University of Barcelona, 08025 Barcelona, Spain * Correspondence: emiliani@gmail.com † The first two authors have equally contributed to the manuscript. Abstract: Introduction: Extracorporeal wave lithotripsy (ESWL) is considered a first-line treatment for renal and ureteral stones up to 10–20 mm in diameter. Complications are uncommon, with a reported rate of 0–6% in the literature. Bowel perforation has only been described in a few case reports but requires rapid diagnosis and treatment. Methods: A review of the literature from PubMed/Medline, Embase, Cochrane, and Web of Science databases was performed including studies reporting bowel perforation secondary to ESWL between January 1990 and June 2022. Results: We found 16 case reports of intestinal perforation in the literature. Although some patients had previously undergone abdominal surgery or had inflammatory intestinal disease, others were without comorbidities that could lead to complications. Abdominal pain was the main symptom and imaging was required to confirm the diagnosis, which usually necessitated a surgical intervention. As regards the ESWL technique, it appears that the combination of a high energy level and the prone position constitutes a Citation: Fontanet, S.; Farré, A.; risk factor for these rare complications. At the authors’ centre, only one case has been reported among Angerri, O.; Kanashiro, A.; 24,000 ESWL procedures over 20 years: A 59-year-old female who underwent ESWL for a distal right Suquilanda, E.; Bollo, J.; Gallego, M.; ureteral stone presented acute abdominal pain and free intraperitoneal pelvic fluid on ultrasound. Sánchez-Martín, F.M.; Millán, F.; A CT scan revealed a small bowel perforation requiring open laparotomy with primary closure. Palou, J.; et al. Bowel Perforation after Extracorporeal Wave Conclusions: In conclusion, although bowel perforation after ESWL is rare, progressive abdominal Lithotripsy: A Review of the pain with tenderness at physical examination requires proper imaging evaluation to exclude bowel Literature. J. Clin. Med. 2023, 12, 1052. perforation and prompt intervention if required. https://doi.org/10.3390/ jcm12031052 Keywords: ESWL; lithotripsy; stone; urology; bowel perforation Academic Editors: Olivier Traxer, Cristian Fiori and Enrico Checcucci Received: 4 December 2022 1. Introduction Revised: 11 January 2023 Since its introduction in the 1980s [1], extracorporeal wave lithotripsy (ESWL) has Accepted: 24 January 2023 been shown to be a safe, effective, and non-invasive treatment for renal and ureteral stones Published: 29 January 2023 up to 10–20 mm in diameter [2]. In the last two decades, ESWL technology has evolved, especially as regards the quality of shock wave generators, coupling, and stone location, making it possible to optimize results while reducing failure rates [1,3]. Copyright: © 2023 by the authors. Complications are infrequent, occurring in 0–6% of patients according to the litera- Licensee MDPI, Basel, Switzerland. ture [4]. The vast majority appear in the short term and are Clavien-Dindo grades I and This article is an open access article II complications requiring pharmacological treatment. Among these, the most common distributed under the terms and are renal colic (28%), ureteral obstruction (4%), sepsis (1%), renal function impairment conditions of the Creative Commons (0.4%), and renal hematoma (0.4%) [5–7]. Other severe complications, commonly classified Attribution (CC BY) license (https:// as Clavien-Dindo grades III and IV and usually requiring surgical management, include creativecommons.org/licenses/by/ hepatic hematoma, pancreatitis, cardiac arrhythmia, aortic aneurysm rupture, spleen rup- 4.0/). ture, and bowel perforation [7–11]. While gastrointestinal damage has been described as a J. Clin. Med. 2023, 12, 1052. https://doi.org/10.3390/jcm12031052 https://www.mdpi.com/journal/jcm J. Clin. Med. 2023, 12, 1052 2 of 8 rare complication of ESWL, the actual incidence is unknown. Bowel perforations are un- common, having been reported in only 16 cases in the literature to our knowledge [12–27]. Here, we present a review of the literature, with the addition of the only case we have had in our hospital in 20 years. 2. Methods A review of the literature was performed from PubMed, Medline, Embase, Cochrane and Web of Science databases including studies published between January 1990 and June 2022. Two reviewers (A.F. and S.F) conducted the research in the databases previously mentioned. The search was performed by using the combination of the words “ESWL” and “bowel” or “intestinal” and “perforation” or “complications” and “urinary” or “urologic” and “stones”. Those keywords led to 16 results in which ESWL for urologic stones were complicated by colonic or small bowel perforation. A data analysis was performed to evaluate risk factors and preventive measures. 3. Results A total of 16 cases have been reported in the literature since 1997 [12–18,20–27]. De- mographics are summarised in Table 1. Twelve patients were male, three were female, and one was of unknown gender. Patient age ranged from 29 to 78 years. The interval between the ESWL procedure and the onset of symptoms varied between a few hours and 2 days. All patients presented at the emergency department with a main complaint of acute abdominal pain with tenderness at physical examination. Moreover, fever was present in one-third (5/15) of the cases. During the 1990s, a KUB X-ray was performed for diagnostic imaging, whereas since then CT scan has been the main diagnostic tool. A surgical approach with bowel repair was needed in 15 cases due to the high morbid- ity of intestinal perforation or hemodynamic instability. The remaining case was managed conservatively without further complications; this treatment strategy was chosen because the patient was hemodynamically stable without signs of peritonitis. The location of the perforation varied according to the ESWL treatment area. In six of the sixteen cases [14,15,17,18,20,22], the perforation occurred in the colon, while in the remaining nine cases the small bowel was affected. Perilesional findings during surgical exploration [13,20,23] included necrotic areas, bruised areas, congestion, and inflammation. Regarding the stone location prior to ESWL, there was only one renal stone [20], with ureteral stones being the most common. Eight studies reported stone size, and in only one case was the stone larger than 10 mm [27]. The prone position was used in 11 cases, a combination of prone and supine in one, and supine in two [14,16]; in two studies the position was not reported. The total number of shocks delivered varied from 2500 to 6000. Table 2 summarizes the ESWL characteristics. At the authors’ institution, just one case of bowel perforation has been reported after 24,000 ESWL procedures performed over 20 years; this patient needed open surgery and primary closure of the wound, as further discussed below. J. Clin. Med. 2023, 12, 1052 3 of 8 Table 1. Demographic data. Intestine Lithiasis Diagnostic Publication Year Location Gender Age (y) Past Medical History Symptoms Stone Size Location Imaging Affection Right-sided abdominal Chest Geh et al. [12] 1997 Terminal ileum M 55 NA NA Right ureter pain radiography Mid portion of Abdominal pain and Plain abdominal Holmberg et al. [13] 1997 the small bowel M 68 Asthma signs of localized 6 × 4 mm Right mid ureter X-ray (ileum) peritonitis Bilateral kidney stones Left transverse Abdominal Castillon et al. [20] 1999 M 29 treated by ESWL Acute abdominal pain 9 × 5 mm Left renal pelvis colon X-ray (23,500 SW) Prostate cancer and Right-sided abdominal Abdominal and Right Kurtz et al. [21] 1999 Small bowel M 57 bilateral scrotal pain and incipient signs NA chest X-ray and reno-ureteral orchiectomy of peritonitis US Distal sigmoid Pain in the left iliac Abdominal Lipay et al. [22] 2000 M 32 NA 8 mm Left distal ureter colon fossa and diarrhea X-ray Left abdominal pain Olsson et al. [23] 2000 Ileum M 44 NA 6 × 3 mm Left mid ureter CT and mild ecchymosis Billroth II Right distal Klug et al. [24] 2001 Small bowel M 60 Intense abdominal pain NA US penis amputation ureter (L3–L4) Graft replacement for Left lower abdominal Kajikawa et al. [25] 2001 Jejunum M 69 NA Left ureter CT bilateral iliac aneurysm pain Central abdominal pain Abdominal and El-Faqih [26] 2002 Proximal ileum M 38 NA 10 × 6 mm Right mid ureter and fever chest X-ray Severe abdominal pain Rodriguez 2003 Ileum F 51 History of stone disease and nausea, vomiting 14 × 8 mm Left mid ureter Contrast CT Netto et al. [27] and fever Congenital Abdominal and flank hypospadias, ureteral Right proximal Abdominal Maker et al. [14] 2004 Cecum M 44 pain and nausea, NA strictures, recurrent ureter X-ray and CT vomiting nephrolithiasis J. Clin. Med. 2023, 12, 1052 4 of 8 Table 1. Cont. Intestine Lithiasis Diagnostic Publication Year Location Gender Age (y) Past Medical History Symptoms Stone Size Location Imaging Affection Anterior pelvic Acute abdominal Right distal Cardinaux et al. [15] 2009 Cecum F 78 exenteration with 5 mm CT tenderness and fever ureter ureterosigmoidostomy Crohn’s disease Left flank abdominal Chhor et al. [16] 2009 Jejunum M 33 complicated by jejunal NA Right ureter CT pain and fever abscess Descending Left quadrant Kurz et al. [17] 2009 M 40 NA 4 × 8 mm Left ureter L4 US colon abdominal pain Arrebal et al. [18] 2010 Ascending colon - 34 NA Abdominal pain + fever NA Right ureter NA History of recurrent Left hemi-abdominal reno-ureteral colic pain and nausea, Galeano et al. [19] 2022 Small bowel F 56 NA NA CT requiring several vomiting and sessions of ESWL haematuria y = years; NA = not available; M = male; F = female; ESWL = External Shock Wave Lithotripsy; US = ultrasound; CT = computed tomography; SW = shock waves. J. Clin. Med. 2023, 12, 1052 5 of 8 Table 2. Characteristics of ESWL. Number of Shock Publication Year Position Energy Lithotripter Waves Geh et al. [12] 1997 Prone NA NA NA Holmberg et al. [13] 1997 Prone 6.5 kV 4500 Siemens Lithostar Plus Castillon et al. [20] 1999 Prone 8–9 kV 4500 Storz Modulith Kurtz et al. [21] 1999 Prone and supine 6 kV 4000 Siemens Lithostar Plus Lipay et al. [22] 2000 Prone 7 kV 3000 NA Siemens Lithostar with Olsson et al. [23] 2000 Prone 6 kV 4000 shock tube C Klug et al. [24] 2001 NA NA 5000 Modulith SL 10 Kajikawa et al. [25] 2001 Prone NA NA NA El-Faqih [26] 2002 Prone 6.5 kV 4000 Siemens Lithostar Plus Rodriguez 2003 Prone 4–6 kV 6000 Siemens Lithostar SWS-C Netto et al. [27] Maker et al. [14] 2004 Supine 6.5 kV 2500 NA Cardinaux et al. [15] 2009 Prone 6–7 kV 3000 Doli S lithotripter Chhor et al. [16] 2009 Supine NA 3000 Dornier Delta II Siemens lithostar Kurz et al. [17] 2009 Prone 6 kV 4000 modularis Dornier Doly EMSE Arrabal et al. [18] 2010 Prone 200 J 3400 220F-XXP Galeano et al. [19] 2022 NA NA NA NA NA = not available; kV = kilovolts; J = joules; SL = Siemens Lithostar; SWS-C = Shock Wave System C. 4. Discussion The incidence of bowel perforation after ESWL is unknown. Our literature review revealed reports of only 16 cases, although cases of gastrointestinal damage other than per- forations have been described in single case series. These other complications have included gastric or duodenal erosions, ureterocolic fistula, gastrojejunal anastomotic dehiscence, small bowel obstruction and strangulation, cecal ulcers, sigmoid colon hematoma, peripan- creatic hematoma, peripancreatic abscess, pancreatitis, and rectal bleeding [14,28,29]. Interestingly, most cases of intestinal perforation after ESWL are seen in males, and patient age varies greatly. The predominance of male cases can perhaps be ascribed to the higher incidence of urolithiasis in the male population. Although some of the patients that we identified had a medical history of abdominal surgeries or intestinal inflammatory disease, most had no relevant past medical history or risk factors. Nonetheless, patient selection should be made carefully, or complications are likely to occur in these cases. In this review, in the vast majority of cases (13/16) only one ESWL session was performed before intestinal perforation occurred. However, in one case it was reported that the stone was initially in the renal pelvis, where the first ESWL session was conducted [12]. Additionally, in two other cases [19,20] more previous ESWL sessions were described but it was not clearly specified if they were performed for the same stones. The interval from the procedure to the onset of symptoms varied between a few hours and 2 days, with the typical presentation being acute abdominal pain with tenderness at physical examination. Patient’s management was surgical from the beginning in 12 cases because of clinical signs of peritonitis [12–14,17,18,20,21,24,27]. Only in four cases [19,22,23,25] was conservative management with antibiotic initially preferred. In three of them, due to clinical worsening, patients had to undergo surgery between 24 and 48 h. In the other case [19], the patient J. Clin. Med. 2023, 12, 1052 6 of 8 remained hemodynamically stable and a control CT scan was performed at 7 days with signs of improvement. Finally, there was one case [16] where obstructive stones was first suspected, so a double J stent was placed. Then, due to clinical signs of peritonitis, a CT was performed revealing signs of bowel perforation, so the patient finally underwent surgery. Therefore, a surgical approach with bowel repair was required in all cases except one patient [19]. There were no fatal outcomes and clinical recovery after surgery was complete. ESWL treatment can affect either the small bowel or the colon, depending on the stone location. In our review, the mean stone diameter was 8.2 mm, and in only one case did the stone diameter exceed 10 mm. As regards the ESWL technique, it appears that the combination of a high energy level and the prone position constitutes a risk factor for these rare complications. The single case of bowel perforation after ESWL at the authors’ institution, where 24,000 ESWL procedures have been performed over the past 20 years, was in a 59-year-old female with a past medical history of dyslipidemia, chronic bronchitis, and a C-section. Initially, in the context of colic lumbar pain, she had been diagnosed as having a 17 mm right distal ureteral stone at her referring hospital. As the patient presented with moderate hydronephrosis, a right nephrostomy tube was placed, and she was referred to our centre for definitive treatment of the stone. Three weeks later, under sedation, she underwent a first ESWL session, resulting in partial fragmentation. The patient was placed in the supine position on a Lithoskop lithotripter (Siemens, Munich, Germany), which delivered 4500 shocks to the stone with a total energy of 175 joules. Four hours after the procedure, the patient returned to the emergency department due to discomfort and intense right abdominal pain. Physical examination revealed painful palpation and localized tenderness at the flank and right iliac fossa. A blood test showed 15,000 × 109 /L leukocytosis with neutrophilia (82%). She did not present fever, but abdominal pain was worsening despite analgesia. An abdominal ultrasound revealed a small amount of free intraperitoneal fluid. A CT scan with contrast was performed, resulting in the diagnosis of a small bowel perforation at the level of the terminal ileum with free abdominal fluid and a small amount of pneumoperitoneum. The general surgery department evaluated the case and suggested exploratory la- paroscopy, which revealed diffuse purulent peritonitis with possible perforation in the mesenteric margin of the terminal ileum as well as a hematoma in the mesojejunum and two lesions in terminal ileum serosa close to the main lesion. As the lesions could not be clearly assessed, the decision was taken to perform a mini-laparotomy, which con- firmed the perforation identified by laparoscopy. Simple closure was performed without intestinal resection. During the postoperative follow-up, the patient remained hemodynamically stable and afebrile, progressively tolerating an oral diet. She was discharged from the hospital 5 days after the intervention. Follow-up at the first month was unremarkable. Two months later, a right ureteroscopy with laser dusting of the stone and double J stent placement was performed without abnormal intraoperative findings. During endoscopy, no alterations of the ureteral wall were found. Three weeks later, the double J stent was removed, and the patient has since been stone free with no complications. Risk factors for bowel perforation due to ESWL reported in the literature are previous abdominal surgery, prone position, placement of the ureter too close to the intestine, and the use of high energy levels [14]. Prompt diagnosis of a bowel perforation is crucial to avoid further complications. Initial physical examination to assess abdominal acute pain and tenderness should be complemented with a general blood test and the performance of a CT scan. Once the diagnosis has been established, surgery seems to be an effective treatment, with good patient recovery. Stone treatment can be offered at the same time with ureterotomy and stone removal, but in most cases, treatment is deferred. J. Clin. Med. 2023, 12, 1052 7 of 8 5. Conclusions Although bowel perforation is rare, and renal colic is the main complication after ESWL, patients with acute abdominal pain few hours after the procedure should undergo a proper physical exploration to search for peritoneal irritation. Furthermore, it usually requires accurate imaging evaluation. Imaging may enable the physician to rule out an intestinal complication or to initiate prompt intervention if required, bearing in mind the high morbidity of the condition. The combination of a high energy level and the prone position seems to constitute a risk factor for this rare complication. Author Contributions: Conceptualization, E.E. and S.F.; Methodology, A.F.; validation, E.E., O.A. and F.M.; formal analysis, F.M.S.-M.; investigation, A.F.; resources, E.S., M.G., J.B. and D.B.; data curation, A.F. and S.F.; writing—original draft preparation, A.F. and S.F.; writing—review and editing, A.K. and E.E.; visualization, F.M.; supervision, O.A. and J.P.; project administration, E.E. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Data Availability Statement: Data was extracted directly by the cited publications and by analysing our case report. Conflicts of Interest: The authors declare no conflict of interest. References 1. Chaussy, C.G.; Tiselius, H.-G. Engineering Better Lithotripters. Curr. Urol. Rep. 2015, 16, 52. [CrossRef] [PubMed] 2. Turk, C.; Petřík, A.; Sarica, K.; Seitz, C.; Skolarikos, A.; Straub, M.; Knoll, T. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. Eur. Urol. 2016, 69, 468. [CrossRef] [PubMed] 3. Lawler, A.C.; Ghiraldi, E.M.; Tong, C.; Friedlander, J.I. Extracorporeal Shock Wave Therapy: Current Perspectives and Future Directions. Curr. Urol. Rep. 2017, 18, 25. [CrossRef] [PubMed] 4. Simunovic, D.; Sudarevic, B.; Galic, J. Extracorporeal shockwave litho- tripsy in elderly: Impact of age and comorbidity on stone-free rate and complications. J. Endourol. 2010, 24, 1831–1837. [CrossRef] [PubMed] 5. Martín, M.A. Litotricia extracorpórea en españa en el siglo xx. Actas Urológicas Españolas 2000, 24, 699–708. [CrossRef] 6. Silberstein, J.; Lakin, C.M.; Parsons, J.K. Shock wave Lithotripsy and Renal Hemorrhage. Rev. Urol. 2008, 10, 236–241. Available online: http://www.ncbi.nlm.nih.gov/pubmed/18836562 (accessed on 20 September 2022). 7. Nasu, Y.; Kurashige, T.; Kumon, H. Common and Uncommon Complications Related to ESWL. In Treatment of Urolithiasis; Springer: Tokyo, Japan, 2001; pp. 153–166. Available online: http://link.springer.com/10.1007/978-4-431-68517-3_12 (accessed on 10 September 2022). 8. Drach, G.W.; Coordinator, S.; Dretler, S.; Fair, W.; Finlayson, B.; Gillenwater, J.; Griffith, D.; Lingeman, J.; Newman, D.; Study group. Report of the United States Cooperative Study of Extracorporeal Shock Wave Lithotripsy. J. Urol. 1986, 135, 1127–1133. [CrossRef] 9. Karakayali, F.; Sevmis, S.; Ayvaz, I.; Tekin, I.; Boyvat, F.; Moray, G. Acute necrotizing pancreatitis as a rare complication of extracorporeal shock wave lithotripsy. Int. J. Urol. 2006, 13, 613–615. [CrossRef] 10. Gupta, S.; Scambia, J.; Gandillon, C.; Aversano, F.; Batista, R. Abdominal Compartment Syndrome and Necrotizing Pancreatitis Following Extracorporeal Shock Wave Lithotripsy. Urol. Case Rep. 2016, 8, 34–35. [CrossRef] 11. Willekens, I.; Brussaard, C.; Raeymaeckers, S.; De Concinck, V.; De Mey, J. Splenic Rupture: A Rare Complication of Extracorporeal Shock Wave Lithotripsy. J. Belg. Soc. Radiol. 2015, 99, 58–60. [CrossRef] 12. Geh, J.L.C.; Curley, P.; Mayfield, M.P.; Price, J.J. Small bowel perforation after extracorporeal shock wave lithotripsy. BJU Int. 1997, 79, 648–649. [CrossRef] [PubMed] 13. Holmberg, G.; Spinnell, S.; Sjödin, J.-G. Perforation of the Bowel during SWL in Prone Position. J. Endourol. 1997, 11, 313–314. [CrossRef] [PubMed] 14. Maker, V.; Layke, J. Gastrointestinal injury secondary to extracorporeal shock wave lithotripsy: A review of the literature since its inception. J. Am. Coll. Surg. 2004, 198, 128–135. [CrossRef] [PubMed] 15. Cardinaux, C.; Tawadros, T.; Praz, V.; Wisard, M.; Treuthardt, C.; Jichlinski, P. Ischemic Cecal Perforation Secondary to ESWL of Junctional Stone in Ureterosigmoidostomy (Mainz Pouch II). Urology 2009, 73, 1423.e1–1423.e2. [CrossRef] [PubMed] 16. Chhor, V.; Sinaceur, M.; Journois, D. Misleading Abdominal Pain following Extracorporeal Renal Lithotripsy. Urol. Int. 2009, 83, 246–248. [CrossRef] 17. Kurz, W.; Klein, B.; Rumstadt, B. Kolonperforation nach extrakorporaler Stoßwellenlithotripsie. DMW Dtsch. Med. Wochenschr. 2009, 134, 401–403. [CrossRef] [PubMed] J. Clin. Med. 2023, 12, 1052 8 of 8 18. Arrabal Polo, M.A.; Arrabal Martín, M.; Ortiz, J.L.; Zuluaga Gómez, A. Perforación del Colon Ascendente Tras Litotricia Extracorpórea Por Ondas de Choque: Revisión de la Literatura Médica. Actas Urológicas Españolas 2010, 34, 920–921. Available online: https://linkinghub.elsevier.com/retrieve/pii/S0210480610002731 (accessed on 10 September 2022). 19. Galeano, P.F.; Silva, C.R.; Delgado, M.P.G.; Rodriguez, R.P.; Santoyo, J. Intestinal perforation after extracorporeal lithotripsy; Possibility of nonoperative management. J. Clin. Images Med. Case Rep. 2022, 3, 1750. [CrossRef] 20. Castillon, I.; Frieyro, O.; Gonzalez-Enguita, M.D.C.; Vela-Navarrete, R. Colonic perforation after extracorporeal shock wave lithotripsy. BJU Int. 2001, 83, 720–721. [CrossRef] 21. Kurtz, V.; Müller-Sorg, M.; Federmann, G. Dünndarmperforation nach Nephro-Uretero-Lithotripsie durch ESWL—eine seltene Komplikation. Der Chir. 1999, 70, 306–307. [CrossRef] 22. Lipay, M.; Araujo, S.; Perosa, M.; Genzini, T.; Hering, F.; Rodrigues, P. Perforation of Sigmoid Colon after Extracorporeal Lithotripsy. J. Urol. 2000, 164, 442. Available online: http://journals.lww.com/00005392-200008000-00043 (accessed on 2 September 2022). [CrossRef] [PubMed] 23. Olsson, L.E.; Anderson, K.R.; Foster, H.E. Small bowel perforation after extracorporeal shock wave lithotripsy. J. Urol. 2000, 164, 775. [CrossRef] [PubMed] 24. Klug, R.; Kurz, F.; Dunzinger, M.; Aufschnaiter, M. Small Bowel Perforation after Extracorporeal Shockwave Lithotripsy of an Ureter Stone. Dig. Surg. 2001, 18, 241–242. [CrossRef] [PubMed] 25. Kajikawa, T.; Nozawa, T.; Owari, Y.; Fujisawa, H.; Kaneko, T.; Noro, K.; Takata, K. Bowel perforation after extracorporeal shock wave lithotripsy. Jpn. J. Urol. 2001, 92, 586–588. [CrossRef] 26. El-Faqih, S.R. Small bowel perforation after extracorporeal shockwave lithotripsy for ureteric stone: A case report and review of the literature. Saudi J. Gastroenterol. 2002, 8, 59–61. 27. Netto, N.R.; Ikonomidis, J.A.; Longo, J.A.; Netto, M.R. Small-Bowel Perforation after Shockwave Lithotripsy. J. Endourol. 2003, 17, 719–720. [CrossRef] 28. Gitonga, E.N.; Shen, H. Small bowel obstruction and strangulation secondary to an adhesive internal hernia post ESWL for right ureteral calculi: A case report and review of literature. BMC Gastroenterol. 2021, 21, 176. [CrossRef] 29. Pereira-Arias, J.G.; Gamarra-Quintanilla, M.; Urdaneta-Salegui, L.F.; Mora-Christian, J.A.; Sánchez-Vázquez, A.; Astobieta- Odriozola, A.; Ibarluzea-González, G. Estado actual de la litotricia extracorpórea por ondas de choque en la litiasis urinaria. Arch. Esp. Urol. 2017, 70, 263–287. Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.