Size and location of defects at the coupling interface affect lithotripter performance
Authors: Li Guangyan , Williams Jr James C. , Pishchalnikov Yuri A. , Liu Ziyue , McAteer James A. 
Published: September 2012

Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?In shock wave lithotripsy air pockets tend to get caught between the therapy head of the lithotripter and the skin of the patient. Defects at the coupling interface hinder the transmission of shock wave energy into the body, reducing the effectiveness of treatment. This in vitro study shows that ineffective coupling not only blocks the transmission of acoustic pulses but also alters the properties of shock waves involved in the mechanisms of stone breakage, with the effect dependent on the size and location of defects at the coupling interface.OBJECTIVE
To determine how the size and location of coupling defects caught between the therapy head of a lithotripter and the skin of a surrogate patient (i.e. the acoustic window of a test chamber) affect the features of shock waves responsible for stone breakage.
MATERIALS AND METHODS
Model defects were placed in the coupling gel between the therapy head of a Dornier Compact‐S electromagnetic lithotripter (Dornier MedTech, Kennesaw, GA, USA) and the Mylar (biaxially oriented polyethylene terephthalate) (DuPont Teijin Films, Chester, VA, USA) window of a water‐filled coupling test system.
A fibre‐optic probe hydrophone was used to measure acoustic pressures and map the lateral dimensions of the focal zone of the lithotripter.
The effect of coupling conditions on stone breakage was assessed using gypsum model stones.
RESULTS
Stone breakage decreased in proportion to the area of the coupling defect; a centrally located defect blocking only 18% of the transmission area reduced stone breakage by an average of almost 30%.
The effect on stone breakage was greater for defects located on‐axis and decreased as the defect was moved laterally; an 18% defect located near the periphery of the coupling window (2.0 cm off‐axis) reduced stone breakage by only ∼15% compared to when coupling was completely unobstructed.
Defects centred within the coupling window acted to narrow the focal width of the lithotripter; an 8.2% defect reduced the focal width ∼30% compared to no obstruction (4.4 mm vs 6.5 mm).
Coupling defects located slightly off centre disrupted the symmetry of the acoustic field; an 18% defect positioned 1.0 cm off‐axis shifted the focus of maximum positive pressure ∼1.0 mm laterally.
Defects on and off‐axis imposed a significant reduction in the energy density of shock waves across the focal zone.
CONCLUSIONS
In addition to blocking the transmission of shock‐wave energy, coupling defects also disrupt the properties of shock waves that play a role in stone breakage, including the focal width of the lithotripter and the symmetry of the acoustic field
The effect is dependent on the size and location of defects, with defects near the centre of the coupling window having the greatest effect.
These data emphasize the importance of eliminating air pockets from the coupling interface, particularly defects located near the centre of the coupling window.