Predictive Prognostic Factors in Non-Calcific Supraspinatus Tendinopathy Treated with Focused Extracorporeal Shock Wave Therapy: An Artificial Neural Network Approach.

The supraspinatus tendon is one of the most involved tendons in the development of shoulder pain. Extracorporeal shockwave therapy (ESWT) has been recognized as a valid and safe treatment. Sometimes the symptoms cannot be relieved, or a relapse develops, affecting the patient's quality of life. Therefore, a prediction protocol could be a powerful tool aiding our clinical decisions. An artificial neural network was run, in particular a multilayer perceptron model incorporating input information such as the VAS and Constant-Murley score, administered at T0 and at T1 after six months. It showed a model sensitivity of 80.7%, and the area under the ROC curve was 0.701, which demonstrates good discrimination. The aim of our study was to identify predictive factors for minimal clinically successful therapy (MCST), defined as a reduction of ≥40% in VAS score at T1 following ESWT for chronic non-calcific supraspinatus tendinopathy (SNCCT). From the male gender, we expect greater and more frequent clinical success. The more severe the patient's initial condition, the greater the possibility that clinical success will decrease. The Constant and Murley score, Roles and Maudsley score, and VAS are not just evaluation tools to verify an improvement; they are also prognostic factors to be taken into consideration in the assessment of achieving clinical success. Due to the lower clinical improvement observed in older patients and those with worse clinical and functional scales, it would be preferable to also provide these patients with the possibility of combined treatments. The ANN predictive model is reasonable and accurate in studying the influence of prognostic factors and achieving clinical success in patients with chronic non-calcific tendinopathy of the supraspinatus treated with ESWT.

Simultaneous High-Frame-Rate Acoustic Plane-Wave and Optical Imaging of Intracranial Cavitation in Polyacrylamide Brain Phantoms during Blunt Force Impact.

Blunt and blast impacts occur in civilian and military personnel, resulting in traumatic brain injuries necessitating a complete understanding of damage mechanisms and protective equipment design. However, the inability to monitor in vivo brain deformation and potential harmful cavitation events during collisions limits the investigation of injury mechanisms. To study the cavitation potential, we developed a full-scale human head phantom with features that allow a direct optical and acoustic observation at high frame rates during blunt impacts. The phantom consists of a transparent polyacrylamide material sealed with fluid in a 3D-printed skull where windows are integrated for data acquisition. The model has similar mechanical properties to brain tissue and includes simplified yet key anatomical features. Optical imaging indicated reproducible cavitation events above a threshold impact energy and localized cavitation to the fluid of the central sulcus, which appeared as high-intensity regions in acoustic images. An acoustic spectral analysis detected cavitation as harmonic and broadband signals that were mapped onto a reconstructed acoustic frame. Small bubbles trapped during phantom fabrication resulted in cavitation artifacts, which remain the largest challenge of the study. Ultimately, acoustic imaging demonstrated the potential to be a stand-alone tool, allowing observations at depth, where optical techniques are limited.

Experimental study on influence of particle shape on shockwave from collapse of cavitation bubble.

The bubble dynamics under the influence of particles is an unavoidable issue in many cavitation applications, with a fundamental aspect being the shockwave affected by particles during bubble collapse. In our experiments, the method of spark-induced bubbles was used, while a high-speed camera and a piezoresistive pressure sensor were utilized to investigate how particle shape affects the evolution of shockwaves. Through the high-speed photography, we found that the presence of the particle altered the consistency of the liquid medium around the bubble, which result in the emitting of water hammer shockwave and implosion shockwave respectively during the collapse of the bubble. This stratification effect was closely related to the bubble-particle relative distance φ and particle shape δ. Specifically, when the bubble-particle relative distance φ < 1.34 e-0.10δ, particles disrupted the medium consistency around the bubbles and led to a nonspherical collapse and the consequent stratification of the shockwave. By measuring the stratified shockwave intensity affected by different particle shapes, we found that the stratified shockwave intensity experienced varying degrees of attenuation. Furthermore, as the particle shape δ increased, the attenuation of the particle on shockwave intensity gradually reduced. These new findings hold significant theoretical implications for elucidating cavitation erosion mechanisms in liquid-solid two-phase flows and applications and prevention strategies in liquid-solid two-phase cavitation fields.

Ultrafast photoacoustic cavitation pumped by picosecond laser for high-efficient and long-term shockwave theranostics.

Photoacoustic (PA) theranostics is a new emerging field that uniquely combines diagnosis and treatment in one modality. However, its current status is compromised by the indispensable dependence on nonreversible phase-change nanoprobes that provides one-time-only action. Here, we demonstrate a picosecond-laser-pumped ultrafast PA cavitation technique for highly efficient shockwave theranostics, guaranteeing sustained PA cavitation by using non-phase-change nanoprobes. Theoretical simulations validate that, when compressing the excitation laser pulse width to hundred-picosecond, the thermal confinement effects of a conventional nanoprobe will induce transient heating of the extremely thin surrounding liquid layer of the nanoprobes beyond its cavitation point in a localized area at nanoscale, resulting in intense cavitation and PA shockwaves by the environment rather than the nanoprobes. Both cellular and mouse model experiments have demonstrated the highly effective anti-tumor effects. This method provides a sustainable, reproducible, and highly effective strategy for PA theranostics, prefiguring great potential for the clinical applications.

Effect of Transcranial Pulse Stimulation for the Treatment of Alzheimer´s Disease and its Related Symptoms.

Alzheimer's disease (AD) is the most common cause of neurodegenerative cognitive impairment. Brain stimulation techniques based on the delivery of transcranial shockwaves are currently being studied for their increasing popularity as an approach to modulate the human brain in a focal and targeted manner making this therapy a promising line of action against AD. In the present manuscript, we review for further understanding whether transcranial pulse stimulation (TPS) is a beneficial treatment for AD patients. PubMed, Google Scholar, and Cochrane databases were accessed with the search criteria set from year 2001 to 2022 and the following keywords were used: "transcranial pulse stimulation", "focused ultrasound", "noninvasive treatment and Alzheimer" and "TPS". The search was focused on papers that provide evidence on the biological bases of the method, as well as its safety and tolerability. Even though more studies are needed with greater scientific rigor, such as a doubleblind and randomized study versus a placebo, TPS is an excellent and safe therapeutic option for AD. This novel approach accompanies currently available treatments and complements them, helping to maintain greater stability of the disease and slowing its progression. The biological effects and potential mechanisms of action of TPS for the improvement of cognitive function are further discussed.

Shockwave versus ultrasound therapy in the enhancement of Aloe vera in cutaneous wound healing.

OBJECTIVE: To investigate the healing efficacy of topical Aloe vera enhanced by shockwave or ultrasound therapy on wounds in rats and compare both effects. METHOD: A total of 75 male albino rats were randomly divided into equal groups A, B, C, D and E. Under anaesthesia, a wound (6cm2) was created on the back of each rat. Group A received topical Aloe vera under occlusive dressing followed by shockwave therapy with the following parameters: 600 shocks, four pulses/second and 0.11mJ/mm2. Group B received topical Aloe vera under occlusive dressing followed by therapeutic ultrasound with the following parameters: pulsed mode, 2:8 duty cycle, 1MHz and 0.5 W/cm2. Group C received the same treatment as group A but in a reversed sequence-the shockwave therapy followed by the Aloe vera gel. Group D received the same treatment as group B but in a reversed sequence-therapeutic ultrasound followed by the Aloe vera gel. And control group E only received topical Aloe vera under occlusive dressing. Each group received three sessions per week, for two weeks. Wound extent and shrinkage rates were measured at study initiation and at the end of each week. RESULTS: There were significant wound reductions in groups A and B compared to C and D, respectively, and in group A compared to group B. CONCLUSION: Shockwaves and ultrasound were found to amplify the effect of the Aloe vera on the wound, and there was improved wound healing in the shockwave group A compared to the ultrasound group B.

A Bone-Penetrating Precise Controllable Drug Release System Enables Localized Treatment of Osteoporotic Fracture Prevention via Modulating Osteoblast-Osteoclast Communication.

Improving local bone mineral density (BMD) at fracture-prone sites of bone is a clinical concern for osteoporotic fracture prevention. In this study, a featured radial extracorporeal shock wave (rESW) responsive nano-drug delivery system (NDDS) is developed for local treatment. Based on a mechanic simulation, a sequence of hollow zoledronic acid (ZOL)-contained nanoparticles (HZNs) with controllable shell thickness that predicts various mechanical responsive properties is constructed by controlling the deposition time of ZOL and Ca2+ on liposome templates. Attributed to the controllable shell thickness, the fragmentation of HZNs and the release of ZOL and Ca2+ can be precisely controlled with the intervention of rESW. Furthermore, the distinct effect of HZNs with different shell thicknesses on bone metabolism after fragmentation is verified. In vitro co-culture experiments demonstrate that although HZN2 does not have the strongest osteoclasts inhibitory effect, the best pro-osteoblasts mineralization results are achieved via maintaining osteoblast-osteoclast (OB-OC) communication. In vivo, the HZN2 group also shows the strongest local BMD enhancement after rESW intervention and significantly improves bone-related parameters and mechanical properties in the ovariectomy (OVX)-induced osteoporosis (OP) rats. These findings suggest that an adjustable and precise rESW-responsive NDDS can effectively improve local BMD in OP therapy.

Near threshold nucleation and growth of cavitation bubbles generated with a picosecond laser.

The nucleation and growth of cavitation bubbles few micrometers in size in water generated by a 60 ps 515 nm fiber laser is observed and visualized near nucleation threshold. The study is performed by monitoring the plasma size, the cavitation bubble size and the emitted shock waves. The latter two aspects are supported by the Gilmore model using a Noble-Abel-stiffened-gas (NASG) equations of state. For the first time, two types of cavitation events are identified and visualized that exhibit a difference of more than two orders of magnitude in the excitation energy converted to mechanical effects with minimal change in excitation laser pulse energy. The result is localized cavitation and reduced mechanical stress on water-based media with potentially positive implications for laser treatments of biological tissue.

The Institute of Physical Medicine and Rehabilitation, Hospital das Clínicas University of São Paulo School of Medicine comprehensive rehabilitation program for elderly people with knee osteoarthritis.

Background: Knee osteoarthritis (OA) is a leading cause of disability in the elderly population. Chronic disabling pain is associated with maladaptive neuroplastic changes in brain networks, commonly associated with central sensitization. The main clinical features of nociplastic pain conditions include combined peripheral and central sensitization, and it is crucial to recognize this type of pain, as it responds to different therapies than nociceptive and neuropathic pain. Objective: To report the effect of the Institute of Physical Medicine and Rehabilitation (IMREA) comprehensive rehabilitation program to reduce pain and to improve functioning in elderly people with knee OA, under the DEFINE cohort. Methods: This is a retrospective observational cohort of 96 patients with knee OA, recruited from October 2018 to December 2019. All patients were evaluated by a trained multidisciplinary team using the Kellgren Lawrence classification, bilateral knee ultrasonography, the visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, rigidity and difficulty scores, the Timed Up and Go Test (TUG), 10-m and 6-min walking test (10 and 6 MWT), Berg Balance Scale, isokinetic dynamometry for knee extension and flexion strength, and pain pressure thresholds. The rehabilitation program included paraspinous lidocaine blocks, focal extracorporeal shockwaves combined with radial pressure waves and functional electrical stimulation according to individual needs. The baseline was compred with the treatment results with a paired t-test. Results: The study sample is composed of 96 participants, mostly females (n = 81, 84.38%), with bilateral osteoarthritis (n = 91, 94.79%), and a mean age of 68.89 (SD 9.73) years. Functional improvement was observed in TUG (p = 0.019), 6-mwt (p = 0.033), right knee flexion strength (p < 0.0001), WOMAC rigidity and difficulty domains (p < 0.0001). Pain was reduced from baseline as measured by WOMAC pain domain (p < 0.0001), VAS for both knees (p < 0.0001), and SF-36 pain domain (p < 0.0001). Pressure pain threshold was modified above the patella (p = 0.005 and p = 0.002 for right and left knees, respectively), at the patellar tendons (p = 0.015 and p = 0.010 for right and left patellar tendons, respectively), left S2 dermatome (p = 0.017), and L1-L2 (p = 0.008). Conclusions: The IMREA comprehensive rehabilitation program improved functioning and reduced disabling pain in elderly people with knee OA. We highlight the relevance and discuss the implementation of our intervention protocol. Although this is an open cohort study, it is important to note the significant improvement with this clinical protocol.

Low-energy Shockwave Therapy in the Management of Wound Healing Following Fournier's Gangrene.

We report on postoperative management of wound healing in four cases of Fournier's gangrene successfully treated with low-intensity shockwave therapy (LI-ESWT). In three cases, LI-ESWT (3 sessions per week with 2000 shockwaves at 3 Hz applied at 0.25 mJ/mm2) was able to close wound dehiscence secondary to plastic surgery with skin flaps. In one patient, LI-ESWT resulted in complete closure of an extensive wound with restoration of the local scrotal and penile skin. This is the first report of successful application of LI-ESWT for this indication. Restoration of local skin rather than wound closure by fibrous tissue could be related to promotion of stem cells, which has been discussed previously for other indications, such as treatment of chronic ulcers and restoration of the pelvic floor.

Mechanosensor Piezo1 mediates bimodal patterns of intracellular calcium and FAK signaling.

Piezo1 belongs to mechano-activatable cation channels serving as biological force sensors. However, the molecular events downstream of Piezo1 activation remain unclear. In this study, we used biosensors based on fluorescence resonance energy transfer (FRET) to investigate the dynamic modes of Piezo1-mediated signaling and revealed a bimodal pattern of Piezo1-induced intracellular calcium signaling. Laser-induced shockwaves (LIS) and its associated shear stress can mechanically activate Piezo1 to induce transient intracellular calcium (Ca[i] ) elevation, accompanied by an increase in FAK activity. Interestingly, multiple pulses of shockwave stimulation caused a more sustained calcium increase and a decrease in FAK activity. Similarly, tuning the degree of Piezo1 activation by titrating either the dosage of Piezo1 ligand Yoda1 or the expression level of Piezo1 produced a similar bimodal pattern of FAK responses. Further investigations revealed that SHP2 serves as an intermediate regulator mediating this bimodal pattern in Piezo1 sensing and signaling. These results suggest that the degrees of Piezo1 activation induced by both mechanical LIS and chemical ligand stimulation may determine downstream signaling characteristics.

Cardiac Shockwave Therapy - A Novel Therapy for Ischemic Cardiomyopathy?

Over the past decades, shockwave therapy (SWT) has gained increasing interest as a therapeutic approach for regenerative medicine applications, such as healing of bone fractures and wounds. More recently, pre-clinical studies have elucidated potential mechanisms for the regenerative effects of SWT in myocardial ischemia. The mechanical stimulus of SWT may induce regenerative effects in ischemic tissue via growth factor release, modulation of inflammatory response, and angiogenesis. Activation of the innate immune system and stimulation of purinergic receptors by SWT appears to enhance vascularization and regeneration of injured tissue with functional improvement. Intriguingly, small single center studies suggest that SWT may improve angina, exercise tolerance, and hemodynamics in patients with ischemic heart disease. Thus, SWT may represent a promising technology to induce cardiac protection or repair in patients with ischemic heart disease.

Two-step aberration correction: application to transcranial histotripsy.

Objective: Phase aberration correction is essential in transcranial histotripsy to compensate for focal distortion caused by the heterogeneity of the intact skull bone. This paper improves the 2-step aberration correction (AC) method that has been previously presented and develops an AC workflow that fits in the clinical environment, in which the computed tomography (CT)-based analytical approach was first implemented, followed by a cavitation-based approach using the shockwaves from the acoustic cavitation emission (ACE).Approach:A 700 kHz, 360-element hemispherical transducer array capable of transmit-and-receive on all channels was used to transcranially generate histotripsy-induced cavitation and acquire ACE shockwaves. For CT-AC, two ray-tracing models were investigated: a forward ray-tracing model (transducer-to-focus) in the open-source software Kranion, and an in-house backward ray-tracing model (focus-to-transducer) accounting for refraction and the sound speed variation in skulls. Co-registration was achieved by aligning the skull CT data to the skull surface map reconstructed using the acoustic pulse-echo method. For ACE-AC, the ACE signals from the collapses of generated bubbles were aligned by cross-correlation to estimate the corresponding time delays.Main results:The performance of the 2-step method was tested with 3 excised human calvariums placed at 2 different locations in the transducer array. Results showed that the 2-step AC achieved 90 ± 7% peak focal pressure compared to the gold standard hydrophone correction. It also reduced the focal shift from 0.84 to 0.30 mm and the focal volume from 10.6 to 2.0 mm3on average compared to the no AC cases.Significance:The 2-step AC yielded better refocusing compared to either CT-AC or ACE-AC alone and can be implemented in real-time for transcranial histotripsy brain therapy.

Malos resultados y complicaciones en el uso de ondas de choque focales y ondas de presión radial en patología musculoesquelética / Poor results and complications in the use of focused shockwaves and radial pressure waves in musculoskeletal pathology

La aplicación de ondas de choque focales y de ondas de presión radial en patología musculoesquelética ha tenido un gran desarrollo y difusión en la última década. Si bien la mayoría de las publicaciones han resaltado su seguridad y eficacia, no están exentas de malos resultados y complicaciones. Esta revisión analiza las principales causas de los malos resultados, efectos adversos y complicaciones, haciendo énfasis en su prevención.(AU)

The application of focused shockwaves and radial pressure waves in musculoskeletal pathology has had a great development in the last decade. Although most of the publications have highlighted their safety and efficacy, poor results and complications can occur. This review analyzes the main causes of its poor results, adverse effects, and complications, emphasizing their prevention.(AU)

[Poor results and complications in the use of focused shockwaves and radial pressure waves in musculoskeletal pathology]. / Malos resultados y complicaciones en el uso de ondas de choque focales y ondas de presión radial en patología musculoesquelética.

The application of focused shockwaves and radial pressure waves in musculoskeletal pathology has had a great development in the last decade. Although most of the publications have highlighted their safety and efficacy, poor results and complications can occur. This review analyzes the main causes of its poor results, adverse effects, and complications, emphasizing their prevention.

Ondas de choque. Evidencias y recomendaciones SETOC (Sociedad Española de Tratamientos con Ondas de Choque) / Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations

El documento consenso SETOC muestra la evidencia científica de la tecnología en ondas de choque extracorpóreas (OCE) y ondas de presión radial (OPR) en diversidad de patologías musculoesqueléticas, cutáneas, espasticidad, urológicas, etc. Las OCE y las OPR son un tratamiento eficaz, seguro, no invasivo, coste-efectivo, bien tolerado por el paciente, sin necesidad de anestesia, que reduce la necesidad de cirugía, con menor riesgo de complicaciones y menor tiempo de recuperación que una cirugía. Por todo ello, las OCE y las OPR deberían ser la primera opción terapéutica de las patologías crónicas mencionadas, cuando las alternativas conservadoras hayan fallado, teniendo en cuenta las recomendaciones de este artículo, de las sociedades científicas y de la evidencia para cada tecnología (AU)

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well (AU)

Incorporating multiple congestion levels into spatiotemporal analysis for the impact of a traffic incident.

Traffic incidents occurring on the road interrupt the smooth mobility of traffic flow and lead to traffic congestion. Although there has been a proliferation of studies that attempt to estimate the spatiotemporal impact of a traffic incident, most, if not all, of them focus exclusively on the differentiation of bi-level traffic status. In this research, we propose to incorporate multiple congestion levels in the spatiotemporal analysis for the impact of a traffic incident, which is new to the literature. The input to our model includes the historical speed on a given road and the occurrence time and location of the incident. The model then outputs the spatiotemporal impact region with multiple congestion levels. We first use a discriminant indicator to initially indicate the traffic status according to the travelling speed of probe vehicles. We then develop an integer programming model with a set of novel constraints to estimate the spatiotemporal region impacted by the incident. Unlike existing studies that only distinguish between uncongested and congested status, our model allows us to determine the impact region with diverse congestion levels. We validate our model using both simulation and real data. Results demonstrate that our approach can not only ensure the consistency of the propagation of shockwaves even when multiple congestion levels are incorporated, but also produce more accurate estimation of the delay caused by the incident when compared to the current state-of-the-art approach.

[Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations]. / Ondas de choque. Evidencias y recomendaciones SETOC (Sociedad Española de Tratamientos con Ondas de Choque).

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well.

Safety of laser-generated shockwave treatment for bacterial biofilms in a cutaneous rodent model.

Bacterial biofilms are often found in chronically infected wounds. Biofilms protect bacteria from antibiotics and impair wound healing. Surgical debridement is often needed to remove the biofilm from an infected wound. Laser-generated shockwave (LGS) treatment is a novel tissue-sparing treatment for biofilm disruption. Previous studies have demonstrated that LGS is effective in disrupting biofilms in vitro. In this study, we aim to determine the safety threshold of the LGS technology in an in vivo rodent model. To understand the in vivo effects of LGS on healthy cutaneous tissue, the de-haired dorsal skin of Sprague-Dawley rats were treated with LGS at three different peak pressures (118, 296, 227 MPa). These pressures were generated using a 1064 nm Nd/YAG laser (pulse duration 5 ns and laser fluence of 777.9 mJ) with laser spot size diameters of 2.2, 3.0, and 4.2 mm, respectively. Following treatment, the animals were observed for 72 h, and a small subset was euthanized at 1-h, 24-h, and 72-h post-treatment and assessed for tissue injury or inflammation under histology. Each treatment group consisted of 9 rats (n = 3/time point for 1-h, 24-h, 72-h post-treatment). An additional 4 control (untreated) rats were included in the analysis, for a total of 31 animals. Gross injuries occurred in 21 (77%) animals and consisted of minor erythema, with prevalence positively correlated with peak pressure (p < 0.05). Of injuries under gross observation, 94% resolved within 24 h. Under histological analysis, the injuries and tissue inflammation were found to be localized to the epidermis and superficial dermis. LGS appears to be well tolerated by cutaneous tissue for the laser energy settings shown to be effective against bacterial biofilm in vitro. All injuries incurred, at even the highest peak pressures, were clinically mild and resolved within 1 day. This lends further support to the overall safety of LGS and serves to translate LGS towards in vivo efficacy studies.

Miniature semi-rigid ureteroscopy with holmium-yttrium-aluminium-garnet laser vs shockwave lithotripsy in the management of upper urinary tract stones >1 cm in children.

OBJECTIVE: To compare the efficacy and safety of miniature semi-rigid ureteroscopy (URS) with holmium (Ho)-yttrium-aluminium-garnet (YAG) laser lithotripsy vs shockwave lithotripsy (SWL) for treating upper urinary tract (UUT) calculi >1 cm in children. PATIENTS AND METHODS: Children with unilateral single UUT ureteric stones of >1 cm were prospectively enrolled in this study. Patients were randomly divided into two groups: Group 1, treated with SWL; and Group 2, treated with URS (6/7.5 F) and laser lithotripsy. The patients' characteristics, stones demographics, operative time, adjunctive procedures, stone-free rate (SFR), re-treatment rate, and complications were statistically analysed and compared. Success was defined as stone-free status (no stone residual of ≥0.3 cm) at 1 month from the initial treatment without any auxiliary procedures. RESULTS: In all, 68 patients with UUT stones met our inclusion criteria. There were no significant differences between the two groups for patient or stone demographics. In Group 1, the SFR was 26/34 (76.4%) and in Group 2 it was 33/34 (97.1%) (P = 0.03). A total of 12 auxiliary procedures in Group 1 and two in Group 2 were needed to reach a 100% SFR (P = 0.014). There were no significant differences between the two groups for operative times, adjunctive procedures, number of complicated cases or complications of Grade ≥III (P = 0.65, P = 0.23, P = 0.77, and P = 0.62, respectively). CONCLUSION: Miniature semi-rigid URS with Ho-YAG laser lithotripsy for UUT ureteric stones of >1 cm in children was more effective than SWL in terms of SFR and re-treatment rate, with no significant difference in the rate or grade of complications. ABBREVIATIONS: EQ: efficiency quotient; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; RCT: randomised controlled trial; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy; US: ultrasonography/ultrasound; URS: ureteroscopy; UUT: upper urinary tract; YAG: yttrium-aluminium-garnet.