title: Prefocal alignment improves stone comminution in shockwave lithotripsy.
abstract: BACKGROUND
  The Dornier HM-3 machine continues to be one of the most effective lithotripters in use. However, tissue damage occurs in most, if not all, shockwave lithotripsy (SWL) treatments. Cavitation appears to contribute to desired stone comminution as well as to undesired tissue damage. Studies of cavitation in electrohydraulic shockwave lithotripters indicate that the greatest cavitation activity occurs, not at the geometric focus, F2, but at a site proximal to F2 by 1 to 3 cm. In clinical practice, however, stones are aligned with F2.
  
  
  METHODS
  In vitro stone comminution, hemolysis, and free-radical production were assessed along the focal axis, and pig kidneys treated with SWL in vivo were sectioned to determine the extent of hemorrhagic injury along the focal axis. Model gypsum stones received 200 shockwaves in vitro at 18 kV.
  
  
  RESULTS
  At F2, the average number of fragments >1.5 mm was 1.3 +/- 0.5, and the weight loss was 11.3 +/- 1.1%. At 2 cm from F2 (F2-2 cm), these values increased to 4 +/- 2.8 and 16.1 +/- 4.2%, respectively. Samples of 10% hematocrit blood were similarly exposed. Hemolysis was equivalent at F2-2 cm (14.7 +/- 2.3%) and F2 (15.2 +/- 3%) but decreased significantly at all other positions. Samples of iodine solution received 1500 shockwaves at 20 kV. Hydroxyl radical production was greatest at F2-2 cm (0.384 +/- 0.035 microM) and decreased significantly distal to this position. The volume of tissue injury in pig kidneys was greatest with prefocal shockwave exposure.
  
  
  CONCLUSIONS
  Stone comminution may be achieved more rapidly without greater tissue damage by a simple shift in stone alignment to F2-2 cm.
authors.affiliation: Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, Seattle 98105, USA.
authors.forename: Dahlia L
authors.initials: DL
authors.lastname: Sokolov
authors.forename: Michael R
authors.initials: MR
authors.lastname: Bailey
authors.forename: Lawrence A
authors.initials: LA
authors.lastname: Crum
authors.forename: Philip M
authors.initials: PM
authors.lastname: Blomgren
authors.forename: Bret A
authors.initials: BA
authors.lastname: Connors
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Evan
mesh_terms: D000818:Animals; D005260:Female; D005609:Free Radicals / Q000032:analysis; D006461:Hemolysis; D007668:Kidney / Q000293:injuries / Q000473:pathology; D007669:Kidney Calculi / Q000628:therapy*; D008096:Lithotripsy / Q000009:adverse effects / Q000379:methods*; D013552:Swine; D014947:Wounds and Injuries / Q000517:prevention & control
chemical_list: D005609:Free Radicals