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Extracorporeal shock wave lithotripsy (ESWL) is the non-invasive treatment of kidney stones (urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) using an acoustic pulse. Lithotripsy and the lithotriptor were developed in the early 1980s in Germany by Dornier Medizintechnik GmbH (now known as Dornier MedTech Systems GmbH)[1], and came into widespread use with the introduction of the HM-3 lithotriptor in 1983. Within a few years, ESWL became a standard treatment of calculosis.

It is estimated that more than one million patients are treated annually with ESWL in the USA alone.[citation needed]

How it works

The lithotriptor attempts to break up the stone with minimal collateral damage by using an externally-applied, focused, high-intensity acoustic pulse. The sedated or anesthetized patient lies down in the apparatus' bed, with the back supported by a water-filled coupling device placed at the level of kidneys. A fluoroscopic x-ray imaging system or an ultrasound imaging system is used to locate the stone and aim the treatment. The first generation lithotriptor known as the HM3, has a half ellipsoid-shaped piece that opens toward the patient. The acoustic pulse is generated at the ellipsoidal focal point that is furthest from the patient and the stone positioned at the opposite focal point receives the focused shock wave. The treatment usually starts at the equipment's lowest power level, with a long gap between pulses, in order to accustom the patient to the sensation. The length of gap between pulses is also controlled to allow cavitaion bubbles to disperse minimizing tissue damage. Second and later generation machines use an acoustic lens to focus the shock wave. This functions much like an optical lens, focusing the shock wave at the desired loci. The frequency of pulses are currently left at a slow rate for more effective comminution of the stone and to minimize morbidity while the power levels are then gradually increased, so as to break up the stone. The final power level usually depends on the patient's pain threshold and the obsevered success of stone breakage. If the stone is positioned near a bone (usually a rib in the case of kidney stones), this treatment may be more uncomfortable because the shock waves can cause a mild resonance in the bone which can be felt by the patient. The sensation of the treatment is likened to an elastic band twanging off the skin. Alternately the patient may be sedated during the procedure. This allows the power levels to be brought up more quickly and a much higher pulse frequency, often up to 120 shocks per minute.

The successive shock wave pressure pulses result in direct shearing forces, as well as cavitation bubbles surrounding the stone, which fragment the stones into smaller pieces that then can easily pass through the ureters or the cystic duct. The process takes about an hour. A ureteral stent (a kind of expandable hollow tube) may be used at the discretion of the urologist. The stent allows for easier passage of the stone by relieving obstruction and through passive dilatation of the ureter.

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