1. Dr. Gustavo Minuzzi Dr. Sandro Varea Sanatorio Allende Cerro, Cordoba, Argentina Extracorporeal Shockwave Lithotripsy

2. Extracorporeal Shockwave Lithotripsy model Duet Magna

3. Duet Magna Equipment  2 Reflectors at 76 degrees  Double Shockwave  Fluoroscopic and Ultrasonographic Localization  In most cases 2 reflectors are used, except some cases involving middle and lower ureter

4. Prospective Study KidneyN%UreterN% Lower calyx3630%Upper2420% Middle calyx65%Middle43% Upper calyx65%Lower3629% UPJ108% December 2010 to February 2012 123 patients with urolithiasis (renal and ureteral) 48% were located in the kidney and 52% in the ureter

5. Distribution According to Stone Size 5-8 mm 9- 12 mm > 12mm Renal 29 11 18 Ureteral 24 27 13 The average size of the treated calculi was 10 mm (min 4 - max 20)

6. Analgesia / Sedation Used Analgesia  Analgesia  115 patients Diclofenac 75 mg.  4 patients tramadol.  Sedation   4 patients with propofol.

7. Shockwave Details  Kidney (average): # Shocks : 3956 Frequency: 84 / minute Treatment time = 47 min.  Ureter (average): # Shocks : 3754 Frequency: 84 / minute Treatment time = 45 min.

8. Results for Renal Stone Treatments Stone-FreeFragments < 4 mm Success Rate Fragments > 4 mm NoFragmentation Total 60.3%34.5%94.8%5.2% ___ UPJ 50%40%90%10% ___ Upper calyx 83.3%16.7%100% ___ Middle calyx 16.6%66.7%83.3%16.7% ___ Lower calyx 63.8%30.6%94.4%5.6% ___

9. Results for Ureteral Stone Treatments Stone-Free Fragments < 4 mm Success Rate Fragments > 4 mm No Fragmentation Total 67.2%9.3% 76.5% 4.6%18.7% Upper ureter 70.8%16.6%87.4%4.2%8.3% Middle ureter 50% ___ 50% ___ 50% Lower ureter 66.7%5.5%72.2%5.5%22.2

10. Average Treatment Time 1.65 General Average: 1.65 Stone-Free Fragments < 4mm Fragments > 4 mm No Fragmentation Average Kidney 1.581.851.5___1.67 Ureter 1.531.51.331.661.54

11. Subjective Pain Sensation  An analog pain scale from 1 to 10 was used  113 patients reported pain sensation between 2 and 5  10 patients reported pain sensation between 6 and 7.

12. Complications / Side-effects  Complications: We had no serious complications such as perirenal Hematoma or sepsis  Side-effects:  Mild hematuria (less than 24 hours without the need of admission) : 41.8 %  Renal colic : 8.9 %  Stein strasse : 3.2 %

13. Conclusion  We have tested the feasibility to perform renal and ureteral calculi treatment with Dual Electromagnetic Shock Wave Technology using only oral analgesia. In our experience it yields satisfactory results, comparable to other lithotripsy systems.