Context The introduction of new lithotripters has increased problems associated with shock wave application. Recent studies concerning mechanisms of stone disintegration, shock wave focusing, coupling, and application have appeared that may address some of these problems. Objective To present a consensus with respect to the physics and techniques used by urologists, physicists, and representatives of European lithotripter companies. Evidence acquisition We reviewed recent literature (PubMed, Embase, Medline) that focused on the physics of shock waves, theories of stone disintegration, and studies on optimising shock wave application. In addition, we used relevant information from a consensus meeting of the German Society of Shock Wave Lithotripsy. Evidence synthesis Besides established mechanisms describing initial fragmentation (tear and shear forces, spallation, cavitation, quasi-static squeezing), the model of dynamic squeezing offers new insight in stone comminution. Manufacturers have modified sources to either enlarge the focal zone or offer different focal sizes. The efficacy of extracorporeal shock wave lithotripsy (ESWL) can be increased by lowering the pulse rate to 60–80 shock waves/min and by ramping the shock wave energy. With the water cushion, the quality of coupling has become a critical factor that depends on the amount, viscosity, and temperature of the gel. Fluoroscopy time can be reduced by automated localisation or the use of optical and acoustic tracking systems. There is a trend towards larger focal zones and lower shock wave pressures. Conclusions New theories for stone disintegration favour the use of shock wave sources with larger focal zones. Use of slower pulse rates, ramping strategies, and adequate coupling of the shock wave head can significantly increase the efficacy and safety of ESWL.

Aim: Despite the extensive experience with minimal invasive stone therapy, there are still different views on the ideal management of renal stones. Materials and Methods: Analysis of the literature includes more than 14,000 patients. We have compared these data with long–term results of two major stone centers in Germany. The results have been compared concerning the anatomical kidney situation, stone size, stone localization and observation time. Results: According to the importance of residual fragments following extracorporeal shock wave lithotripsy (ESWL), we have to distinguish between clinically insignificant residual fragments and clinically significant residual fragments (CIRF). 24 months following ESWL stone passage occurs as a continous process, and if there are no clinical symptoms, any endoscopic procedure should be considered as overtreatment. According to these results, stone–free rates of patients increase in longer follow–up periods. Newer ESWL technology has increased the percentage of CIRF. Conclusion: We consider ESWL in most patients with renal calculi as first–line treatment, except in patients with renal calculi bigger than 30 mm in diameter.

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Most of our knowledge of shockwave-induced renal damage is based on animal experiments and clinical observation. We developed a tissue model using isolated porcine kidneys perfused with Berliner Blau dye in physiologic saline using a Ureteromat Perez-Castro peristaltic pump connected to the renal artery. Reproducible results were obtained under a variety of experimental conditions. Further refinements of the model might consist of interposition of tissue layers in the shockwave path or simulation of ventilatory movements.