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Electronic device to improve the efficiency of extracorporeal lithotripters

Article in Journal of Applied Research and Technology · September 2004

DOI: 10.22201/icat.16656423.2004.2.02.595

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 Electronic device to improve the efficiency of extracorporeal lithotripters, F.Fernández et al, 170-178

ELECTRONIC DEVICE TO IMPROVE THE EFFICIENCY OF EXTRACORPOREAL

LITHOTRIPTERS

F. Fernández1, A. M. Loske1, J. van Cauwelaert1, F. E. Prieto2

1
Centro de Física Aplicada y Tecnología Avanzada, UNAM,
Apdo. Postal 1-1010, C.P. 76000 Querétaro, Qro., México,
Tel. (52) (442) 2381164, Fax: (52) (442) 2381165,
[email protected], [email protected]
2
Instituto de Física, UNAM, Apdo. Postal 20-364,
C.P. 01000, México, D.F., Tel. (52) (55) 562334164,
Fax. (52) (55) 56234165, [email protected]
th th
Received: January 8 2003 and accepted April 30 2003

ABSTRACT

The design and construction of autonomous electronic instrumentation to generate fast high voltage discharges (6
to 10 kV) on a piezoelectric crystal array, in order to produce underwater shock waves, is described. If properly
focused, hundreds of these shock waves are capable of destroying renal and ureteral calculi. This clinical
treatment, developed more than 20 years ago, is known as extracorporeal shock wave lithotripsy (ESWL). In
contrast to standard devices, our system produces two, rather than just one, shock waves with an adjustable delay
between 50 and 950 µsec. The objective is to enhance cavitation-induced damage to the kidney stone without
increasing tissue trauma. Kidney-stone model fragmentation tests, obtained with the novel system, were compared
to those achieved with a conventional piezoelectric shock wave generator, showing a 20% increase in
fragmentation efficiency. Initial in vivo studies with animals have shown reduced tissue trauma.

RESUMEN

Se presenta el diseño y la construcción de instrumentación electrónica autónoma que permite generar descargas
abruptas de alto voltaje (6 a 10 kV) sobre arreglos de cristales piezoeléctricos, para provocar ondas de choque en
agua. Debidamente enfocadas, estas ondas son capaces de destruir cálculos renales y uretrales, según la técnica
médica no invasiva conocida como litotripsia extracorporal. La innovación en este sistema, comparada con la forma
convencional de descargas sucesivas espaciadas durante el orden de segundos, consiste en generar dos impulsos
con retardo variable y controlado entre 50 y 950 microsegundos, repitiendo sucesivamente el proceso con
período también variable y controlado entre 1 y 10 segundos, en lo que se pretende aprovechar el fenómeno de
cavitación para mejorar la eficiencia en la desintegración de cálculos, sin incrementar el daño a los tejidos.
Las pruebas efectuadas con modelos artificiales de cálculos renales, muestran un aumento aproximado del 20% en
la eficiencia del generador de ondas de choque, con respecto a la manera convencional. Estudios recientes in vivo
(con animales) han demostrado una reducción significativa en el daño a los tejidos circundantes al cálculo.

KEYWORDS: Piezoelectric shock wave generation, Tandem shock waves, Cavitation, ESWL.

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1. INTRODUCTION

Extracorporeal shock wave lithotripsy (ESWL) has been used successfully for more than two decades to treat patients
having ureteral, renal, and sometimes even gallbladder, pancreatic and salivary stones [1]. The goal of ESWL is to
provide efficient calculi fragmentation with the least amount of tissue trauma. Even if ESWL is believed to be a safe
and reliable treatment, techniques and clinical devices (called lithotripters) are still evolving and new systems to
reduce tissue damage and increase stone fragmentation efficiency are constantly sought.

Basically, three different methods are used to generate shock waves for clinical applications: electrohydraulic,
electromagnetic and piezoelectric [2,3]. This article is only dealing with piezoelectric shock wave generation;
however, the basic physical principles described here could also be used in electrohydraulic and electromagnetic
lithotripters.

Shock waves are generated in water because its acoustic impedance is similar to that of soft human tissue. Acoustic
cavitation is believed to be one of the major mechanisms involved in stone fragmentation during ESWL [4,5]. The
negative pulse of a lithotripter shock wave normally exceeds the threshold for cavitation in water (or urine) forming a
cloud of bubbles in the vicinity of the lithotripter focus. When these bubbles collapse, they produce high-speed liquid
microjets, damaging the stone surface. Even if the total energy of a single cavitation event is small, its concentration
into a tiny volume may cause an enormous energy density, with large potential for damage. If a second shock wave
is sent during bubble collapse, even higher energy densities can be achieved. This has been shown using either two
shock wave generators or composite reflectors [6,7]. The disadvantage of these systems is the need of two
independent shock wave generators or a different composite reflector for each time delay between shock waves.

The objective of this article is to report the design of novel electric and electronic circuits for a piezoelectric shock
wave generator, in order to enhance cavitation-induced damage to kidney stones without increasing tissue trauma.
The system generates two successive shock waves with an adjustable time delay between 50 and 950 µs, using only
one shock wave generator. Pressure measurements and stone fragmentation efficiency of the new system were
compared to that of a standard piezoelectric lithotripter.

2. THE PIEZOELECTRIC SHOCK WAVE GENERATOR

Standard piezoelectric lithotripters have up to 3000 piezoceramic crystals, arranged on the concave surface of a
metallic spherical segment. Crystals are connected in parallel and stimulated by an electric discharge, which is
generated with a pulse generator, allowing different levels of pulse intensity. Each electric pulse causes expansion of
all the crystals at the same time, producing a pressure wave. A rarefaction or "negative" pressure pulse results when
crystals return to their initial shape. Due to of the spherical arrangement, energy is concentrated at the center (F) of
the sphere (about 0.25 m in radius). As illustrated in Fig. 1-a, this is the position where the kidney stone is placed
during ESWL. The concave dish with the ceramic elements mounted on it (shock wave generator), is placed inside a
cavity filled with degassed water, warmed to body temperature. Piezoelectric crystals are insulated from water by a
flexible polymeric material. A latex membrane couples shock waves into the patient. If the patient is positioned with
the stone located at the focus F, shock waves enter his body, become focused on the calculus, and fracture it (see Fig.
1-b). Patient positioning is performed by ultrasound or fluoroscopy.

For the purpose of this research there was no need for a complete lithotripter; nevertheless, the instrumentation and
electric circuits described in this article may be installed in any standard clinical piezoelectric lithotripter. Because of
this, only the shock wave generator of a Piezolith 2300 extracorporeal shock wave lithotripter (Richard Wolf GmbH,
Knittlingen, Germany) was mounted on a bench. A cylindrical lucite water tank was placed on the piezoelectric shock
wave generator (see Fig. 2). The XYZ positioner, placed on top of the tank, was used to position either needle
hydrophones (Imotec GmbH, Würselen, Germany) or well known spherical standardized kidney stone phantoms at F.

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 Electronic device to improve the efficiency of extracorporeal lithotripters, F.Fernández et al, 170-178

(a) piezoelectric shock wave generator and

(b) focusing for extracorporeal kidney stone disintegration

Figure 1. Schemes of

Figure 2. Photograph showing (a) the high voltage transformer, (b1) the spark gap driver 1, (b2) the spark gap
driver 2, (c1) rectifier 1, C1 and spark gap 1, (c2) rectifier 2, C2 and spark gap 2, (d) the pulse generator,
(e) the hemispherical aluminum backing with the piezoelectric crystals, (f) the XYZ positioner, (g) the water tank,
(h) the PVDF needle hydrophone, and (i) part of the shielding

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The electric circuit of the Piezolith 2300 lithotripter, consisting of a capacitor charging system and a spark gap trigger
unit, was duplicated and both high voltage outputs connected in parallel to the piezoelectric shock wave generator as
shown in Fig. 3. Two spark gap drivers and a specially designed pulse generator can also be seen on this figure.

Figure 3. Diagram of the novel circuit

The high voltage transformer (input: 220 V , 60 Hz; output: 5.32 kV ) charges C1 and C2 up to 7.5 kV , through a 100
RMS RMS DC

kΩ resistor and rectifying bridges 1 and 2 formed with NTE517 (15 kV, 0.55 A) diodes. The 100 kΩ resistor reduces the
surge current to maximum 75 mA, at a 50 ms charging time constant. Capacitors C1 and C2 maintain 7.5 kV until DC

either spark gap SG1 or SG2 is fired. At this instant, the energy stored in one of the capacitors is discharged through a
3 Ω resistor and diode D1, exciting the piezoelectric crystal array. A digital oscilloscope connected to T1 and T2 is used
to observe the electric discharges and measure the time delay between them. D1 and D2 prevent undesirable return
of positive and negative pulses, due to ringing of the piezoelectric crystal array.

Spark gaps SG1 and SG2 basically consist of two main electrodes (input and output electrode) separated a distance
large enough to resist 7.5 kV , and a trigger electrode, located next to the output electrode. A high voltage, low
DC

current, electric discharge between the trigger and the output electrode ionizes the gas between main electrodes,
inducing the high energy discharge. After the first spark gap (SG1) is fired, diode D2 prevents the pulse, generated by
the crystals when retracting, to trigger spark gap number two (SG2). Without D2, a negative peak was seen traveling
from the piezoelectric crystals to the output of SG2 and the increased voltage difference between input-output
electrodes would fire SG2 before arrival of the trigger pulse coming from the pulse generator. This was handled by
grounding the negative peak through D2. Positive pulse reflections were prevented by D1. Since the time for the
piezoelectric crystals to return to their initial dimensions is less than one microsecond [8], tandem shock wave
generation with minimum delay of 10 s (between 50 and 950 s) is possible, by means of the spark gap drivers and
the special pulse generator.

Each spark gap driver receives a 50 µs TTL signal and produces a 12 kV, 3 mA, 5 µs pulse output, enough to ionize
either SG1 or SG2. The pulse generator was designed to trigger both systems with an adjustable time delay between
50 and 950 µs. Delay can be varied in 10 µs steps. Due to this, two similar shock waves are generated at the desired
time delay. The system can be operated in manual single-shot tandem shock wave mode, or in automatic tandem
mode at an adjustable frequency between 0.1 and 1.0 Hz. A four digit counter registers the number of generated
tandem shock waves. More details on the electronics are given in the following section.

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3. INSTRUMENTATION

3.1 The spark gap drivers

As shown in Fig. 4, each spark gap driver operates with a 12 V, 1.2 A-h, independent rechargeable battery unit, in order
to have floating output terminals over common ground. The basic arrangement is similar to spark plug discharge
circuits used in some combustion engines. A standard automobile coil was used in the Darlington arrangement
formed by Q3 and Q4 transistors, whose transition time [9] sets the amplitude and duration of the output high voltage
pulse. A SN74121 integrated circuit (IC) in monostable operation supplies a 2.8 ms TTL pulse [10], controlling transistor
Q2 which drives the Darlington setup. The IC is triggered by Q1. To insulate the spark gap driver from the pulse
generator, an opto-coupled interrupter module (ECG3100, led-phototransistor) was used to drive Q1 (only the
phototransistor is shown in Fig. 4). Diode D1 allows battery recharging with a standard charging unit, not shown in
Fig. 4. With full battery charge, the system has 12 hours of autonomy.

Figure 4. Diagram of the spark gap driver circuits

3.2 The special pulse generator

In this stage, our established design specifications were the generation and coupling of the three time-base signals
(with TTL levels) mentioned in section 2:

1 : A variable frequency from 0.1 to 1 Hz, in order to repeat the two succesive shock waves (tandem shock
st

waves) in automatic mode.

2 : The 50 s duty cycle pulses (spark gap drivers input), corresponding to each shock wave generation.
nd

3 : The variable short-time delay (50 to 950 s) between the two succesive shock waves.
rd

The diagram of the pulse generator circuit is shown in Fig. 5. The automatic-mode low frequency signal was obtained
using IC1 (XR2240) in a stable operation with time base period T = (Rv1+R1)C1 and final period To = 64T. This was
achieved using the 6 bit of the internal binary counter as an output [11]. For C = 1.5 µF, R1 = 10 kΩ and Rv1 = 0 –
th

100 kΩ, To ranges between 0.96 and 10.56 s, i.e. a frequency from 0.095 to 1.04 Hz. Pins 10 and 11 of the XR2240 are
reset and trigger inputs activated with positive-going control pulses. The output of this time base (pin 6) provides the
necessary rise time to activate the second time base obtained by means of a typical monostable configuration with
the IC2 (SN74121), where T = Ln (2)(15 kΩ)(4.7 nF) = 48.87 µs is the duty cycle for the first discharge pulse sent to spark
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gap driver 1. This was achieved by means of the led (in the opto-coupler module) supported by the 2N2222 transistor
array, whose input is connected to IC2 output (pin 6). Input of IC2 (pin 5) also is connected to the collector of
transistor BC547 operating as a switch to fire the second time base in manual mode, by means of the start pushbutton
and the toggle selector in corresponding position.

Figure 5. Diagram of the pulse generator

The third time base was obtained as the first one, but using the XR2240 (IC3) in mono stable operation fired by IC2
output. Using the 3 bit of its internal binary counter as output and C2 = 12 nF, R2 = 1 kΩ, Rv2 = 0 – 20 kΩ, this stage
rd

provides a 48 – 1008 µs delay interval. The delay may be varied with precision by adjusting the ten-turn potentiometer
Rv2. After the selected time delay finishes, a positive-going pulse is generated at IC3 output (pin 3) which fires IC4 (in
identical configuration to IC2), to provide the second discharge pulse for spark gap driver 2 using the above
mentioned optical coupling. The digital counter was assembled with four TIL306 microcircuits in a typical
configuration suggested by the manufacturer [12].

4. EVALUATION AND RESULTS

4.1 Electronic instrumentation

Before installing the novel device on the lithotripter shock wave generator, each spark gap driver was loaded in excess
of its design specifications, using a Mazda model 92-4265, 18 inches, 30 watt gas-filled tube. These type of discharge
lamp is used in photocopying machines. A set of 1000 tandem discharges were delivered to the gas-filled tube at a
delay of 500 µs, a frequency of 2/3 Hz and a temperature of 18.2 ± 0.2 C, registered using an Extech 445800
o

hygrothermometer. The delay between tandem discharges was observed on a Gould DS0-475 oscilloscope at a 50 µs
time scale, using a 1000:1 high-voltage probe (Schlumberger model 70-457E). No delay variation larger than ± 5 µs
could be detected. The process was repeated at five different temperatures (10.0, 12.3, 15.0, 22.1 and 25.2 C ± 0.2 C) o o

with the same result. Finally, 9600 tandem discharges were delivered to the discharge lamp at a delay of 400 µs, and
the same frequency of 2/3 Hz. Temperature was allowed to vary between 15.4 and 17.9 C ± 0.2 C. During the whole
o o

process (4 hours) the delay was measured every 5 minutes. No variation larger than ± 5 µs was observed.

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 Electronic device to improve the efficiency of extracorporeal lithotripters, F.Fernández et al, 170-178

4.2 Tandem shock wave generation

The system was arranged as shown in Fig. 3. The trigger and channel one of a digital oscilloscope (Tektronix Inc.,
Beaverton, OR, USA, model 2430A ) was connected to T1 and T2, respectively. Pressure variations at the focus F of the
shock wave generator were registered using a piezoelectric pressure transducer (Kistler Instruments AG, Winterthur,
Switzerland, model 603B1) connected to a Kistler 5004 charge amplifier. Water level inside the test tank was set 10 cm
above F. Figure 6 shows a typical graph observed on the oscilloscope at 0.5 V/div and 200 µs/div using a 550 µs delay.
The spark gap high voltage discharge signals were registered on the screen at the preset delay. About 230 µs after the
oscilloscope was triggered, the first shock wave reached the hydrophone at F. This was the time needed for the
pressure wave to travel from the piezoelectric crystal array to the hydrophone at a velocity of about 1500 m/s. About
550 µs after firing the first spark gap, the signal of the second spark gap appeared on the screen. The second shock
wave also was registered about 230 µs after its generation.

Figure 6. Pressure waveform obtained at the focus of the tandem shock wave
generator at a delay of 550 µs between shock waves

In order to evaluate the fragmentation efficiency of model kidney stones at 11 different delays between tandem
shock waves, a set of four 1.6 ± 0.1 g spherical stone phantoms (diameter = 1.5 ± 0.01 cm), manufactured by High
Medical Technologies in Kreuzlingen Switzerland (model AST 109), were placed one by one in a polyethylene bag at F
and exposed to 500 tandem shock waves for each delay. Delays were increased from 100 to 600 µs in steps of 50 µs.
Before shock wave application, stone phantoms were saturated in water for 10 minutes. Shock wave exposed model
kidney stones were strained through a 1 x 1 mm nylon mesh. Stones and fragments were dried in an oven at 50 C o

and weighed on a precision scale (Sartorius GmbH, Göttingen, Germany, model 2842) with an accuracy of ± 10 g. -4

Figure 7 shows the fragmentation efficiency defined as F = 100(Wi - Wf)/Wi, where Wi is the initial (intact) stone
weight and Wf the final weight of the fragments. Maximum fragmentation efficiency was observed at 250 µs. At
delays above about 400 µs F was comparable to the efficiency obtained when exposing models to 1000 single shock
waves using the standard system.

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Figure 7. Fragmentation efficiency of spherical kidney stone phantoms exposed to 500

tandem shock waves generated at 7.5 kV using different delays between first and second shock wave

5. CONCLUSIONS

Kidney stone fragmentation efficiency during ESWL depends on several factors such as shape, composition and
location of the calculus, as well as number of shock waves, pressure profile, and administration frequency. Our results
seem to indicate that cavitation-induced damage to model kidney stones can be enhanced using a piezoelectric
tandem shock wave generator. The electric and electronic circuits described here could be installed in clinical
lithotripters without changing the design of the device. Increased fragmentation efficiency of about 20%, compared
to the standard configuration, was obtained at a shock wave delay of 250 µs. These results are comparable to data
obtained using bifocal reflectors for electrohydraulic shock wave generators [6]. Enhanced calculi fragmentation
using the piezoelectric tandem shock wave generator is based on the fact that collapse of cavitation bubbles formed
by the first shock wave can be intensified significantly if a second shock wave arrives at the bubbles during or shortly
after their stable phase [13]. The main advantage of our system is that there is no need to manufacture a new hybrid
reflector for every desired time delay between shock waves. Due to this, delays could be adjusted depending on the
size, composition and location of the kidney stone. In vitro and in vivo experiments will be necessary to determine
whether tandem shock wave application should be used clinically.

6. ACKNOWLEDGEMENTS

The authors would like to acknowledge technical assistance by Arturo Méndez, Edgar Méndez, Helmuth Busch and
Mario Granizo. The Piezolith 2300 shock wave generator was donated to our univeristy by Dewimed S.A. de C.V.

7. REFERENCES

[1] Loske, A. M., Prieto, F. E. "Shock Waves in Medicine, Commented Bibliographical Data Base". Mexico City,
CIC-UNAM, 1995.
[2] Loske, A. M., Prieo, F.E. "Fundamentos Técnicos de Litotripsia Extracorporal". México City: JGE Editores, 1999.
[3] Loske, A. M. "Applications of shock waves in medicine", in Handbook of Shock Waves, Ben-Dor, G., Elperin, T.,
Igra O., Lifshitz, A. (ed.). New York: Academic Press, 2001, Vol. 2, chapter XII.
[4] Crum, L. A. “Cavitation microjets as a contributory mechanism for renal calculi disintegration in ESWL.” J. Urol.
1988; 140, pp, 1587 – 1590.
[5] Lokhandwalla, M., Sturtevant, B. “Fracture mechanics model of stone comminution in ESWL and implications
for tissue damage”. Phys. Med. Biol. 2000, 45, pp, 1923 – 1949.

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Journal of Applied Research and Technology
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[6] Prieto, F. E., Loske, A. M. "Bifocal reflector for electrohydraulic lithotripters". The Journal of Endourology, vol.
13, number 2, 1999, 65-75.
[7] Xi, X., Zhong, P. “Improvement of stone fragmentation during shock-wave lithotripsy using a combined
EH/PEAA shock-wave generator – in vitro experiments”. Ultrasound Med. Biol. 2000, 26, 457 – 467.
[8] Cady, W. “Piezoelectricity: An Introduction to the Theory and Applications of Electromechanical Phenomena in
Crystals”. New York. Dover Publications Inc., vol. I, 1964.
[9] The Power Semiconductor Data Book, Texas Instruments Inc., USA, 1971.
[10] TTL Logic Data Book, Texas Instruments Inc., USA, 1988.
[11] Exar Databook, Exar Corp., USA , 1992.
[12] Optoelectronics Data Book, Texas Instruments Inc., USA, 1972.
[13] Zhong P., Cocks, F. H. Cioanta, I., Preminger, G. M. “Controlled, forced collapse of cavitation bubbles for
improved stone fragmentation during shock wave lithotripsy”. J. Urol. 1997, 158; 2323 – 2328.

Authors Biography

Francisco Fernández Escobar,

Was born in Acapulco city in 1953. He obtained a B.Sc. degree in Physics at the Facultad de Ciencias, UNAM (Faculty of
Science of the UNAM) in Mexico City and completed his M.Sc. studies at the same university. As experimental
physicist, he has worked at Universidad Nacional Autónoma de México (National Autonomous University of Mexico,
UNAM), since 1976; first in the field of electronic scientific instrumentation at Facultad de Física (Science Faculty 1976 -
1986) and at Instituto de Física (Physics Institute 1986–2001); and recently in the field of shock waves experimentation
at Centro de Física Aplicada y Tecnología Avanzada of the National Autonomous University of Mexico (The Center of
Applied Physics and Advanced Technology, UNAM) in Juriquilla, Querétaro.

Achim Max Loske Mehling,

Was born in Mexico City in 1960. He completed a B.Sc. degree in Physics Engineering at the UI (Universidad
Iberoamericana) in Mexico City, a M.Sc. degree in Physics at the Facultad de Ciencias, UNAM (Faculty of Science of the
UNAM) in Mexico City, and a Ph.D. in Applied Physics at the Centro de Investigación Científica y de Educación
Superior de Ensenada, Baja California, Mexico. His master and doctoral thesis involved experimentation of shock
waves applied to medicine at the Instituto de Física, UNAM (Physics Institute of the UNAM) Achim Loske is Head of
the Shock Wave Laboratory at the Centro de Física Aplicada y Tecnología Avanzada of the UNAM (Center of Applied
Physics and Advanced Technology of the National Autonomous University of Mexico) in Juriquilla, Querétaro. He
received the Gabino Barreda Medal in 1997 and is member of the Sistema Nacional de Investigadores (Nacional
System of Research), the “Sociedad Mexicana para la Divulgación de la Ciencia y la Técnica”, and the “Sociedad
Mexicana de Instrumentación”.
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