The inexorable advance of shock wave technology

The treatment modalities available for urolithiasis have radically changed over the last 35 years. Innovations from all over the world have revolutionized the treatment options in stone management. Extensive open surgery with a significant mortality rate has been replaced almost entirely by minimally invasive or non-invasive procedures for the treatment of stones of any type, size or location. Similarly to other great developments in history, the road to modern stone management has been long and rocky.

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Image of a kidney suffering from kidney stones

Stones in the kidney, ureter and bladder have been around for millenniums. In fact, the first »registered« stone was discovered in the kidney of an Egyptian mummy dated from around 4800 BC. The surgical removal of stones from the human body, referred to as lithotomy, was first performed in 400 BC. Initially, the procedure was limited to the treatment of bladder stones and was performed by removing the stones through perineal incisions. This was done by using knives and clamps which frequently caused fatal wounds instead of curing the patient.

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In 1022, the German Emperor Henry II underwent lithotomy by a Benedictine monk at the monastery of Monte Cassino. Two years later, he died at the age of 51 after recurrence of nephrolithiasis. Picture of the tomb of Henry II in Bamberg Cathedral, Germany.

The procedure did not change significantly over the centuries until Francisco de Romanis and his student Mariano Santo developed the »Sectio Mariana« in 1520 AD. Dilators and a special knife were used to incise and dilate the rear part of the urethra in order to be able to remove the stone by means of forceps. However, complications – such as haemorrhage, incontinence, fistulas and impotence – and the high mortality rate associated with this procedure remained a continual problem.

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Instruments used for the »Marian Operation«                                                                   The »lithontripteur« by Jean Civiale (1823)

Despite many medical innovations – among which the »lithontripteur« developed by Jean Civiale (1823), the cystoscope by Maximilian Nitze (1879) and the introduction of ureteroscopic stone removal by Howard H. Young (1912) – minor to severe injuries to the perineum and ureter during the surgical management of stones in the kidney, ureter or bladder remained very common.

Major progress was made when Harold H. Hopkins developed the rod lens system and launched the first rigid endoscope with rod lenses in 1967 in cooperation with KARL STORZ. This innovation enabled physicians to view inside the patient's body with better image quality in a minimally invasive procedure.

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Modern KARL STORZ endoscope with rod lens system developed by Harold H. Hopkins

In 1953, Mulvaney took up research into the disintegration of calculi by ultrasonic vibrations. Current was applied to a piezoceramic plate which vibrated at high frequency. This vibrational energy was transmitted through a metal probe to the stone, causing the calculus to fragment. However, as the tip of the metal probe became very hot as a result of the continual vibrations, thermal injury to surrounding tissue could be caused during the treatment.

The development of the percutaneous nephroscope by Professor Peter Alken, M.D., in 1980 marked a decisive step forward in stone management as this instrument was the first device to enable minimally invasive access to the calculus to be removed.

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Prepuncture ultrasound for PNL by Professor Peter Alken, M.D.

Parallel to the development of other intracorporeal procedures for the disintegration of urinary stones – such as electrohydraulic lithotripsy in the early 1980s or laser lithotripsy in 1983 – the first extracorporeal shock wave lithotripter for clinical application, the »HM1«, was presented to the medical world in 1980.

February 1980, Munich, Germany:
the first patient - Sensation is in the air: for the first time ever, a kidney stone patient is treated with an extracorporeal shock wave lithotripter. The procedure is performed by a team of physicians headed by Professor Christian Chaussy, M.D., at the University Hospital of Ludwig Maximilian University in Munich. The shock waves applied are generated mechanically outside the patient's body and directed at the stone to be treated. The kidney stone disintegrates into fragments as small as grains of sand that pass spontaneously.

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Lithotripter »HM1« (1980) - © Deutsches Museum Bonn, Lithotripter, Medical instruments

The experiment conducted at the University Hospital in Munich works out well. The first field test using the new method of applying shock waves that are generated outside the body is a success – and the response that follows is overwhelming. Shortly after the first treatment, the procedure referred to as extracorporeal shock wave lithotripsy (SWL) is celebrated as a revolution. In 1984, the one-thousandth patient is treated with SWL and millions of others follow in the years after.

Since then, the medical potential of shock waves has been continuously developed and diversified for a variety of applications. Today, shock waves are used with great success in the treatment of many indications in urology, orthopaedics, dermatology, cardiology and other disciplines.

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MODULITH® SLX-F2 »connect«: the latest-generation lithotripter from STORZ MEDICAL



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