The usual technique of shock wave lithotripsy (SWL) is to begin at a low voltage level and increase the voltage in increments for a few hundred shocks until a target voltage has been reached. The goals are to minimize pain (and thereby minimize patient movement), enhance safety, and possibly enhance fragmentation.1'3 However, does voltage escalation amount to wasting several hundred shocks at too low a power? This randomized, double-blind SWL trial compared immediate vs delayed voltage escalation using the Phillips LithoTron litho-tripter. Notwithstanding some minor methodologic concerns, the study was conducted about as well as it could have been. The fragmentation and stone-free outcomes favored the immediate vs delayed voltage escalation strategy. Immediate voltage escalation required fewer shocks to achieve the first fragmentation and resulted in a better 3-month success rate, with trends favoring immediate voltage escalation for the 2-week and 3-month outcomes.
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