Treatment Time Reduction Using Tandem Shockwaves for Lithotripsy: AnIn VivoStudy

Kriging model to study the dynamics of a bubble subjected to tandem shock waves as used in biomedical applications

The purpose of this work was to develop a metamodel (Kriging model) to identify the most important input parameters of shock wave pressure profiles as used in biomedical applications without solving a large number of differential equations. Shock wave-induced cavitation is involved in several biological effects. During bubble collapse, secondary shock waves and microjets are formed. For some applications, it is desirable to enhance this phenomenon by applying a second shock wave before bubble collapse; however, the delay between the leading shock wave and the second pressure pulse has yet to be optimized. This optimization can be done using numerical analysis. A metamodel that predicts the most convenient ranges for the input variables and provides information on the joint effects between the input variables was tested. Because the metamodel is an analytical expression, running it fifty thousand times and analyzing variables, such as the pressure amplitude, delay between pulses, and pressure rise time, was fast and easy. Furthermore, this method can be a helpful tool to study the joint effect between the input variables and reduce the computation time. The metamodel can also be adapted to analyze simulations based on equations different from the Gilmore-Akulichev formulation, which was used in this study.

Preliminary Report on Stone Breakage and Lesion Size Produced by a New Extracorporeal Electrohydraulic (Sparker Array) Discharge Device

OBJECTIVE

To determine if an innovative extracorporeal electrohydraulic shock wave (SW) device (sparker array [SPA]) can effectively fracture artificial stones in vitro and in vivo, and if SPA treatment produces a renal lesion in our pig model of lithotripsy injury. Results of these experiments will be used to help evaluate the suitability of this device as a clinical lithotripter.

MATERIALS AND METHODS

Ultracal-30 artificial stones were placed in a holder at the focus of the SPA and treated with 600 SWs (21.6 kV, 60 shocks/min). Stone fragments were collected, dried, and weighed to determine stone breakage. In vivo stone breakage entailed implanting stones into pigs. These stones were treated with 600 or 1200 SWs and the fragments were collected for analysis. Lesion analysis consisted of treating the left kidney of pigs with 1200 or 2400 SWs and quantitating the hemorrhagic lesion.

RESULTS

In vitro, 71% ± 2% of each artificial stone was fractured to <2 mm in size. In vivo stone breakage averaged 63%. Renal injury analysis revealed that only 1 of 7 kidneys showed evidence of hemorrhagic injury in the treated area.

CONCLUSION

The SPA consistently comminuted artificial stones demonstrating its ability to fracture stones like other lithotripters. Also, the SPA caused little to no renal injury at the settings used in this study. These findings suggest further research is warranted to determine the potential of this device as a clinical lithotripter.

Shock wave-induced permeabilization of mammalian cells

Controlled permeabilization of mammalian cell membranes is fundamental to develop gene and cell therapies based on macromolecular cargo delivery, a process that emerged against an increasing number of health afflictions, including genetic disorders, cancer and infections. Viral vectors have been successfully used for macromolecular delivery; however, they may have unpredictable side effects and have been limited to life-threatening cases. Thus, several chemical and physical methods have been explored to introduce drugs, vaccines, and nucleic acids into cells. One of the most appealing physical methods to deliver genes into cells is shock wave-induced poration. High-speed microjets of fluid, emitted due to the collapse of microbubbles after shock wave passage, represent the most significant mechanism that contributes to cell membrane poration by this technique. Herein, progress in shock wave-induced permeabilization of mammalian cells is presented. After covering the main concepts related to molecular strategies whose applications depend on safer drug delivery methods, the physics behind shock wave phenomena is described. Insights into the use of shock waves for cell membrane permeation are discussed, along with an overview of the two major biomedical applications thereof-i.e., genetic modification and anti-cancer shock wave-assisted chemotherapy. The aim of this review is to summarize 30 years of data showing underwater shock waves as a safe, noninvasive method for macromolecular delivery into mammalian cells, encouraging the development of further research, which is still required before the introduction of this promising tool into clinical practice.

Anatomical Comparison of the Renal Arteries in the Rabbit and European Hare

The aim of this paper was to compare the level of origin of the renal arteries in the rabbit and hare. The study was carried out on ten adult rabbits and ten adult European hares using the corrosion cast technique. After the euthanasia, the vascular network was perfused with saline. Batson’s corrosion casting kit No. 17 was used as a casting medium. After polymerization of the medium, the maceration was carried out in KOH solution. We found variable levels of the origin of renal arteries in the rabbit, in the hare and between both species. In the rabbit, the right renal artery originated at the level of the second lumbar vertebra in 70 % of the cases and at the level of the first lumbar vertebra in 30 % of the cases, and the left-sided renal artery originated in 60 % of the cases at the level of the second lumbar vertebra and at the level of the third lumbar vertebra in 40 % of the cases. In the hare, the bilateral renal arteries originated at the level of the second lumbar vertebra. According to the results, it can be concluded that the origin level of the renal arteries from the abdominal aorta is more variable in the domesticated rabbit in comparison with the hare.

Arrangement of Renal Arteries in Guinea Pig

The aim of this study was to describe origin, localization, and variations of renal arteries in guinea pig. The study was carried out on 26 adult guinea pigs. We prepared corrosion casts of the guinea pig arterial system. Batson's corrosion casting kit no. 17 was used as the casting medium. In 57.7% of specimens, a. renalis dextra was present as a single vessel with different level of its origin from aorta abdominalis. In 38.5% of specimens, two aa. renales dextrae were present with variable origin and arrangement. The presence of three aa. renales dextrae we found in one specimen. In 76.9% of specimens, a. renalis sinistra was present as a single vessel with different level of its origin from aorta abdominalis and variable arrangement. In 23.1% of specimens, we found two aa. renales sinistrae with variable origin and arrangement. The anatomical knowledge of the renal arteries, and its variations are of extreme importance for the surgeon that approaches the retroperitoneal region in several experiments, results of which are extrapolated in human. This is the first work dealing with the description of renal arteries arrangement in guinea pig. Anat Rec, 300:556-559, 2017. © 2016 Wiley Periodicals, Inc.

Review on Lithotripsy and Cavitation in Urinary Stone Therapy

Cavitation is the sudden formation of vapor bubbles or voids in liquid media and occurs after rapid changes in pressure as a consequence of mechanical forces. It is mostly an undesirable phenomenon. Although the elimination of cavitation is a major topic in the study of fluid dynamics, its destructive nature could be exploited for therapeutic applications. Ultrasonic and hydrodynamic sources are two main origins for generating cavitation. The purpose of this review is to give the reader a general idea about the formation of cavitation phenomenon and existing biomedical applications of ultrasonic and hydrodynamic cavitation. Because of the high number of the studies on ultrasound cavitation in the literature, the main focus of this review is placed on the lithotripsy techniques, which have been widely used for the treatment of urinary stones. Accordingly, cavitation phenomenon and its basic concepts are presented in Section II. The significance of the ultrasound cavitation in the urinary stone treatment is discussed in Section III in detail and hydrodynamic cavitation as an important alternative for the ultrasound cavitation is included in Section IV. Finally, side effects of using both ultrasound and hydrodynamic cavitation in biomedical applications are presented in Section V.

Combined short and long-delay tandem shock waves to improve shock wave lithotripsy according to the Gilmore-Akulichev theory

Extracorporeal shock wave lithotripsy is a common non-invasive treatment for urinary stones whose fragmentation is achieved mainly by acoustic cavitation and mechanical stress. A few years ago, in vitro and in vivo experimentation demonstrated that such fragmentation can be improved, without increasing tissue damage, by sending a second shock wave hundreds of microseconds after the previous wave. Later, numerical simulations revealed that if the second pulse had a longer full width at half maximum than a standard shock wave, cavitation could be enhanced significantly. On the other side, a theoretical study showed that stress inside the stone can be increased if two lithotripter shock waves hit the stone with a delay of only 20 μs. We used the Gilmore-Akulichev formulation to show that, in principle, both effects can be combined, that is, stress and cavitation could be increased using a pressure pulse with long full width at half maximum, which reaches the stone within hundreds of microseconds after two 20 μs-delayed initial shock waves. Implementing the suggested pressure profile into clinical devices could be feasible, especially with piezoelectric shock wave sources.

Tandem shock waves to enhance genetic transformation of Aspergillus niger

Filamentous fungi are used in several industries and in academia to produce antibiotics, metabolites, proteins and pharmaceutical compounds. The development of valuable strains usually requires the insertion of recombinant deoxyribonucleic acid; however, the protocols to transfer DNA to fungal cells are highly inefficient. Recently, underwater shock waves were successfully used to genetically transform filamentous fungi. The purpose of this research was to demonstrate that the efficiency of transformation can be improved significantly by enhancing acoustic cavitation using tandem (dual-pulse) shock waves. Results revealed that tandem pressure pulses, generated at a delay of 300 μs, increased the transformation efficiency of Aspergillus niger up to 84% in comparison with conventional (single-pulse) shock waves. This methodology may also be useful to obtain new strains required in basic research and biotechnology.

Shock waves and DNA-cationic lipid assemblies: a synergistic approach to express exogenous genes in human cells

Cationic lipid/DNA complexes (lipoplexes) represent a powerful tool for cell transfection; however, their use is still limited by important concerns, including toxicity and poor internalization into deep tissues. In this work, we investigated the use of shock wave-induced acoustic cavitation in vitro for the transfection of lipoplexes in human embryo kidney 293 cells. We selected shock waves with the ability to internalize 10-kDa fluorescein isothiocyanate-dextran into cells while maintaining survival rates above 50%. Cell transfection was tested using the green fluorescent protein-encoding plasmid pCX::GFPGPI2. Confocal microscopy and fluorescence-assisted cell sorting analyses revealed successful transfection after treatments ranging from 1 to 3 min using 60 to 180 shock waves at peak amplitudes of 12.3 ± 1.5 MPa. Interestingly, the combination of shock waves and lipoplexes induced a 3.1- and 3.8-fold increase in the expression of the reporter gene compared with the use of lipoplexes or shock waves alone, respectively. These results indicate that cationic DNA assembly and shock waves act in a synergistic manner to promote transfection of human cells, revealing a potential approach for non-invasive site-specific gene therapy.

Shockwave lithotripsy-new concepts and optimizing treatment parameters

The treatment of kidney stone disease has changed dramatically over the past 30 years. This change is due in large part to the arrival of extracorporeal shock wave lithotripsy (ESWL). ESWL along with the advances in ureteroscopic and percutaneous techniques has led to the virtual extinction of open surgical treatments for kidney stone disease. Much research has gone into understanding how ESWL can be made more efficient and safe. This article discusses the parameters that can be used to optimize ESWL outcomes as well as the new concepts that are affecting the efficacy and efficiency of ESWL.

Anatomical relationship between the collecting system and the intrarenal arteries in the rabbit: contribution for an experimental model

Intrarenal anatomy was studied in detail to evaluate how useful rabbits could be as a urologic model. Only one renal artery was observed, which was divided into dorsal and ventral branches in all cases. Three segmental arteries (cranial, mesorenal and caudal) was the most frequent branching pattern found in both the dorsal and ventral division. There was an important artery related to the ureteropelvic junction in both dorsal and ventral surfaces in all specimens. The cranial pole was supplied by both dorsal and ventral divisions of the renal artery in 23 of 41 casts (56%). Although the cranial pole of the rabbit kidney could be useful as a model because of the resemblances with human kidney, the different relationship between the intrarenal arteries and the kidney collecting system in other regions of the kidney must be taken into consideration by the urologists, when using rabbit kidney in urological research.

Modified shock waves for extracorporeal shock wave lithotripsy: a simulation based on the Gilmore formulation

Extracorporeal shock wave lithotripsy (SWL) is a reliable therapy for the treatment of urolithiasis. Nevertheless, improvements to enhance stone fragmentation and reduce tissue damage are still needed. During SWL, cavitation is one of the most important stone fragmentation mechanisms. Bubbles with a diameter between about 7 and 55μm have been reported to expand and collapse after shock wave passage, forming liquid microjets at velocities of up to 400m/s that contribute to the pulverization of renal calculi. Several authors have reported that the fragmentation efficiency may be improved by using tandem shock waves. Tandem SWL is based on the fact that the collapse of a bubble can be intensified if a second shock wave arrives tenths or even a few hundredths of microseconds before its collapse. The object of this study is to determine if tandem pulses consisting of a conventional shock wave (estimated rise time between 1 and 20ns), followed by a slower second pressure profile (0.8μs rise time), have advantages over conventional tandem SWL. The Gilmore equation was used to simulate the influence of the modified pressure field on the dynamics of a single bubble immersed in water and compare the results with the behavior of the same bubble subjected to tandem shock waves. The influence of the delay between pulses on the dynamics of the collapsing bubble was also studied for both conventional and modified tandem waves. For a bubble of 0.07mm, our results indicate that the modified pressure profile enhances cavitation compared to conventional tandem waves at a wide range of delays (10-280μs). According to this, the proposed pressure profile could be more efficient for SWL than conventional tandem shock waves. Similar results were obtained for a ten times smaller bubble.

Novel instrumentation in urologic surgery: Shock wave lithotripsy

Extracorporeal shock wave lithotripsy (SWL) was first introduced in 1980 and it rapidly revolutionized the treatment of stone disease. SWL is a non-invasive, outpatient procedure that now accounts for the majority of stone removal procedures. Since the introduction of first generation lithotripter, the Dornier HM3 machine, SWL devices have undergone many modifications secondary to limitations, in efforts to create a more effective and efficient way to treat stones and decrease possible morbidities. Herein, we review the evolution of the technology and advances in the instrumentation over the last three decades.

Enhanced shock wave-assisted transformation of Escherichia coli

The objective of the study was to demonstrate that shock wave-induced transfer of DNA into bacteria can be increased by enhancing cavitation using dual-pulse (tandem) shock waves. Escherichia coli and plasmid were transferred to test vials. Competent cells were prepared at different concentrations of CaCl(2). Single pulses and tandem shock waves were compared as were three treatment temperatures: 0, 10 and 25 °C. Three delays (250, 500, 750 μs) between double pulses were tested. Characterization was achieved by using a plasmid that provided green fluorescent protein expression. At 0 °C double pulses generated at a delay of 750 μs significantly increased the number of fluorescent colonies compared with single pulses. In general, the lowest temperature enhanced the mean number of transformants compared with the two higher temperatures. A strong influence of the CaCl(2) concentration on the transformation efficiency was also found. The main conclusion is that gene transfer to target cells may be increased up to 50 times at 0 °C by enhancing cavitation using pairs of shock waves.

Shock wave lithotripsy: advances in technology and technique

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.