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Treatment of kidney stones: current lithotripsy devices are proving less effective in some cases

Nature Clinical Practice Urology volume 3, pages 236–237 (2006)Cite this article

Following the introduction of the Dornier® HM3 lithotriptor (Dornier Medizintechnik GmbH, Germering, Germany) in the early 1980s, shock-wave lithotripsy (SWL) was established as the preferred treatment for 80–90% of calculi in the upper urinary tract. Percutaneous nephrolithotomy has since been reserved for large stones, stones in patients with aberrant anatomy, or SWL failures. Despite the proven effectiveness of the Dornier® HM3, with stone-free rates of 77–90% for solitary renal calculi of less than 1 cm,1 the perceived disadvantages of its design spurred interest in the development of new lithotriptors. Although over 40 lithotriptors have since been introduced, comparisons have been hindered by several factors. There is a paucity of appropriately designed trials containing data that are sufficiently stratified as to allow any comparative analysis of lithotriptors. Comparison of outcomes has been further hampered by the absence of standards to quantify the power and efficiency of the machines. Despite the general consensus that re-treatment rates are an appropriate indicator of lithotriptor effectiveness, there remains a lack of agreement as to the definition of a successful SWL outcome (e.g. stone-free status versus the presence of small residual fragments). Finally, the increasing use of CT scanning has made it difficult to compare stone-free rates in studies that employ this follow-up imaging modality with studies that include plain radiographs.

Among the perceived drawbacks of the Dornier® HM3 is the lack of portability inherent in its large-capacity water tub, as well as the need for patient anesthesia. One of the technical modifications of second-generation lithotriptors was to replace the water bath with dry coupling. Instead of the patient being submerged in a water chamber, the shock head was enclosed in a water-filled chamber, capped by a latex membrane that could be coupled to the body with an ultrasound gel. Further efforts concentrated on making SWL an anesthesia-free procedure. The sensation of pain during SWL is directly related to the energy density of the shock wave as it enters the body. To solve this problem, and reduce or eliminate the need for anesthesia, second-generation lithotriptors were designed with a wider aperture at the shock-wave source in order to spread the acoustic energy over a broader area of skin. Widening the aperture of the shock-wave source, however, narrows the focal zone, which makes targeting of the stone more difficult.

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Authors and Affiliations

  1. Fellow in Endourology and Laparoscopy at Clarian/Methodist Hospital and Indiana University School of Medicine,

    Nicole L Miller & James E Lingeman

  2. Director of Research at the Methodist Hospital Institute for Kidney Stone Disease,

    Nicole L Miller & James E Lingeman

  3. a Volunteer Clinical Professor in the Department of Urology at Indiana University School of Medicine, Indianapolis, IN, USA

    Nicole L Miller & James E Lingeman

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  1. Nicole L Miller
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Correspondence to James E Lingeman.

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JE Lingeman is a consultant/advisor and meeting participant/lecturer for Lumenis; an investor, meeting participant/lecturer, and is involved in a scientific study/trial for Boston Scientific; a consultant/advisor for Olympus; and a meeting participant/lecturer for Karl Storz.

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Miller, N., Lingeman, J. Treatment of kidney stones: current lithotripsy devices are proving less effective in some cases. Nat Rev Urol 3, 236–237 (2006). https://doi.org/10.1038/ncpuro0480

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