CLINIC REPORT OF THE TREATMENT OF RENAL AND URENAL CALCULUS WITH DOUBLE IMPULSE LOW-ENERGY ESWL(717CASES)

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Zhang Ze, Li Xun, Tang Fengling , Long Teng,Feng Guiping,Chen Guizheng,
Ou Lili,Wu Kaijun

Department of urology, the Minimally Invasive Surgery Center, The First Affiliated Hospital of Guang Zhou Medical College, Guang Zhou, 510230, P.R.China

Abstract
Objective
To evaluate the efficiency, advancement and complication of Double Impulse low-energy lithotripter on renal and ureteral calculus.
Methods
Treated 717 cases of renal and ureteral calculus with Double Impulse low-energy lithotripter from September, 2001 to April,2003 in our hospital, the treatment voltage is from 3 to 9kV, the diameter of 467 cases renal calculus is below 2.0cm,the average number of shock wave is 2300;The diameter of 250 cases ureteral calculus is below 1.0cm and the average number of shock wave is 2800.
Results
The stone-free rate after ESWL of upper-pole and mid-pole calyceal stones is 89.5% and re-treatment rate is 13.2%; the stone-free rate of low-pole calyceal stones is 81.6% and re-treatment rate was 17.4; For renal pelvic calculi it is 92.9% and 5.7%;For ureteral calculus it is 95.2% and 6.4%.
Conclusion
The treatment of renal and ureteral calculus with Double Impulse low-energy ESWL machine is high efficient and safer.

Key words: Double Impulse,ESWL,renal and ureteral calculus
We treated 717 cases of renal and ureteral calculus from Sep，2001 to Apr,2003 in our hospital,using VG style low energy ESWL machine with Double Impulse technology which is researched and manufactured by the joint effort of the Institute of Urology of Beijing University and Zhanjiang Haibin Medical Equipment Co.,Ltd .The effect is satisfied,complication is very limited.The details is as follows:

Datas and methods
1.Common datas
The 717 cases include 435 man and 282 women,the age is from 7 years old to 82,the average age is 46 years old.The renal stone 467 cases,including upper-pole and midpole calyceal stones are 190 cases, low-pole calyceal stones are 207 cases, renal pelvic calculus are 70 cases; The ureteral calculus 250 cases,including upper ureteral calculus 213 cases,mid ureteral calculus 20 cases,lower ureteral calculus 17 cases.

The stone location is by X-ray or B ultrasound before treatment.The standard of the cases is that the diameter of the renal stone not more than 2.0cm,the ureteral calculus is not more than 1.0cm.In our hospital when the diameter of the renal stone is more than 2.0cm and the ureteral calculus more than 1.0cm we often treat by PCN or URSL.The mid and lower ureteral calculus we often treat by URSL.

2.Treatment methods
All the patients are treated by the HB-ESWL-VG Lithotripter with Double Impulse shock wave source of low energy Electrohydralic style.The positive stones are located by the X-ray and the negative stones by B ultrasound machine,during the treatment we do stone location from different angles and moniter the stone in time,adjust the body position and the energy of the shock wave.The patients should lie on his back when treat the renal stone and lie prostrate when treat the ureteral calculus.Before the treatment we will do blood routine examination,urine routine examination and electrocardiogram,the patients with clear infection character should be treated after controlling the infection.The food is forbidden at the treatment day,reduce the stomach and intestines wriggling and amassed gas.During the treatment keep watch on the blood pressure and pulse, may be should do the work for stop pain or infusion.The work voltage is from 3 to 9kV,the number of the shockwave is from 1000 to 3000 times,the average number for renal stones is 2300 times and for ureteral calculus it is about 2800 times.If the patient need to be treated once more,the intermission time is 1 or 2 weeks.After the stone-breaking,we do some treatment with Western or Chinese style and some other assist treatment to help the patient excrete the stones.After the stone-breaking operation,we keep watch on every patient by B ultrasound or X-ray from 3 days to 3 months.

Results
1. Renal stones
1.1.Upper-pole and midpole calyceal stones are 190 cases in total, re-treatment rate was 13.2%, low-pole calyceal stones are 207 cases in total and the re-treatment rate is 17.4%.3 months afer ESWL,the stone-free rate for upper-pole and midpole calyceal stones is 89.5%,for low-pole calyceal stones it is 81.6%.
1.2. Renal pelvic calculi are 70 cases in total,the stone-breaking rate is 98.6%,re-treatment rate is 5.7%,the stone-free rate is 92.9% 3 months after ESWL.

2. Ureteral calculus
2.1.Upper ureteral calculus:213 cases in total,the stone-breaking rate is 97.7%,re-treated rate is 7.0%,the stone-free rate is 95.3% after 3 month.
2.2.Mid and lower ureteral calculus:37 cases in total,the stone-breaking rate is 100%,re-treated rate is 2.7%,the stone-free rate is 94.6% after 3 month.

3.Tolerability and complications
3.1.Tolerability:Most of the patients(610 cases) is in good condition during the treatment,no clear pain or other uncomfortable.Some of the patients(107 cases) feel pain but not very much,more patients feel pain during the treatment for renal stone than ureteral calculus,but no one stop the treatment because of the uncomfortable he(she) can not hold on..
3.2.Complication:We can see very light hematuria from almost all of the patients after treatment.It disappeared after one day naturally,no need for more treatment.There are 276 cases whose skin appear very little red spot and it disappeared in 1 or 2 days.No other serious complication even for 1 case.

Discussion
The technology of ESWL is used very widely today,more and more ESWL machine used in clinic,the technology of ESWL machine in China developped continuously.Some of the manufacturers of ESWL machine develop the high energy to low energy[1][2],but the low energy reduce the effection of treatment.Double Impulse technology for low energy ESWL machine do a very good job to settle this problem.
Double Impulse technology is a new technology used in ESWL machine in the recent years,the principle is as follows:Create two shockwave pulse continuously in a certen time range,achieve double cavitation,make the energy of shockwave farther focus on the center,increase the efficiency of stone-breaking.[3]
Because the Double Impuse technology can increase the efficiency of stone-breaking,the energy are all below 9kV for the 717 cases above mentioned,reach satisfied effect and reduce the tissue injury.
According to our experience,if the diameter of the renal stone is not more than 2cm,the best choice is ESWL.But if it is bigger than 2cm,treated by ESWL machine will cause more complications,then better choice is PCNL for these cases,especial for staghorn stone[1].Compare the datas with some other reports from China and some other countries,such as the report of Professor Liu Suaiguang,whose data is: the stone-free rate for upper-pole calyceal stones is 73.7%,for mid-pole calyceal stones it is 61.1%,for low-pole calyceal stones it is 78.7%[4].A foreign report shows that after the ESWL treatment,the stone-free rate reaches 90% for upper-pole and mid-pole calyceal stones whose diameter is not more than 2cm[5,6,7].For low-pole calyceal stones,it is different from 41% to 79%[5,7,9].In our cases, the stone-free rate for upper-pole and mid-pole calyceal stones is 89.5%,re-treatment rate is 13.2%.For low-pole calyceal stones the stone-free rate is 81.6% and the re-treatment rate is 17.4%,the effect is satisfied.
Another foreign report shows that after 1990,the treatment of ESWL for the renal pelvic calculus whose diameter not more than 2cm cause the following results,the stone-free rate is more than 90%[10],some reaches 99%.There are 70 cases of renal pelvic calculus in our reports,the stone-breaking rate is 98.6%,re-treatment rate is 5.7%,the stone-free rate is 92.9% after 3 months,the Double Impulse technology bring our patients very satisfied effect.
According to a local report in China,when use the low energy ESWL machine to treat the Ureteral calculus,the stone-free rate can reach to 99.3%[11].Another foreign report shows that the stone-free rate of upper ureteral calculus is above 90%[10],for mid and lower ureteral calculus it is 97%[12].In our reports there are 213 cases of upper ureteral calculus,the stone-free rate is 95.3% and the re-treatment rate is 7.0% after 3 months;For the 37 cases of mid and lower ureteral calculus,the stone-free rate is 94.6% and the re-treatment rate is 2.7% after 3 months.The diameter of all the ureteral calculus in this group is no more than 1cm,if it is bigger than 1cm,our hospital will treat by URSL.
All the 717 cases are treated by ESWL machine with Double Impulse technology,the complication is very few,most of the hematuria disappears in 24 hours,about 33% of the patients whose skin appear very little red spot and most of them disappeared in 1 or 2 days. No other serious complications even for 1 case.It is a little similar to another local report [11]

Conclusion
In conclusion,compare with the single pulse lithotripter,the treatment of renal and ureteral calculus with Double Impulse low-energy lithotripter has the following character:high efficiency,low re-treatment rate,very few tissue injury,no serious complications.

References
1.Guo Yinlu,The Science of Endourology,1995,399 429.3
2.Eisenberger F, Schmidt A. ESWL and the future of stone management. World J Urol. 1993;11(1):2-6.
3.Chow GK, Streem SB. Extracorporeal lithotripsy. Update on technology. Urol Clin North Am. 2000 May;27(2):315-22.
4.Liu Shuaiguang,Deng Shunzhong,Peng Shiping,etc,The Clinic Report for the Treatment of Upper-pole and Midpole calyceal stones by ESWL(224 case),Clinic Urology,2000;15(5:205-206)　
5.Chaussy C, Schmiedt E, Jocham D, et al. First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. J Urol. 1982 Mar;127(3):417-20.
6.Lingeman JE, Newman D, Mertz JH, et al. Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience. J Urol. 1986 Jun;135(6):1134-7.
7.Graff J, Schmidt A, Pastor J, et al. New generator for low pressure lithotripsy with the Dornier HM3: preliminary experience of 2 centers. J Urol. 1988 May;139(5):904-7.
8.Drach GW, Dretler S, Fair W, et al. Report of the United States cooperative study of extracorporeal shock wave lithotripsy. J Urol. 1986 Jun;135(6):1127-33.
9.Lingeman JE, Siegel YI, Steele B, et al. Management of lower pole nephrolithiasis: a critical analysis. J Urol. 1994 Mar;151(3):663-7.
10.Ehreth JT, Drach GW, Arnett ML, Extracorporeal shock wave lithotripsy: multicenter study of kidney and upper ureter versus middle and lower ureter treatments. J Urol. 1994 Nov;152(5 Pt 1):1379-85.
11.Liang Lili,Guo Yinglu,etc,Clinic Report for the Treatment of Renal and Ureteral Calculi,Chinese Urology Journal
12.Anderson KR, Keetch DW, Albala DM, et al Optimal therap for the distal ureteral stone: extracorporeal shock wave lithotripsy versus ureteroscopy. J Urol. 1994 Jul;152(1):62-5.
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CLINICAL REPORT OF UROLITHIASIS TREATED BY
THE LITHOTRIPTOR OF DOUBLE IMPULSE

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Han Jianzhi1,Liang Lili2,Yang Xin1,Li Bin1,Gao Shaoqing1,
Huang Changing 1,Chen Zhongxin1,Guo Yinglu2

1. The Teaching Hospital of Guangdong Medical College
2. The Institute of Urology of Beijing University

[Abstract]
Purpose
The efficiency of lithotripter, tolerance of patient and complications are observed clinically when the Double Impulse used for ESWL.
Method
Adapt to select 30 case of renal stone or ureter stone to treated by the ESWL machine with Double-Impulse technology.
Result
The crushing degree of calculus on the image and the granular calculus discharged by the patient are better than single pulse lithotripstor .All patients are calm in treatment,no evident uncomfortable,the hematuria is very light,the granular calculuses are thin and the discharged are all right.
Conclusion
Compared to the single-pulse lithotriptor,the Double-Impulse lithotriptor is excellent.The efficiency is higher, the tolerability of patient is better,the injury of tissue is smaller,the complication is lighter.So the Double-Impulse lithotriptor is the progress direction for the ESWL.

[key word] Double-Impulse,Lithotriptor,Urolithiasis

There are 30 cases urolithiasis treated in our hospital from January to Febrery, 2002. All the patients are treated by the HB-VG style ESWL machine with Double Impulse technology which is researched and manufactured by the joint effort of the Institute of Urology of Beijing University and Zhanjiang Haibin Medical Equipment Co.,Ltd(Picture 1).We get very good effect in clinic,the detail is as follows:

Clinic Datas
1.Common Datas
There are 30 cases in total,including 18 man and 12 weman,The age is from 22 years old to 69.
Position of the stone:Left kidney stone 8 cases,left ureteral calculi 7 cases;Right kidney stone 6 cases,right ureteral calculi 9 cases.
The measurement of the stone:staghorn stone 3 cases,5 kidney stone bigger than 2cm,renal pelvic calculi smaller than 2cm 4 case, calyceal stones 2 cases.

2.Method
2.1.Body position: the patients lie down on his back if the stones above the top of the iliac bone and lie prostrate if the stones below the top of the iliac bone.
2.2.The shockwave energy and the times:The kidney stone shock 1000 to 2500 times,the voltage is 5 to 7 kV;The ureteral calculi shock 1500 to 3000 times,the voltage is 5-8kV.The times decided according to the broken situation of the stone.The bigger stone will re-treated after 1 to 2 weeks.All the patients do not use any pain-killer or sedative.

3.Asistant treatment:The 3 cases of staghorn stone and 1 case whose stone is bigger than 2cm are all equipped with the Double J tube before ESWL.The 3 cases whose ureteral calculi stay in the same position more than 6 months are treated with ESWL after insert the ureter pipe.The other patients are all treated directly with ESWL.All the low-pole calyceal stone patients are treated by pating the right area of the patient’s body to help excreting the stones after ESWL..

Results
1.Renal stone
The renal stones not bigger than 2cm treated on time by ESWL,shock times no more than 2500 and the voltage no more than 8kV,the stone-breaking situation in the screen appears satisfied.The renal stones bigger than 2cm and 3 case of staghorn stones treated 2 to 6 times by ESWL,the stone-breaking situation looks satisfied in the screen,the patient’s do not appear clear uncomfortable.The stone broken rate is 100%,the stone-free rate in 1 month is 87.32% and after 2 month it reaches 97%.The Double Impulse technology get satisfied effection than the single pulse.
(Picture 2 A,B)
2. Ureteral calculus
16 cases in total,2 cases whose stone bigger than 2cm treated twice by the ESWL and excreted the stone safe.In the 14 cases whose stone smaller than 2cm,13 cases treated successfully by one time.(Picture 3 A,B,C)The other case who ever treated in other hospital by the imported ESWL machine but failed,we treated again but the effection is not very good appears in the screen.After one week,we check with the ureteroscopy,it is not broken.Then we treat by URSL and the operation is successful.Now we still do not know why it is can not be treated by the ESWL.
3.Complications
3.1. Hematuria:We can see light hematuria from all the patients treated by ESWL.Renal stone patients can not see hematuria after passing urine for 1 to 5 times,the ureteral calculi patients can not see hematuria after passing urine for 1 to 2 times.
3.2.Part of the skin injury:12 cases whose skin appear very little red spot and it disappear next day.No skin damaged.
3.3. Tolerability:27 cases have no uncomfortable or pain.3 cases whose age is over 60 years old(2 cases renal stone,one case ureteral calculi) feel light pain,after stop a few minutes then continue treatment and finish the treatment successful.All patients do not have pain-killer or sedative.
3.4.Stone street:2 cases have the stone street for 3cm to 6cm,one have the Double J tube.The stones looks very small in the screen,the patients do not have the pain or fever sign,after adjust the re-treatment time and adjust the body position shock,the stone free by themselves.

Discussion

1.Double Impulse technology means that the shockwave source create two shockwave pulse continuously in a certen time range,achieve double cavitation.[1-2]According to the concerned study,Double Impulse can rise the effection 40% than the single pulse,After the practice in clinical,we find that the Double Impulse technology can get better effection than single pulse for stone-breaking under the same shock time and voltage.
2.Practice and study shows that the Double Impulse can make the shockwave focus on the target,so it bring smaller injury of the tissue compare with the single pulse.[3-4]For this reason,all patients in this group can finish treatment without pain-killer or sedative.All the patients have light blood in their urine and it disappear after passing urine for several times.
Conclusion
Compared with the single-pulse lithotriptor,the Double-Impulse lithotriptor is excelent, the efficiency is higher, the tolerability of patient is better,the injury of tissue is smaller, the complication is lighter.So the Double-Impulse lithotriptor is the progress direction for the ESWL[5-6].

Reference
[1]．Chow GK. And Streem SB. Extracorporeal lithotripsy
update on technology. Urologic Clinics of North
America. 2000;27:2 315-322
[2]．Cleveland RO, Bailey MR, Fineberg N, et al; Design
and characterization of a research electro-hydraulic lithotripter patterned after the Dornier HM3. Review of Scientific Instruments, June 2000, 71, p 2514-2525.
[3]．Lokhandwalla M. and Sturtevant B..Fracture mechanics
model of stone comminution in ESWL and implications
for tissue damage. Physics in Medicine & Biology,
July 2000, 45, p 1923-1940
[4]．Onnors, N. The Effect of Discharge Voltage on Renal
Injury and Impairment Caused by Lithotripsy in The
Pig, J Am Soc nephrol, 2000; Feb 11(2): 310-8
[5].Sun Xizhao,ESWL TECHNOLOG,Shanghai,2001.
[6].Han Jianzi,Zhuang Qianyuan,
The Practice of the Science of Endourology,Guangzhou,2001

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