Lithiotripsy is a treatment that uses shockwaves to break up kidney stones into smaller pieces. It originated in the 19th century from the Greek words for "stone" and "rubbing". There are different types of lithiotripsy including extracorporeal where shockwaves are applied externally to break stones, and intracorporeal where instruments are inserted internally through the urethra or cystoscope. Complications can include bleeding, infection, or stone fragments remaining that require further treatment. Preventing stone recurrence involves dietary changes and medications depending on the stone composition.

1. LITHIOTRIPSY
BY :- DR. GAURAV KUMAR
2017V44M
HIPPOCRATIC OATH : “I will not cut, even for the
stone, but leave such procedures for the practitioners
of the craft”

2. What is Lithiotripsy ???
• Origin :- mid of the 19th century
from litho- ‘of stone’ + Greek tripsis ‘rubbing’, from tribein ‘to rub’
• Meaning :- अश्मरीभंजक
• Dr. Christian Chaussey and colleagues at Munich, succeeded in using
the principle of shockwaves to treat kidney stones by developing a
lithotripsy machine.
• Definition :- a treatment, typically using ultrasound shock waves, by
which a kidney stone or other calculus is broken into small particles
that can be passed out by the body
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3. PHYSICS OF LITHIOTRIPSY
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4. CONTENTS
• ABOUTTHE STONES
• SIGNS & SYMPTOMS
• DIAGNOSIS
• INSTRUMENTATION
• TYPES OF LITHIOTRIPSIES ( with procedures & positioning of the patients)
• PERCUTANEOUS NEPHROLITHIOTOMY (PCNL)
• COMPLICATIONS & CONTRAINDICATIONS
• PREVENTIONOF STONE FORMATION
• CONCLUSION
• BIBLIOGRAPHY
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5. ABOUT KIDNEY STONES
• When substances that are normally excreted through the kidneys
remain in the urinary tract, they may crystallize and harden into a
kidney stone.
• If the stones break free of the kidney, they can travel through, and get
lodged in, the narrower passages of the urinary tract.
• Some kidney stones are small or smooth enough to pass easily through
the urinary tract without discomfort. Other stones may have rough
edges or grow as large as a pea causing extreme pain as they travel
through or become lodged in the urinary tract.
• The areas most prone to trapping kidney stones are the bladder,
ureters, and urethra
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6. CAUSES OF STONE FORMATION
• Hypocalcemia and hypercalciuria caused by hyperparathyroidism,
renal tubular acidosis, multiple myeloma, and excessive intake of
vitamin D, milk and alkali.
• Chronic dehydration, Poor fluid intake, and immobility.
• Diet high in purines and abnormal purine metabolism. (Hyperuricemia
and gout).
• Genetic predisposition for urolithiasis / genetic disorders.
• Chronic infection with urea – splitting bacteria (Proteus vulgaris).
• Chronic obstruction with stasis of urine, foreign bodies within the
urinary tract.
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7. Types of kidney stones
• Calcium stones
a normal part of a healthy diet
normally flushed out with the rest of
the urine
excess calcium – not used by the
body - stone
• Struvite stones
composed of magnesium, phosphate,
and ammonia,
occur after a urinary tract infection
• Uric acid stones
occur when urine is too acidic, such
as gout or malignancies
• Cystine stones
consist of cystine,
 building blocks that make up
muscles, nerves, and other parts of
the body
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9. Calcium phosphate Hydroxyl apatite
(HA) only
Hydroxyl
apatite
&
Whitlockite
(WI)
Hydroxyl
apatite
&
Brushite
(BR)
Number of stones
100% (23)
All from SMG
‘intra-glandular were all
HA only’
52% (12)
12 (HA only)
43% (10)
10 (HA+WI)
4%(1)
1 (HA + BR)
23
Teymoortash (2003)
100% (19) 68% ()13 6
19
Anneroth (1975)
Teymoortash A, Buck P, Jepsen H,Wernereymoranra: Sialolith crystals localized intraglandularly
and in theWharton’s duct of the human submandibular gland: an X-ray diffraction analysis
Archives of Oral Biology (2003)48,233-236
Anneroth G, Eneroth CM, Isacsson G: Crystalline structure of salviary calculi. A microradiographic
and microdiffractometric study
J Oral Pathol 1975 Nov;4(5):266-72
Salivary Stone Mineral Composition
When a stone is available, clinicians should obtain a stone analysis at least once. ( Clinical Principle)
Stone composition of uric acid, cystine or struvite implicates specific metabolic or genetic abnormalities, and knowledge of stone composition
may help direct preventive measures. Journal of Urology 192, Issue 2 2014 Pearle M et al “Medical Management of Kidney Stones: AUA
Guideline”

10. SIGNS & SYMPTOMS
• No symptom
• Pain: sudden or severe pain
• Nausea, vomiting
• Renal colic
• Frequent and painful urination,
• Hematuria
• Urinary tract infection: Block the urinary tract
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11. Diagnosis
• USG is the major diagnostic tool in large as well as small animals
• Contrast Radiography
• Endoscopy
• X-rays are useful only in small animals
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12. INSTRUMENTATION
MALE FEMALE
- Male dogs require small outer diameter
(O.D.) flexible endoscopes.An example is
the Storz Flex X2 with an O.D. of 2.5 mm
(7.5fr), a working length of 70 cm. and a 1.2
mm (3.6 fr.) biopsy channel
- Female dogs need a rigid cystoscope, or
telescope.An example is the Wolf Panview
II telescope which has a 4mm (12 fr.) O.D.,
a 30 cm working length and a 25 deg.
angle-of-view.

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14. INTRACORPOREAL LITHIOTRIPSY
• Fragmenting urolith within the body
• Direct application of mechanical crushing devices or shock wave energy
• Limited by the size of cytoscopic instruments
• The most common technique - Electrohydraulic Lithiotripsy
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15. ELECTROHYDRAULIC LITHIOTRIPSY
• Disintegration of stones from an intracorporeal electric
discharge
• The probe is advanced to the stone through the working
channel of an endoscope. The position is monitored via
direct endoscopic view and via x-ray.
• A controlled, very fast electric discharge centered at the tip
of the probe generates a spark plasma. This expanding
plasma and later the collapse of a cavitation bubble create
sharp rising shock waves which disintegrate the stone in
seconds
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17. PNEUMATIC LITHIOTRIPSY
• Intracorporeal Pneumatic Lithotripter is powerful and based on
pneumatically driven projectiles that strike a metallic probe placed
endoscopically on a calculus (kinetic energy to mechanical energy).
Probe is passing through rigid endoscopic channel and placed on stone.
• Stone (Calculus) break by Ballistic energy and convert in to small
fragments. Fragments will be collect by endoscopic basket (Stone
Basket) or grasper (Forceps).
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19. Pneumatic Lithotripsy for
Sialolithiasis

20. Endoscopic Salivary Stone Fragmentation with Pneumatic Lithotripsy
Henry Hoffman, MD,Jack Kolenda MD, Rohan RWalvekar MD
Feasibility of stone Fragmentation with Pneumatic Lithotripsy (StonebreakerTM)
in a live porcine model
Rohan RWalvekar, MD*; Jack Kolenda, MD; Henry Hoffman, MD

21. A flexible nitanal contact probe adapted to the Stonebreaker™ urologicCO2 gas-driven hand-held pneumatic lithotripser
was deployed through a sialendoscope to disrupt 8 parotid and submandbular stones embedded in separate 3-D
printed plastic models of the mouth and submandibular glands. Simulation included endoscopic removal of small
stone fragments by standard basket retrieval supplement by irrigation and suction through a salivary duct introducer system.

26. LASER LITHIOTRIPSY
• Laser lithiotripsy was invented at the Wellman Center for
Photomedicine at Massachusetts General Hospital in the
1980s to remove impacted urinary stones.
• Optical fibers carry light pulses that pulverize the stone.
• The procedure is performed under general anesthesia via
cystoscopy. The patient is anesthetized and a cystoscope is
passed through the urethra into the bladder, addressing
urethral stones as they are encountered.
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29. CONTD. :-
• A Holmium:YAG laser fiber is
passed down the working
channel of the scope and the
laser is placed against the urolith
and fired to break it up. Once
the pieces of urolith are small
enough to safely pass out of the
bladder and through the urethra,
a voiding urohydropulsion
is performed to remove them.
Uroliths in the urethra may also
be removed after breaking up
using a stone basket passed
through the scope.
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30. CONTD. :-
• As such, some dogs are not considered good candidates for
laser lithotripsy, including :
1. Male dogs < 15 pounds, because the endoscope may be too large to
traverse the urethra
2. Male dogs with more than 2 bladder stones >5 mm in diameter
(depending on the size of the dog)
3. Female dogs in which the entire bladder is full of stones >5 mm in
diameter
4. Dogs with uncontrolled UTI - once infection is controlled, lithotripsy
can be considered.
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31. PNEUMATIC LITHIOTRIPSY vs LASER LITHIOTRIPSY
Prospective RandomizedTrial Comparing
Pneumatic Lithotripsy and Holmium Laser
For Management of Middle and Distal Ureteral Calculi
J of Endourology 2014 Li et al
Three-year study of 9482 pts ending 2012
1. Stone free rate equal after 3 months
2. Operative time shorter for laser
a. Laser group = 28 minutes
b. Pneumatic = 41 minutes
3. Higher stricture rate (p=0.02) with laser
Pneumatic versus laser ureteroscopic
lithotripsy: a comparison of initial
outcomes and cost
Int Urol Nephrol (2014) Demir et al
Retrospective study of 187 patients
Treated with either holmium laser
($1,350 per probe) or pneumatic
Device ($60 per probe)
1. Laser more expensive but more effective
2. Higher stricture and perforation rate
with pneumatic device
3. Concept of ‘retropulsion’ -- less with laser
Salivary Laser Issues
1. Special oral protection - +/- laser tube
2. Extra nurse (‘laser nurse’)
3. Extra set-up time
4. Eye protection (personnel, patient)
5. Risk of laser fire
Pneumatic lithotripsy will transmit mechanical energy via a rigid probe on the stone

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33. Technical Specifications of Holmium: Yag Laser
1) LASER TYPE = PULSE HOLMIUM:YAG
2) WAVELENGTH = 2.1 MICRON
3) PULSE DURATION = 350 MICROSECS
4) POWER TO TISSUE = VARIABLE 1 - 20 WATTS
5) ENERGY/PULSE = 1 J - 1.8 J
6) AIMING BEAM = 3 MILL WATTS (RED)
7) BEAM DELIVERY = LOW WATER QUARTZ FIBRE (400MM)
8) DIMENSIONS = 79 CM H X 36 CMW X 53 CM D
9) WEIGHT = 64 KG
10) COST = 20W £70000

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35. EXTRACORPOREAL
LITHIOTRIPSY
• Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to
break a kidney stone into small pieces that can more easily travel
through the urinary tract and pass from the body
• You lie on a water-filled cushion, and the surgeon uses X-rays
or ultrasound tests to precisely locate the stone. High-energy sound
waves pass through your body without injuring it and break the stone
into small pieces.These small pieces move through the urinary tract
and out of the body more easily than a large stone.
• The surgeon may use a stent if you have a large stone. A stent is a
small, short tube of flexible plastic mesh that holds the ureter open.
This helps the small stone pieces to pass without blocking the ureter.
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Photo by DiverDave - Own work.
Licensed under CC BY-SA 3.0
viaWikimedia Commons –
http://commons.wikimedia.org/wiki/File:Lithotriptor_machine.jpg#/media/File:Lithotriptor_machine.jpg

37. CONTD. :-
• All lithotripters share similar
technologic principles in having
main components :
1. A shockwave generator
2. A focusing system
3. A coupling system
4. An imaging/localization units
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An example of a dog undergoing extracorporeal shock wave lithotripsy treatment.
The urolith to be treated is
positioned in the focal zone
using fluoroscopic guidance.
The patient is returned to the
treatment position for shock
wave application.

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A procedure for eliminating a calculus in the renal pelvis, ureter, bladder, or gallbladder. It may be
crushed surgically or by using a noninvasive method such as a hydraulic, or high-energy, shock
wave or a pulsed dye laser. The fragments may then be expelled or washed out.

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Position for stones in gallbladder
(Patient is lying on a fluid-filled bag)

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Position for stones in common
bile duct. Patient is in a water bath.

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45. Percutaneous nephrolithotomy
(tunnel surgery)
• A surgical procedure for stones that cannot be treated with lithotripsy
or endoscopic procedures. It involves the removal of a stone through a
thin tube tunneled through a small incision in the back into the kidney
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Telescopic Teflon
Metal Dilators

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49. COMPLICATIONS
• Bleeding around the organ
• Infection
• Obstruction of the urinary tract by stone fragments
• Stone fragments left that may require more lithotripsies
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50. CONTRAINDICATIONS
• Pregnant patients
• Patients on “blood thinners” or patients with bleeding disorders.
Aspirin or other blood thinners must be discontinued for at least 1
week prior to lithotripsy.
• Patients with chronic kidney infection, as some fragments may not
pass, so the bacteria will not be completely eliminated from the kidney.
• Patients with obstruction or scar tissue in the ureter, which may prevent
stone fragments from passing.
• Patients who require immediate and/or complete clearance of stone
material.
• Patients with stones composed of cystine and calcium, as these stones
do not fragment well with lithotripsy
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PREVENTION OF STONE FORMATION

52. 1. CALCIUM OXALATE STONES
 Instruct on diet –
avoid excess of calcium and phosphorus; maintain a low sodium
diet (sodium restriction decreases amount of calcium absorbed in
intestine)
 Teach purpose of drug therapy –
thiazide diuretics to reduce urine calcium excretion, allopurinol
therapy to reduce uric acid concentration.
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53. 2. URIC ACID STONES
 Teach methods to alkalinize urine to enhance urate solubility.
 Instruct on testing urine pH.
 Teach purpose of taking allopurinol – to lower uric acid
concentration.
 Provide information about reduction of dietary purine intake (low
protein – red meat, fish, fowl)
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54. 3. STRUVITE STONE
Teach signs and symptoms of urinary infection; encourage him to
report infection immediately; must be treated vigorously.
Try to avoid prolonged periods of recumbency – slows renal drainage
and alters calcium metabolism.
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55. CONCLUSION
• Due to major complication of suture leakage and unwanted trauma
minimal invasive & non invasive procedures are far better for
affections of upper urinary tract, oral cavity & gall bladder stones to be
used at referral hospitals.
• Cystoscopy requires very limited instrumentation and can be easily
started at our clinics here at LUVAS.
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56. BILBLIOGRAPHY
• http://advinurology.com/surgery/intracorporeal-pneumatic-
lithotripsy/
• www.google.com
• Text book of SMALL ANIMAL SURGERY 3rd edition by Douglas Slatter
• Comparison of Ultrasonic and Pneumatic Intracorporeal Lithotripsy
Techniques during Percutaneous Nephrolithotomy
(TolgaKarakan,AkifDiri,AhmetMetinHascicek,BeratCemOzgur, SerkanOzcan,andMuzafferEroglu
Sa˘glıkBakanlı˘gıAnkaraE˘gitimveAras¸tırmaHastanesiS ¸¨
ukriyeMh.,UlucanlarCd.No.89,06340Ankara,Turkey)
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57. • Ppt- MINIMAL INVASIVE SURGICAL PROCEDURES OF
URINARYTRACT (DAMANVIR SINGH, L-2016-V-87-M ).
• Lithotripsy: an update on urologic applications in small animals
(India F. Lane, DVM, MS Department of Small Animal Clinical Sciences, University of Tennessee, College of
Veterinary Medicine, C247 Veterinary Teaching Hospital, 2407 River Drive,Knoxville, TN 37996–4544, USA)
• Ppt- Endoscopic Salivary Stone Fragmentation with Pneumatic
Lithotripsy (Henry Hoffman, MD, Jack Kolenda MD, Rohan R Walvekar MD)
• Ppt – Anesthetic Management of Minimally Invasive Urologic Surgeries-
by Dr. Varsha Kothari
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58. • Ppt -Extracorporeal shock wave lithotripsy- MUSTAFA KHALIL IBRAHIM
TBILISI STATE MEDICAL UNIVERSITY 4th year, 1st semester, 2nd group
• Laser Lithotripsy for Treatment of Canine Uroliths
(ELLEN B. DAVIDSON, DVM, Diplomate ACVS, JERRY W. RITCHEY, DVM, PhD, Diplomate
ACVP, RUSSELL D. HIGBEE, DVM, PhD, MICHAEL D. LUCROY, DVM, MS, Diplomate
ACVIM (Oncology), and KENNETH E. BARTELS, DVM, MS)
• Laser Lithotripsy- PATIENT CARE, STAFF EDUCATION- Amoy Lowe, RN; Linda Sharon
Gabriel, RN
• Laser Lithotripsy for Treatment of Urethral and Bladdder Uroliths-Julie
K. Byron, DVM, MS, DACVIM
• http://www.auanet.org/index_hi.cfm
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