Impact of Advanced Lithotripter Technology on SWL Success: Insights from Modulith SLK Inline Outcomes

Impact of Advanced Lithotripter Technology on SWL Success: Insights from Modulith SLK Inline Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Advanced Lithotripter Technology on SWL Success: Insights from Modulith SLK Inline Outcomes Erhan ERDOĞAN¹, Gamze ŞİMŞEK¹, Alper AŞIK, Göksu SARICA, Kemal SARICA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5441405/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Feb, 2025 Read the published version in World Journal of Urology → Version 1 posted 9 You are reading this latest preprint version Abstract This study aims to evaluate the success rate of Shock Wave Lithotripsy (SWL) in treating kidney stones using the Modulith SLK Inline lithotripter, with a focus on the importance of device efficacy as emphasized in EAU guidelines. Patients and methods : This retrospective single-center study includes 208 patients who underwent SWL treatment for kidney stones between June 2023 and June 2024. Treatment outcomes were collected and analyzed in detail, considering patients' demographic characteristics (age, gender) and stone parameters (size, location, and hardness [Hounsfield Unit, HU]). The success of SWL was defined as achieving complete stone clearance or the presence of clinically insignificant residual fragments (CIRF) (< 4 mm). This sample of 208 patients was specifically selected to evaluate the performance of the Modulith SLK Inline lithotripter in treating stones smaller than 15 mm, aiming to examine SWL’s potential as a non-invasive yet effective treatment option for smaller, more manageable stones. This study seeks to provide detailed insights into the optimal use cases of SWL. Results : The mean age of the 208 patients was 42.2 ± 12.7 years (18–75), with a male-to-female ratio of 1.9:1. The overall success rate of SWL was 78.8%, with 164 patients achieving a complete stone-free status. With the inclusion of the cases with CIRF the overall success rate was assessed as 92.3%. While the mean stone size in successful cases was 10.3 mm, this value was 12.5 mm, in cases with residual fragments or treatment failure. A statistically significant relationship was found between stone size and treatment success rates (p < 0.001). The mean Hounsfield Unit (HU) value for all patients was 874.0 ± 283.2, with significantly lower HU values in patients who achieved a completely stone-free status ( p = 0.049). Stone localization did not significantly affect the success rates after SWL ( p = 0.377). Conclusions : SWL has demonstrated its effectiveness in kidney stone treatment with a 78.8% complete stone-free rate using the Modulith SLK Inline lithotripter. Higher success rates were achieved with smaller stones (< 15 mm) and lower HU values. These findings support the significance of advanced lithotripter technology in establishing SWL as a valuable non-invasive option for stones under 15 mm. Shock wave lithotripsy Kidney stones Modulith SLK Inline Treatment success Lithotripter technology Introduction Urolithiasis is a significant health problem affecting millions of people worldwide. The incidence of kidney stones varies significantly across different regions of the world. The prevalence is reported to be approximately 10–15% in developed countries and continuing to increase, particularly in industrialized countries, due to dietary and lifestyle changes associated with modernization [ 1 ]. Based on the underlying risk factors the disease may be recurrent in a certain percent of the cases and obstruction as well as infection related problems may affect the upper urinary tract with irreversible changes if not treated on time. Additionally severe renal colic may affect the life quality in these cases necessitating and urgent management at each attack. Based on the facts above symptomatic and obstructing stones require a rational management in order to render the patients stone free with less or no complications along with minimal impact on the quality of life. Regarding the treatment, management of kidney stones have evolved from invasive surgical procedures to minimal invasive approaches over the last 3–4 decades. Currently, management options for kidney stones include extracorporeal shock wave lithotripsy (ESWL) flexible ureteroscopy (fURS), percutaneous nephrolithotomy (PCNL) and open surgery, and [ 2 ]. Based on the evidence based data published so far, available international guidelines (EAU-AUA) do offer SWL as the first option for renal stones sizing less than < 15 mm. [ 2 , 3 ]. Each of these methods has specific indications ( with certain advantages and disadvantages) based on stone (size, number, location, and hardness) as well as patient related factors. When evaluated with respect to the invasive nature of the alternatives, SWL remains as the only “true noninvasive” option applied for the management of kidney stones in all parts of the world [ 3 ]. SWL was first introduced in the early 1980s as a technique that uses shock waves generated outside the body to fragment urinary stones [ 4 ]. This method allows kidney stones to be disintegrated into smaller pieces, which then may pass spontaneously through the urinary tract [ 5 ]. Over the years, parallel to technological advancements noted lithotriptor technology, the safety and efficacy of SWL have improved considerably, making it a preferred method in the effective and safe management of both kidney or ureteral stones [ 6 ]. Despite its noninvasive, practical and highly safe application however, it has been well shown that the success rates of SWL applications may vary depending on several factors, such as stone size, stone location, hardness, and body mass index (BMI) of the cases treated [ 7 ]. Reported studies have shown that the success rates for stones smaller than 2 cm range between 70% and 90% [ 8 ]. However, the effectiveness decreases for larger or harder stones where repeated sessions and auxiliary procedures may be required. On the other hand again, despite its widespread acceptance, SWL has some certain disadvantages such as the potential for renal injury in risk patients, the chance of incomplete stone clearance and the need for additional procedures in patients with residual fragments. However, due to its non-invasive nature, minimal anesthesia requirements, and the possibility of outpatient treatment, SWL remains a valuable option in the management of urolithiasis. Outcomes will be even more successful if the decision making is made with a very careful patient/stone selection based on the clear indications given in the published guidelines and the treatments are carried out with an effective lithotriptor [ 9 ]. This study focuses specifically on outcomes with the Modulith SLK Inline lithotripter, known for its precision in targeting and fragmenting stones. In line with EAU Guidelines for Urolithiasis treatment, successful SWL treatment relies on factors such as stone size, hardness, patient habitus, and the lithotripter used. This study aims to present data that demonstrates the success of this device when paired with guideline-based patient selection criteria. Thus, in this present study we aimed to evaluate the overall success rate of Shock Wave Lithotripsy (SWL) performed with an effective lithotriptor in the non-invasive treatment of kidney stones in a single center. Patients and methods This retrospective study was conducted between June 2023 and June 2024, following approval by the local Ethics Committee (approval number: 298/2024). A total of 208 patients undergoing SWL for renal medium sized ( 18 years), with radiologically confirmed opaque renal stones (< 15 mm) located in the different parts of the kidney, were included in the study. The overall mean stone size was 9.3 ± 2.7 mm (7.4 mm- 15.0 mm). Patients with a solitary kidney, renal functional deterioration, significant skeletal deformities, active urinary tract infections, pregnancy, or coagulopathies were excluded from the study program. In addition to the plain abdominal film and sonographic evaluation, the diagnosis and detailed characteristics of renal stones were confirmed with non-contrast computed tomography (NCCT) in all cases. In addition to the location and size, the density of the stones was assessed in the NCCT images in terms of Hounsfield Unit (HU) values. All patients underwent a comprehensive clinical evaluation, including urinalysis, urine culture test, complete blood count, coagulation profile, and renal function tests. Patients were instructed to fast for at least 6 hours prior to the procedure, and prophylactic antibiotics were administered if deemed necessary. SWL procedures were performed using a Modulith SLK inline lithotripter (Storz Medical, Switzerland), under analgesic treatment with non-steroidal anti-inflammatory drugs (NSAIDs). Patients were positioned in the supine position, and stones were localized using fluoroscopy or ultrasonography. Regarding stone localization during treatment, the inline imaging capabilities of the MODULITH SLK Inline lithotripter system increase precision by allowing real-time visualization of stone targeting and highly effective fragmentation. This not only improves stone clearance rates, but also reduces the risk of complications. The unique stone-directed shockwave delivery with perfect alignment (keeping the stone always in the shockwave path) offers, an innovative and patient-centered approach to SWL, providing a non-invasive yet highly effective treatment solution for stones. Sedative analgesia with pethidine was administered in selected cases, but none of the patients required general anesthesia. A total of 3000 shock waves were delivered per session. Treatment sessions were repeated at 7-day intervals, with a maximum of 3 sessions per patient, depending on the degree of stone fragmentation and the patient’s response to treatment. To assess the stone-free (SF) status, a plain abdominal X-ray (KUB) was performed on the 7th day after the last SWL session. Final stone-free status was evaluated with non-contrast CT (NCCT) three months after the last treatment session. Complete stone clearance ( stone free status) was defined as the absence of any detectable stones or the presence of clinically insignificant residual fragments (less than 4 mm). Failure was defined as the presence of residual stone fragments larger than 4 mm after 3 successful SWL sessions. Symptomatic patients was offered alternative treatment options such as ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL), depending on the size and location of the residual stones. For statistical analysis, mean and standard deviation (SD) values were calculated. Independent t-test and Mann-Whitney U test were used for this purpose. The Chi-square test was employed for categorical parameters. One-way ANOVA was used to compare stone-free rates across different stone localizations. A p-value of less than 0.05 was considered statistically significant. Results A total of 208 patients undergoing SWL were included into this study program. The mean age of the patients was 42.2 ± 12.7 years, with an age range of 18–75 years. Of these patients, 137 (65.9%) were male and 71 (34.1%) were female ( M/F 1.9:1). There was no statistically significant relationship between gender and treatment success ( p = 0.60) (Table 1 ). Table 1 The demographic characteristics of the patients Demographic Characteristics Value Patients (n) 208 Mean age (years ± SD) 42.2 ± 12.7 Male patients (n,%) 137 (65.9) Female patients (n,%) 71 (34.1) The distribution of stones based on their localization within the kidney is as follows: 58 patients (27.9%) had stones located in the renal pelvis, 27 patients (13.0%) in the upper calyx, 56 patients (26.9%) in the middle calyx, and 67 patients (32.2%) in the lower calyx. Following SWL treatment, completely stone-free status was achieved in 49 out of 58 patients (84.5%) with stones in the renal pelvis, while 5 patients (8.6%) had residual fragments (< 4 mm), and 4 patients (6.9%) experienced treatment failure. In cases with the upper calyceal calculi, 23 out of 27 patients (85.2%) became stone-free, with 1 patient (3.7%) having residual fragments and 3 patients (11.1%) experiencing treatment failure. In the middle calyx, successful outcomes were achieved in 43 out of 56 patients (76.8%), with residual fragments in 9 patients (16.1%) and treatment failure in 4 patients (7.1%). In the lower calyx, 49 out of 67 patients (73.1%) became stone-free, while 13 patients (19.4%) had residual fragments, and 5 patients (7.5%) experienced treatment failure. The chi-square test evaluating the relationship between stone localization within the kidney and treatment success rates indicated no statistically significant difference between stone localization and treatment success ( p = 0.377). The overall evaluation of success rates for all stones, SWL was found to be successful in 164 out of 208 patients (78.8%) with completely stone-free status, residual fragments (< 4 mm) were present in 28 patients (13.5%), and treatment failure occurred in 16 patients (7.7%) (Table 2 ). Based on these outcomes we may say that the overall success rate of SWL in renal stones sizing < 15 mm will be 92.3% with the inclusion of asymptomatic small fragments (< 4 mm) which could be passed spontaneously over time. Table 2 Stone Localization Distribution and Treatment Success Rates and Outcomes for Each Localization Stone Localization Number of Patients (n) Percentage (%) Stone-free (n, %) Residual Fragments (n, %) Failed (n, %) Renal pelvis 58 27.9 49 (84.5%) 5 (8.6%) 4 (6.9%) Upper calyx 27 13.0 23 (85.2%) 1 (3.7%) 3 (11.1%) Middle calyx 56 26.9 43 (76.8%) 9 (16.1%) 4 (7.1%) Lower calyx 67 32.2 49 (73.1%) 13 (19.4%) 5 (7.5%) Total 208 100 164 (78.8%) 28 (13.5%) 16 (7.7%) The mean Hounsfield Unit (HU) of the stones in the patients included in the study was determined to be 874.0 ± 283.2 (263–1781). While this value was 862.7 ± 286.2 in patients who achieved a completely stone-free status, it was 1032.5 ± 360.2 in those with residual fragments or treatment failure, statistical analysis of HU difference between these groups showed a statistically significant difference ( p = 0.049). It was particularly noted that stones with an HU value below 1000 had a higher likelihood of being effectively fragmented and cleared with SWL (Table 3 ). Table 3 Evaluation of the success rates based on mean Hounsfield Unit (HU) Values Mean HU p Overall stones 874.0 ± 283.2 0.049 Stone-free 862.7 ± 286.2 Residual fragments or Failed treatment 10325 ± 360.2 When examining the relationship between stone size and treatment success, while the mean stone size was calculated as 10.3 mm (7.4–15.2 mm) in patients with successful outcomes, it was 12.5 mm (9.1–13.9 mm) in those with residual fragments or treatment failure. Again a statistically significant relationship was found between stone size and SWL success ( p < 0.001). Finally, evaluation of the complications observed in our group revealed hematuria, to be the most common complication being detected in 132 patients (63.4%). It was managed conservatively with high fluid intake and resolved spontaneously in the vast majority of the cases. As the second most common complication, renal colic was observed in 11 patients (5.3%) and managed with analgesics/antispasmodic agents which revealed symptoms in all patients. Steinstrasse was observed in only 1 patient (0.5%) and this patient was treated with ureteral stent placement. Last but not least, renal hematoma formation was noted in 2 patients (0.9%), and both cases were managed with close monitoring and supportive care, resulting in spontaneous resolution without necessitating any further interventions (Table 4 ). Table 4 Complications Observed After SWL Complication type n % Renal colic 11 5.3 Hematuria 132 63.4 Steinstrasse 1 0.5 Renal hematoma 2 0.9 Discussion The EAU Guidelines for Urolithiasis treatment emphasize that the success of SWL is influenced by factors including stone characteristics, patient habitus, and the efficacy of the lithotripter itself. This study highlights that not all lithotripters perform equally; the superior technology of the Modulith SLK Inline can achieve better outcomes than older or less precise devices. Poor lithotripter performance or improper case selection often results in suboptimal outcomes and higher retreatment rates. In contrast, advanced shockwave technology like the Modulith SLK Inline, combined with careful patient selection per EAU criteria, provides a pathway to high success rates in SWL without resorting to invasive procedures. This study’s findings validate the importance of choosing an effective lithotripter and adhering to best practices, ultimately supporting the Modulith SLK Inline’s role in improving patient outcomes and minimizing the need for surgical alternatives. SWL has been clinically introduced in 1980 by Chaussy et al., and became the preferred treatment modality in the “true noninvasive” management of urinary stones with the safe and effective results obtained both in adults and children [ 4 ]. The practical and cost effective characteristics of this modality have led the urologists to perform it in more than 90% of the medium sized (10–20 mm) stones in adult patients without any anesthesia requirement as well as hospitalization [ 2 , 3 ]. Currently both EAU and AUA guidelines still recommend this particular modality as the preferred option for stones sizing less than 20 mm [ 2 , 3 , 10 ]. In addition to these facts, as we all know well, the clinical practice patterns of urinary stone management have been found to be affected to a certain extent by the COVID-19 pandemic. Unprecedented introduction of COVID-19 has dramatically influenced all parts of medicine and changed our practice patterns in stone management to a certain extent by selecting the best approach particularly in urgent cases and postpone and/or reschedule elective procedures to limit the risk of infection spread. Based on the facts and evident changes in the practice patterns, elective stone procedures such as RIRS and PCNL needed to be postponed during the outbreak of the pandemic. While timely management of these cases in the emergency department was crucial, other urgent solutions including medical management to some extent and widespread application of SWL (in an outpatient based manner) gained more importance. SWL was the only treatment choice which allowed stone management without any anesthesia and relevant risks for the spread of the infection during this critical period. Significant compulsory alterations in stone related interventions were noted in all parts of the world and in a well conducted survey during this period, vast majority of the experts (89.4%) tended to change their treatment strategy particularly in patients referring to the emergency departments during COVID-19 period. As a “true noninvasive” modality, SWL emerged as a very valuable alternative during this highly critical era (in other words its revival has been realized) with advantages of no anesthesia requirement, chance of treatment away from the patient and less risk of disease spread [ 11 , 12 ]. However, despite its noninvasive, practical and successful natüre, SWL mat has some certain disadvantages. As a major factor, it is well known that the efficacy of this modality tends to diminish in patients with hard (with high density) and larger sized stones (> 20 mm). Some minor complications (pain, hematuria and obstruction) and auxiliary procedures for complete stone clearance could be required in certain percent of such cases [ 1 ]. Thus, treatment outcomes may be influenced by some unpredictable stone (size, composition, location) and patient (BMI, collecting system anatomy) factors. A dedicated experienced team, careful patient selection along with a cooperative work with the cases are crucial factors for a successful SWL procedure. [ 2 , 7 , 13 – 17 ]. Last but not least, certain stone types, such as cysteine or calcium oxalate monohydrate stones, may not respond optimally to SWL and may necessitate alternative treatment methods [ 18 ]. In the light of the facts mentioned above, it is clear that although the role of minimal invasive flexible ureteroscopic stone treatment tended to increase over the last 2–3 decades, accumulated published data in literature has revealed comparable stone free rates between these two modalities particularly for small (less than 1 cm) and medium (1 to 2 cm) sized renal stones [ 19 , 20 ]. However, it should be kept in mind well that, despite its minimally invasive nature, ureteroscopic procedures may reveal certain complications as a major disadvantage when compared with SWL [ 21 , 22 ]. The reported success rates after SWL in terms of SF status were found to range between 48% and 85%. Related to this issue, while Padhye et al. reported an overall stone-free rate of 91.7% in upper tract stones [ 23 ], Ghimire et al. reported a clearance rate of 91.1% in 112 patients with renal stones [ 24 ]. Additionally, success rates of 74% for kidney stones and 88% for ureteric stones were reported by Al-Marhoon et al. [ 25 ]. When the outcomes were evaluated in a stone size based manner, Gupta et al. found a higher stone clearance rate of 90.8% for relatively smaller stones (< 11 mm ) with a mean stone density value of 750 HU [ 26 ]. These results were inconsistent with the outcomes reported by Hamal et al., where 85.9%, 90.25%, and 50.5% success rates for the upper, middle, and lower calyx, respectively [ 27 ]. With respect to the complications associated with SWL applications, limited minor ( flank region pain or discomfort and microscopic haematuria) complications have been reported in the literature [ 21 , 22 , 28 ]. Evaluation of our results revealed that the overall complete SF rate after SWL treatment was found to be 78.8%. Evaluation of the success rates on stone location based manner, revealed that while a complete SF status was achieved in 84.5% of renal pelvic stones these rates were 85.2% in cases with upper calyx stones,76.8% in the middle and 73.1% in lower calyx stones. In addition to the size of the stone the hardness (HU value) was found to be another critical parameter to be taken into account for a successful outcome after SWL. Related to this issue, while the mean HU was 862.7 ± 286.2 in patients with successful outcomes, the mean HU was found to be 1032.5 ± 360.2 in unsuccessful patients with residual fragments with statistically significant difference between two groups of cases. Last but not least, stone size was calculated as 10.3 mm in patients with successful outcomes, while it was 12.5 mm in those with residual fragments or treatment failure. A statistically significant relationship was found between stone size and SWL success ( p < 0.001). In the light of our findings and the reported data in the literature we may definitely emphasize the important place of SWL both in adults and pediatric cases when indications are selected in a proper way. SWL has gained more importance particularly after the critical COVID 19 era and it is still the best treatment alternative in the noninvasive management of upper tract calculi with its high success and significantly limited complication rates. The application needs to be done by an experienced team based on technical requirements. Patient selection is the key factor and as our results also indicate it seems to be the preferred treatment choice for stones sizing less than 15 mm with a HU value of < 1000. By this way the vast majority of such stones will be treated in a safe manner without any need for more invasive procedures which are significantly prone to more severe complications. Patients need to be a part of the decision making period where they really will get detailed information about the advantages and disadvantages of all available management options for a rational decision. Our study is not free of limitations. First of all, the retrospective natüre of the methodology and relatively smaller number of the cases (although it is an acceptable caseload treated in a year period) might constitute a major drawback. Additionally, lack of long term evaluation of the cases for possible complications might be another limitation to be stated. However, as our main aim is to outline the efficacy and safety of SWL in the management of carefully selected cases, we believe that our results will highlight the valuable place of this modality in the “true noninvasive” management of such cases. SWL has its important place among the other treatment alternatives particularly demonstrating its “revival” after COVID-19 era with guidelines based on clear indications. Conclusions In light of our findings and existing literature, SWL holds a vital role in the non-invasive management of small to medium-sized stones in both adult and pediatric cases. SWL’s significance has grown, especially following the COVID-19 era, positioning it as a preferred treatment alternative for upper urinary tract stones due to its high success rate and minimal complications when performed by an experienced team according to guideline-based indications. Our study demonstrated that SWL, using the advanced Modulith SLK Inline lithotripter, achieved a complete stone-free rate of 78.8%. However, as stone size and hardness increased, success rates declined, highlighting the importance of precise case selection. Patients with smaller stones (< 15 mm) and lower HU values achieved notably higher success rates. These findings reinforce that SWL, supported by advancements in lithotripter technology, remains a valuable non-invasive option, especially for stones under 15 mm. 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Cite Share Download PDF Status: Published Journal Publication published 25 Feb, 2025 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 14 Jan, 2025 Reviews received at journal 26 Dec, 2024 Reviewers agreed at journal 18 Dec, 2024 Reviewers agreed at journal 18 Dec, 2024 Reviewers agreed at journal 16 Dec, 2024 Reviewers invited by journal 29 Nov, 2024 Editor assigned by journal 15 Nov, 2024 Submission checks completed at journal 14 Nov, 2024 First submitted to journal 12 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5441405","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":384506675,"identity":"0fde5829-60c8-4720-9624-4f9991313a87","order_by":0,"name":"Erhan ERDOĞAN¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYFACHiBmY5AzAHMMLIjXYmzAwAzSIkG8lsQNYC0MRGjhlz578HNB2b307ez9Rzf8KJBg4G/vTsCrRbIvL1l6xrni3J09h9lu9gAdJnHm7Aa8WgzO8BhI87Yl5G64kcx2gweoxUAiF78W+zM8xr+BWtINgFpu/iFGiwEPjxnIlgSQlttE2SJxhsfMmudcguGGM4fNbssYSPAQ9At/D4/xbZ6yBHmD443Pbr75YyPH396LXwsG4CFN+SgYBaNgFIwCrAAA/tBACOj9dgoAAAAASUVORK5CYII=","orcid":"","institution":"Sancaktepe Sehit Prof. Dr. Ilhan Varank Research and Training Hospital","correspondingAuthor":true,"prefix":"","firstName":"Erhan","middleName":"","lastName":"ERDOĞAN¹","suffix":""},{"id":384506676,"identity":"2693261b-b80d-46fc-a331-3bd7b8f401d9","order_by":1,"name":"Gamze ŞİMŞEK¹","email":"","orcid":"","institution":"Sancaktepe Sehit Prof. Dr. Ilhan Varank Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gamze","middleName":"","lastName":"ŞİMŞEK¹","suffix":""},{"id":384506677,"identity":"214b05b9-dadf-4c37-ab80-23270523576c","order_by":2,"name":"Alper AŞIK","email":"","orcid":"","institution":"Sancaktepe Sehit Prof. Dr. Ilhan Varank Research and Training Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alper","middleName":"","lastName":"AŞIK","suffix":""},{"id":384506678,"identity":"7dd97978-ca9a-46db-b9ad-f3348037e6fa","order_by":3,"name":"Göksu SARICA","email":"","orcid":"","institution":"Biruni University Medical School","correspondingAuthor":false,"prefix":"","firstName":"Göksu","middleName":"","lastName":"SARICA","suffix":""},{"id":384506679,"identity":"dd69e4db-478e-4877-93a8-9758aa9c7ea4","order_by":4,"name":"Kemal SARICA","email":"","orcid":"","institution":"Biruni University","correspondingAuthor":false,"prefix":"","firstName":"Kemal","middleName":"","lastName":"SARICA","suffix":""}],"badges":[],"createdAt":"2024-11-12 17:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5441405/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5441405/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-025-05517-4","type":"published","date":"2025-02-25T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77622713,"identity":"10a7ebcc-64a0-447c-8388-417c803e7c9b","added_by":"auto","created_at":"2025-03-03 16:09:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":463416,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5441405/v1/ee120781-ca39-49e1-abce-499bdd139d35.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Advanced Lithotripter Technology on SWL Success: Insights from Modulith SLK Inline Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrolithiasis is a significant health problem affecting millions of people worldwide. The incidence of kidney stones varies significantly across different regions of the world. The prevalence is reported to be approximately 10\u0026ndash;15% in developed countries and continuing to increase, particularly in industrialized countries, due to dietary and lifestyle changes associated with modernization [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the underlying risk factors the disease may be recurrent in a certain percent of the cases and obstruction as well as infection related problems may affect the upper urinary tract with irreversible changes if not treated on time. Additionally severe renal colic may affect the life quality in these cases necessitating and urgent management at each attack.\u003c/p\u003e \u003cp\u003eBased on the facts above symptomatic and obstructing stones require a rational management in order to render the patients stone free with less or no complications along with minimal impact on the quality of life. Regarding the treatment, management of kidney stones have evolved from invasive surgical procedures to minimal invasive approaches over the last 3\u0026ndash;4 decades. Currently, management options for kidney stones include extracorporeal shock wave lithotripsy (ESWL) flexible ureteroscopy (fURS), percutaneous nephrolithotomy (PCNL) and open surgery, and [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Based on the evidence based data published so far, available international guidelines (EAU-AUA) do offer SWL as the first option for renal stones sizing less than \u0026lt;\u0026thinsp;15 mm. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Each of these methods has specific indications ( with certain advantages and disadvantages) based on stone (size, number, location, and hardness) as well as patient related factors. When evaluated with respect to the invasive nature of the alternatives, SWL remains as the only \u0026ldquo;true noninvasive\u0026rdquo; option applied for the management of kidney stones in all parts of the world [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSWL was first introduced in the early 1980s as a technique that uses shock waves generated outside the body to fragment urinary stones [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This method allows kidney stones to be disintegrated into smaller pieces, which then may pass spontaneously through the urinary tract [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Over the years, parallel to technological advancements noted lithotriptor technology, the safety and efficacy of SWL have improved considerably, making it a preferred method in the effective and safe management of both kidney or ureteral stones [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite its noninvasive, practical and highly safe application however, it has been well shown that the success rates of SWL applications may vary depending on several factors, such as stone size, stone location, hardness, and body mass index (BMI) of the cases treated [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Reported studies have shown that the success rates for stones smaller than 2 cm range between 70% and 90% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the effectiveness decreases for larger or harder stones where repeated sessions and auxiliary procedures may be required.\u003c/p\u003e \u003cp\u003eOn the other hand again, despite its widespread acceptance, SWL has some certain disadvantages such as the potential for renal injury in risk patients, the chance of incomplete stone clearance and the need for additional procedures in patients with residual fragments. However, due to its non-invasive nature, minimal anesthesia requirements, and the possibility of outpatient treatment, SWL remains a valuable option in the management of urolithiasis. Outcomes will be even more successful if the decision making is made with a very careful patient/stone selection based on the clear indications given in the published guidelines and the treatments are carried out with an effective lithotriptor [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study focuses specifically on outcomes with the Modulith SLK Inline lithotripter, known for its precision in targeting and fragmenting stones. In line with EAU Guidelines for Urolithiasis treatment, successful SWL treatment relies on factors such as stone size, hardness, patient habitus, and the lithotripter used. This study aims to present data that demonstrates the success of this device when paired with guideline-based patient selection criteria. Thus, in this present study we aimed to evaluate the overall success rate of Shock Wave Lithotripsy (SWL) performed with an effective lithotriptor in the non-invasive treatment of kidney stones in a single center.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e This retrospective study was conducted between June 2023 and June 2024, following approval by the local Ethics Committee (approval number: 298/2024). A total of 208 patients undergoing SWL for renal medium sized (\u0026lt;\u0026thinsp;15 mm) stones were included. Informed consent was obtained from all patients prior to the procedure.\u003c/p\u003e \u003cp\u003eWhile adult patients (\u0026gt;\u0026thinsp;18 years), with radiologically confirmed opaque renal stones (\u0026lt;\u0026thinsp;15 mm) located in the different parts of the kidney, were included in the study. The overall mean stone size was 9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 mm (7.4 mm- 15.0 mm). Patients with a solitary kidney, renal functional deterioration, significant skeletal deformities, active urinary tract infections, pregnancy, or coagulopathies were excluded from the study program.\u003c/p\u003e \u003cp\u003eIn addition to the plain abdominal film and sonographic evaluation, the diagnosis and detailed characteristics of renal stones were confirmed with non-contrast computed tomography (NCCT) in all cases. In addition to the location and size, the density of the stones was assessed in the NCCT images in terms of Hounsfield Unit (HU) values.\u003c/p\u003e \u003cp\u003eAll patients underwent a comprehensive clinical evaluation, including urinalysis, urine culture test, complete blood count, coagulation profile, and renal function tests. Patients were instructed to fast for at least 6 hours prior to the procedure, and prophylactic antibiotics were administered if deemed necessary.\u003c/p\u003e \u003cp\u003eSWL procedures were performed using a Modulith SLK inline lithotripter (Storz Medical, Switzerland), under analgesic treatment with non-steroidal anti-inflammatory drugs (NSAIDs). Patients were positioned in the supine position, and stones were localized using fluoroscopy or ultrasonography. Regarding stone localization during treatment, the inline imaging capabilities of the MODULITH SLK Inline lithotripter system increase precision by allowing real-time visualization of stone targeting and highly effective fragmentation. This not only improves stone clearance rates, but also reduces the risk of complications. The unique stone-directed shockwave delivery with perfect alignment (keeping the stone always in the shockwave path) offers, an innovative and patient-centered approach to SWL, providing a non-invasive yet highly effective treatment solution for stones. Sedative analgesia with pethidine was administered in selected cases, but none of the patients required general anesthesia. A total of 3000 shock waves were delivered per session.\u003c/p\u003e \u003cp\u003eTreatment sessions were repeated at 7-day intervals, with a maximum of 3 sessions per patient, depending on the degree of stone fragmentation and the patient\u0026rsquo;s response to treatment.\u003c/p\u003e \u003cp\u003eTo assess the stone-free (SF) status, a plain abdominal X-ray (KUB) was performed on the 7th day after the last SWL session. Final stone-free status was evaluated with non-contrast CT (NCCT) three months after the last treatment session. Complete stone clearance ( stone free status) was defined as the absence of any detectable stones or the presence of clinically insignificant residual fragments (less than 4 mm).\u003c/p\u003e \u003cp\u003eFailure was defined as the presence of residual stone fragments larger than 4 mm after 3 successful SWL sessions. Symptomatic patients was offered alternative treatment options such as ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL), depending on the size and location of the residual stones.\u003c/p\u003e \u003cp\u003eFor statistical analysis, mean and standard deviation (SD) values were calculated. Independent t-test and Mann-Whitney U test were used for this purpose. The Chi-square test was employed for categorical parameters. One-way ANOVA was used to compare stone-free rates across different stone localizations. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 208 patients undergoing SWL were included into this study program. The mean age of the patients was 42.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7 years, with an age range of 18\u0026ndash;75 years. Of these patients, 137 (65.9%) were male and 71 (34.1%) were female ( M/F 1.9:1). There was no statistically significant relationship between gender and treatment success (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.60) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe demographic characteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic Characteristics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale patients (n,%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137 (65.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale patients (n,%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (34.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003eThe distribution of stones based on their localization within the kidney is as follows: 58 patients (27.9%) had stones located in the renal pelvis, 27 patients (13.0%) in the upper calyx, 56 patients (26.9%) in the middle calyx, and 67 patients (32.2%) in the lower calyx. Following SWL treatment, completely stone-free status was achieved in 49 out of 58 patients (84.5%) with stones in the renal pelvis, while 5 patients (8.6%) had residual fragments (\u0026lt;\u0026thinsp;4 mm), and 4 patients (6.9%) experienced treatment failure. In cases with the upper calyceal calculi, 23 out of 27 patients (85.2%) became stone-free, with 1 patient (3.7%) having residual fragments and 3 patients (11.1%) experiencing treatment failure. In the middle calyx, successful outcomes were achieved in 43 out of 56 patients (76.8%), with residual fragments in 9 patients (16.1%) and treatment failure in 4 patients (7.1%). In the lower calyx, 49 out of 67 patients (73.1%) became stone-free, while 13 patients (19.4%) had residual fragments, and 5 patients (7.5%) experienced treatment failure.\u003c/p\u003e \u003cp\u003eThe chi-square test evaluating the relationship between stone localization within the kidney and treatment success rates indicated no statistically significant difference between stone localization and treatment success (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.377). The overall evaluation of success rates for all stones, SWL was found to be successful in 164 out of 208 patients (78.8%) with completely stone-free status, residual fragments (\u0026lt;\u0026thinsp;4 mm) were present in 28 patients (13.5%), and treatment failure occurred in 16 patients (7.7%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Based on these outcomes we may say that the overall success rate of SWL in renal stones sizing\u0026thinsp;\u0026lt;\u0026thinsp;15 mm will be 92.3% with the inclusion of asymptomatic small fragments (\u0026lt;\u0026thinsp;4 mm) which could be passed spontaneously over time.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStone Localization Distribution and Treatment Success Rates and Outcomes for Each Localization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStone Localization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Patients (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStone-free (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResidual Fragments (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFailed (n, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49 (84.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper calyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle calyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43 (76.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower calyx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49 (73.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13 (19.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e164 (78.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003cp\u003eThe mean Hounsfield Unit (HU) of the stones in the patients included in the study was determined to be 874.0\u0026thinsp;\u0026plusmn;\u0026thinsp;283.2 (263\u0026ndash;1781). While this value was 862.7\u0026thinsp;\u0026plusmn;\u0026thinsp;286.2 in patients who achieved a completely stone-free status, it was 1032.5\u0026thinsp;\u0026plusmn;\u0026thinsp;360.2 in those with residual fragments or treatment failure, statistical analysis of HU difference between these groups showed a statistically significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049). It was particularly noted that stones with an HU value below 1000 had a higher likelihood of being effectively fragmented and cleared with SWL (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of the success rates based on mean Hounsfield Unit (HU) Values\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean HU\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall stones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e874.0\u0026thinsp;\u0026plusmn;\u0026thinsp;283.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStone-free\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e862.7\u0026thinsp;\u0026plusmn;\u0026thinsp;286.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual fragments or Failed treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10325\u0026thinsp;\u0026plusmn;\u0026thinsp;360.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cp\u003eWhen examining the relationship between stone size and treatment success, while the mean stone size was calculated as 10.3 mm (7.4\u0026ndash;15.2 mm) in patients with successful outcomes, it was 12.5 mm (9.1\u0026ndash;13.9 mm) in those with residual fragments or treatment failure. Again a statistically significant relationship was found between stone size and SWL success (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eFinally, evaluation of the complications observed in our group revealed hematuria, to be the most common complication being detected in 132 patients (63.4%). It was managed conservatively with high fluid intake and resolved spontaneously in the vast majority of the cases. As the second most common complication, renal colic was observed in 11 patients (5.3%) and managed with analgesics/antispasmodic agents which revealed symptoms in all patients. Steinstrasse was observed in only 1 patient (0.5%) and this patient was treated with ureteral stent placement. Last but not least, renal hematoma formation was noted in 2 patients (0.9%), and both cases were managed with close monitoring and supportive care, resulting in spontaneous resolution without necessitating any further interventions (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications Observed After SWL\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal colic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSteinstrasse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The EAU Guidelines for Urolithiasis treatment emphasize that the success of SWL is influenced by factors including stone characteristics, patient habitus, and the efficacy of the lithotripter itself. This study highlights that not all lithotripters perform equally; the superior technology of the Modulith SLK Inline can achieve better outcomes than older or less precise devices.\u003c/p\u003e \u003cp\u003ePoor lithotripter performance or improper case selection often results in suboptimal outcomes and higher retreatment rates. In contrast, advanced shockwave technology like the Modulith SLK Inline, combined with careful patient selection per EAU criteria, provides a pathway to high success rates in SWL without resorting to invasive procedures. This study\u0026rsquo;s findings validate the importance of choosing an effective lithotripter and adhering to best practices, ultimately supporting the Modulith SLK Inline\u0026rsquo;s role in improving patient outcomes and minimizing the need for surgical alternatives.\u003c/p\u003e \u003cp\u003eSWL has been clinically introduced in 1980 by Chaussy et al., and became the preferred treatment modality in the \u0026ldquo;true noninvasive\u0026rdquo; management of urinary stones with the safe and effective results obtained both in adults and children [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The practical and cost effective characteristics of this modality have led the urologists to perform it in more than 90% of the medium sized (10\u0026ndash;20 mm) stones in adult patients without any anesthesia requirement as well as hospitalization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Currently both EAU and AUA guidelines still recommend this particular modality as the preferred option for stones sizing less than 20 mm [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to these facts, as we all know well, the clinical practice patterns of urinary stone management have been found to be affected to a certain extent by the COVID-19 pandemic. Unprecedented introduction of COVID-19 has dramatically influenced all parts of medicine and changed our practice patterns in stone management to a certain extent by selecting the best approach particularly in urgent cases and postpone and/or reschedule elective procedures to limit the risk of infection spread. Based on the facts and evident changes in the practice patterns, elective stone procedures such as RIRS and PCNL needed to be postponed during the outbreak of the pandemic. While timely management of these cases in the emergency department was crucial, other urgent solutions including medical management to some extent and widespread application of SWL (in an outpatient based manner) gained more importance. SWL was the only treatment choice which allowed stone management without any anesthesia and relevant risks for the spread of the infection during this critical period.\u003c/p\u003e \u003cp\u003eSignificant compulsory alterations in stone related interventions were noted in all parts of the world and in a well conducted survey during this period, vast majority of the experts (89.4%) tended to change their treatment strategy particularly in patients referring to the emergency departments during COVID-19 period. As a \u0026ldquo;true noninvasive\u0026rdquo; modality, SWL emerged as a very valuable alternative during this highly critical era (in other words its revival has been realized) with advantages of no anesthesia requirement, chance of treatment away from the patient and less risk of disease spread [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, despite its noninvasive, practical and successful nat\u0026uuml;re, SWL mat has some certain disadvantages. As a major factor, it is well known that the efficacy of this modality tends to diminish in patients with hard (with high density) and larger sized stones (\u0026gt;\u0026thinsp;20 mm). Some minor complications (pain, hematuria and obstruction) and auxiliary procedures for complete stone clearance could be required in certain percent of such cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Thus, treatment outcomes may be influenced by some unpredictable stone (size, composition, location) and patient (BMI, collecting system anatomy) factors. A dedicated experienced team, careful patient selection along with a cooperative work with the cases are crucial factors for a successful SWL procedure. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Last but not least, certain stone types, such as cysteine or calcium oxalate monohydrate stones, may not respond optimally to SWL and may necessitate alternative treatment methods [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the light of the facts mentioned above, it is clear that although the role of minimal invasive flexible ureteroscopic stone treatment tended to increase over the last 2\u0026ndash;3 decades, accumulated published data in literature has revealed comparable stone free rates between these two modalities particularly for small (less than 1 cm) and medium (1 to 2 cm) sized renal stones [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, it should be kept in mind well that, despite its minimally invasive nature, ureteroscopic procedures may reveal certain complications as a major disadvantage when compared with SWL [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe reported success rates after SWL in terms of SF status were found to range between 48% and 85%. Related to this issue, while Padhye et al. reported an overall stone-free rate of 91.7% in upper tract stones [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Ghimire et al. reported a clearance rate of 91.1% in 112 patients with renal stones [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, success rates of 74% for kidney stones and 88% for ureteric stones were reported by Al-Marhoon et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. When the outcomes were evaluated in a stone size based manner, Gupta et al. found a higher stone clearance rate of 90.8% for relatively smaller stones (\u0026lt;\u0026thinsp;11 mm ) with a mean stone density value of 750 HU [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These results were inconsistent with the outcomes reported by Hamal et al., where 85.9%, 90.25%, and 50.5% success rates for the upper, middle, and lower calyx, respectively [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith respect to the complications associated with SWL applications, limited minor ( flank region pain or discomfort and microscopic haematuria) complications have been reported in the literature [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvaluation of our results revealed that the overall complete SF rate after SWL treatment was found to be 78.8%. Evaluation of the success rates on stone location based manner, revealed that while a complete SF status was achieved in 84.5% of renal pelvic stones these rates were 85.2% in cases with upper calyx stones,76.8% in the middle and 73.1% in lower calyx stones. In addition to the size of the stone the hardness (HU value) was found to be another critical parameter to be taken into account for a successful outcome after SWL. Related to this issue, while the mean HU was 862.7\u0026thinsp;\u0026plusmn;\u0026thinsp;286.2 in patients with successful outcomes, the mean HU was found to be 1032.5\u0026thinsp;\u0026plusmn;\u0026thinsp;360.2 in unsuccessful patients with residual fragments with statistically significant difference between two groups of cases.\u003c/p\u003e \u003cp\u003eLast but not least, stone size was calculated as 10.3 mm in patients with successful outcomes, while it was 12.5 mm in those with residual fragments or treatment failure. A statistically significant relationship was found between stone size and SWL success (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIn the light of our findings and the reported data in the literature we may definitely emphasize the important place of SWL both in adults and pediatric cases when indications are selected in a proper way. SWL has gained more importance particularly after the critical COVID 19 era and it is still the best treatment alternative in the noninvasive management of upper tract calculi with its high success and significantly limited complication rates. The application needs to be done by an experienced team based on technical requirements. Patient selection is the key factor and as our results also indicate it seems to be the preferred treatment choice for stones sizing less than 15 mm with a HU value of \u0026lt;\u0026thinsp;1000. By this way the vast majority of such stones will be treated in a safe manner without any need for more invasive procedures which are significantly prone to more severe complications. Patients need to be a part of the decision making period where they really will get detailed information about the advantages and disadvantages of all available management options for a rational decision.\u003c/p\u003e \u003cp\u003eOur study is not free of limitations. First of all, the retrospective nat\u0026uuml;re of the methodology and relatively smaller number of the cases (although it is an acceptable caseload treated in a year period) might constitute a major drawback. Additionally, lack of long term evaluation of the cases for possible complications might be another limitation to be stated. However, as our main aim is to outline the efficacy and safety of SWL in the management of carefully selected cases, we believe that our results will highlight the valuable place of this modality in the \u0026ldquo;true noninvasive\u0026rdquo; management of such cases. SWL has its important place among the other treatment alternatives particularly demonstrating its \u0026ldquo;revival\u0026rdquo; after COVID-19 era with guidelines based on clear indications.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn light of our findings and existing literature, SWL holds a vital role in the non-invasive management of small to medium-sized stones in both adult and pediatric cases. SWL\u0026rsquo;s significance has grown, especially following the COVID-19 era, positioning it as a preferred treatment alternative for upper urinary tract stones due to its high success rate and minimal complications when performed by an experienced team according to guideline-based indications. Our study demonstrated that SWL, using the advanced Modulith SLK Inline lithotripter, achieved a complete stone-free rate of 78.8%. However, as stone size and hardness increased, success rates declined, highlighting the importance of precise case selection. Patients with smaller stones (\u0026lt;\u0026thinsp;15 mm) and lower HU values achieved notably higher success rates. These findings reinforce that SWL, supported by advancements in lithotripter technology, remains a valuable non-invasive option, especially for stones under 15 mm. The Modulith SLK Inline\u0026rsquo;s enhanced capabilities underscore its effectiveness in optimizing treatment outcomes and reducing the need for surgical interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAA and GŞ collected the patient data, GS performed the statistical analyses, EE and KS wrote the manuscript, and all authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePearle MS, Goldfarb DS, Assimos DG et al (2014) Medical management of kidney stones: AUA guideline. J Urol 192(2):316\u0026ndash;324. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.juro.2014.05.006\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2014.05.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026uuml;rk C, Petř\u0026iacute;k A, Sarica K et al (2016) EAU guidelines on diagnosis and conservative management of urolithiasis. Eur Urol 69(3):468\u0026ndash;474. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.eururo.2015.07.040\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2015.07.040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssimos D, Krambeck A, Miller NL et al (2016) Surgical management of stones: American Urological Association/Endourological Society Guideline, Part I. 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BJU Int 95(9):1285\u0026ndash;1288. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1464-410X.2005.05520.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2005.05520.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamal BK, Bhandari BB, Thapa N (2015) Extracorporeal shock wave lithotripsy in management of urolithiasis. J Patan Acad Health Sci 20(1):4\u0026ndash;7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalem S, Mehrsai A, Zartab H, Shahdadi N, Pourmand G (2010) Complications and outcomes following extracorporeal shock wave lithotripsy: A prospective study of 3,241 patients. Urol Res 38(2):135\u0026ndash;142. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00240-009-0247-8\u003c/span\u003e\u003cspan address=\"10.1007/s00240-009-0247-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Shock wave lithotripsy, Kidney stones, Modulith SLK Inline, Treatment success, Lithotripter technology","lastPublishedDoi":"10.21203/rs.3.rs-5441405/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5441405/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e This study aims to evaluate the success rate of Shock Wave Lithotripsy (SWL) in treating kidney stones using the Modulith SLK Inline lithotripter, with a focus on the importance of device efficacy as emphasized in EAU guidelines.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatients and methods\u003c/b\u003e: This retrospective single-center study includes 208 patients who underwent SWL treatment for kidney stones between June 2023 and June 2024. Treatment outcomes were collected and analyzed in detail, considering patients' demographic characteristics (age, gender) and stone parameters (size, location, and hardness [Hounsfield Unit, HU]). The success of SWL was defined as achieving complete stone clearance or the presence of clinically insignificant residual fragments (CIRF) (\u0026lt;\u0026thinsp;4 mm). This sample of 208 patients was specifically selected to evaluate the performance of the Modulith SLK Inline lithotripter in treating stones smaller than 15 mm, aiming to examine SWL\u0026rsquo;s potential as a non-invasive yet effective treatment option for smaller, more manageable stones. This study seeks to provide detailed insights into the optimal use cases of SWL.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: The mean age of the 208 patients was 42.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7 years (18\u0026ndash;75), with a male-to-female ratio of 1.9:1. The overall success rate of SWL was 78.8%, with 164 patients achieving a complete stone-free status. With the inclusion of the cases with CIRF the overall success rate was assessed as 92.3%. While the mean stone size in successful cases was 10.3 mm, this value was 12.5 mm, in cases with residual fragments or treatment failure. A statistically significant relationship was found between stone size and treatment success rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean Hounsfield Unit (HU) value for all patients was 874.0\u0026thinsp;\u0026plusmn;\u0026thinsp;283.2, with significantly lower HU values in patients who achieved a completely stone-free status (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049). Stone localization did not significantly affect the success rates after SWL (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.377).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e: SWL has demonstrated its effectiveness in kidney stone treatment with a 78.8% complete stone-free rate using the Modulith SLK Inline lithotripter. Higher success rates were achieved with smaller stones (\u0026lt;\u0026thinsp;15 mm) and lower HU values. These findings support the significance of advanced lithotripter technology in establishing SWL as a valuable non-invasive option for stones under 15 mm.\u003c/p\u003e","manuscriptTitle":"Impact of Advanced Lithotripter Technology on SWL Success: Insights from Modulith SLK Inline Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-02 14:31:35","doi":"10.21203/rs.3.rs-5441405/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-14T09:38:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-26T12:17:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299081427763399306992976121564647054832","date":"2024-12-18T13:22:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184595067298577410236402684408437892142","date":"2024-12-18T09:45:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116484876885824480053975843751151125360","date":"2024-12-16T13:23:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-29T10:54:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-15T12:23:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-14T17:41:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2024-11-12T17:02:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"46713612-5511-44e5-b003-335d5f2c7177","owner":[],"postedDate":"December 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:05:38+00:00","versionOfRecord":{"articleIdentity":"rs-5441405","link":"https://doi.org/10.1007/s00345-025-05517-4","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2025-02-25 15:57:52","publishedOnDateReadable":"February 25th, 2025"},"versionCreatedAt":"2024-12-02 14:31:35","video":"","vorDoi":"10.1007/s00345-025-05517-4","vorDoiUrl":"https://doi.org/10.1007/s00345-025-05517-4","workflowStages":[]},"version":"v1","identity":"rs-5441405","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5441405","identity":"rs-5441405","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}