Adult urology| Volume 61, ISSUE 6, P1092-1096, June 2003

Variability of renal stone fragility in shock wave lithotripsy



      To measure, in an in vitro study, the number of shock waves to complete comminution for 195 human stones, representing six major stone types. Not all renal calculi are easily broken with shock wave lithotripsy. Different types of stones are thought to have characteristic fragilities, and suggestions have been made in published reports of variation in the fragility within some types of stones, but few quantitative data are available.


      Kidney stones classified by their dominant mineral content were broken in an unmodified Dornier HM3 lithotripter or in a research lithotripter modeled after the HM3, and the number of shock waves was counted for each stone until all fragments passed through a sieve (3-mm-round or 2-mm-square holes).


      The mean ± SD number of shock waves to complete comminution was 400 ± 333 per gram (n = 39) for uric acid; 965 ± 900 per gram (n = 75) for calcium oxalate monohydrate; 1134 ± 770 per gram (n = 21) for hydroxyapatite; 1138 ± 746 per gram (n = 13) for struvite; 1681 ± 1363 per gram (n = 23) for brushite; and 5937 ± 6190 per gram (n = 24) for cystine. The variation for these natural stones (83% ± 15% coefficient of variation) was greater than that for artificial (eg, gypsum-based) stones (17% ± 8%).


      The variability in stone fragility to shock waves is large, even within groups defined by mineral composition. Thus, knowing the major composition of a stone may not allow adequate prediction of its fragility in lithotripsy treatment. The variation in stone structure could underlie the variation in stone fragility within type, but testing of this hypothesis remains to be done.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Lingeman JE, Lifshitz DA, and Evan AP: Surgical management of urinary lithiasis, in Walsh PC (Ed): Campbell’s Urology, 8th ed. Philadelphia, WB Saunders, 2002, vol 4, pp 3361–3451

        • Rassweiler J.J
        • Renner C
        • Chaussy C
        • et al.
        Treatment of renal stones by extracorporeal shockwave lithotripsy.
        Eur Urol. 2001; 39: 187-199
        • Kerbl K
        • Rehman J
        • Landman J
        • et al.
        Current management of urolithiasis.
        J Endourol. 2002; 16: 5281-5288
        • Dretler S.P
        Stone fragility—a new therapeutic distinction.
        J Urol. 1988; 139: 1124-1127
        • Zhong P
        • Preminger G.M
        Physics of shock-wave lithotripsy.
        in: Coe F.L Favus M.J Pak C.Y.C Kidney Stones Medical and Surgical Management. Lippincott-Raven,, Philadelphia1996: 529-548
        • Hillman B.J
        • Drach G.W
        • Tracey P
        • et al.
        Computed tomographic analysis of renal calculi.
        AJR Am J Roentgenol. 1984; 142: 549-552
        • Mitcheson H.D
        • Zamenhof R.G
        • Bankoff M.S
        • et al.
        Determination of the chemical composition of urinary calculi by computerized tomography.
        J Urol. 1983; 130: 814-819
        • Newhouse J.H
        • Prien E.L
        • Amis E.S
        • et al.
        Computed tomographic analysis of urinary calculi.
        AJR Am J Roentgenol. 1984; 142: 545-548
        • Resnick M.I
        • Kursh E.D
        • Cohen A.M
        Use of computerized tomography in the delineation of uric acid calculi.
        J Urol. 1984; 131: 9-10
        • Nakada S.Y
        • Hoff D.G
        • Attai S
        • et al.
        Determination of stone composition by noncontrast spiral computed tomography in the clinical setting.
        Urology. 2000; 55: 816-819
        • Mostafavi M.R
        • Ernst R.D
        • Saltzman B
        Accurate determination of chemical composition of urinary calculi by spiral computerized tomography.
        J Urol. 1998; 159: 673-675
        • Saw K.C
        • McAteer J.A
        • Monga A.G
        • et al.
        Helical CT of urinary calculi.
        AJR Am J Roentgenol. 2000; 175: 329-332
        • Bhatta K.M
        • Prien Jr, E.L
        • Dretler S.P
        Cystine calculi—rough and smooth.
        J Urol. 1989; 142: 937-940
        • Joseph P
        • Mandal A.K
        • Singh S.K
        • et al.
        Computerized tomography attenuation value of renal calculus.
        J Urol. 2002; 167: 1968-1971
        • Saw K.C
        • McAteer J.A
        • Fineberg N.S
        • et al.
        Calcium stone fragility is predicted by helical CT attenuation values.
        J Endourol. 2000; 14: 471-474
        • Cleveland R.O
        • Bailey M.R
        • Fineberg N.S
        • et al.
        Design and characterization of a research electrohydraulic lithotripter patterned after the Dornier HM3.
        Rev Sci Instr. 2000; 71: 2514-2525
        • Dretler S.P
        Special article.
        J Endourol. 1994; 8: 1-3
        • Evan A.P
        • Willis L.R
        • Lingeman J.E
        • et al.
        Renal trauma and the risk of long-term complications in shock wave lithotripsy.
        Nephron. 1998; 78: 1-8
        • Zhong P
        • Preminger G.M
        Mechanisms of differing stone fragility in extracorporeal shockwave lithotripsy.
        J Endourol. 1994; 8: 263-268
        • Heimbach D
        • Munver R
        • Zhong P
        • et al.
        Acoustic and mechanical properties of artificial stones in comparison to natural kidney stones.
        J Urol. 2000; 164: 537-544
        • Prien E.L
        • Frondel C
        Studies in urolithiasis.
        J Urol. 1947; 57: 949-994
        • Daudon M
        • Donsimoni R
        • Hennequin C
        • et al.
        Sex and age-related composition of 10617 calculi analyzed by infrared-spectroscopy.
        Urol Res. 1995; 23: 319-326
        • Williams Jr,, J.C
        • Paterson R.F
        • Kopecky K.K
        • et al.
        High resolution detection of internal structure in renal calculi by helical CT.
        J Urol. 2002; 167: 322-326
      2. McAteer JA, Cleveland RO, Rietjens DL, et al:Cavitation promotes spall failure of model kidney stones treated by shock wave lithotripsy in vitro. Proceedings of the 17th International Congress on Acoustics, 2002, vol VII, pp 188–189

        • Heimbach D
        • Aslan P
        • Kuo R.S
        • et al.
        An in vitro study of stone fragility comparing natural calcium and cystine stones with artificial stone phantoms.
        J Urol. 1998; 159 (abstract): 176
        • Chang C.C
        • Liang S.M
        • Pu Y.R
        • et al.
        In vitro study of ultrasound based real-time tracking of renal stones for shock wave lithotripsy.
        J Urol. 2001; 166: 28-32
        • Greenstein A
        • Matzkin H
        Does the rate of extracorporeal shock wave delivery affect stone fragmentation?.
        Urology. 1999; 54: 430-432
        • Cathignol D
        • Tavakkoli J
        • Birer A
        • et al.
        Comparison between the effects of cavitation induced by two different pressure-time shock waveform pulses.
        IEEE Trans Ultrason Ferroelectr Freq Control. 1998; 45: 788-799
        • Zhong P
        • Zhou Y
        Suppression of large intraluminal bubble expansion in shock wave lithotripsy without compromising stone comminution.
        J Acoustic Soc Am. 2001; 110: 3283-3291
        • Whelan J.P
        • Finlayson B
        An experimental model for the systematic investigation of stone fracture by extracorporeal shock wave lithotripsy.
        J Urol. 1988; 140: 395-400

      Linked Article