Modeling elastic wave propagation in kidney stones with application to shock wave lithotripsy

Numerical investigation of shock-induced bubble collapse dynamics and fluid-solid interactions during shock-wave lithotripsy

In this paper we investigate the bubble collapse dynamics under shock-induced loading near soft and rigid bio-materials, during shock wave lithotripsy. A novel numerical framework was developed, that employs a Diffuse Interface Method (DIM) accounting for the interaction across fluid-solid-gas interfaces. For the resolution of the extended variety of length scales, due to the dynamic and fine interfacial structures, an Adaptive Mesh Refinement (AMR) framework for unstructured grids was incorporated. This multi-material multi-scale approach aims to reduce the numerical diffusion and preserve sharp interfaces. The presented numerical framework is validated for cases of bubble dynamics, under high and low ambient pressure ratios, shock-induced collapses, and wave transmission problems across a fluid-solid interface, against theoretical and numerical results. Three different configurations of shock-induced collapse applications near a kidney stone and soft tissue have been simulated for different stand-off distances and bubble attachment configurations. The obtained results reveal the detailed collapse dynamics, jet formation, solid deformation, rebound, primary and secondary shock wave emissions, and secondary collapse that govern the near-solid collapse and penetration mechanisms. Significant correlations of the problem configuration to the overall collapse mechanisms were found, stemming from the contact angle/attachment of the bubble and from the properties of solid material. In general, bubbles with their center closer to the kidney stone surface produce more violent collapses. For the soft tissue, the bubble movement prior to the collapse is of great importance as new structures can emerge which can trap the liquid jet into induced crevices. Finally, the tissue penetration is examined for these cases and a novel tension-driven tissue injury mechanism is elucidated, emanating from the complex interaction of the bubble/tissue interaction during the secondary collapse phase of an entrapped bubble in an induced crevice with the liquid jet.

Shockwaves delivery for aortic valve therapy-Realistic perspective for clinical translation?

Calcific aortic valve disease (CAVD) is the most frequent valvular heart disorder, and the one with the highest impact and burden in the elderly population. While the quality and standardization of the current aortic valve replacements has reached unprecedented levels with the commercialization of minimally-invasive implants and the design of procedures for valve repair, the need of supplementary therapies able to block or retard the course of the pathology before patients need the intervention is still awaited. In this contribution, we will discuss the emerging opportunity to set up devices to mechanically rupture the calcium deposits accumulating in the aortic valve and restore, at least in part, the pliability and the mechanical function of the calcified leaflets. Starting from the evidences gained by mechanical decalcification of coronary arteries in interventional cardiology procedures, a practice already in the clinical setting, we will discuss the advantages and the potential drawbacks of valve lithotripsy devices and their potential applicability in the clinical scenario.

Improving burst wave lithotripsy effectiveness for small stones and fragments by increasing frequency: theoretical modeling and ex vivo study

INTRODUCTION AND OBJECTIVE

In clinical trial NCT03873259, a 2.6-mm lower pole stone was treated transcutaneously and ex vivo with 390-kHz burst wave lithotripsy (BWL) for 40 minutes and failed to break. The stone was subsequently fragmented with 650-kHz BWL after a 4-minute exposure. This study investigated how to fragment small stones and why varying BWL frequency may more effectively fragment stones to dust.

METHODS

A linear elastic model was used to calculate the stress created inside stones from shock wave lithotripsy (SWL) and different BWL frequencies mimicking the stone's size, shape, lamellar structure, and composition. To test model predictions about the impact of BWL frequency, matched pairs of stones (1-5 mm) were treated at 1) 390 kHz, 2) 830 kHz, and 3) 390 kHz followed by 830 kHz. The mass of fragments greater than 1 and 2 mm was measured over 10 minutes of exposure.

RESULTS

The linear elastic model predicts that the maximum principal stress inside a stone increases to more than 5.5 times the pressure applied by the ultrasound wave as frequency is increased, regardless of composition tested. The threshold frequency for stress amplification is proportionate to the wave speed divided by the stone diameter. Thus, smaller stones may be likely to fragment at higher frequency, but not lower frequency below a limit. Unlike with SWL, this amplification in BWL occurs consistently with spherical and irregularly shaped stones. In water tank experiments, stones smaller than the threshold size broke fastest at high frequency (p=0.0003), whereas larger stones broke equally well to sub-millimeter dust at high, low, or mixed frequency.

CONCLUSIONS

For small stones and fragments, increasing frequency of BWL may produce amplified stress in the stone causing the stone to break. Using the strategies outlined here, stones of all sizes may be turned to dust efficiently with BWL.

Multiphysics Analysis of Ultrasonic Shock Wave Lithotripsy and Side Effects on Surrounding Tissues

Background:

Today, the most common method for kidney stone therapy is extracorporeal shock wave lithotripsy. Current research is a numerical simulation of kidney stone fragmentation via ultrasonic shock waves. Most numerical studies in lithotripsy have been carried out using the elasticity or energy method and neglected the dissipation phenomenon. In the current study, it is solved by not only the linear acoustics equation, but also the Westervelt acoustics equation which nonlinearity and dissipation are involved.

Objective:

This study is to compare two methods for simulation of shock wave lithotripsy, clarifying the effect of shock wave profiles and stones’ material, and investigating side effects on surrounding tissues

Material and Methods:

Computational study is done using COMSOL Multiphysics, commercial software based on the finite element method. Nonlinear governing equations of acoustics, elasticity and bioheat-transfer are coupled and solved.

Results:

A decrease in the rise time of shock wave leads to increase the produced acoustic pressure and enlarge focus region. The shock wave damages kidney tissues in both linear and nonlinear simulation but the damage due to high temperature is very negligible compared to the High Intensity Focused Ultrasound (HIFU).

Conclusion:

Disaffiliation of wave nonlinearity causes a high incompatibility with reality. Stone’s material is an important factor, affecting the fragmentation

Maximizing mechanical stress in small urinary stones during burst wave lithotripsy

Unlike shock wave lithotripsy, burst wave lithotripsy (BWL) uses tone bursts, consisting of many periods of a sinusoidal wave. In this work, an analytical theoretical approach to modeling mechanical stresses in a spherical stone was developed to assess the dependence of frequency and stone size on stress generated in the stone. The analytical model for spherical stones is compared against a finite-difference model used to calculate stress in nonspherical stones. It is shown that at low frequencies, when the wavelength is much greater than the diameter of the stone, the maximum principal stress is approximately equal to the pressure amplitude of the incident wave. With increasing frequency, when the diameter of the stone begins to exceed about half the wavelength in the surrounding liquid (the exact condition depends on the material of the stone), the maximum stress increases and can be more than six times greater than the incident pressure. These results suggest that the BWL frequency should be elevated for small stones to improve the likelihood and rate of fragmentation.

Variations of stress field and stone fracture produced at different lateral locations in a shockwave lithotripter field

During clinical procedures, the lithotripter shock wave (LSW) that is incident on the stone and resultant stress field is often asymmetric due to the respiratory motion of the patient. The variations of the LSW-stone interaction and associated fracture pattern were investigated by photoelastic imaging, phantom experiments, and three-dimensional fluid-solid interaction modeling at different lateral locations in a lithotripter field. In contrast to a T-shaped fracture pattern often observed in the posterior region of the disk-shaped stone under symmetric loading, the fracture pattern gradually transitioned to a tilted L-shape under asymmetric loading conditions. Moreover, the model simulations revealed the generation of surface acoustic waves (SAWs), i.e., a leaky Rayleigh wave on the anterior boundary and Scholte wave on the posterior boundary of the stone. The propagation of SAWs on the stone boundary is accompanied by a progressive transition of the LSW reflection pattern from regular to von Neumann and to weak von Neumann reflection near the glancing incidence and, concomitantly, the development and growth of a Mach stem, swirling around the stone boundary. The maximum tensile stress and stress integral were produced by SAWs on the stone boundary under asymmetric loading conditions, which drove the initiation and extension of surface cracks into the bulk of the stone that is confirmed by micro-computed tomography analysis.

Tri-modality cavitation mapping in shock wave lithotripsy

Shock wave lithotripsy (SWL) has been widely used for non-invasive treatment of kidney stones. Cavitation plays an important role in stone fragmentation, yet it may also contribute to renal injury during SWL. It is therefore crucial to determine the spatiotemporal distributions of cavitation activities to maximize stone fragmentation while minimizing tissue injury. Traditional cavitation detection methods include high-speed optical imaging, active cavitation mapping (ACM), and passive cavitation mapping (PCM). While each of the three methods provides unique information about the dynamics of the bubbles, PCM has most practical applications in biological tissues. To image the dynamics of cavitation bubble collapse, we previously developed a sliding-window PCM (SW-PCM) method to identify each bubble collapse with high temporal and spatial resolution. In this work, to further validate and optimize the SW-PCM method, we have developed tri-modality cavitation imaging that includes three-dimensional high-speed optical imaging, ACM, and PCM seamlessly integrated in a single system. Using the tri-modality system, we imaged and analyzed laser-induced single cavitation bubbles in both free field and constricted space and shock wave-induced cavitation clusters. Collectively, our results have demonstrated the high reliability and spatial-temporal accuracy of the SW-PCM approach, which paves the way for the future in vivo applications on large animals and humans in SWL.

Towards an understanding of the chemo-mechanical influences on kidney stone failure via the material point method

This paper explores the use of the meshfree computational mechanics method, the Material Point Method (MPM), to model the composition and damage of typical renal calculi, or kidney stones. Kidney stones are difficult entities to model due to their complex structure and failure behavior. Better understanding of how these stones behave when they are broken apart is a vital piece of knowledge to medical professionals whose aim is to remove these stone by breaking them within a patient’s body. While the properties of individual stones are varied, the common elements and proportions are used to generate synthetic stones that are then placed in a digital experiment to observe their failure patterns. First a more traditional engineering model of a Brazil test is used to create a tensile fracture within the center of these stones to observe the effect of stone consistency on failure behavior. Next a novel application of MPM is applied which relies on an ultrasonic wave being carried by surrounding fluid to model the ultrasonic treatment of stones commonly used by medical practitioners. This numerical modeling of Extracorporeal Shock Wave Lithotripsy (ESWL) reveals how these different stones failure in a more real-world situation and could be used to guide further research in this field for safer and more effective treatments.

Experimental Investigation and Mechanism Analysis on Rock Damage by High Voltage Spark Discharge in Water: Effect of Electrical Conductivity

High voltage spark discharge (HVSD) could generate strong pressure waves that can be combined with a rotary drill bit to improve the penetration rate in unconventional oil and gas drilling. However, there has been little investigation of the effect of electrical conductivity on rock damage and the fragmentation mechanism caused by HVSD. Therefore, we conducted experiments to destroy cement mortar, a rock-like material, in water with five conductivity levels, from 0.5 mS/cm to 20 mS/cm. We measured the discharge parameters, such as breakdown voltage, breakdown delay time, and electrical energy loss, and investigated the damage mechanism from stress waves propagation using X-ray computed tomography. Our study then analyzed the influence of conductivity on the surface damage of the sample by the pore size distribution and the cumulative pore area, as well as studied the dependence of internal damage on conductivity by through-transmission ultrasonic inspection technique. The results indicated that the increase in electrical conductivity decreased the breakdown voltage and breakdown delay time and increased the energy loss, which led to a reduction in the magnitude of the pressure wave and, ultimately, reduced the sample damage. It is worth mentioning that the relationship between the sample damage and electrical conductivity is non-linear, showing a two-stage pattern. The findings suggest that stress waves induced by the pressure waves play a significant role in sample damage where pores and two types of tensile cracks are the main failure features. Compressive stresses close horizontal cracks inside the sample and propagate vertical cracks, forming the tensile cracks-I. Tensile stresses generated at the sample–water interface due to the reflection of stress waves produce the tensile cracks-II. Our study is the first to investigate the relationship between rock damage and electrical conductivity, providing insights to guide the design of drilling tools based on HVSD.

Modeling of photoelastic imaging of mechanical stresses in transparent solids mimicking kidney stones

Theoretical and numerical models were developed to calculate the polariscopic integrated light intensity that forms a projection of the dynamic stress within an axisymmetric elastic object. Although the model is general, this paper addressed its application to measurements of stresses in model kidney stones from a burst wave lithotripter for stone fragmentation. The stress was calculated using linear elastic equations, and the light propagation was modeled in the instantaneous case by integrating over the volume of the stone. The numerical model was written in finite differences. The resulting images agreed well with measured images. The measured images corresponded to the maximum shear stress distribution, although other stresses were also plotted. Comparison of the modeled and observed polariscope images enabled refinement of the photoelastic constant by minimizing the error between the calculated and measured fields. These results enable quantification of the stress within the polariscope images, determination of material properties, and the modes and mechanisms of stress production within a kidney stone. Such a model may help in interpreting elastic waves in structures, such as stones, toward improving lithotripsy procedures.

On the Effects of Constitutive Properties and Roughness of a Hard Inclusion in Soft Tissue on B-mode Images

We perform finite element modeling of pulse-echo ultrasound of a hard inclusion in a soft tissue to gain a better understanding of B-mode image brightness characteristics. We simulate a pressure wave emitted by an ultrasound transducer through the inclusion-tissue medium by prescribing suitable boundary conditions, and collect the scattered wave response to simulate the behavior of the transducer array used for pulse-echo ultrasound. We form B-mode images from simulated channel data using standard delay and sum beamforming. We establish the accuracy of the finite element model by comparing the point spread function with that obtained from Field II ultrasound simulation program. We also demonstrate qualitative validation by comparing the brightness characteristics of rough and smooth surfaced circular inclusions with experimental images of a cylindrical metal tool immersed in a water tank. We next conduct simulation studies to evaluate changes in B-mode image brightness intensity and contrast related to different constitutive properties, namely, compressibility of the inclusion, impedance contrast between the host and inclusion, and surface roughness of the inclusion. We find that the intensity observed behind a hard inclusion in the axial direction is strongly affected by the compressibility and roughness of the inclusion. Also, the perceived width of the stone based on the intensity is greater for rougher stones. Our study indicates that imaging of compressible inclusions may benefit from targeted B-mode image forming algorithms. Our modeling framework can potentially be useful in differentiating hard inclusions from surrounding parenchyma, and for classifying kidney stones or gallstones.

An investigation of elastic waves producing stone fracture in burst wave lithotripsy

Burst wave lithotripsy is a method to noninvasively fragment urinary stones by short pulses of focused ultrasound. In this study, physical mechanisms of stone fracture during burst wave lithotripsy were investigated. Photoelasticity imaging was used to visualize elastic wave propagation in model stones and compare results to numerical calculations. Epoxy and glass stone models were made into rectangular, cylindrical, or irregular geometries and exposed in a degassed water bath to focused ultrasound bursts at different frequencies. A high-speed camera was used to record images of the stone during exposure through a circular polariscope backlit by a monochromatic flash source. Imaging showed the development of periodic stresses in the stone body with a pattern dependent on frequency. These patterns were identified as guided wave modes in cylinders and plates, which formed standing waves upon reflection from the distal surfaces of the stone model, producing specific locations of stress concentration in the models. Measured phase velocities compared favorably to numerically calculated modes dependent on frequency and material. Artificial stones exposed to bursts produced cracks at positions anticipated by this mechanism. These results support guided wave generation and reflection as a mechanism of stone fracture in burst wave lithotripsy.

The effect of focus size and intensity on stone fragmentation in SWL on a piezoelectric lithotripter

Purpose

We aim to analyze the efficacy of different focus sizes and the influence of pulse pressure (intensity) during shock wave lithotripsy (SWL) in terms of stone fragmentation.

Methods

Combination of three focal sizes (F1 = 2 mm, F2 = 4 mm, F3 = 8 mm) and 11 output pressure settings (intensity 10–20) of a piezoelectric lithotripter (Wolf PiezoLith 3000) were tested on artificial stones (n = 99). The stones were placed within a 2 mm mesh cage. The needed number of shockwaves (SW) to first visible crack, 50% and 100% stone disintegration were recorded.

Results

Similar number of SW’s were observed until the first crack 10, 11 and 11 SW’s for F1, F2, and F3, respectively (p > 0,05). The median number of SW needed for 50% stone disintegration was 245 for F1 group, 242 for F2 group and 656 for F3 group. F1 vs F2 p = 0.7, F1 vs F3 and F2 vs F3 p < 0.05. Similarly, with larger focus size a higher number of shockwaves were necessary for 100% stone disintegration. 894, 877 and 1708 SW’s for F1, F2 and F3, respectively. Only for F1 vs F3 and F2 vs F3 (all p < 0.05) a statistical difference was observed. These findings were consistent in all different power settings, with an increased difference in lower power levels (≤ 14).

Conclusions

A smaller focus size, as well as a higher peak pressure results in a more effective stone fragmentation. However, these results need to be confirmed in an in vivo setting with multiple parameters interfering the efficacy, like BMI, respiration or stone migration.

Nanosecond shock wave-induced surface acoustic waves and dynamic fracture at fluid-solid boundaries

We investigate the generation and propagation characteristics of leaky Rayleigh waves (LRWs) caused by a spherical shock wave incident on a water-glass boundary both experimentally and numerically. The maximum tensile stress produced on the solid boundary is attributed to the dynamic interaction between the LRWs and an evanescent wave generated concomitantly along the boundary. The resultant tensile stress field drives the initiation of crack formation from pre-existing surface flaws and their subsequent extension along a circular trajectory, confirmative with the direction of the principal stress on the boundary. We further demonstrate that this unique ringlike fracture pattern, prevalent in damage produced by high-speed impact, can be best described by the Tuler-Butcher criterion for dynamic failure in brittle materials. The orientation of the ring fracture extension into the solid also follows closely with the trajectory of the local maximum tensile stress distribution.

Shock-Induced Damage and Dynamic Fracture in Cylindrical Bodies Submerged in Liquid

Understanding the response of solid materials to shock loading is important for mitigating shock-induced damages and failures, as well as advancing the beneficial use of shock waves for material modifications. In this paper, we consider a representative brittle material, BegoStone, in the form of cylindrical bodies and submerged in water. We present a computational study on the causal relationship between the prescribed shock load and the resulting elastic waves and damage in the solid material. A recently developed three-dimensional computational framework, FIVER, is employed, which couples a finite volume compressible fluid solver with a finite element structural dynamics solver through the construction and solution of local, one-dimensional fluid-solid Riemann problems. The material damage and fracture are modeled and simulated using a continuum damage mechanics model and an element erosion method. The computational model is validated in the context of shock wave lithotripsy and the results are compared with experimental data. We first show that after calibrating the growth rate of microscopic damage and the threshold for macroscopic fracture, the computational framework is capable of capturing the location and shape of the shock-induced fracture observed in a laboratory experiment. Next, we introduce a new phenomenological model of shock waveform, and present a numerical parametric study on the effects of a single shock load, in which the shock waveform, magnitude, and the size of the target material are varied. In particular, we vary the waveform gradually from one that features non-monotonic decay with a tensile phase to one that exhibits monotonic decay without a tensile phase. The result suggests that when the length of the shock pulse is comparable to that of the target material, the former waveform may induce much more significant damage than the latter one, even if the two share the same magnitude, duration, and acoustic energy.

Fragmentation of brittle material by shock wave lithotripsy. Momentum transfer and inertia: a novel view on fragmentation mechanisms

Shock wave lithotripsy is the only non-invasive stone therapy and in clinical use since 1980. In spite of decades with millions of patients treated, the mechanism of fragmentation is still under debate. Detailed knowledge of the fragmentation process is required for improvements regarding safety and efficiency. The purpose of this paper is to gain a deeper insight into the mechanism of fragmentation by drawing attention to basic physical laws of inertia and momentum transfer. Many fragmentation experiments are based on the overall efficiency of multiple shock waves in crushing kidney stones or artificial model stones utilizing small baskets or latex pouches. Due to the high dynamic nature of the fragmentation process, in vitro and in vivo, a detailed action of a single shock wave on a particular stone target is difficult to investigate. We utilized a bifilar stone suspension, which allowed us to observe horizontal movements of model stones, their return to the initial position and orientation for repeated exposure of separate identical shocks. The method does not describe the entire fragmentation process in detail but elucidates a mechanism, which may be effective throughout shock wave lithotripsy in general. Measurements on model stones in water revealed forces in the range of 370 N, acceleration values of 100,000-200,000 m/s² (≈ 10,000 g) and gained momentum of 3.7 × 10^- 4 kg m/s we consider sufficient to break most human urinary stones. Fracture patterns of repeated identical shock waves show typical features supporting spallation (Hopkinson effect) and the mechanism of momentum transfer. Schlieren and photo-elastic images provide a visual impression of spatial stress in a transparent acrylic glass cylinder, cavitation fields outside and at the surface of the cylinder, which are compatible with the inertia model. The proposed mechanism covers coarse as well as fine fragmentation. Collapsing cavitation bubbles may have an impact on the fragmentation process but although expected, a direct action of micro-jets on sample surfaces could not be detected.

An experimentally-calibrated damage mechanics model for stone fracture in shock wave lithotripsy

A damage model suggested by the Tuler-Butcher concept of dynamic accumulation of microscopic defects is obtained from experimental data on microcrack formation in synthetic kidney stones. Experimental data on appearance of microcracks is extracted from micro-computed tomography images of BegoStone simulants obtained after subjecting the stone to successive pulses produced by an electromagnetic shock-wave lithotripter source. Image processing of the data is used to infer statistical distributions of crack length and width in representative transversal cross-sections of a cylindrical stone. A high-resolution finite volume computational model, capable of accurately modeling internal reflections due to local changes in material properties produced by material damage is used to simulate the accumulation of damage due to successive shocks. Comparison of statistical distributions of microcrack formation in computation and experiment allows calibration of the damage model. The model is subsequently used to compute fracture of a different aspect-ratio cylindrical stone predicting concurrent formation of two main fracture areas as observed experimentally.

Quantitative Assessments of Mechanical Responses upon Radial Extracorporeal Shock Wave Therapy

Although radial extracorporeal shock wave therapy (rESWT) has been widely used to treat orthopedic disorders with promising clinical results, rESWT largely relies on clinicians' personal experiences and arbitrary judgments, without knowing relationships between administration doses and effective doses at target sites. In fact, practitioners lack a general and reliable way to assess propagation and distribution of pressure waves inside biological tissues quantitatively. This study develops a methodology to combine experimental measurements and computational simulations to obtain pressure fields from rESWT through calibrating and validating computational models with experimental measurements. Wave pressures at the bottom of a petri dish and inside biological tissues are measured, respectively, by attaching and implanting flexible membrane sensors. Detailed wave dynamics are simulated through explicit finite element analyses. The data decipher that waves from rESWT radiate directionally and can be modeled as acoustic waves generated from a vibrating circular piston. Models are thus established to correlate pressure amplitudes at the bottom of petri dishes and in the axial direction of biological tissues. Additionally, a pilot simulation upon rESWT for human lumbar reveals a detailed and realistic pressure field mapping. This study will open a new avenue of personalized treatment planning and mechanism research for rESWT.

Multiphase fluid-solid coupled analysis of shock-bubble-stone interaction in shockwave lithotripsy

A novel multiphase fluid-solid-coupled computational framework is applied to investigate the interaction of a kidney stone immersed in liquid with a lithotripsy shock wave (LSW) and a gas bubble near the stone. The main objective is to elucidate the effects of a bubble in the shock path to the elastic and fracture behaviors of the stone. The computational framework couples a finite volume 2-phase computational fluid dynamics solver with a finite element computational solid dynamics solver. The surface of the stone is represented as a dynamic embedded boundary in the computational fluid dynamics solver. The evolution of the bubble surface is captured by solving the level set equation. The interface conditions at the surfaces of the stone and the bubble are enforced through the construction and solution of local fluid-solid and 2-fluid Riemann problems. This computational framework is first verified for 3 example problems including a 1D multimaterial Riemann problem, a 3D shock-stone interaction problem, and a 3D shock-bubble interaction problem. Next, a series of shock-bubble-stone-coupled simulations are presented. This study suggests that the dynamic response of a bubble to LSW varies dramatically depending on its initial size. Bubbles with an initial radius smaller than a threshold collapse within 1 μs after the passage of LSW, whereas larger bubbles do not. For a typical LSW generated by an electrohydraulic lithotripter (p_max  = 35.0MPa, p_min  =- 10.1MPa), this threshold is approximately 0.12mm. Moreover, this study suggests that a noncollapsing bubble imposes a negative effect on stone fracture as it shields part of the LSW from the stone. On the other hand, a collapsing bubble may promote fracture on the proximal surface of the stone, yet hinder fracture from stone interior.

Acoustic Radiation Force of a Quasi-Gaussian Beam on an Elastic Sphere in a Fluid

Acoustic radiation force has many applications. One of the related technologies is the ability to noninvasively expel stones from the kidney. To optimize the procedure it is important to develop theoretical approaches that can provide rapid calculations of the radiation force depending in stone size and elastic properties, together with ultrasound beam diameter, intensity, and frequency. We hypothesize that the radiation force nonmonotonically depends on the ratio between the acoustic beam width and stone diameter because of coupling between the acoustic wave in the fluid and shear waves in the stone. Testing this hypothesis by considering a spherical stone and a quasi-Gaussian beam was performed in the current work. The calculation of the radiation force was conducted for elastic spheres of two types. Dependence of the magnitude of the radiation force on the beam diameter at various fixed values of stone diameters was modeled. In addition to using real material properties, speed of shear wave in the stone was varied to reveal the importance of shear waves in the stone. It was found that the radiation force reaches its maximum at the beamwidth comparable to the stone diameter; the gain in the force magnitude can reach 40% in comparison with the case of a narrow beam.

Comparison of Broad vs Narrow Focal Width Lithotripter Fields

OBJECTIVE

To investigate the impact of lithotripter focal width on stone fragmentation.

MATERIALS AND METHODS

A modified reflector was used to reduce -6 dB beam size of the HM3 lithotripter, while increasing concomitantly peak pressure. Fragmentation in vitro was assessed with modified and original reflectors using BegoStone phantoms. A membrane holder was used to mimic lithotripsy in vivo, and a matrix holder was used to assess variations of fragmentation power in the focal plane of the lithotripter field. Stone fragmentation in vivo produced by the two reflectors was further compared in a swine model.

RESULTS

Stone fragmentation in vitro after 500 (or 2000) shocks was ∼60% (or ∼82%) vs ∼40% (or ∼75%) with original and modified reflector, respectively (p ≤ 0.0016). Fragmentation power with the modified reflector was the highest on the lithotripter axis, but dropped rapidly in the lateral direction and became insignificant at radial distances >6.0 mm. Stone fragmentation with the original reflector was lower along the lithotripter axis, but fragmentation power decayed slowly in lateral direction, with appreciable fragmentation produced at 6.0 mm. Stone fragmentation efficiency in vivo after 500 (or 2000) shocks was ∼70% (or ∼90%) vs ∼45% (or ∼80%) with original and modified reflector, respectively (p ≤ 0.04).

CONCLUSIONS

A lithotripter field with broad beam size yields superior stone comminution when compared with narrow beam size under comparable effective acoustic pulse energy both in vivo and in vitro. These findings may facilitate future improvements in lithotripter design to maximize comminution efficiency while minimizing tissue injury.

Effects of Stone Size on the Comminution Process and Efficiency in Shock Wave Lithotripsy

The effects of stone size on the process and comminution efficiency of shock wave lithotripsy (SWL) were investigated in experiments, numerical simulations and scale analysis. Cylindrical BegoStone phantoms with approximately equal height and diameter of either 4, 7 or 10 mm, in a total aggregated mass of about 1.5 g, were treated in an electromagnetic shock wave lithotripter field. The resultant stone comminution was found to correlate closely with the average peak pressure, P_+(avg), incident on the stones. The P_+(avg) threshold necessary to initiate stone fragmentation in water increased from 7.9 to 8.8 to 12.7 MPa, respectively, as stone size decreased from 10 to 7 to 4 mm. Similar changes in the P_+(avg) threshold were observed for the 7- and 10-mm stones treated in 1,3-butanediol, in which cavitation is suppressed, suggesting that the observed size dependency is due to changes in stress distribution within stones of different size. Moreover, the slope of the correlation curve between stone comminution and ln(P¯_+(avg)) in water increased with decreasing stone size, whereas the opposite trend was observed in 1,3-butanediol. The progression of stone comminution in SWL exhibited size-dependence: the 7- and 10-mm stones fragmented into progressively smaller pieces, whereas a significant portion (>30%) of the 4-mm stones reached a stalemate within the size range of 2.8 ∼ 4 mm, even after 1000 shocks. Analytical scaling considerations suggest size-dependent fragmentation behavior, a hypothesis further supported by numerical model calculations that reveal changing patterns of constructive and destructive wave interference and, thus, variations in the maximum tensile stress or stress integral produced in cylindrical and spherical stone of different sizes.

Shifting the Split Reflectors to Enhance Stone Fragmentation of Shock Wave Lithotripsy

Shock wave lithotripsy (SWL) has been used widely in urology for about three decades to treat kidney calculi. Technical development to improve performance (i.e., stone fragmentation efficiency) is continuous. Low-pressure wide-focus lithotripters have already achieved promising results. In this study, the lithotripter field and profile of lithotripter shock waves were changed simultaneously using a cost-effective and convenient design. An intact parabolic reflector was split into four pieces, and each part was moved individually. By shifting the split reflectors, the focused acoustic beams were separated. As a result, the beam width in the focal region could be increased. Both numerical models of wave propagation using a k-wave approach and hydrophone measurements showed similar pressure waveforms at the focus and the distributions along and transverse to the lithotripter axis. The increase of the shifting distance from 0 mm to 7 mm resulted in the increase of -6 dB beam width from 7.1 mm to 13.9 mm and location of tensile peak on axis moving from z = -14 mm to 1 mm. The Lithotripters at 10 kV (intact reflector) and at 12 kV with the split reflectors shifted by 5 mm were compared with each other because of their similar peak positive pressures at the focus (8.07 MPa ± 0.05 MPa vs. 7.90 MPa ± 0.11 MPa, respectively). However, there were significant differences in their positive beam width (8.7 mm vs. 10.2 mm), peak negative pressure (-6.34 MPa ± 0.04 MPa vs. -7.13 MPa ± 0.13 MPa), the maximum tensile stress (7.55 MPa vs. 8.95 MPa) and shear stress (6.1 MPa vs. 7.76 MPa) in a 10-mm diameter spherical stone and bubble collapse time (127.6 μs ± 5.4 μs vs. 212.7 μs ± 8.2 μs). As a result, stone fragmentation efficiency was enhanced about 1.8-fold (57.9% ± 4.6% vs. 32.2% ± 5.6%, p < 0.05) when shifting the split reflectors. These results suggest that this new reflector design could change the characteristics of the lithotripter field and increase stone fragmentation efficiency.

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.

In Vitro Assessment of Three Clinical Lithotripters Employing Different Shock Wave Generators

OBJECTIVE

To test the hypothesis that shock wave lithotripsy machines vary in their ability to fragment standardized artificial urinary calculi.

MATERIALS AND METHODS

An in vitro test configuration was used to fragment synthetic U-30 Gypsum (U.S. Gypsum, Chicago, IL) stones (mean length 7.1 ± 0.2 mm, mean diameter 6.5 ± 0.07 mm, mean mass 299 ± 16 mg) using the Sonolith i-sys (EDAP TMS, Vaulx-en-Velin, France), Modulith SLX F2 (Storz Medical AG, Tägerwilen, Switzerland), and Piezolith 3000 (Richard Wolf GmbH, Knittlingen, Germany) lithotripters. Gypsum stones were placed at the nominal focus and treated with 250, 500, or 1000 shocks. The residual mass following passage through a 2-mm wire mesh was measured and compared using ANOVA and the Tukey-Kramer HSD test.

RESULTS

There was no statistically significant difference between the Modulith SLX F2 and Piezolith 3000 lithotripters for 250 and 1000 shock treatments (p = 0.34 and 0.31, respectively). The Piezolith 3000 demonstrated the most favorable stone mass reduction for 500 shock treatments (187.4 ± 45.2 mg). The Sonolith i-sys was found to be significantly less effective than the other lithotripters for all shockwave conditions. Furthermore, performance of the Sonolith i-sys decreased beyond a threshold generator electrode age of 6000 shocks.

CONCLUSIONS

This in vitro study found considerable variability in the ability of lithotripters to fragment synthetic urinary calculi. Synthetic stones were employed to provide a repeatable means of assessing variability in fragmentation efficiency of lithotripters. The Modulith SLX F2 and Piezolith 3000 are broadly equal and resulted in greater fragmentation efficiencies than the Sonolith i-sys. The performance of the Sonolith i-sys deteriorates at 6000 shocks, before the specified lifetime of 20,000 shocks.

Finite element modelling of radial shock wave therapy for chronic plantar fasciitis

Therapeutic use of high-amplitude pressure waves, or shock wave therapy (SWT), is emerging as a popular method for treating musculoskeletal disorders. However, the mechanism(s) through which this technique promotes healing are unclear. Finite element models of a shock wave source and the foot were constructed to gain a better understanding of the mechanical stimuli that SWT produces in the context of plantar fasciitis treatment. The model of the shock wave source was based on the geometry of an actual radial shock wave device, in which pressure waves are generated through the collision of two metallic objects: a projectile and an applicator. The foot model was based on the geometry reconstructed from magnetic resonance images of a volunteer and it comprised bones, cartilage, soft tissue, plantar fascia, and Achilles tendon. Dynamic simulations were conducted of a single and of two successive shock wave pulses administered to the foot. The collision between the projectile and the applicator resulted in a stress wave in the applicator. This wave was transmitted into the soft tissue in the form of compression-rarefaction pressure waves with an amplitude of the order of several MPa. The negative pressure at the plantar fascia reached values of over 1.5 MPa, which could be sufficient to generate cavitation in the tissue. The results also show that multiple shock wave pulses may have a cumulative effect in terms of strain energy accumulation in the foot.

Strategies to optimize shock wave lithotripsy outcome: Patient selection and treatment parameters

Shock wave lithotripsy (SWL) was introduced in 1980, modernizing the treatment of upper urinary tract stones, and quickly became the most commonly utilized technique to treat kidney stones. Over the past 5-10 years, however, use of SWL has been declining because it is not as reliably effective as more modern technology. SWL success rates vary considerably and there is abundant literature predicting outcome based on patient- and stone-specific parameters. Herein we discuss the ways to optimize SWL outcomes by reviewing proper patient selection utilizing stone characteristics and patient features. Stone size, number, location, density, composition, and patient body habitus and renal anatomy are all discussed. We also review the technical parameters during SWL that can be controlled to improve results further, including type of anesthesia, coupling, shock wave rate, focal zones, pressures, and active monitoring. Following these basic principles and selection criteria will help maximize success rate.

Fragmentation of urinary calculi in vitro by burst wave lithotripsy

PURPOSE

We developed a new method of lithotripsy that uses short, broadly focused bursts of ultrasound rather than shock waves to fragment stones. We investigated the characteristics of stone comminution by burst wave lithotripsy in vitro.

MATERIALS AND METHODS

Artificial and natural stones (mean ± SD size 8.2 ± 3.0 mm, range 5 to 15) were treated with ultrasound bursts using a focused transducer in a water bath. Stones were exposed to bursts with focal pressure amplitude of 6.5 MPa or less at a 200 Hz burst repetition rate until completely fragmented. Ultrasound frequencies of 170, 285 and 800 kHz were applied using 3 transducers, respectively. Time to fragmentation for each stone type was recorded and fragment size distribution was measured by sieving.

RESULTS

Stones exposed to ultrasound bursts were fragmented at focal pressure amplitudes of 2.8 MPa or greater at 170 kHz. Fractures appeared along the stone surface, resulting in fragments that separated at the surface nearest to the transducer until the stone was disintegrated. All natural and artificial stones were fragmented at the highest focal pressure of 6.5 MPa with a mean treatment duration of 36 seconds for uric acid stones to 14.7 minutes for cystine stones. At a frequency of 170 kHz the largest artificial stone fragments were less than 4 mm. Exposure at 285 and 800 kHz produced only fragments less than 2 mm and less than 1 mm, respectively.

CONCLUSIONS

Stone comminution with burst wave lithotripsy is feasible as a potential noninvasive treatment method for nephrolithiasis. Adjusting the fundamental ultrasound frequency allows for stone fragment size to be controlled.

Effect of the body wall on lithotripter shock waves

PURPOSE

Determine the influence of passage through the body wall on the properties of lithotripter shock waves (SWs) and the characteristics of the acoustic field of an electromagnetic lithotripter.

METHODS

Full-thickness ex vivo segments of pig abdominal wall were secured against the acoustic window of a test tank coupled to the lithotripter. A fiber-optic probe hydrophone was used to measure SW pressures, determine shock rise time, and map the acoustic field in the focal plane.

RESULTS

Peak positive pressure on axis was attenuated roughly proportional to tissue thickness-approximately 6% per cm. Irregularities in the tissue path affected the symmetry of SW focusing, shifting the maximum peak positive pressure laterally by as much as ∼2 mm. Within the time resolution of the hydrophone (7-15 ns), shock rise time was unchanged, measuring ∼17-21 ns with and without tissue present. Mapping of the field showed no effect of the body wall on focal width, regardless of thickness of the body wall.

CONCLUSIONS

Passage through the body wall has minimal effect on the characteristics of lithotripter SWs. Other than reducing pulse amplitude and having the potential to affect the symmetry of the focused wave, the body wall has little influence on the acoustic field. These findings help to validate laboratory assessment of lithotripter acoustic field and suggest that the properties of SWs in the body are much the same as have been measured in vitro.

Experimentally validated multiphysics computational model of focusing and shock wave formation in an electromagnetic lithotripter

A multiphysics computational model of the focusing of an acoustic pulse and subsequent shock wave formation that occurs during extracorporeal shock wave lithotripsy is presented. In the electromagnetic lithotripter modeled in this work the focusing is achieved via a polystyrene acoustic lens. The transition of the acoustic pulse through the solid lens is modeled by the linear elasticity equations and the subsequent shock wave formation in water is modeled by the Euler equations with a Tait equation of state. Both sets of equations are solved simultaneously in subsets of a single computational domain within the BEARCLAW framework which uses a finite-volume Riemann solver approach. This model is first validated against experimental measurements with a standard (or original) lens design. The model is then used to successfully predict the effects of a lens modification in the form of an annular ring cut. A second model which includes a kidney stone simulant in the domain is also presented. Within the stone the linear elasticity equations incorporate a simple damage model.

A heuristic model of stone comminution in shock wave lithotripsy

A heuristic model is presented to describe the overall progression of stone comminution in shock wave lithotripsy (SWL), accounting for the effects of shock wave dose and the average peak pressure, P+(avg), incident on the stone during the treatment. The model is developed through adaptation of the Weibull theory for brittle fracture, incorporating threshold values in dose and P+(avg) that are required to initiate fragmentation. The model is validated against experimental data of stone comminution from two stone types (hard and soft BegoStone) obtained at various positions in lithotripter fields produced by two shock wave sources of different beam width and pulse profile both in water and in 1,3-butanediol (which suppresses cavitation). Subsequently, the model is used to assess the performance of a newly developed acoustic lens for electromagnetic lithotripters in comparison with its original counterpart both under static and simulated respiratory motion. The results have demonstrated the predictive value of this heuristic model in elucidating the physical basis for improved performance of the new lens. The model also provides a rationale for the selection of SWL treatment protocols to achieve effective stone comminution without elevating the risk of tissue injury.

Single-shot measurements of the acoustic field of an electrohydraulic lithotripter using a hydrophone array

Piezopolymer-based hydrophone arrays consisting of 20 elements were fabricated and tested for use in measuring the acoustic field from a shock-wave lithotripter. The arrays were fabricated from piezopolymer films and were mounted in a housing to allow submersion into water. The motivation was to use the array to determine how the shot-to-shot variability of the spark discharge in an electrohydraulic lithotripter affects the resulting focused acoustic field. It was found that the dominant effect of shot-to-shot variability was to laterally shift the location of the focus by up to 5 mm from the nominal acoustic axis of the lithotripter. The effect was more pronounced when the spark discharge was initiated with higher voltages. The lateral beamwidth of individual, instantaneous shock waves were observed to range from 1.5 mm to 24 mm. Due to the spatial variation of the acoustic field, the average of instantaneous beamwidths were observed to be 1 to 2 mm narrower than beamwidths determined from traditional single-point measurements that average the pressure measured at each location before computing beamwidth.

Assessment of a modified acoustic lens for electromagnetic shock wave lithotripters in a swine model

PURPOSE

The acoustic lens of the Modularis electromagnetic shock wave lithotripter (Siemens, Malvern, Pennsylvania) was modified to produce a pressure waveform and focal zone more closely resembling that of the original HM3 device (Dornier Medtech, Wessling, Germany). We assessed the newly designed acoustic lens in vivo in an animal model.

MATERIALS AND METHODS

Stone fragmentation and tissue injury produced by the original and modified lenses of the Modularis lithotripter were evaluated in a swine model under equivalent acoustic pulse energy (about 45 mJ) at 1 Hz pulse repetition frequency. Stone fragmentation was determined by the weight percent of stone fragments less than 2 mm. To assess tissue injury, shock wave treated kidneys were perfused, dehydrated, cast in paraffin wax and sectioned. Digital images were captured every 120 μm and processed to determine functional renal volume damage.

RESULTS

After 500 shocks, the mean ± SD stone fragmentation efficiency produced by the original and modified lenses was 48% ± 12% and 52% ± 17%, respectively (p = 0.60). However, after 2,000 shocks, the modified lens showed significantly improved stone fragmentation compared to the original lens (mean 86% ± 10% vs 72% ± 12%, p = 0.02). Tissue injury caused by the original and modified lenses was minimal at a mean of 0.57% ± 0.44% and 0.25% ± 0.25%, respectively (p = 0.27).

CONCLUSIONS

With lens modification the Modularis lithotripter demonstrates significantly improved stone fragmentation with minimal tissue injury at a clinically relevant acoustic pulse energy. This new lens design could potentially be retrofitted to existing lithotripters, improving the effectiveness of electromagnetic lithotripters.

Evaluation of the LithoGold LG-380 lithotripter: in vitro acoustic characterization and assessment of renal injury in the pig model

PURPOSE

Conduct a laboratory evaluation of a novel low-pressure, broad focal zone electrohydraulic lithotripter (TRT LG-380).

METHODS

Mapping of the acoustic field of the LG-380, along with a Dornier HM3, a Storz Modulith SLX, and a XiXin CS2012 (XX-ES) lithotripter was performed using a fiberoptic hydrophone. A pig model was used to assess renal response to 3000 shockwaves (SW) administered by a multistep power ramping protocol at 60 SW/min, and when animals were treated at the maximum power setting at 120 SW/min. Injury to the kidney was assessed by quantitation of lesion size and routine measures of renal function.

RESULTS

SW amplitudes for the LG-380 ranged from (P(+)/P(-)) 7/-1.8 MPa at PL-1 to 21/-4 MPa at PL-11 while focal width measured ~20 mm, wider than the HM3 (8 mm), SLX (2.6 mm), or XX-ES (18 mm). For the LG-380, there was gradual narrowing of the focal width to ~10 mm after 5000 SWs, but this had negligible effect on breakage of model stones, because stones positioned at the periphery of the focal volume (10 mm off-axis) broke nearly as well as stones at the target point. Kidney injury measured less than 0.1% FRV (functional renal volume) for pigs treated using a gradual power ramping protocol at 60 SW/min and when SWs were delivered at maximum power at 120 SW/min.

CONCLUSIONS

The LG-380 exhibits the acoustic characteristics of a low-pressure, wide focal zone lithotripter and has the broadest focal width of any lithotripter yet reported. Although there was a gradual narrowing of focal width as the electrode aged, the efficiency of stone breakage was not affected. Because injury to the kidney was minimal when treatment followed either the recommended slow SW-rate multistep ramping protocol or when all SWs were delivered at fast SW-rate using maximum power, this appears to be a relatively safe lithotripter.

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.

Size and location of defects at the coupling interface affect lithotripter performance

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? In shock wave lithotripsy air pockets tend to get caught between the therapy head of the lithotripter and the skin of the patient. Defects at the coupling interface hinder the transmission of shock wave energy into the body, reducing the effectiveness of treatment. This in vitro study shows that ineffective coupling not only blocks the transmission of acoustic pulses but also alters the properties of shock waves involved in the mechanisms of stone breakage, with the effect dependent on the size and location of defects at the coupling interface.

OBJECTIVE

• To determine how the size and location of coupling defects caught between the therapy head of a lithotripter and the skin of a surrogate patient (i.e. the acoustic window of a test chamber) affect the features of shock waves responsible for stone breakage.

MATERIALS AND METHODS

• Model defects were placed in the coupling gel between the therapy head of a Dornier Compact-S electromagnetic lithotripter (Dornier MedTech, Kennesaw, GA, USA) and the Mylar (biaxially oriented polyethylene terephthalate) (DuPont Teijin Films, Chester, VA, USA) window of a water-filled coupling test system. • A fibre-optic probe hydrophone was used to measure acoustic pressures and map the lateral dimensions of the focal zone of the lithotripter. • The effect of coupling conditions on stone breakage was assessed using gypsum model stones.

RESULTS

• Stone breakage decreased in proportion to the area of the coupling defect; a centrally located defect blocking only 18% of the transmission area reduced stone breakage by an average of almost 30%. • The effect on stone breakage was greater for defects located on-axis and decreased as the defect was moved laterally; an 18% defect located near the periphery of the coupling window (2.0 cm off-axis) reduced stone breakage by only ~15% compared to when coupling was completely unobstructed. • Defects centred within the coupling window acted to narrow the focal width of the lithotripter; an 8.2% defect reduced the focal width ~30% compared to no obstruction (4.4 mm vs 6.5 mm). • Coupling defects located slightly off centre disrupted the symmetry of the acoustic field; an 18% defect positioned 1.0 cm off-axis shifted the focus of maximum positive pressure ~1.0 mm laterally. • Defects on and off-axis imposed a significant reduction in the energy density of shock waves across the focal zone.

CONCLUSIONS

• In addition to blocking the transmission of shock-wave energy, coupling defects also disrupt the properties of shock waves that play a role in stone breakage, including the focal width of the lithotripter and the symmetry of the acoustic field • The effect is dependent on the size and location of defects, with defects near the centre of the coupling window having the greatest effect. • These data emphasize the importance of eliminating air pockets from the coupling interface, particularly defects located near the centre of the coupling window.

Stone comminution correlates with the average peak pressure incident on a stone during shock wave lithotripsy

To investigate the roles of lithotripter shock wave (LSW) parameters and cavitation in stone comminution, a series of in vitro fragmentation experiments have been conducted in water and 1,3-butanediol (a cavitation-suppressive fluid) at a variety of acoustic field positions of an electromagnetic shock wave lithotripter. Using field mapping data and integrated parameters averaged over a circular stone holder area (R(h)=7 mm), close logarithmic correlations between the average peak pressure (P(+(avg))) incident on the stone (D=10 mm BegoStone) and comminution efficiency after 500 and 1000 shocks have been identified. Moreover, the correlations have demonstrated distinctive thresholds in P(+(avg)) (5.3 MPa and 7.6 MPa for soft and hard stones, respectively), that are required to initiate stone fragmentation independent of surrounding fluid medium and LSW dose. These observations, should they be confirmed using other shock wave lithotripters, may provide an important field parameter (i.e., P(+(avg))) to guide appropriate application of SWL in clinics, and facilitate device comparison and design improvements in future lithotripters.

Evaluation of shock wave lithotripsy injury in the pig using a narrow focal zone lithotriptor

What's known on the subject? and What does the study add? Of all the SW lithotriptors manufactured to date, more research studies have been conducted on and more is known about the injury (both description of injury and how to manipulate injury size) produced by the Dornier HM-3 than any other machine. From this information have come suggestions for treatment protocols to reduce shock wave (SW)-induced injury for use in stone clinics. By contrast, much less is known about the injury produced by narrow-focus and high-pressure lithotriptors like the Storz Modulith SLX. In fact, a careful study looking at the morphology of the injury produced by the SLX itself is lacking, as is any study exploring ways to reduce renal injury by manipulating SW delivery variables of this lithotriptor. The present study quantitates the lesion size and describes the morphology of the injury produced by the SLX. In addition, we report that reducing the SW delivery rate, a manoeuvre known to lower injury in the HM-3, does not reduce lesion size in the SLX.

OBJECTIVE

• To assess renal injury in a pig model after treatment with a clinical dose of shock waves using a narrow focal zone (≈3 mm) lithotriptor (Modulith SLX, Karl Storz Lithotripsy).

MATERIALS AND METHODS

• The left kidney of anaesthetized female pigs were treated with 2000 or 4000 shock waves (SWs) at 120 SWs/min, or 2000 SWs at 60 SWs/min using the Storz SLX. • Measures of renal function (glomerular filtration rate and renal plasma flow) were collected before and 1 h after shock wave lithotripsy (SWL) and the kidneys were harvested for histological analysis and morphometric quantitation of haemorrhage in the renal parenchyma with lesion size expressed as a percentage of functional renal volume (FRV). • A fibre-optic probe hydrophone was used to determine acoustic output and map the focal width of the lithotriptor. • Data for the SLX were compared with data from a previously published study in which pigs of the same age (7-8 weeks) were treated (2000 SWs at 120 or 60 SWs/min) using an unmodified Dornier HM3 lithotriptor.

RESULTS

• Treatment with the SLX produced a highly focused lesion running from cortex to medulla and often spanning the full thickness of the kidney. Unlike the diffuse interstitial haemorrhage observed with the HM3, the SLX lesion bore a blood-filled core of near-complete tissue disruption devoid of histologically recognizable kidney structure. • Despite the intensity of tissue destruction at the core of the lesion, measures of lesion size based on macroscopic determination of haemorrhage in the parenchyma were not significantly different from kidneys treated using the HM3 (2000 SWs, 120 SWs/min: SLX, 1.86 ± 0.52% FRV; HM3, 3.93 ± 1.29% FRV). • Doubling the SW dose of the SLX from 2000 to 4000 SWs did not significantly increase lesion size. In addition, slowing the firing rate of the SLX to 60 SWs/min did not reduce the size of the lesion (2.16 ± 0.96% FRV) compared with treatment at 120 SWs/min, as was the case with the HM3 (0.42 ± 0.23% FRV vs 3.93 ± 1.29% FRV). • Renal function fell significantly below baseline in all treated groups but was similar for both lithotriptors. • Focal width of the SLX (≈2.6 mm) was about one-third that of the HM3 (≈8 mm) while peak pressures were higher (SLX at power level 9: P+≈90 MPa, P-≈-12 MPa; HM3 at 24 kV: P+≈46 MPa, P-≈-8 MPa).

CONCLUSIONS

• The lesion produced by the SLX (narrow focal width, high acoustic pressure) was a more focused, more intense form of tissue damage than occurs with the HM3. • Slowing the SW rate to 60 SWs/min, a strategy shown to be effective in reducing injury with the HM3, was not protective with the SLX. • These findings suggest that the focal width and acoustic output of a lithotriptor affect the renal response to SWL.

Reduction of bubble cavitation by modifying the diffraction wave from a lithotripter aperture

PURPOSE

A new method was devised to suppress the bubble cavitation in the lithotripter focal zone to reduce the propensity of shockwave-induced renal injury.

MATERIALS AND METHODS

An edge extender was designed and fabricated to fit on the outside of the ellipsoidal reflector of an electrohydraulic lithotripter to disturb the generation of diffraction wave at the aperture, but with little effect on the acoustic field inside the reflector.

RESULTS

Although the peak negative pressures at the lithotripter focus using the edge extender at 20 kV were similar to that of the original configuration (-11.1 ± 0.9 vs -10.6 ± 0.7 MPa), the duration of the tensile wave was shortened significantly (3.2 ± 0.54 vs 5.83 ± 0.56 μs, P<0.01). There is no difference, however, in both the amplitude and duration of the compressive shockwaves between these two configurations as well as the -6 dB beam width in the focal plane. The significant suppression effect of bubble cavitation was confirmed by the measured bubble collapse time using passive cavitation detection. At the lithotripter focus, while only about 30 shocks were needed to rupture a blood vessel phantom using the original HM-3 reflector at 20 kV, no damage could be produced after 300 shocks using the edge extender. Meanwhile, the original HM-3 lithotripter at 20 kV can achieve a stone comminution efficiency of 50.4 ± 2.0% on plaster-of-Paris stone phantom after 200 shocks, which is comparable to that of using the edge extender (46.8 ± 4.1%, P=0.005).

CONCLUSIONS

Modifying the diffraction wave at the lithotripter aperture can suppress the shockwave-induced bubble cavitation with significant reduced damage potential on the vessel phantom but satisfactory stone comminution ability.

Educational demonstration of a spherically propagating acoustic shock

Exploding gas-filled balloons are common chemistry demonstrations. They also provide an entertaining and educational means to experimentally verify nonlinear acoustical theory as described by the Earnshaw solution to the lossless Burgers equation and weak-shock theory. This article describes the theory, the demonstration, and the results of a propagation experiment carried out to provide typical results. Data analysis shows that an acetylene-oxygen balloon produces an acoustic shock whose evolution agrees well with weak-shock theory. On the other hand, the pressure wave generated by a hydrogen-oxygen balloon also propagates nonlinearly, but does not approach N-wave-like, weak-shock formation over the propagation distance. Overall, the experiment shows that popular demonstrations of chemical reactions can be extended from chemistry classrooms to a pedagogical tool for the student of advanced physical acoustics.

How to improve results with extracorporeal shock wave lithotripsy

OBJECTIVE

Shock wave lithotripsy (SWL) has greatly revolutionized the treatment of patients suffering from stone disease. There are a number of patient- and device-specific factors that can affect treatment outcome. Herein, we review practices that can increase the likelihood of SWL treatment success.

METHODS

A systematic literature review was performed to identify studies of SWL treatment parameters.

RESULTS

Among the factors affecting the outcome of SWL were patient selection criteria, such as stone burden, stone location, and anatomic features. Additionally, technical aspects of the SWL procedure also can affect outcome; these factors include the acoustic output of the lithotripter, the coupling of the lithotripter to the patient, and the power, total number, and rate of shock wave delivery.

CONCLUSIONS

The outcome of SWL can be optimized with close attention to patient selection criteria as well as the manner in which the treatment is performed.

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.

Shock wave technology and application: an update

CONTEXT

The introduction of new lithotripters has increased problems associated with shock wave application. Recent studies concerning mechanisms of stone disintegration, shock wave focusing, coupling, and application have appeared that may address some of these problems.

OBJECTIVE

To present a consensus with respect to the physics and techniques used by urologists, physicists, and representatives of European lithotripter companies.

EVIDENCE ACQUISITION

We reviewed recent literature (PubMed, Embase, Medline) that focused on the physics of shock waves, theories of stone disintegration, and studies on optimising shock wave application. In addition, we used relevant information from a consensus meeting of the German Society of Shock Wave Lithotripsy.

EVIDENCE SYNTHESIS

Besides established mechanisms describing initial fragmentation (tear and shear forces, spallation, cavitation, quasi-static squeezing), the model of dynamic squeezing offers new insight in stone comminution. Manufacturers have modified sources to either enlarge the focal zone or offer different focal sizes. The efficacy of extracorporeal shock wave lithotripsy (ESWL) can be increased by lowering the pulse rate to 60-80 shock waves/min and by ramping the shock wave energy. With the water cushion, the quality of coupling has become a critical factor that depends on the amount, viscosity, and temperature of the gel. Fluoroscopy time can be reduced by automated localisation or the use of optical and acoustic tracking systems. There is a trend towards larger focal zones and lower shock wave pressures.

CONCLUSIONS

New theories for stone disintegration favour the use of shock wave sources with larger focal zones. Use of slower pulse rates, ramping strategies, and adequate coupling of the shock wave head can significantly increase the efficacy and safety of ESWL.

Simulation of the effects of cavitation and anatomy in the shock path of model lithotripters

We report on recent efforts to develop predictive models for the pressure and other flow variables in the focal region of shock wave lithotripters. Baseline simulations of three representative lithotripters (electrohydraulic, electromagnetic, and piezoelectric) compare favorably with in vitro experiments (in a water bath). We proceed to model and investigate how shock focusing is altered by the presence of material interfaces associated with different types of tissue encountered along the shock path, and by the presence of cavitation bubbles that are excited by tensile pressures associated with the focused shock wave. We use human anatomical data, but simplify the description by assuming that the tissue behaves as a fluid, and by assuming cylindrical symmetry along the shock path. Scattering by material interfaces is significant, and regions of high pressure amplitudes (both compressive and tensile) are generated almost 4 cm postfocus. Bubble dynamics generate secondary shocks whose strength depends on the density of bubbles and the pulse repetition frequency (PRF). At sufficiently large densities, the bubbles also attenuate the shock. Together with experimental evidence, the simulations suggest that high PRF may be counterproductive for stone comminution. Finally, we discuss how the lithotripter simulations can be used as input to more detailed physical models that attempt to characterize the mechanisms by which collapsing cavitation models erode stones, and by which shock waves and bubbles may damage tissue.

A simple method for fabricating artificial kidney stones of different physical properties

A simple method for preparing artificial kidney stones with varying physical properties is described. BegoStone was prepared with a powder-to-water ratio ranging from 15:3 to 15:6. The acoustic properties of the phantoms were characterized using an ultrasound transmission technique, from which the corresponding mechanical properties were calculated based on elastic wave theory. The measured parameters for BegoStone phantoms of different water contents are: longitudinal wave speed (3,148-4,159 m/s), transverse wave speed (1,813-2,319 m/s), density (1,563-1,995 kg/m(3)), longitudinal acoustic impedance (4.92-8.30 kg/m(2) s), transverse acoustic impedance (2.83-4.63 kg/m(2) s), Young's modulus (12.9-27.4 GPa), bulk modulus (8.6-20.2 GPa), and shear modulus (5.1-10.7 GPa), which cover the range of corresponding properties reported in natural kidney stones. In addition, diametral compression tests were carried out to determine tensile failure strength of the stone phantoms. BegoStone phantoms with varying water content at preparation have tensile failure strength from 6.9 to 16.3 MPa when tested dry and 3.2 to 7.1 MPa when tested in water-soaked condition. Overall, it is demonstrated that this new BegoStone preparation method can be used to fabricate artificial stones with physical properties matched with those of natural kidney stones of various chemical compositions.

Effect of lithotripter focal width on stone comminution in shock wave lithotripsy

Using a reflector insert, the original HM-3 lithotripter field at 20 kV was altered significantly with the peak positive pressure (p(+)) in the focal plane increased from 49 to 87 MPa while the -6 dB focal width decreased concomitantly from 11 to 4 mm. Using the original reflector, p(+) of 33 MPa with a -6 dB focal width of 18 mm were measured in a pre-focal plane 15-mm proximal to the lithotripter focus. However, the acoustic pulse energy delivered to a 28-mm diameter area around the lithotripter axis was comparable ( approximately 120 mJ). For all three exposure conditions, similar stone comminution ( approximately 70%) was produced in a mesh holder of 15 mm after 250 shocks. In contrast, stone comminution produced by the modified reflector either in a 15-mm finger cot (45%) or in a 30-mm membrane holder (14%) was significantly reduced from the corresponding values (56% and 26%) produced by the original reflector (no statistically significant differences were observed between the focal and pre-focal planes). These observations suggest that a low-pressure/broad focal width lithotripter field will produce better stone comminution than its counterpart with high-pressure/narrow focal width under clinically relevant in vitro comminution conditions.