- Extracorporeal shockwave lithotripsy (ESWL) uses shockwaves to fragment kidney stones noninvasively. It was discovered in the 1980s during military research.
- ESWL uses different generators (electrohydraulic, electromagnetic, piezoelectric) to focus shockwaves on stones. Ultrasound and fluoroscopy are used for imaging. Stone fragmentation occurs through mechanisms like spall fracture and squeezing.
- While usually low risk, ESWL can potentially cause acute extrarenal or renal injuries. Chronic risks include higher blood pressure and stone recurrence. Techniques like adequate anesthesia and coupling aim to optimize outcomes.
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
What is New In Minimally Invasive Surgery for UrologySiewhong Ho
Dr Ho Siew Hong gave a series of Continous Medical Education lectures to doctors of Gleneagles, Mount Elizabeth and East Shore Hospitals on the latest in Urology surgery
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
What is New In Minimally Invasive Surgery for UrologySiewhong Ho
Dr Ho Siew Hong gave a series of Continous Medical Education lectures to doctors of Gleneagles, Mount Elizabeth and East Shore Hospitals on the latest in Urology surgery
Background.
Treatment Algorithm.
Pre-Op preparation.
Surgical Techniques and Technology in stone removal:
Intracorporeal Lithotripters.
Extracorporeal Shock wave Lithotripsy.
Percutaneous Nephrolithotomy.
Ureteroscopic Management of Stones.
Laparoscopic and Open stone Surgery.
Urinary stones During Pregnancy.
AUA and EAU guidelines.
Questions.
TURP step by step operative urology series
for more resources:
www.uronotes2012.blogspot.com
enter your mail & press follow us by mail to receive our daily feeds
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
Background.
Treatment Algorithm.
Pre-Op preparation.
Surgical Techniques and Technology in stone removal:
Intracorporeal Lithotripters.
Extracorporeal Shock wave Lithotripsy.
Percutaneous Nephrolithotomy.
Ureteroscopic Management of Stones.
Laparoscopic and Open stone Surgery.
Urinary stones During Pregnancy.
AUA and EAU guidelines.
Questions.
TURP step by step operative urology series
for more resources:
www.uronotes2012.blogspot.com
enter your mail & press follow us by mail to receive our daily feeds
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
The presentation was an attempt to provide an insight into cosmic, terrestrial and man-created explosions and shock waves phenomenon.
The shock waves discussed in this presentation were caused by a very sudden release of chemical, nuclear, electrical or mechanical energy in a limited space.
The study of shock wave phenomenon is of great interest and importance. In many cases, it will save lives to know more about this subject.
Kidney Hospitals in India – Laparoscopic Surgery, Lithotripsy Centre, Dialysi...Dinesh Patel
Kidney hospital for kidney care including laparoscopic surgery, lithotripsy centre, dialysis centre, nephrological care by nephrologist, urologist and transplant physician in Ahmedabad, India.
Simple C arm construction for PCNL puncture simulation .
Interpretation ,Demonstration Evolution ,
https://youtu.be/Pzx5lSQQOU0
https://youtu.be/Ucfe99z3kHg
https://youtu.be/axD0-SklFMw
https://youtu.be/XAXvcciwJJU
University of Iowa's College of Veterinary Medicine student Heather Hagens presents a case of Feline Urethral Obstruction as seen at Iowa Veterinary Specialties.
Explore the various applications of snubbers, sway braces and sway struts in piping systems and equipment. Learn how these products help prevent pipe system failure due to seismic loads, flow transients, wind loads, safety valve thrust loads or pipe rupture. Discover the various tests performed within PT&P’s facility to ensure product quality, including cycle testing, travel testing and load testing. Finally, view the value-added services offered by PT&P and rest assure that your shock control, restraint and support device needs can be covered by our 24x7 web-based emergency services, field services and quick-turn around time when you need it most.
Sample trial brief for California civil caseLegalDocsPro
This sample trial brief for a California civil case is used by a party in a California litigation case. The sample can be modified and used in most California litigation cases, it also includes a memorandum of points and authorities with citiations to case law and statutory authority and a proof of service by mail. This is a preview of the sample sold by LegalDocsPro.
This is a presentation i did for a class on basics on renal colic as my professor asked me to do.Here i collected just the basic things about renal colic including renal anatomy,aeitology,cause,clinical feature and management.Hope it will help you.All the information source are verified.Thank You.
Evidence based radial shock wave therapyCORR MEDICAL
PEDRro: Physiotherapy Evidence Database. Radial Shockwave Therapy.
+info: http://ondaschoque.net
CORR MEDICAL. Expertos en ondas de choque ESWL, ESWT y rESW. Distribuidores exclusivos de los constructores líderes: Electro Medical Sytems y JenaMedTech.
energy devices are d most important part of an operation theator and surgery. in this presentation i have briefly described various energy devices used in general surgery and laparoscopy.
*Therapeutic Ultrsound*
1. Waves
2. Wave characteristics
3. Ultrasound
4. Ultrasound Unit
5. US Transducer
6. US Control Unit
7. Production od US
8. US Modes
9. US Parameters
10. US Treatment Time
11. Coupling medium
12. Physiological effects
13. Acoustic Streaming
14. Method of Application
15. Indications
16. Contraindications
17. Precaution
18. Technique of application
using physiotherapy modalities for improve the healing of wound specially for bed ulcer, vascular ulcer , post infected surgical wound , diabetic foot ulcers
Trauma from occlusion in Periodontics.pptxSUBHRADIPKAYAL
Contents
1. Definitions
2. Introduction
3. Classification of Trauma from occlusion
4. Stages of tissue response
5. Clinical features
6. Radiological features
7. Trauma from occlusion and plaque associated periodontal disease
8. Treatment of TFO
9. References
Definitions
• When occlusal forces exceed the adaptive capacity of tissues, tissue injury results. The resultant injury is termed as trauma from occlusion. - Carranza 10th edition
• Trauma from occlusion is a term used to describe pathologic alterations or adaptive changes which develop in the periodontium as a result of undue force produced by the masticatory muscles. - Lindhe 6th edition
• Stillman (1917) as “a condition where injury results to the supporting structures of the teeth by the act of bringing the jaws into a closed position”.
• WHO (1978) defined trauma from occlusion as “damage in the periodontium caused by stress on the teeth produced directly or indirectly by teeth of the opposing jaw”.
• Injury resulting in tissue changes within the attachment apparatus as a result of occlusal force(s). - AAP Glossary of periodontal terms 2001; 4th Edition
Introduction
• The periodontal ligament has a cushioning effect on forces applied to teeth as means to accommodate forces exerted on the crown.
• When there is increase in occlusal forces, changes occur in the periodontium in order to accommodate such forces.
• Changes occur in magnitude, direction, duration and frequency of increased occlusal forces.
Increased magnitude of occlusal forces
• Widening of periodontal ligament space.
• An increase in number and width of periodontal ligament fibers.
• An increase in the density of alveolar bone.
Changes in direction of occlusal forces
• Reorientation of the stresses and strains within the periodontium.
• The principal fibers of the periodontal ligament are arranged so that they best accommodate occlusal forces along the long axis of the tooth.
• Lateral (horizontal) and torque (rotational) forces are more likely to injure the periodontium.
Duration and frequency of occlusal forces
• Constant pressure on the bone is more injurious than intermittent forces.
• The more frequent the application of an intermittent force, the more injurious the force is to the periodontium.
Classification
According to mode of onset
1. Acute
2. Chronic
According to the capacity of the periodontium to resist to occlusal forces
1. Primary
2. Secondary
Acute trauma from occlusion
• Acute trauma from occlusion results from an abrupt occlusal impact such as that produced by biting on a hard object. Restorations or prosthetic appliances that interfere with or alter the direction of occlusal forces on the teeth may also induce acute trauma.
• Clinical features
1. Tooth pain
2. Sensitivity to percussion
3. Tooth mobility
Chronic trauma from occlusion
• It is more common than acute trauma from occlusion and is of greater clinical significance.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. HISTORICAL OVERVIEW
High-energy shockwaves have been recognized for many years. Example of high-
energy shockwaves is the potentially window shattering sonic boom created when
aircraft pass beyond the speed of sound.
Engineers at Dornier Medical Systems during research on the effects of shockwaves
on military hardware to determine if the shockwaves striking the wall of a military
tank would damage the lungs of enemy member,discovered the possibility of safely
applying shockwave energy to human tissue when an engineer touched a target
body by chance. The engineer felt a sensation similar to an electric shock,
although the contact point at the skin showed no damage at all. In the course of
this effort the engineers discovered that shockwaves generated in water could
pass through living tissue (except for the lung) without damage but that brittle
materials in the path of the shockwaves would be fragmented.
4. 1-Electrohydraulic Generator:
• shockwave is generated by an
underwater spark discharge.
• For the shockwave to be focused
onto a calculus the electrode is
placed at one focus (termed F1)
of an ellipsoid, and the target
(the kidney stone) is placed at
the other focus (termed F2).
• Disadvantages are the
substantial pressure fluctuations
from shock to shock and a
relatively short electrode life.
5. 2.Electromagnetic Generator:
An electrical current pass
through conductors producing
strong magnetic field moving the
plate against the water and
thereby generating a pressure
wave.
The energy in the shockwave is
concentrated onto the target by
focusing it with an acoustic lens.
Advantage: Introduction of
energy into the patient’s body
over a large skin area, which
may cause less pain.
6. 3.Piezoelectric Generator:
These generators are made of a ceramic
elements each of which can be induced to
rapidly expand by the application of a
high-voltage pulse.The piezoelectric
elements are usually placed inside of a
spherical dish to permit convergence of
the shockfront.
The advantages include the focusing
accuracy, a long service life, and the
possibility of an anesthetic-free
treatment because of the relatively low
energy density at the skin entry point of
the shockwave.
8. 1.Fluoroscopy Alone :
Advantages of fluoroscopy include its familiarity to most urologists, the
ability to visualize radiopaque calculi throughout the urinary tract, the
ability to use iodinated contrast agents to aid in stone localization, and
the ability to display anatomic detail.
The disadvantages include the exposure of the staff and patient to
ionizing radiation, the high maintenance demands of the equipment, and
the inability to visualize radiolucent calculi without the use of
radiographic contrast agents.
9. 2. Ultrasonography Alone
Advantages: is inexpensive to manufacture and to maintain compared
with fluoroscopic systems. Another advantage is in the treatment of
children and infants when one is concerned about the dose of ionizing
radiation. In addition, ultrasonography can localize slightly opaque or
nonopaque calculi.
Disadvantages: requires a highly trained operator. It is almost impossible
to view a stone in areas such as the middle third of the ureter or when
there is an indwelling ureteral catheter. Once a stone is fragmented, it is
difficult to identify each individual stone piece.
10. 3. Combination of Ultrasonography
and Fluoroscopy
In some cases combining ultrasonography and fluoroscopy for stone
localization are clearly advantageous but each system has a drawback
that limits one of the functions of the system.
12. A typical shockwave involves an initial
short compressive front with
pressures of about 40 MPa that is
followed by a longer, lower-amplitude
negative (tensile) pressure of 10 MPa,
with the entire pulse lasting for a
duration of 4 µsec.The ratio of the
positive to negative peak pressures is
approximately 5:1.
13. 1-spall fracture
Once the shockwave enters the
stone it will be reflected at sites
of impedance mismatch. One
such location is at the distal
surface of the stone at the stone-
fluid (urine) interface. As the
shockwave is reflected, it is
inverted in phase to a tensile
(negative) wave. If the tensile
wave exceeds the tensile
strength of the stone, there is an
induction of microcracks that
eventually coalesce, resulting in
stone fragmentation, which is
termed spallation
14. 2- Squeezing-splitting or
circumferential compression
The shockwave advances faster
through the stone than in the
fluid outside the stone. The
shockwave that propagates in
the fluid outside the stone
produces a circumferential force
on the stone, resulting in a
tensile stress in the stone that is
at its maximum at the proximal
and distal ends of the stone
15. 3- shear stress
The shock waves propagate
through the stone and will result
in regions of high shear stress
inside the stone. Many materials
are weak in shear, particularly if
they consist of layers, because
the bonding strength of the
matrix between layers often has
a low ultimate shear stress.
16. 4- Superfocusing
The shockwave that is reflected
at the distal surface of the stone
can be focused either by
refraction or by diffraction from
the corners of the stone.
17. 5- Cavitation
During the negative pressure
wave, the pressure inside the
bubble falls below the vapor
pressure of the fluid, and the
bubble fills with vapor and grows
rapidly in size (almost three
orders of magnitude)and then
collapse violently, giving rise to
high pressures and temperatures.
18. 6- Dynamic fracture
the damage induced by SWL
accumulates during the course of
the treatment, leading to the
eventual destruction of the
stone.
20. 1. Acute Extrarenal Damage
visceral injuries, such as perforation of the colon, hepatic hematoma,
splenic rupture, pancreatitis, and abdominal wall abscess.
Extrarenal vascular complications such as rupture of the hepatic artery,
rupture of the abdominal aorta, and iliac vein thrombosis.
Thoracic events, such as pneumothorax and urinothorax.
shockwaves could induce cardiac arrhythmia, an observation that led to
electrocardiographic synchronization with R-wave triggering on the
Dornier HM3 device.
The development of diabetes was related to the total number of
shockwaves and the power level of the lithotripter.
21. 2. Acute Renal Injury
Hematuria is so common that it may be considered an incidental finding,
and its severity is rarely of concern. Although hematuria was initially
considered to be a consequence of irritation of the urothelium as stones
were fragmented by shockwaves, it is now known that shockwaves
rupture blood vessels and can damage surrounding renal tubules .
risk factors:
• unsatisfactory control of their hypertension at the time of SWL
• diabetes mellitus
• coronary artery disease
• Obesity.
22. 3. Chronic Renal Injury
accelerated rise in systemic blood pressure because
1. subcapsular hematomas can induce hypertension, such changes are
generally transient.
2. Mesangial proliferation after SWL could induce hypertensive changes
decrease in renal function
increase in the rate of stone recurrence (Stone recurrence rates may be
higher after SWL because of residual stone debris)
induction of brushite stone disease.
24. wider focal width increase the likelihood of stone breakage because the kidney
tends to move, as a consequence of respiratory motion, the stone may move in
and out of a narrow focal zone.
Optimal coupling permits the efficient transfer of energy from the lithotripter
to the patient; poor coupling will reduce stone breakage. Most commonly,
energy transfer through a coupling medium is attenuated by air pockets in the
coupling interface itself.
Decrease the rate of shockwaves because the dynamic bubbles are given a
longer time interval to dissipate with a slower rate and therefore have less of a
shielding effect and energy draw from subsequent shocks.
Decrease the energy setting on the machine. Increasing the power setting on
most electromagnetic lithotripters actually narrows the focal zone which
decreases stone breakage and may also increase the risk of renal injury.
To reduce stone motion, urologists can perform SWL with general anesthesia,
which will control the patient’s respiratory rate and volume.
26. 1. in 1980s regional or general anesthesia was used in all instances because
the unmodified HM3 device produced a powerful shockwave and
treatment at recommended energy levels caused intolerable pain.
2. Short-acting agents, such as the narcotic alfentanil and the sedative-
hypnotics midazolam and propofol can be used in various combinations to
allow most SWL treatments with any lithotripter.
3. topical agents e.g.EMLA cream, a mixture of lidocaine and prilocaine, has
been shown to reduce anesthesia requirements during SWL . EMLA cream
should be applied at least 45 minutes before SWL.
4. Children and extremely anxious individuals may be served best by
general anesthesia. Patients who received general anesthesia
experienced a significantly greater stone-free rate than did those
patients who underwent intravenous sedation. Possible explanation for
this is the more controlled respiratory excursion that is conferred by the
general anesthetic.
28. Safe shock wave dosage is unknown. Shock waves induce trauma,
including intrarenal and perirenal hemorrhage and edema, and thus the
minimal shocks needed to achieve fragmentation should be given.
Determination of adequate fragmentation during treatment may be
difficult. Initial sharp edges become fuzzy or blurred .Stones that were
initially visualized may disappear after successful fragmentation.
Intermittent visualization ensures accurate focusing and assessment of
progress and eventual termination of the procedure.
30. Indications
The American Urological Association Stone Guidelines Panel has classified ESWL as a
potential first-line treatment for ureteral and renal stones smaller than 2 cm.
32. The reasons for poor clearance
of fragments from the lower pole
after SWL are unclear. The
gravity-dependent position of
the lower pole calyx may impede
the passage of stone
fragments,The examination of
the angle formed between the
lower infundibulum and the renal
pelvis and if the angle greater
than 90 degrees it should
facilitate drainage of fragments
from the lower pole.
33. Contraindications
Absolute
1. Pregnancy
2. uncorrected blood clotting disorders (including anticoagulation)
3. known renal artery stenosis
4. Acute UTI or urosepsis
5. Uncorrected obstruction distal to the stone
6. Abdominal aortic aneurysm
Relative
1. Uncontrolled HT
2. Morbid obesity
3. Renal ectopy or malformation
4. Renal insuficiency
5. Cardiac pacemaker
37. Patients should be encouraged to maintain an active ambulatory status
to facilitate stone passage.
Fluid intake should be encouraged.
Severe pain unresponsive to routine intravenous or oral medications
should alert the physician for perirenal hematomas. In such a situation,
CT scan should then be undertaken to stage the injury.
Steinstrasse (stone street) Asymptomatic individuals can be followed up
with serial KUBs and ultrasonography. Severe pain or fever requires
intervention. Percutaneous nephrostomy drainage is usually
uncomplicated owing to the associated hydronephrosis. Decompressing
the collecting system allows for effective coaptation of the ureteral walls
and encourages resolution of the problem. If steinstrasse does not resolve
,retrograde endoscopic manipulations is required.