20 years after introduction of shock wave lithotripsy into clinical practice, the pioneering HM3 spark gap lithotripter of Dornier is still in use in some places. On the other hand advanced electro-magnetic lithotripsy systems are available. The most important component of a lithotripter is the shock wave generating system, which may be considered the motor of a lithotripter. It determines fragmentation efficiency, side effects, anesthesia requirements and the possibility to implement different localization modalities. It also influences economic aspects such as running costs, patient throughput and the like. Below we want to discuss general aspects of shock wave generation with special attention to the effect of big and small focal spot sizes. Based on the core technology, different lithotripter concepts may be tailored to the specific needs of individual customers.
Like with medical drugs, physical therapeutic systems mostly combine the medical benefit with some sort of side effect. This principle of Paracelsus (16th century) holds true also for shock waves. They may not only fragmentize stones but also create superficial bleeding up to severe hematomas. The ideal lithotripter, thus, would expose shock wave energy only to the precise stone location and nowhere else. The shock wave focus should have well defined spherical shape matched to the stone dimensions of approximately 10 mm in diameter. Ideally shockwaves should not affect kidney parenchyma and other sensitive tissue surrounding the stone. Technically seen, spherical focal zones require spherical access from all sides outside the human body, which cannot be realized due to anatomic and other technical reasons. Realistically, a certain shockwave transparent tissue window of limited dimensions is used to transmit the acoustic energy over a relatively wide surface area into the body and concentrate the waves on the target or treatment area.
Progress with respect to the old HM3 Lithotripter is obvious due to reduced pain sensation and anesthesia requirements while maintaining fragmentation efficiency. Analgosedation instead of general anesthesia and dramatically less skin lesions are the results of modern large aperture systems. This is a big step ahead towards higher patient throughput and cost reduction.
If stone disintegration would be considered to be the only indicator for quality in ESWL, the past two decades would have brought only little progress with respect to the HM3. Both the in vivo and in vitro studies shown above indicate no significant difference between the former gold standard first generation spark gap lithotripter and the best currently available electro-magnetic lithotripters. However, as seen in the last chapters there are a couple of other quite important factors that also contribute considerably to quality in ESWL. Significant progress of modern devices can be stated, with respect to anesthesia requirements, skin lesions, imaging, multi-functionality, patient comfort, radiation exposure etc. Likewise, very few hospitals would be able to afford the purchasing and running costs of the early lithotripters. State of the art electromagnetic lithotripters do offer a higher overall quality than first generation systems, for only a fraction of the costs. While maintaining the fragmentation efficiency at the level of the gold standard HM3, a new gold standard is created for the combined features of stone fragmentation and ergonomics.
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