Ultrasound Monitoring of Kidney Stone Extracorporeal Shockwave Lithotripsy with an External Transducer: Does Fatty Tissue Cause Image Distortions That Affect Stone Comminution?

Ultrasound imaging, using either an inline or an external transducer, is a standard method for extracorporeal shockwave lithotripsy (SWL) monitoring. This study investigates whether image distortions caused by the low sound speed of fatty tissue could lead to incorrect stone positioning such that disintegration is affected.To define the accuracy needed for SWL monitoring, the dependency of fragmentation efficiency on the distance between stone center and SWL focus was examined by in vitro model stone tests. In a clinical study, 15 patients with kidney stones were treated with a Dornier Sigma FarSight. This lithotripter was equipped with both an inline and an external transducer. They were operated alternately to check for inconsistencies, which would indicate ultrasound image distortions. In addition, the ultrasound paths from the transducer to the SWL focus were analyzed for error estimation.In the model stone tests, the number of shock waves required for complete fragmentation doubled if the stone was about 7.5 to 10 mm off focus in lateral direction. In the clinical trial, the stone positions obtained from an inline and an external transducer coincided within a 5 mm range of tolerance, but that approach suffered from some practical difficulties, resulting in measurement imprecision. The sound path analysis showed that the lengths through fatty tissue were too short to result in significant image distortion. The body mass index (20-31 kg/m(2)) was representative, except for very obese patients. Additional confirmation of correct stone positioning could be achieved quite easily by looking for pixel movement in the B-mode image or employing Doppler hit/miss monitoring.Within the study group, no image distortion caused by fatty tissue that could be clinically relevant for SWL was observed.