title: Optimization of treatment strategy used during shockwave lithotripsy to maximize stone fragmentation efficiency.
abstract: OBJECTIVE
  Previous studies have demonstrated that treatment strategy plays a critical role in ensuring maximum stone fragmentation during shockwave lithotripsy (SWL). We aimed to develop an optimal treatment strategy in SWL to produce maximum stone fragmentation.
  
  
  METHODS
  Four treatment strategies were evaluated using an in-vitro experimental setup that mimics stone fragmentation in the renal pelvis. Spherical stone phantoms were exposed to 2100 shocks using the Siemens Modularis (electromagnetic) lithotripter. The treatment strategies included increasing output voltage with 100 shocks at 12.3 kV, 400 shocks at 14.8 kV, and 1600 shocks at 15.8 kV, and decreasing output voltage with 1600 shocks at 15.8 kV, 400 shocks at 14.8 kV, and 100 shocks at 12.3 kV. Both increasing and decreasing voltages models were run at a pulse repetition frequency (PRF) of 1 and 2 Hz. Fragmentation efficiency was determined using a sequential sieving method to isolate fragments less than 2 mm. A fiberoptic probe hydrophone was used to characterize the pressure waveforms at different output voltage and frequency settings. In addition, a high-speed camera was used to assess cavitation activity in the lithotripter field that was produced by different treatment strategies.
  
  
  RESULTS
  The increasing output voltage strategy at 1 Hz PRF produced the best stone fragmentation efficiency. This result was significantly better than the decreasing voltage strategy at 1 Hz PFR (85.8% vs 80.8%, P=0.017) and over the same strategy at 2 Hz PRF (85.8% vs 79.59%, P=0.0078).
  
  
  CONCLUSIONS
  A pretreatment dose of 100 low-voltage output shockwaves (SWs) at 60 SWs/min before increasing to a higher voltage output produces the best overall stone fragmentation in vitro. These findings could lead to increased fragmentation efficiency in vivo and higher success rates clinically.
authors.affiliation: Department of Surgery, Division of Urology, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: Daniel Z
authors.initials: DZ
authors.lastname: Yong
authors.forename: Michael E
authors.initials: ME
authors.lastname: Lipkin
authors.forename: W Neal
authors.initials: WN
authors.lastname: Simmons
authors.forename: Georgy
authors.initials: G
authors.lastname: Sankin
authors.forename: David M
authors.initials: DM
authors.lastname: Albala
authors.forename: Pei
authors.initials: P
authors.lastname: Zhong
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Preminger
mesh_terms: D006801:Humans; D007669:Kidney Calculi / Q000601:surgery*; D008096:Lithotripsy / Q000379:methods*; D019047:Phantoms, Imaging; D016896:Treatment Outcome