Departments of Anatomy and Cell Biology, Indiana University School of Medicine Methodist Hospital Institute for Kidney Stone Disease, Indianapolis, IN 46202, USA.
BJU Int. 2012 Nov;110(9):1376-85. doi: 10.1111/j.1464-410X.2012.11160.x. Epub 2012 Apr 23.
What's known on the subject? and What does the study add? Of all the SW lithotriptors manufactured to date, more research studies have been conducted on and more is known about the injury (both description of injury and how to manipulate injury size) produced by the Dornier HM-3 than any other machine. From this information have come suggestions for treatment protocols to reduce shock wave (SW)-induced injury for use in stone clinics. By contrast, much less is known about the injury produced by narrow-focus and high-pressure lithotriptors like the Storz Modulith SLX. In fact, a careful study looking at the morphology of the injury produced by the SLX itself is lacking, as is any study exploring ways to reduce renal injury by manipulating SW delivery variables of this lithotriptor. The present study quantitates the lesion size and describes the morphology of the injury produced by the SLX. In addition, we report that reducing the SW delivery rate, a manoeuvre known to lower injury in the HM-3, does not reduce lesion size in the SLX.
• To assess renal injury in a pig model after treatment with a clinical dose of shock waves using a narrow focal zone (≈3 mm) lithotriptor (Modulith SLX, Karl Storz Lithotripsy).
• The left kidney of anaesthetized female pigs were treated with 2000 or 4000 shock waves (SWs) at 120 SWs/min, or 2000 SWs at 60 SWs/min using the Storz SLX. • Measures of renal function (glomerular filtration rate and renal plasma flow) were collected before and 1 h after shock wave lithotripsy (SWL) and the kidneys were harvested for histological analysis and morphometric quantitation of haemorrhage in the renal parenchyma with lesion size expressed as a percentage of functional renal volume (FRV). • A fibre-optic probe hydrophone was used to determine acoustic output and map the focal width of the lithotriptor. • Data for the SLX were compared with data from a previously published study in which pigs of the same age (7-8 weeks) were treated (2000 SWs at 120 or 60 SWs/min) using an unmodified Dornier HM3 lithotriptor.
• Treatment with the SLX produced a highly focused lesion running from cortex to medulla and often spanning the full thickness of the kidney. Unlike the diffuse interstitial haemorrhage observed with the HM3, the SLX lesion bore a blood-filled core of near-complete tissue disruption devoid of histologically recognizable kidney structure. • Despite the intensity of tissue destruction at the core of the lesion, measures of lesion size based on macroscopic determination of haemorrhage in the parenchyma were not significantly different from kidneys treated using the HM3 (2000 SWs, 120 SWs/min: SLX, 1.86 ± 0.52% FRV; HM3, 3.93 ± 1.29% FRV). • Doubling the SW dose of the SLX from 2000 to 4000 SWs did not significantly increase lesion size. In addition, slowing the firing rate of the SLX to 60 SWs/min did not reduce the size of the lesion (2.16 ± 0.96% FRV) compared with treatment at 120 SWs/min, as was the case with the HM3 (0.42 ± 0.23% FRV vs 3.93 ± 1.29% FRV). • Renal function fell significantly below baseline in all treated groups but was similar for both lithotriptors. • Focal width of the SLX (≈2.6 mm) was about one-third that of the HM3 (≈8 mm) while peak pressures were higher (SLX at power level 9: P+≈90 MPa, P-≈-12 MPa; HM3 at 24 kV: P+≈46 MPa, P-≈-8 MPa).
• The lesion produced by the SLX (narrow focal width, high acoustic pressure) was a more focused, more intense form of tissue damage than occurs with the HM3. • Slowing the SW rate to 60 SWs/min, a strategy shown to be effective in reducing injury with the HM3, was not protective with the SLX. • These findings suggest that the focal width and acoustic output of a lithotriptor affect the renal response to SWL.
关于这个主题已知的内容是什么？这项研究增加了什么？到目前为止，在所有制造的 SW 碎石机中，对 Dornier HM-3 产生的损伤（包括损伤的描述和如何操纵损伤大小）进行了更多的研究，并且对其了解更多，而其他机器则知之甚少。由此产生了一些治疗方案的建议，以减少用于结石诊所的冲击波（SW）诱导的损伤。相比之下，对于像 Storz Modulith SLX 这样的窄焦点和高压碎石机产生的损伤知之甚少。事实上，缺乏对 SLX 本身产生的损伤形态的仔细研究，也没有任何研究探索通过操纵 SW 传递变量来减少这种碎石机的肾损伤的方法。本研究定量了病变大小，并描述了 SLX 产生的损伤形态。此外，我们报告说，降低 SW 传递率（已知在 HM-3 中降低损伤的操作）并不能减少 SLX 中的病变大小。
• 使用窄焦点区域（≈3mm）碎石机（Modulith SLX，Karl Storz 碎石术）评估猪模型中使用临床剂量冲击波治疗后的肾损伤。
• 在麻醉的雌性猪的左肾中，以 120 SW/min 的速度使用 Storz SLX 用 2000 或 4000 个冲击波（SW）治疗，或用 60 SW/min 的速度用 2000 个 SW 治疗。• 在冲击波碎石术（SWL）前和 1 小时后收集肾功能（肾小球滤过率和肾血浆流量）的测量值，并对肾脏进行组织学分析和形态计量学定量分析，出血在肾实质中的百分比表示为功能肾体积（FRV）的百分比。• 使用光纤探头水听器来确定声输出并绘制碎石机的焦点宽度。• 将 SLX 的数据与之前发表的研究进行比较，该研究中使用相同年龄（7-8 周）的猪（以 120 或 60 SW/min 的速度使用未修改的 Dornier HM3 碎石机治疗）。
• 使用 SLX 治疗会产生高度聚焦的病变，从皮质延伸到髓质，并且经常跨越肾脏的整个厚度。与 HM3 观察到的弥漫性间质出血不同，SLX 病变具有充满充满组织破坏的核心，几乎没有可识别的肾脏结构。• 尽管病变核心处的组织破坏强度很高，但基于实质内出血的宏观确定来测量病变大小的测量值与使用 HM3 治疗的肾脏没有显着差异（2000 SW，120 SW/min：SLX，1.86±0.52% FRV; HM3，3.93±1.29% FRV）。• 将 SLX 的 SW 剂量从 2000 增加到 4000 并不显著增加病变大小。此外，将 SLX 的发射率降低到 60 SW/min 与以 120 SW/min 治疗相比，不会减小病变大小（2.16±0.96% FRV），与 HM3 一样（0.42±0.23% FRV 与 3.93±1.29% FRV）。• 所有治疗组的肾功能均明显低于基线，但两种碎石机的肾功能相似。• SLX 的焦点宽度（≈2.6mm）约为 HM3 的三分之一（≈8mm），而峰值压力更高（SLX 在功率水平 9 时：P+≈90MPa，P-≈-12MPa; HM3 在 24kV 时：P+≈46MPa，P-≈-8MPa）。
• SLX（窄焦点宽度，高声压）产生的病变比 HM3 更集中，更严重的组织损伤形式。• 将 SW 速度降低到 60 SW/min，这是一种在 HM3 中被证明可以有效减少损伤的策略，但对 SLX 无效。• 这些发现表明碎石机的焦点宽度和声输出会影响 SWL 对肾脏的反应。
