The role of stress waves and cavitation in stone comminution in shock wave lithotripsy

Using an experimental system that mimics stone fragmentation in the renal pelvis, we have investigated the role of stress waves and cavitation in stone comminution in shock-wave lithotripsy (SWL). Spherical plaster-of-Paris stone phantoms (D = 10 mm) were exposed to 25, 50, 100, 200, 300 and 500 shocks at the beam focus of a Dornier HM-3 lithotripter operated at 20 kV and a pulse repetition rate of 1 Hz. The stone phantoms were immersed either in degassed water or in castor oil to delineate the contribution of stress waves and cavitation to stone comminution. It was found that, while in degassed water there is a progressive disintegration of the stone phantoms into small pieces, the fragments produced in castor oil are fairly sizable. From 25 to 500 shocks, clinically passable fragments (< 2 mm) produced in degassed water increases from 3% to 66%, whereas, in castor oil, the corresponding values are from 2% to 11%. Similar observations were confirmed using kidney stones with a primary composition of calcium oxalate monohydrate. After 200 shocks, 89% of the fragments of the kidney stones treated in degassed water became passable, but only 22% of the fragments of the kidney stones treated in castor oil were less than 2 mm in size. This apparent size limitation of the stone fragments produced primarily by stress waves (in castor oil) is likely caused by the destructive superposition of the stress waves reverberating inside the fragments, when their sizes are less than half of the compressive wavelength in the stone material. On the other hand, if a stone is only exposed to cavitation bubbles induced in SWL, the resultant fragmentation is much less effective than that produced by the combination of stress waves and cavitation. It is concluded that, although stress wave-induced fracture is important for the initial disintegration of kidney stones, cavitation is necessary to produce fine passable fragments, which are most critical for the success of clinical SWL. Stress waves and cavitation work synergistically, rather than independently, to produce effective and successful disintegration of renal calculi in SWL