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LITHOSTAR Modularis - A Proven System with New, Innovative Features

Article · January 2003

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LITHOSTAR Modularis –
A Proven System with New, Innovative Features

B. Granz, M. Lanski, R. Nanke, M. Mahler, A. Rohwedder, C. Chaussy, S. Thüroff

Reprint from electromedica 1, 2003, page 53-57
 Innovative Methods – Advanced Modalities
LITHOSTAR Modularis –
A Proven System with New, Innovative Features
B. Granz 1, M. Lanski 1, R. Nanke 1, M. Mahler 1, A. Rohwedder 1, C. Chaussy 2, S. Thüroff 2
1
Siemens AG, Medical Solutions, Erlangen, Germany
2
Munich-Harlaching Teaching Hospital, Ludwig Maximilian University, Munich, Germany
Keywords
• lithotripsy module • shock wave parameter
• shock wave head • C-arm coupling
Abstract
Two innovations by the Siemens Medical Solutions
division Med SP expand and optimize the potential
applications for the clinical workflow of the known
urological platform MODULARIS Uro Plus.
First, another lithotripsy module, the LITHOSTAR™
Modularis Vario (Siemens AG, Medical Solutions),
was developed in addition basing on the conventional
LITHOSTAR Modularis, which features a special
mechanical coupling system that now also allows the
adaptation of the SIREMOBIL Compact L, along with
the use of numerous X-ray C-arms from other manu-
facturers. Second, a new shock wave therapy head was
developed for both lithotripsy modules, the LITHOSTAR
Modularis and LITHOSTAR Modularis Vario, with the
objective of increasing efficiency relative to safety of
treatment, ease of use and patient comfort.
Mathematical modeling has made it possible to
further improve the shock wave parameters. Increasing
the penetration depth to 14 cm makes it easier to adjust
the shock wave focus on the concretion to be treated,
especially in adipose patients, thereby resulting in a
distinctly elevated rate of therapeutic effect, and hence
efficacy.
In addition, the conventional spark gap in the electri-
cal circuit was replaced by the new semiconductor switch
for triggering the shock wave, reducing the maintenance
considerably.
These innovations and new products allow for better
customer benefits of the modular urological platform
Siemens MODULARIS.
53 electromedica 71 (2003) no. 1
80
60
Pressure [MPa]
40
20
-20 Steep edge caused
by nonlinear effects
-40
0 1 2 3 4 5 6
Time [µs]
Fig. 1
Typical time-dependent behaviour
of pressure in shock wave focus.
Introduction
Extracorporeal shock wave lithotripsy (ESWL), the
disintegration of urinary stones using focused ultrasound
shock waves, has been the method of choice in uro-
lithiasis since its introduction over 20 years ago. The
electromagnetic shock wave head, first introduced on
the market with the LITHOSTAR from Siemens, has
gained universal acceptance among the three physical
principles for shock wave generation. Even many users
of the “first-generation” electrohydraulic shock wave
generation principle or the piezoelectric principle have
switched to the electromagnetic shock wave. After three
successive lithotripter systems generations that were
introduced in 1980, 1987 and 1998, respectively, there
appears to be little leeway for new development as loca-
lization, operation and patient comfort became increas-
ingly perfected. While there might be no revolutions,
consistent progress requires that we take numerous small
steps in the right direction. To this end, we always draw
on verified research results, analytically classifying and
utilizing other worldwide results of our customers in
addition to our own studies.
 Lithotripters generate pressure pulses that are
steepened up by nonlinear propagation to shock waves
in the focus, which is directed at the urinary stones, and
appear impressive in their steepness and maximal peak
pressure values (Fig. 1). Pressure peaks normally range
from 50 to 150 MPa (500 to 1500 bar). And yet, this
often propagated and advertised peak pressure value
alone is irrelevant for stone disintegration. It has been
scientifically proven that the energy content of an
expanded focus with moderate peak sound pressure
results in extensive stone disintegration, and not the
narrow, high-pressure peak [1]. We have always used
this principle in our LITHOSTAR products [2, 3], and
this with great success [4]. Current studies that describe
the process of stone disintegration in lithotripsy [5]
confirm this approach. We are currently offering the
LITHOSTAR Multiline and LITHOSTAR Modularis
(Fig. 2), two lithotripters that permit all urological stone
treatments.
We are also continuing to consistently pursue this
successful course with our latest shock wave therapy
head, which is being implemented in the LITHOSTAR
Modularis and LITHOSTAR Modularis Vario lithotripsy
modules. Described below are the novel methods and
components that have been incorporated in the new
shock wave module: Modeling methods for optimizing
shock wave generation, increase in the penetration depth
to 14 cm, use of a semiconductor switch and the mecha-
nical coupling system for various X-ray C-arms.
Materials and Methods
Modeling Methods for Optimizing Shock Wave
Generation
Mathematically modeling the formation and propa-
gation of the shock wave from the electromagnetic source
[2] up to the focus is indispensable for fine tuning and
utilizing optimal components. How an electromagnetic
shock wave source works is described in detail in [6]
along with the physical correlations. A charged high-
voltage capacitor is instantaneously discharged via a flat
coil, in front of which a metal membrane is situated as a
secondary coil. The mutual magnetic repulsion between
the two coils (Lenz’ rule) pushes the membrane in
an adjacent water volume, thereby generating a plane
pressure wave, which is then concentrated in the focus
by an acoustic lens. This plane wave directly after the
membrane already embodies all characteristics essential
for stone disintegration, e. g., energy.
In principle focusing merely concentrates the initial
sonic energy on a small area, thus increasing the field
parameters pressure and intensity by the focal gain.
Absorption and reflection are neglected in this context.
The local effect of the shock wave in the focus solely ori-
ginates from the raising of the pressure and the intensity
by the focal gain above the stone disintegration threshold
[7], a value characteristic for kidney stones.
It is sufficient to consider the initial plane pressure
wave at the membrane to optimize shock wave energy.
Fig. 2
Presentation of
MODULARIS Litho with
MODULARIS Uro
endourology table,
SIREMOBIL Iso-C X-ray
C-arm and LITHOSTAR
Modularis lithotripsy module.
electromedica 71 (2003) no. 1 54
Innovative Methods – Advanced Modalities
To this end, a finite element program is used to model
the flat coil with its individual windings and the mem-
brane. Since we assume an axially symmetrical system, a
Membrane two-dimensional calculation is sufficient. The tightly
packed magnetic field between the coil and membrane
Axis of Symmetry

along with the low ambient stray field emerge as the

initial result (Fig. 3).
Additional results of this calculation include macros-
Flat coil
Magnetic
copic values like stray inductance and electrical resis-
field lines tance of the flat coil. The time-dependent currents and
magnetic forces between the flat coil and membrane
can then be calculated for the oscillator comprised of
the high-voltage capacitor, flat coil and additional
Fig. 3 cable inductances (Fig. 4). Solving Newton’s differential
Magnetic field distribution
between flat coil and membrane equation of motion, which includes the membrane mass
as well as in environment. to be accelerated and the water compression adjacent
to the membrane as additional components, results in the
time dependent displacement z(t) of the membrane. All
other quantities, like membrane pressure or energy, can
Switch
be derived from this displacement z(t) and the known
surface area. As a result, the ultrasound characteristics of
the system are set.
High voltage

Coil

Capacitor
Fig. 5 shows the time-dependent displacement z(t)
Resistor of the membrane for three different coil configurations.
As evident, there is rapid movement within the first 5 µs,
until a plateau with a displacement of about 10-30 µm is
reached after about 15 µs when the damped oscillation of
the oscillator has decayed. A high displacement means
Fig. 4
Schematic diagram of an electro-
both high pressure at this location and high mechanical
magnetic shock wave source. tensile stress on the membrane. As an alternative, the
Closing the switch initiates the desired high energy can be achieved by increasing the
shock wave generation. winding surface area at a smaller membrane displace-
ment. Varying the sole input variable “flat coil winding”
hence makes it possible to find the optimum pressure
and energy values for the target values high source
30
service life and stone disintegration.
Configuration A
Membrane extension [µm]

25

20 Increase of Penetration Depth to 14 cm

15
Configuration B The above statements would suggest that it makes
no difference if the stone to be disintegrated lies in the
10
Configuration C axial focus or not, since the shock wave energy is identi-
5 cal in areas in front of and behind it (disregarding tissue
0
absorption). By contrast, it is true that disintegration is
0 5 10 15 20 25 30 most effective in the focus, since the energy here is
Time [µs] concentrated on an area tailored to the stone size, and
a high percentage of the pressure is above the disinte-
Fig. 5 gration threshold. As shown by the axial distribution of
Time-dependent behaviour of positive pressure peak p + in Fig. 6, the source of the two
membrane extension for various
coil configurations. MODULARIS lithotripsy modules now has a focus
distance of 14 cm instead of the previous 12 cm. With the
matched penetration depth of up to 14 cm, the new shock
wave source conforms to the anatomical realities and
expanded indications of ESWL, and can simplify treat-
ment courses in obese patients.
electromedica 71 (2003) no. 1 55
 In addition to this application-related advantage,
closer examination of the basic physical relations
reveals another positive effect of increasing the axial
focus position. The following applies by approximation
for the full width half maximum (fwhm) ∆x of the lateral
focal pressure distribution of a monofrequent acoustic
wave:
∆x = 1.4 •  • F / A (1)
where  is the wavelength in the propagation medium,
F is the focus distance and A is the effective aperture of
the focusing lens. The axial fwhm ∆z is about 10 times
greater than ∆x. Even though an ultrasound shock wave
pulse in the focus is far from monofrequent (Fig. 1), this
approximation is helpful. As evident from formula (1),
shifting the focus position from 12 to 14 cm increases
the fwhm by the same ratio, i. e., a greater active focus
is obtained for stone disintegration, when the energy
of the shock wave is increased concurrently. In addition
to simplifying adjustment, this also increases the shock
wave treatment efficiency, and a lower retreatment rate
is prognosed [8]. All effects achieved by increasing
the focus position are therefore of the same positive
nature.
Implementation of a Semiconductor Switch
Fig. 4 shows the schematic diagram of an electro-
magnetic shock wave source. When the switch is closed,
the charged capacitor is discharged via the flat coil,
during which the entire capacitor current flows through
the switch. Capacitor voltages of 20 kV and peak currents
of 10 kA place high demands on the switch. Spark gaps
triggered by an additional high-voltage pulse are com-
monly used today for these switches. The disadvantage
lies in the limited service life, which means the spark
gaps need frequent replacement, and in the added elec-
tronics complexity involved in ignition with another
high-voltage pulse.
In using a semiconductor switch, we opted for a novel
solution. Its advantages are smaller package size, longer
service life and simpler triggering by a 5 V signal. Of
course, this switch must fulfill very special conditions,
e. g., a low on-resistance or a fast switching phase in the
ms range. Semiconductor switches demonstrated their
superior properties in service life tests, so that this part
must no longer be replaced. Because these switches are
electrically indistinguishable from the ignited spark
gaps in the ON state, the oscillator according to Fig. 4
exhibits the same time and amplitude behavior, and
hence an identical magnetic force field between the flat
coil and membrane, resulting in an identical shock wave
generation. As a consequence, this part can be imple-
mented instead of the spark gap resulting in the same
therapeutic efficacy. These new semiconductor switches
are available to all customers worldwide.
56 electromedica 71 (2003) no. 1
100
Normalized pressure [%]
New
Previous Modularis
80 shock wave shock wave
source source
60
40
20
180
100 120 140 160
Axial distance [mm]
Fig. 6
Axial pressure distribution and
location of focus.
Mechanical Coupling System for
Various X-Ray C-Arms
The modular technology in the LITHOSTAR
Modularis for using other high-quality equipment
components (MODULARIS Uro endourology table,
SIREMOBIL Iso-C X-ray C-arm, SONOLINE Adara
ultrasound device) represents an attractive enhancement
for use even outside ESWL applications. To increase
flexibility and variability even further for the customer,
the LITHOSTAR Modularis Vario lithotripsy module
can also be combined with the SIREMOBIL Compact L
and numerous X-ray C-arms of other manufacturers, as
opposed to the LITHOSTAR Modularis.
A mechanical coupling system adjustable for many
X-ray C-arms is clamped onto the extension of the chassis
of the X-ray C-arm. The lithotripsy module is docked and
latched to this mechanical coupling system of the X-ray
C-arm by means of a precision yoke. The adjustment
phantom connected to the shock wave head and a cross-
hair on the image intensifier are used to manually align
the central beam of the C-arm to the isocenter via X-ray
imaging. The base of the MODULARIS Uro table is pro-
vided with another positioning yoke that enables the
alignment of the endourology table relative to the X-ray
C-arm. Therapy can then take place in the usual manner.
Due to this innovative mechanical coupling system, the
lithotripsy module makes it possible to treat stones to-
gether with numerous different X-ray C-arms, including
those made by various manufacturers.
Consequently, we are also giving even those customers
who already own a X-ray C-arm the opportunity to treat
stones, which is particularly interesting for customers
on a limited budget. Therefore, we are providing price-
sensitive markets as India, Brazil or Asia with access to
modern medical technology, and are entering into com-
petition with the low-end manufacturers in these regions.
 Innovative Methods – Advanced Modalities
The conventional LITHOSTAR Modularis litho-
tripsy module continues to offer a convenient, simple
and reliable coupling to the SIREMOBIL Iso-C and
SIREMOBIL Iso-C3D X-ray C-arms. Other advantages
of this established interface include central operation
using only a single hand-held remote control and moto-
rized X-ray C-arm angulation for localizing stones. This
permits easy operation of the complete system even
from a greater distance, e. g., behind a lead glass wall.
Result
The LITHOSTAR Modularis modular platform has
for years proven itself highly effective in clinical practice
as a diagnostic and therapeutic urological device. The
new LITHOSTAR Modularis Vario lithotripsy module
combines the proven attributes of the previous module
with the following advantages: The effective ultrasound
shock wave with the increased penetration depth ensures
a high level of patient comfort and an improved ease of
operation. The increased service life and optional inter-
face for various X-ray C-arms also represents an impor-
tant step in the right direction with regard to the constant
discussion of costs in health care.
The LITHOSTAR Modularis Vario lithotripsy module
presents an advanced solution that continues on the path
of success achieved by the LITHOSTAR product family.
Calculations relating to the magnetic field and pressure pulse generation
were performed by Mr. Röckelein at Siemens Corporate Technology,
Erlangen.
The information about both the LITHOSTAR Modularis Vario and
new therapy head is being provided for planning purposes. The product
requires 510(k) review and is not commercially available in the U.S.
Literature
[1] Granz B, Köhler G. What makes a Shock Wave Efficient in
Lithotripsy. J. Stone Disease 1992; 4:123-128.
[2] Reichenberger H, Naser G. Electromagnetic Acoustic Source
for the Extracorporal Generation of Shock Waves in Lithotripsy.
Siemens Forsch.- u. Entwickl.-Ber. 1986; 15(4): 187-194.
[3] Folberth W et al. Pressure Distribution and Energy Flow in the
Focal Region of two different Electromagnetic Shock Wave Sources.
J. Stone Disease 1992; 4(1): 1-7.
[4] Teichmann JMH et al. In Vitro Comparison of Shock Wave
Lithotripsy Machines. J. Urol. 2000; 164: 1259 -1264.
[5] Xi X, Zhong P. Dynamic Photoelastic Study of the Transient Stress
Field in Solids during Shock Wave Lithotripsy. J. Acoust. Soc. Am. 2001;
109(3): 1226-1239.
[6] Eisenmenger W. Elektromagnetische Erzeugung von ebenen
Druckstößen in Flüssigkeiten. Akustische Beihefte, ACUSTICA, 1962;
12: 185-202.
[7] Granz B, Köhler G. Quantitative Assignment of Shock Wave Para-
meters to Stone Disintegration in Lithotripsy. Conference Proceedings
Ultrasonics International, Butterworth Heinemann, 1991: 61- 64.
[8] Lingeman JE. Extracorporeal Shock Wave Lithotripsy – what
happened?. J. Urol. 2003; 169: 63.
Author’s address
Dr. Bernd Granz
Siemens AG, Medical Solutions
Special Systems
Hartmannstr. 48
D-91052 Erlangen
Germany
Tel.: +49 (0) 9131 84-4987
Fax: +49 (0) 9131 84-6387
e-mail: bernd.granz@siemens.com

The views expressed by the author do not necessarily

coincide with the opinion of the Siemens company.

Original images always lose a certain amount

of detail when reproduced.

Siemens AG, Medical Solutions

Henkestr. 127, D-91052 Erlangen
Germany
Order No. A91100-M1500-C505-1-7600
Telephone: ++49 9131 84-0 Printed in Germany
www.SiemensMedical.com CC 65505 SD 07032.

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