Abstract
Shock wave lithotripsy (SWL) is the only noninvasive method for stone removal. Once considered as a primary option for the treatment of virtually all stones, SWL is now recognized to have important limitations that restrict its use. In particular, the effectiveness of SWL is severely limited by stone burden, and treatment with shock waves carries the risk of acute injury with the potential for long-term adverse effects. Research aiming to characterize the renal response to shock waves and to determine the mechanisms of shock wave action in stone breakage and renal injury has begun to suggest new treatment strategies to improve success rates and safety. Urologists can achieve better outcomes by treating at slower shock wave rate using a step-wise protocol. The aim is to achieve stone comminution using as few shock waves and at as low a power level as possible. Important challenges remain, including the need to improve acoustic coupling, enhance stone targeting, better determine when stone breakage is complete, and minimize the occurrence of residual stone fragments. New technologies have begun to address many of these issues, and hold considerable promise for the future.
Key Points
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Shock wave lithotripsy (SWL) is the only noninvasive surgical technique to remove urinary stones, and is the most common treatment for solitary, uncomplicated, small upper urinary tract calculi
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Some stone types can be highly resistant to shock waves; clinically relevant residual fragments are common in SWL, and re-treatment following SWL is common
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Shock wave treatment can rupture blood vessels, and acute renal injury can be severe; inflammation in the kidney following SWL can lead to scarring with permanent loss of functional renal mass
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Success rate in SWL is significantly increased by treating at a slow shock wave rate; renal injury is also reduced by treatment at slow shock wave rate, and by step-wise treatment employing a pause between steps
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Lithotripter focal width affects stone breakage, and a wide focal zone is an advantage
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Most urologists are likely to overtreat with shock waves because the breakage end point is hard to judge; new technologies are being developed to target stones, assess breakage and clear fragments
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References
Chaussy, C. et al. First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. J. Urol. 127, 417–420 (1982).
Chaussy, C., Brendel, W. & Schmiedt, E. Extracorporeally induced destruction of kidney stones by shock waves. Lancet 2, 1265–1268 (1980).
Chaussy, C. G. & Fuchs, J. Current state and future developments of noninvasive treatment of human urinary stones with extracorporeal shock wave lithotripsy. J. Urol. 141, 782–789 (1989).
Dretler, S. P. Stone fragility—a new therapeutic distinction. J. Urol. 139, 1124–1127 (1988).
Klee, L. W., Brito, C. G. & Lingeman, J. E. The clinical implications of brushite calculi. J. Urol. 145, 715–718 (1991).
Zhong, P., Chuong, C. J. & Preminger, G. M. Characterization of fracture toughness of renal calculi using a microindentation technique. J. Mater. Sci. Lett. 12, 1460–1462 (1993).
Kim, S. C. et al. Cystine calculi: correlation of CT-visible structure, CT number, and stone morphology with fragmentation by shock wave lithotripsy. Urol. Res. 35, 319–324 (2007).
Lingeman, J. E., Matlaga, B. R. & Evan, A. P. in Campbell–Walsh Urology (eds Wein, A. J., Kavoussi, L. R., Novick, A. C., Partin, A. W. & Peters, C. A.) 1431–1507 (W. B. Saunders, Philadelphia, 2007).
No authors listed. Consensus conference. Prevention and treatment of kidney stones. JAMA 260, 977–981 (1988).
Kaude, J. V., Williams, C. M., Millner, M. R., Scott, K. N. & Finlayson, B. Renal morphology and function immediately after extracorporeal shock-wave lithotripsy. Am. J. Roentgenol. 145, 305–313 (1985).
Evan, A. P. & McAteer, J. A. in Kidney Stones: Medical and Surgical Management (eds Coe, F. L., Favus, M. J., Pak, C. Y. C., Parks, J. H. & Preminger, G. M.) 549–570 (Lippincott–Raven, Philadelphia, 1996).
McAteer, J. A. & Evan, A. P. The acute and long-term adverse effects of shock wave lithotripsy. Semin. Nephrol. 28, 200–213 (2008).
Newman, R. et al. Pathological effects of ESWL on canine renal tissue. Urology 29, 194–200 (1987).
Willis, L. R. et al. Shockwave lithotripsy: dose-related effects on renal structure, hemodynamics, and tubular function. J. Endourol. 19, 90–101 (2005).
Evan, A. P. & Willis, L. R. in Smith's Textbook on Endourology (eds Smith, A. D. et al.) 353–365 (B. C. Decker, Inc., Hamilton, ON, Canada, 2007).
Willis, L. R. et al. Prevention of lithotripsy-induced renal injury by pre-treating kidneys with low-energy shock waves. J. Am. Soc. Nephrol. 17, 663–673 (2006).
Handa, R. K. et al. Pretreatment with low-energy shock waves induces renal vasoconstriction during standard shock wave lithotripsy (SWL): a treatment protocol known to reduce SWL-induced renal injury. BJU Int. 103, 1270–1274 (2009).
Connors, B. A. et al. Effect of initial shock wave voltage on shock wave lithotripsy-induced lesion size during step-wise voltage ramping. BJU Int. 103, 104–107 (2009).
McAteer, J. A., Evan, A. P., Williams, J. C. Jr & Lingeman, J. E. Treatment protocols to reduce renal injury during shock wave lithotripsy. Curr. Opin. Urol. 19, 192–195 (2009).
Janetschek, G. et al. New onset hypertension after extracorporeal shock wave lithotripsy: age related incidence and prediction by intrarenal resistive index. J. Urol. 158, 346–351 (1997).
Frauscher, F., Höfle, G. & Janetschek, G. Re: A randomized controlled trial to assess the incidence of new onset hypertension in patients after shock wave lithotripsy for asymptomatic renal calculi. J. Urol. 162, 806 (1999).
Krambeck, A. E. et al. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of follow-up. J. Urol. 175, 1742–1747 (2006).
Parks, J. H., Worcester, E. M., Coe, F. L., Evan, A. P. & Lingeman, J. E. Clinical implications of abundant calcium phosphate in routinely analyzed kidney stones. Kidney Int. 66, 777–785 (2004).
Preminger, G. M. et al. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J. Urol. 173, 1991–2000 (2005).
Lingeman, J. E. et al. in Stone Disease: Second International Consultation on Stone Disease (eds Denstedt, J. & Khoury, S.) 85–135 (Heath Publications, Editions 21, Paris, 2008).
Albala, D. M. et al. Lower Pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. J. Urol. 166, 2072–2080 (2001).
Pearle, M. S. et al. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1cm or less. J. Urol. 179, S69–S73 (2008).
Sheir, K. Z., Madbouly, K. & Elsobky, E. Prospective randomized comparative study of the effectiveness and safety of electrohydraulic and electromagnetic extracorporeal shock wave lithotriptors. J. Urol. 170, 389–392 (2003).
Pareek, G. et al. Extracorporeal shock wave lithotripsy success based on body mass index and Hounsfield units. Urology 65, 33–36 (2005).
Perks, A. E. et al. Stone attenuation and skin-to-stone distance on computed tomography predicts for stone fragmentation by shock wave lithotripsy. Urology 72, 765–769 (2008).
Wolf, J. S. Jr. Treatment selection and outcomes: ureteral calculi. Urol. Clin. North Am. 34, 421–430 (2007).
Segura, J. W. et al. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. J. Urol. 58, 1915–1921 (1997).
Preminger, G. M. et al. 2007 guideline for the management of ureteral calculi. J. Urol. 178, 2418–2434 (2007).
Pearle, M. S. et al. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J. Urol. 173, 2005–2009 (2005).
Kerbl, K. et al. Current management of urolithiasis: progress or regress? J. Endourol. 16, 281–288 (2002).
Matlaga, B. R. Contemporary surgical management of upper urinary tract calculi. J. Urol. 181, 2152–2156 (2009).
Strope, S. A., Wolf, J. S. Jr, Faerber, G. J., Roberts, W. W. & Hollenbeck, B. K. Changing practice locations for upper urinary tract stone disease. J. Urol. 182, 1005–1011 (2009).
Matlaga, B. R. Are we correctly managing urinary calculi? J. Urol. 182, 826–827 (2009).
Strope, S. A. et al. Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: evidence from the state of Florida. Med. Care 47, 403–410 (2009).
Hillman, B. J. et al. Physicians' utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA 268, 2050–2054 (1992).
Mitchell, J. M. & Scott, E. Physician ownership of physical therapy services: effects on charges, utilization, profits, and service characteristics. JAMA 268, 2055–2059 (1992).
McAteer, J. A. et al. in Renal Stone Disease 2: Proceedings of the 2nd International Urolithiasis Research Symposium (eds Evan, A. P., Lingeman, J. E., McAteer, J. A. & Williams, J. C. Jr) 243–248 (AIP Proceedings 1049, 2008).
Connors, B. A. et al. Reducing shock number dramatically decreases lesion size in a juvenile kidney model. J. Endourol. 20, 607–611 (2006).
Connors, B. A. et al. The effect of discharge voltage on renal injury and impairment caused by lithotripsy in the pig. J. Am. Soc. Nephrol. 11, 310–318 (2000).
McAteer, J. A. et al. in Renal Stone Disease: Proceedings of the First International Urolithiasis Research Symposium (eds Evan, A. P., Lingeman, J. E. & Williams, J. C. Jr) 287–301 (American Institute of Physics, Melville, NY, 2007).
Pace, K. T., Ghiculete, D., Harju, M. & Honey, R. J. Shock wave lithotripsy at 60 or 120 shocks per minute: a randomized, double-blind trial. J. Urol. 174, 595–599 (2005).
Yilmaz, E. et al. Optimal frequency in extracorporeal shock wave lithotripsy: prospective randomized study. Urology 66, 1160–1164 (2005).
Madbouly, K. et al. Slow versus fast shock wave lithotripsy rate for urolithiasis: a prospective randomized study. J. Urol. 173, 127–130 (2005).
Chacko, J., Moore, M., Sankey, N. & Chandhoke, P. S. Does a slower treatment rate impact the efficacy of extracorporeal shock wave lithotripsy for solitary kidney or ureteral stones? J. Urol. 175, 1370–1374 (2006).
Kato, Y., Yamaguchi, S., Hori, J., Okuyama, M. & Kakizaki, H. Improvement of stone comminution by slow delivery rate of shock waves in extracorporeal lithotripsy. Int. J. Urol. 13, 1461–1465 (2006).
Weiland, D., Lee, C., Ugarte, R. & Monga, M. Impact of shockwave coupling on efficacy of extracorporeal shockwave lithotripsy. J. Endourol. 21, 137–140 (2007).
Semins, M. J., Trock, B. J. & Matlaga, B. R. The effect of shock wave rate on the outcome of shock wave lithotripsy: a meta-analysis. J. Urol. 179, 194–197 (2008).
Cleveland, R. O. & McAteer, J. A. in Smith's Textbook on Endourology (eds Smith, A. D. et al.) 317–332 (B. C. Decker, Inc., Hamilton, ON, 2007).
Pishchalnikov, Y. A. et al. Air pockets trapped during routine coupling in dry-head lithotripsy can significantly reduce the delivery of shock wave energy. J. Urol. 176, 2706–2710 (2006).
Neucks, J. S. et al. Improved acoustic coupling for shock wave lithotripsy. Urol. Res. 36, 61–66 (2008).
Evan, A. P., McAteer, J. A., Connors, B. A., Blomgren, P. M. & Lingeman, J. E. Renal injury in SWL is significantly reduced by slowing the rate of shock wave delivery. BJU Int. 100, 624–627 (2007).
Evan, A. P. et al. Independent assessment of a wide-focus, low-pressure electromagnetic lithotripter: absence of renal bioeffects in the pig. BJU Int. 101, 382–388 (2007).
Connors, B. A. et al. Shock wave lithotripsy at 60 SWs per minute reduces renal injury in the porcine model. BJU Int. 104, 1004–1008 (2009).
Zhu, S., Cocks, F. H., Preminger, G. M. & Zhong, P. The role of stress waves and cavitation in stone comminution in shock wave lithotripsy. Ultrasound Med. Biol. 28, 661–671 (2002).
Pishchalnikov, Y. A., McAteer, J. A. & Williams, J. C. Jr. Effect of firing rate on the performance of shock wave lithotriptors. BJU Int. 102, 1681–1686 (2008).
Pishchalnikov, Y. A. et al. Cavitation selectively reduces the negative-pressure phase of lithotripter shock waves. Acoustic Research Letters Online 6, 280–286 (2005).
Zhong, P., Zhou, Y. & Zhu, S. Dynamics of bubble oscillation in constrained media and mechanisms of vessel rupture in SWL. Ultrasound Med. Biol. 27, 119–134 (2001).
Carstensen, E. L., Gracewski, S. & Dalecki, D. The search for cavitation in vivo . Ultrasound Med. Biol. 26, 1377–1385 (2000).
Freund, J. B. in Renal Stone Disease: Proceedings of the First International Urolithiasis Research Symposium (eds Evan, A. P., Lingeman, J. E. & Williams, J. C. Jr) 256–359 (American Institute of Physics, Melville, NY, 2007).
Freund, J. B., Colonius, T. & Evan, A. P. A cumulative shear mechanism for tissue damage initiation in shock-wave lithotripsy. Ultrasound Med. Biol. 33, 1495–1503 (2007).
Zhou, Y., Cocks, F. H., Preminger, G. M. & Zhong, P. The effect of treatment strategy on stone comminution efficiency in shock wave lithotripsy. J. Urol. 172, 349–354 (2004).
Maloney, M. E. et al. Progressive increase of lithotripter output produces better in-vivo stone comminution. J. Endourol. 20, 603–606 (2006).
Demirci, D. et al. Comparison of conventional and step-wise shockwave lithotripsy in management of urinary calculi. J. Endourol. 21, 1407–1410 (2007).
Mobley, T. B., Myers, D. A., Grine, W. B., Jenkins, J. M. & Jordan, W. R. Low energy lithotripsy with the Lithostar: treatment results with 19,962 renal and ureteral calculi. J. Urol. 149, 1419–1424 (1993).
Coleman, A. J., Saunders, J. E., Preston, R. C. & Bacon, D. R. Pressure waveforms generated by a Dornier extracorporeal shock-wave lithotripter. Ultrasound Med. Biol. 13, 651–657 (1987).
Coleman, A. J. & Saunders, J. E. A survey of the acoustic output of commercial extracorporeal shock wave lithotripters. Ultrasound Med. Biol. 15, 213–217 (1989).
Cathignol, D., Mestas, J. L., Gomez, F. & Lenz, P. Influence of water conductivity on the efficiency and the reproducibility of electrohydraulic shock wave generation. Ultrasound Med. Biol. 17, 819–828 (1991).
Ng, C. F., McLornan, L., Thompson, T. J. & Tolley, D. A. Comparison of 2 generations of piezoelectric lithotriptors using matched pair analysis. J. Urol. 172, 1887–1891 (2004).
Xi, X. & Zhong, P. Improvement of stone fragmentation during shock-wave lithotripsy using a combined EH/PEAA shock-wave generator-in vitro experiments. Ultrasound Med. Biol. 26, 457–467 (2000).
Zhou, Y., Cocks, F. H., Preminger, G. M. & Zhong, P. Innovations in shock wave lithotripsy technology: updates in experimental studies. J. Urol. 172, 1892–1898 (2004).
Weizer, A. Z., Zhong, P. & Preminger, G. M. New concepts in shock wave lithotripsy. Urol. Clin. North Am. 34, 375–382 (2007).
Fernandez, F., Fernandez, G. & Loske, A. M. Treatment time reduction using tandem shockwaves for lithotripsy: an in vitro study. J. Endourol. 23, 1247–1253 (2009).
Sokolov, D. L., Bailey, M. R. & Crum, L. A. Use of a dual-pulse lithotripter to generate a localized and intensified cavitation field. J. Acoust. Soc. Am. 110, 1685–1695 (2001).
Sokolov, D. L., Bailey, M. R. & Crum, L. A. Dual-pulse lithotripter accelerates stone fragmentation and reduces cell lysis in vitro . Ultrasound Med. Biol. 29, 1045–1052 (2003).
Handa, R. K. et al. Assessment of renal injury with a clinical dual-head lithotripter delivering 240 shock waves per minute. J. Urol. 181, 884–889 (2009).
Sheir, K. Z. et al. Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: a prospective randomized study of effectiveness and safety in comparison to standard single-pulse technique. BJU Int. 101, 1420–1426 (2008).
McAteer, J. A. et al. Independent evaluation of the LithoGold LG-380 lithotripter: in vitro acoustic characteristics and assessment of renal injury in the pig model. J. Urol. 181 (4 Suppl.), 665–666 (2009).
Pishchalnikov, Y. A., VonDerHaar, R. J., Williams, J. C. & McAteer, J. A. The advantage of a broad focal zone in SWL: in vitro stone breakage comparing two electromagnetic lithotripters. J. Urol. 179, 464–465 (2008).
Cleveland, R. O., Anglade, R. & Babayan, R. K. Effect of stone motion on in vitro comminution efficiency of Storz Modulith SLX. J. Endourol. 18, 629–633 (2004).
Cleveland, R. O. & Sapozhnikov, O. A. Modeling elastic wave propagation in kidney stones with application to shock wave lithotripsy. J. Acoust. Soc. Am. 118, 2667–2676 (2005).
Sapozhnikov, O. A., Maxwell, A. D., MacConaghy, B. & Bailey, M. R. A mechanistic analysis of stone fracture in lithotripsy. J. Acoust. Soc. Am. 121, 1190–1202 (2007).
Eisenmenger, W. et al. The first clinical results of “wide focus and low pressure” ESWL. Ultrasound Med. Biol. 28, 769–774 (2002).
Tan, E. C., Tung, K. H. & Foo, K. T. Comparative studies of extracorporeal shock wave lithotripsy by Dornier HM3, EDAP LT 01 and Sonolith 2000 devices. J. Urol. 146, 294–297 (1991).
Ueda, S. et al. Perirenal hematomas caused by SWL with EDAP LT-01 lithotripter. J. Endourol. 7, 11–15 (1993).
Fuselier, H. A., Prats, L., Fontenot, C. & Gauthier, A. Comparison of mobile lithotriptors at one institution: Healthtronics Lithotron, Dornier MFL-5000, and Dornier Doli. J. Endourol. 13, 539–542 (1999).
Graber, S. F., Danuser, H., Hochreiter, W. W. & Studer, U. E. A prospective randomized trial comparing 2 lithotriptors for stone disintegration and induced renal trauma. J. Urol. 169, 54–57 (2003).
Gerber, R., Studer, U. E. & Danuser, H. Is newer always better? A comparative study of 3 lithotriptor generations. J. Urol. 173, 2013–2016 (2005).
Williams, J. C. Jr et al. Variability of renal stone fragility in shock wave lithotripsy. Urology 61, 1092–1097 (2003).
Owen, N. R., Bailey, M. R., Crum, L. A., Sapozhnikov, O. A. & Trusov, L. A. The use of resonant scattering to identify stone fracture in shock wave lithotripsy. J. Acoust. Soc. Am. 121, EL41–EL47 (2007).
Leighton, T. G. et al. A passive acoustic device for real-time monitoring of the efficacy of shockwave lithotripsy treatment. Ultrasound Med. Biol. 34, 1651–1665 (2008).
Orkisz, M. et al. Image based renal stone tracking to improve efficacy in extracorporeal lithotripsy. J. Urol. 160, 1237–1240 (1998).
Thomas, J. L. & Fink, M. Time reversal focusing applied to lithotripsy. Ultrason. Imaging 18, 106–121 (1996).
Chang, C. C. et al. In vitro study of ultrasound based real-time tracking of renal stones for shock wave lithotripsy: part 1. J. Urol. 166, 28–32 (2001).
Bohris, C., Bayer, T. & Lechner, C. Hit/miss monitoring of ESWL by spectral Doppler ultrasound. Ultrasound Med. Biol. 29, 705–712 (2003).
Owen, N. R. et al. Vibroacoustography for targeting kidney stones during lithotripsy [abstract #2aBB11]. J. Acoust. Soc. Am. 116, 2509 (2004).
Shah, A. et al. Ultrasound to facilitate clearance of residual stones [abstract #9337]. JSLS 13 (Suppl.) (2009).
Sapozhnikov, O. A., Bailey, M. R., Cunitz, B. W., Kaczkowski, P. J. & Oweis, G. F. Moving stones inside a kidney using acoustic radiation force. Proceedings of the IEEE International Ultrasonics Symposium (2009) (in press).
Jacobs, B. L., Smaldone, M. C., Smaldone, A. M., Ricchiuti, D. J. & Averch T. D. Effect of skin-to-stone distance on shockwave lithotripsy success. J. Endourol. 22, 1623–1628 (2008).
Whelan, J. P., Finlayson, B., Welch, J. & Newman, R. C. The blast path: theoretical basis, experimental data and clinical application. J. Urol. 140, 401–404 (1988).
Pishchalnikov, Y. A. et al. Strategies to improve SWL for obese patients: in vitro assessment of targeting stones along the distal acoustic axis [abstract #1626]. J. Urol. 181 (4 Suppl.), 585 (2009).
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Lingeman, J., McAteer, J., Gnessin, E. et al. Shock wave lithotripsy: advances in technology and technique. Nat Rev Urol 6, 660–670 (2009). https://doi.org/10.1038/nrurol.2009.216
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DOI: https://doi.org/10.1038/nrurol.2009.216
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