title: Synchronous twin-pulse technique to improve efficacy of SWL: preliminary results of an experimental study.
abstract: OBJECTIVE
  Extracorporeal shockwave lithotripsy (SWL) is the treatment of choice for the majority of renal and ureteral stones. The Dornier HM3 lithotripter has good results but with some limitations and complications. A number of second- and third-generation machines have been developed employing different energy sources, focusing devices, and coupling media. These devices overcome some of the limitations and lessen the complications but at the expense of the success rate. Use of the consecutive double-pulse technique (as in the MFL 5000) and of combined under-table and over-table modules consecutively (as in the Siemens Lithostar Plus) improves the efficacy of fragmentation. The aim of this study was to study the effects of the use of synchronous twin pulses generated by under-table and over-table identical shockwave reflectors for stone fragmentation.
  
  
  METHODS
  We designed a lithotripter with two identical shockwave generators and identical reflectors (twin heads). One reflector was under the table and fixed, while the second reflector was over the table and hangs on a C-arm so that the angle between the axes of the two reflectors could be changed. The second focal points (F2) of the two reflectors lay in the same position. A lucent lightweight acrylic water tank with one side sealed by a silicon rubber membrane was fixed to the SWL table so that the membrane coupled with the water cushions of both reflectors. The tank was filled with degassed water and the targeted material was fixed on a holder and immersed in the water so as to be at F2. Comparison of the use of one shockwave source and two shockwave sources simultaneously was done relative to: (1) cavitation effect on aluminum foil; (2) quality of disintegration, shape of the focal zone, and ideal position of F2 using ceramic blocks; and (3) disintegrative efficacy using dental bone cement.
  
  
  RESULTS
  The cavitation effect became more localized with the use of two reflectors. Also, the volume and rate of stone disintegration increased with the use of the two reflectors, with production of fine (<2-mm) fragments. The focal zone became smaller and conical with no propagation of shockwaves beyond F2. These results were more evident if the angle between the axes of the reflectors was 90 degrees.
  
  
  CONCLUSIONS
  This new technique of SWL may improve the efficacy of treatment of urinary tract stones. It also may be less harmful to the renal tissues, but animal experiments must be carried out to prove this.
authors.affiliation: Mansoura Urology and Nephrology Center, Mansoura University, Egypt. kzsheir@hotmail.com
authors.forename: K Z
authors.initials: KZ
authors.lastname: Sheir
authors.forename: A M
authors.initials: AM
authors.lastname: El-Sheikh
authors.forename: M A
authors.initials: MA
authors.lastname: Ghoneim
mesh_terms: D004867:Equipment Design; D005240:Feasibility Studies; D006801:Humans; D008096:Lithotripsy / Q000295:instrumentation* / Q000379:methods; D008962:Models, Theoretical; D019047:Phantoms, Imaging; D014545:Urinary Calculi / Q000628:therapy*