الفهرس 
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Abstract
Introduction :SWL has been considered the treatment of choice for uncomplicated renal stones less than 20 mm and ureteral stones less than 10 mm. The overall stone-free rates have been reported to be 80% to 90%. Some techniques were developed to enhance the efficacy of SWL. In 2001, the synchronous twin-pulse technique using twin-head lithotripter was developed.Patient and methods:Patients with single renal stone less than 2 cm or upper lumbar ureteric stone less than 1cm that amenable for SWL were randomly assigned to two groups. In group1, patients were treated with the alternating bidirectional approach during the first SWL session only and if another one or more sessions were needed, the standard approach was used (study group). In group 2, patients were treated with the standard approach during the first session and other needed SWL sessions (control group). The efficacy of SWL after the first session in both groups was assessed.Results For renal stones, there was no significant difference between groups in stone disintegration and stone-free rate after the first session. For lumbar ureteric stones, complete stone disintegration and stone-free rate after the first session were significantly higher in group 1. Both approaches were safe and comparable regarding the incidence of urosepsis, steinstrasse formation and renal injury.Conclusion:The alternating bidirectional approach is as effective and safe as the standard approach during SWL for renal stones, while it is significantly more effective than the standard approach with similar safety during SWL for upper lumbar ureteric stones.