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Gul T, Laymon M, Alrayashi M, Abdelkareem M, Salah M. Successful treatment of staghorn stones with flexible ureteroscopy and thulium fiber laser (TFL) lithotripsy: initial experience with 32 cases. Urolithiasis 2024; 52:102. [PMID: 38937284 PMCID: PMC11211131 DOI: 10.1007/s00240-024-01598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 06/12/2024] [Indexed: 06/29/2024]
Abstract
Purpose To investigate the efficacy and safety of flexible ureteroscopy with thulium fiber laser lithotripsy for management of renal staghorn stones. Materials and Methods Thirty-two patients with staghorn stones were recruited. Stone characteristics including: width, length, volume and density were analyzed. Ablation speed, laser efficacy and laser activity were recorded. The primary outcome was to assess stone free rate after the procedure using spiral CT scan. Results The median stone volume was 7339 (3183–53838) mm3. Median operative and lasing time were 135 (70–200) and 117 (50–180) minutes, respectively. The mean total energy delivered was 63.9 ± 30 KJ with a median ablation speed of 1.3 (0.5–4.9) mm3/sec. Mean laser efficacy was 7.5 ± 3.6 Joules/mm3. A total of 12 complications occurred in 8 patients (25%). The median hospital stay was 7 (3.5–48) hours and 30 patients (93.7%) were discharged on the same day of surgery. After the first session, seventeen patients (53%) were stone free with no residual fragments while six (19%) patients had residuals £ 2 mm. Nine patients (28%) had residuals > 2 mm with median residual size of 4 (3–9) mm. A second intervention was required in 4 cases.The overall stone free rate after completion of treatment was 65.6%. Conclusion Flexible ureteroscopy with thulium fiber laser lithotripsy is a safe and effective treatment option for staghorn stones with stone free rate comparable to standard PCNL with advantages of minimal morbidity, minimal blood loss and shorter hospital stay.
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Affiliation(s)
- Tawiz Gul
- Urology Section, Surgery Department, Hazm Mebaireek general hospital, Hamad medical corporation, Doha, Qatar.
- College of Medicine, Qatar University, Doha, Qatar.
| | - Mahmoud Laymon
- Urology and Nephrology center, Mansoura University, Mansoura, Egypt.
| | - Maged Alrayashi
- Urology Section, Surgery Department, Hazm Mebaireek general hospital, Hamad medical corporation, Doha, Qatar
| | - Mohamed Abdelkareem
- Urology Section, Surgery Department, Hazm Mebaireek general hospital, Hamad medical corporation, Doha, Qatar
| | - Morshed Salah
- Urology Section, Surgery Department, Hazm Mebaireek general hospital, Hamad medical corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
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Becker B, Hook S, Gross AJ, Rosenbaum C, Filmar S, Herrmann J, Netsch C. [Thulium or holmium laser or both: where will the journey take us?]. Aktuelle Urol 2024; 55:236-242. [PMID: 38604230 DOI: 10.1055/a-2286-1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
The Holmium:YAG laser has been the gold standard for laser lithotripsy over the past three decades and, since the late 1990s, also for prostate enucleation. Pulsed thulium fibre lasers (TFL) demonstrated their efficacy in in-vitro experiments and were introduced to the market a few years ago. Initial clinical results for TFL in lithotripsy and enucleation are very promising. In addition to TFL, a pulsed Thulium:YAG solid-state laser has been introduced, but clinical data for this laser are currently limited. This article aims to review the key technological differences between Ho:YAG lasers and pulsed thulium lasers and compare/discuss the initial clinical results for stone lithotripsy and laser enucleation.In-vitro studies have demonstrated the technical superiority of TFL compared with Ho:YAG lasers. However, as TFL is still a new technology, only limited studies are available to date, and optimal settings for lithotripsy have not been established. For enucleation, the differences of TFL compared with a high-power Ho:YAG laser seem to be clinically irrelevant. Initial studies on pulsed Tm:YAG lasers show good results, but there continues to be a lack of comparative studies.Based on the current literature, pulsed thulium lasers have the potential of being an alternative to Ho:YAG lasers. However, further studies are necessary to determine the optimal laser technology for enucleation and lithotripsy of urinary stones, considering all parameters, including efficacy, safety, and cost.
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Affiliation(s)
- Benedikt Becker
- Abteilung für Urologie, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Sophia Hook
- Abteilung für Urologie, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Andreas J Gross
- Abteilung für Urologie, Asklepios Klinik Barmbek, Hamburg, Germany
| | | | - Simon Filmar
- Abteilung für Urologie, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Jonas Herrmann
- Urologie und Urochirurgie, Universitätsklinikum Mannheim, Mannheim, Germany
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Li Z, Wu S, Liu T, Li S, Wang X. Optimal parameter settings of thulium fiber laser for ureteral stone lithotripsy: a comparative study in two different testing environments. Urolithiasis 2024; 52:78. [PMID: 38801419 DOI: 10.1007/s00240-024-01585-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
This study aims to identify optimal parameters for using Thulium fiber lasers (TFL) in ureteral stone lithotripsy to ensure laser safety and maximize efficacy. Our goal is to improve the outcomes of single-use semi-rigid ureteroscopy for treating stones located in the proximal ureter. A clinically relevant thermal testing device was designed to investigate heating effects during TFL stone fragmentation. The device was utilized to identify safe power thresholds for TFL at various irrigation rates. Three other devices were used to assess varying pulse energy effects on stone fragmentation efficiency, dusting, retropulsion, and depth of tissue vaporization. Comparative experiments in fresh porcine renal units were performed to validate the efficacy and safety of optimal TFL parameters for semi-rigid ureteroscopy in proximal ureteral stone procedures. Our study found that the improved device generated a higher thermal effect. Furthermore, the safe power threshold for laser lithotripsy increased as the irrigation rate was raised. At an irrigation rate of 40 ml/min, it is safe to use an average power of less than 30 watts. Although increasing pulse energy has a progressively lower effect on fragmentation and dust removal efficiency, it did lead to a linear increase in stone displacement and tissue vaporization depth. Thermal testing showed 20 W (53.87 ± 2.67 °C) indicating potential urothelial damage. In our study of laser lithotripsy for proximal ureteral stones, the group treated with 0.3 J pulses had several advantages compared to the 0.8 J group: Fewer large fragments (> 4 mm): 0 vs. 1.67 fragments (1-2.25), p = 0.002, a lower number of collateral tissue injuries: 0.50 (0-1.25) vs. 2.67 (2-4), p = 0.011, and lower stone retropulsion grading: 0.83 (0.75-1) vs. 1.67 (1-2), p = 0.046. There was no significant difference in operating time between the groups (443.33 ± 78.30 s vs. 463.17 ± 75.15 s, p = 0.664). These findings suggest that TFL irradiation generates a greater thermal effect compared to non-irradiated stones. Furthermore, the thermal effect during laser lithotripsy is influenced by both power and irrigation flow rate. Our study suggests that using a power below 15 W with an irrigation flow rate of 20 ml/min is safe. Moreover, a pulse energy of 0.3 J appears to be optimal for achieving the best overall stone fragmentation effect.
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Affiliation(s)
- Zhilong Li
- Department of Urology, Cancer Precision Diagnosis and Treatment and Translational Medicine, Hubei Engineering Research Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, China
| | - Shaojie Wu
- Department of Urology, Cancer Precision Diagnosis and Treatment and Translational Medicine, Hubei Engineering Research Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, China
| | - Tongzu Liu
- Department of Urology, Cancer Precision Diagnosis and Treatment and Translational Medicine, Hubei Engineering Research Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, China.
| | - Sheng Li
- Department of Urology, Cancer Precision Diagnosis and Treatment and Translational Medicine, Hubei Engineering Research Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, China.
| | - Xinghuan Wang
- Department of Urology, Cancer Precision Diagnosis and Treatment and Translational Medicine, Hubei Engineering Research Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, China.
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Falahatkar R, Falahatkar S, Khajavi Gaskarei MA, Afzalipoor M, Mojtahedi A, Aligolighasemabadi N, Deilami A, Mirzaei Dahka S, Keivanlou MH, Jafari A. The global, prevalence, and risk factors of postoperative fever after percutaneous nephrolithotomy: A systematic review and meta-analysis. Asian J Urol 2024; 11:253-260. [PMID: 38680584 PMCID: PMC11053330 DOI: 10.1016/j.ajur.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/26/2022] [Indexed: 05/01/2024] Open
Abstract
Objective This study aimed to explore the global, prevalence, and risk factors of fever after percutaneous nephrolithotomy (PCNL) by conducting a systematic review and meta-analysis. Methods The high-sensitivity searching was conducted without time limitation until December 30, 2020 in Web of Sciences, Scopus, and PubMed based on inclusion and exclusion criteria. Results The prevalence rates of fever and sepsis among patient undergoing PCNL were estimated 9.5% (95% confidence interval [CI]: 9.3%-9.7%), and 4.5% (95% CI: 4.2%-4.8%), respectively. Nephrostomy tube was used in 9.96% (95% CI: 9.94%-9.97%) of patients. The mean preoperative white blood cells of patients were 6.401×109/L; 18.3% and 4.55% of patients were considered as the positive urinary culture and pyuria, respectively. About 20.4% of patients suffered from residual stones. The odds ratios (ORs) of fever in patients who suffering from diabetes mellitus, hydronephrosis, staghorn stones, and blood transfusion were 4.62 (95% CI: 2.95-7.26), 1.04 (95% CI: 0.81-1.34), 2.57 (95% CI: 0.93-7.11), and 2.65 (95% CI: 1.62-4.35), respectively. Patients who underwent PCNL in prone position were more likely to develop fever (OR: 1.23; 95% CI: 0.75-2.00) than patients in supine position. Conclusion The current study showed that patients who suffer from diabetes mellitus, hydronephrosis, staghorn stones, nephrostomy tube or double-J stent, blood transfusion, and also patients who underwent PCNL in prone position surgery are more likely to develop a postoperative fever after PCNL.
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Affiliation(s)
- Reza Falahatkar
- Urology Research Center, Guilan University of Medical Sciences, Guilan, Rasht, Iran
| | - Siavash Falahatkar
- Urology Research Center, Guilan University of Medical Sciences, Guilan, Rasht, Iran
| | | | | | - Ali Mojtahedi
- Microbiology Department, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Neda Aligolighasemabadi
- Department of Internal Medicine, School of Medicine, Guilan University of Medical Siences, Rasht, Iran
| | - Ahmad Deilami
- Urology Research Center, Guilan University of Medical Sciences, Guilan, Rasht, Iran
| | - Samaneh Mirzaei Dahka
- School of Nursing and Midwifery, Guilan University of Medical Sciences, Guilan, Rasht, Iran
| | | | - Alireza Jafari
- Urology Research Center, Guilan University of Medical Sciences, Guilan, Rasht, Iran
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Corrales M, Panthier F, Solano C, Candela L, Traxer O. Laser safety, warnings, and limits in retrograde intrarenal surgery. Actas Urol Esp 2024; 48:19-24. [PMID: 37356576 DOI: 10.1016/j.acuroe.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To analyze the current information about laser safety in retrograde intrarenal surgery (RIRS), focusing on the two main laser technologies that we use in urology, the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, and the thulium fiber laser (TFL). METHODS Narrative overview of the most relevant articles published in MEDLINE and Scopus databases about this subject. RESULTS TFL and Ho:YAG laser at similar settings (0.2 J/40 Hz) have similar volume-averaged temperature increase and the average heating rate increase proportionally to laser power, especially when high frequencies are used. Recent preclinical data, comparing both laser technologies at different laser settings, agreed that when the delivered energy increases in expenses of higher frequencies, the thermal damage increases too. Higher frequencies, despite of the rise of temperature in the irrigation medium, can cause accidental thermal lasering lesions. CONCLUSION The use of low frequency settings and a proper irrigation is critical to avoid thermal injury in endoscopic laser lithotripsy. In addition, the use of laser safety eyeglasses is recommended in Ho:YAG and TFL ELL.
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Affiliation(s)
- M Corrales
- GRC n.° 20, Grupo de Investigación Clínica Litiasis Urinaria, Hospital Tenon, Universidad de La Sorbona, París, France; Servicio de Urología, Universidad de La Sorbona, Hospital Tenon (AP-HP), Paris, France.
| | - F Panthier
- GRC n.° 20, Grupo de Investigación Clínica Litiasis Urinaria, Hospital Tenon, Universidad de La Sorbona, París, France; Servicio de Urología, Universidad de La Sorbona, Hospital Tenon (AP-HP), Paris, France
| | - C Solano
- GRC n.° 20, Grupo de Investigación Clínica Litiasis Urinaria, Hospital Tenon, Universidad de La Sorbona, París, France; Servicio de Urología, Universidad de La Sorbona, Hospital Tenon (AP-HP), Paris, France
| | - L Candela
- GRC n.° 20, Grupo de Investigación Clínica Litiasis Urinaria, Hospital Tenon, Universidad de La Sorbona, París, France; Servicio de Urología, Universidad de La Sorbona, Hospital Tenon (AP-HP), Paris, France; Division de Oncología Experimental/Unidad de Urología, URI, IRCCS Hospital San Raffaele, Milán, Italy
| | - O Traxer
- GRC n.° 20, Grupo de Investigación Clínica Litiasis Urinaria, Hospital Tenon, Universidad de La Sorbona, París, France; Servicio de Urología, Universidad de La Sorbona, Hospital Tenon (AP-HP), Paris, France
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6
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Kronenberg P, Cerrato C, Juliebø-Jones P, Herrmann T, Tokas T, Somani BK. Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review. World J Urol 2023; 41:3817-3827. [PMID: 37906263 DOI: 10.1007/s00345-023-04669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/26/2023] [Indexed: 11/02/2023] Open
Abstract
PURPOSE Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment. METHODS We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print. RESULTS Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser. CONCLUSION The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.
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Affiliation(s)
| | - Clara Cerrato
- University Hospital Southampton NHS Trust, Southampton, UK
| | | | - Thomas Herrmann
- Department of Urology, Kantonspital Frauenfeld, Spital Thurgau AG, Frauenfeld, Switzerland
- Training and Research in Urological Surgery and Technology (T.R.U.S.T.)-Group, Hall in Tirol, Austria
| | - Theodoros Tokas
- Training and Research in Urological Surgery and Technology (T.R.U.S.T.)-Group, Hall in Tirol, Austria
- Department of Urology, Medical School, University General Hospital of Heraklion, University of Crete, Heraklion, Greece
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Panthier F, Abid N, Hoznek A, Traxer O, Meria P, Almeras C. 2022 Recommendations of the AFU Lithiasis Committee: Laser - utilization and settings. Prog Urol 2023; 33:825-842. [PMID: 37918982 DOI: 10.1016/j.purol.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 11/04/2023]
Abstract
Endocorporeal lithotripsy has progressed thanks to the development of lasers. Two laser sources are currently available: Holmium:YAG (Ho:YAG) and more recently Thulium Fiber Laser (TFL). The settings generally used are dusting, fragmentation, and "pop-corning". These are the first recommendations on laser use for stone management and their settings. Settings must be modulated and can be changed during the treatment according to the expected and obtained effects, the location and stone type that is treated. METHODOLOGY: These recommendations have been developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.
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Affiliation(s)
- F Panthier
- GRC lithiase, AP-HP, Sorbonne université, Paris, France; Laboratoire PIMM, arts et métiers Paris Tech, Paris, France
| | - N Abid
- Department of Urology and Transplantation Surgery, Hospices Civils de Lyon, Edouard-Herriot Hospital, Lyon, France
| | - A Hoznek
- Service d'urologie, hôpital Henri-Mondor, AP-HP, université Paris Est Créteil, Paris, France
| | - O Traxer
- GRC lithiase, AP-HP, Sorbonne université, Paris, France; Laboratoire PIMM, arts et métiers Paris Tech, Paris, France
| | - P Meria
- Service d'urologie, hôpital Saint-Louis, AP-HP, centre université Paris Cité, Paris, France
| | - C Almeras
- UroSud, clinique La Croix du Sud, Quint-Fonsegrives, France.
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Solano C, Corrales M, Panthier F, Candela L, Doizi S, Traxer O. Navigating urolithiasis treatment: assessing the practicality and performance of thulium fiber laser, holmium YAG, and thulium YAG in real-world scenarios. World J Urol 2023; 41:2627-2636. [PMID: 37468656 DOI: 10.1007/s00345-023-04487-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/07/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The management of urolithiasis has undergone significant advancements with the introduction of pulsed lasers, particularly the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, which is currently considered the gold standard in endourology. However, the Ho:YAG laser has certain limitations, such as the inability to support small laser fibers (150 μm) and the requirement of a heavy water cooling system, making it challenging to transfer between operating rooms. These limitations have led to the emergence of new laser technologies, including the thulium fiber laser (TFL) and the thulium:yttrium-aluminum-garnet laser (Tm:YAG), as potential alternatives to the Ho:YAG laser. METHODS In this review, we aimed to evaluate the effectiveness and safety of TFL, Ho:YAG, and Tm:YAG lasers in real-life scenarios by comparing clinical trial data with laboratory findings. A literature review was conducted, and relevant in vitro studies and clinical trials until March 2023 were analyzed. RESULTS The findings indicate that TFL has demonstrated high ablation efficiency for stones of any composition, size, and location, superior the capabilities of Ho:YAG lasers. TFL has shown superior dusting and fragmentation abilities, lower retropulsion, and increased patient safety. The laser parameters, such as ablation efficiency, speed, operative time, dust quality, retropulsion, visibility, temperature safety, and stone-free rate, were compared between laboratory studies and clinical outcomes. CONCLUSION Although the number of studies on TFL is limited, the available evidence suggests that TFL represents a significant advancement in laser technology for lithotripsy. However, further research is needed to fully explore the implications and limitations of TFL and Tm:YAG lasers.
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Affiliation(s)
- Catalina Solano
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
- Department of Endourology, Uroclin S.A.S, Medellín, Colombia
| | - Mariela Corrales
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Frederic Panthier
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Luigi Candela
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
- Division of Experimental Oncology/Unit of Urology, URI-Urological Research Institute IRCCS Ospedale San Raffaele, Milan, Italy
| | - Steeve Doizi
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
| | - Olivier Traxer
- GRC n20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.
- Service d'Urologie, Assistance-Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 Rue de la Chine, 75020, Paris, France.
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Singh A, Vaddi CM, Ganesan S, Batra R, Ramakrishna P, Swamy S, Anandan H, Babu M, Panda R, Ganpule A, Sabnis R, Desai M. A multicentric non-randomized prospective observational study on the clinical efficiency of thulium fibre laser in large volume stones (> 1000 mm 3). World J Urol 2023; 41:2289-2295. [PMID: 37418016 DOI: 10.1007/s00345-023-04476-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 06/02/2023] [Indexed: 07/08/2023] Open
Abstract
PURPOSE Our objective was to analyse the clinical efficiency of TFL in large volume stones during retrograde intrarenal surgery. MATERIALS AND METHODS Patients with large volume renal stones (> 1000 mm3) operated at two different centres, from May 2020 to April 2021, were enrolled in this study. Retrograde intrarenal surgery was performed using 60W Superpulse thulium fibre laser™ (IPG Photonics, Russia). Demographic data, stone parameters, laser time, and total operating time were recorded, and laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. NCCT KUB was done at 3 months postoperatively to calculate stone-free rate. RESULTS A total of 76 patients were included and analysed in the study. Mean stone volume was 1753.12 ± 1245.81 (1169.27-2193.25) mm3, mean stone density was 1104.46 ± 313.09 (875.00-1317.00) HU, mean laser time was 537.79 ± 689.89 (21.00-1080.00) sec, mean operating time was 43.38 ± 12.96 (35.00-51.25) min, mean laser efficacy was 20.30 ± 15.5 (8.88-25.57) J/mm3, and mean ablation speed was 1.32 ± 0.7 (0.82-1.64) mm3/sec. A strong positive correlation was found between the stone volume and ablation speed (r = 0.659, p = 0.000), and a moderate negative correlation was found between the stone volume and laser efficacy (J/mm3) (r = - 0.392, p = 0.000). With increasing volume of the stone, J/mm3 decreased significantly and ablation speed increased significantly (p < 0.001). Complications occurred in 21.05% (16/76) patients, most of which were Clavien grades 1-2. Overall SFR is 96.05%. CONCLUSION Laser efficiency increases at higher stone volumes (> 1000 mm3), as less energy is required to ablate every mm3 of stone.
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Affiliation(s)
- Abhishek Singh
- Muljibhai Patel Urological Hospital, Dr V V Desai Road, Nadiad, Gujarat, 387001, India
| | - Chandra Mohan Vaddi
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India
| | - Soundarya Ganesan
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India.
| | - Rohan Batra
- Muljibhai Patel Urological Hospital, Dr V V Desai Road, Nadiad, Gujarat, 387001, India
| | - Paidakula Ramakrishna
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India
| | - Siddalinga Swamy
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India
| | - Hemnath Anandan
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India
| | - Manas Babu
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India
| | - Rakesh Panda
- Preeti Urology and Kidney Hospital, 307, Remedy Hospital Ln, MIG 1, Kukatpally Housing Board Colony, Kukatpally, Hyderabad, Telangana, 500072, India
| | - Arvind Ganpule
- Muljibhai Patel Urological Hospital, Dr V V Desai Road, Nadiad, Gujarat, 387001, India
| | - Ravindra Sabnis
- Muljibhai Patel Urological Hospital, Dr V V Desai Road, Nadiad, Gujarat, 387001, India
| | - Mahesh Desai
- Muljibhai Patel Urological Hospital, Dr V V Desai Road, Nadiad, Gujarat, 387001, India
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Hughes T, Tzelves L, Somani BK. Cystine Stones: Developments in Minimally Invasive Surgery and Their Impact on Morbidity and Stone Clearance. Res Rep Urol 2023; 15:175-185. [PMID: 37303487 PMCID: PMC10254682 DOI: 10.2147/rru.s381190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023] Open
Abstract
Cystinuria is a rare genetic condition that is responsible for cystine stones. Besides stone recurrence, patients with cystine stones have reduced health-related quality of life, increased rates of chronic kidney disease and hypertension. Although lifestyle measures, medical therapy and close follow up are essential to reduce and monitor cystine stone recurrences, surgical intervention is frequently needed for most cystinuria patients. Shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy and active surveillance all have a role, and technological advances in endourology are vital in achieving a stone-free status and to prevent recurrences. The complexity of managing cystine stones necessitates a multidisciplinary team discussion, patient involvement and an individualised approach in a specialist centre for optimum management. Thulium fibre laser and virtual reality may have an increasing role in the future of cystine stone management.
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Affiliation(s)
- Thomas Hughes
- Department of Urology, Warwick Hospital, Warwick, UK
| | - Lazaros Tzelves
- Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Bhaskar K Somani
- Department of Urology, University Hospital Southampton, Southampton, UK
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11
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Jiang P, Okhunov Z, Afyouni AS, Ali S, Hosseini Sharifi SH, Bhatt R, Brevik A, Ayad M, Larson K, Osann K, Patel RM, Landman J, Clayman RV. Comparison of Superpulse Thulium Fiber Laser vs Holmium Laser for Ablation of Renal Calculi in an In Vivo Porcine Model. J Endourol 2023; 37:335-340. [PMID: 36401505 DOI: 10.1089/end.2022.0445] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction and Objectives: We sought to compare the effectiveness and efficiency of the superpulse thulium fiber laser (sTFL to the holmium: yttrium-aluminum-garnet [Ho:YAG] laser for ureteroscopic "dusting" of implanted renal stones in an in vivo porcine model. Methods: Twenty-four porcine kidneys (12 juvenile female Yorkshire pigs) were randomized to Ho:YAG or sTFL treatment groups. Canine calcium oxalate stones were scanned with computed tomography to calculate stone volume and stone density; the stones were randomized and implanted into each renal pelvis via an open pyelotomy. In all trials, a 14F, 35 cm ureteral access sheath was placed. With a 9.9F dual lumen flexible ureteroscope, laser lithotripsy was performed using dusting settings: Ho:YAG 200 μm laser fiber at 16 W (0.4 J, 40 Hz) or sTFL 200 μm laser fiber at 16 W (0.2 J, 80 Hz). Lithotripsy continued until no fragments over 1 mm were observed. No stone basketing was performed. Throughout the procedures, intrarenal and renal pelvis temperatures were measured using two percutaneously positioned K-type thermocouples, one in the upper pole calyx and one in the renal pelvis. After the lithotripsy, the ureteropelvic junction was occluded, the kidneys were bivalved, and all residual fragments were collected, dried, weighed, and then measured with an optical laser particle sizer. Results: Implanted stones were similar in volume and density in both groups. Intraoperative collecting system temperatures were similar for both groups (all <44°C). Compared to Ho:YAG, sTFL ablated stones faster (9 vs 27 minutes, p < 0.001) with less energy expenditure (8 vs 26 kJ, p < 0.001), and a greater stone clearance rate (73% vs 45%, p = 0.001). After sTFL lithotripsy, 77% of the remaining fragments were ≤1 mm vs 17% of fragments ≤1 mm after Ho:YAG treatment (p < 0.001). Conclusions: In an in vivo porcine kidney, using dusting settings, sTFL lithotripsy resulted in shorter ablation times, higher stone clearance rates, and markedly smaller stone fragments than Ho:YAG lithotripsy.
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Affiliation(s)
- Pengbo Jiang
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Zhamshid Okhunov
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Andrew S Afyouni
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Sohrab Ali
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | | | - Rohit Bhatt
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Andrew Brevik
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Maged Ayad
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Krista Larson
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Kathryn Osann
- Department of Medicine and Program in Public Health, UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Roshan M Patel
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Jaime Landman
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
| | - Ralph V Clayman
- Department of Urology and UC Irvine School of Medicine, Irvine, Orange, California, USA
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12
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Enikeev D, Herrmann TRW, Taratkin M, Azilgareeva C, Borodina A, Traxer O. Thulium fiber laser in endourology: current clinical evidence. Curr Opin Urol 2023; 33:95-107. [PMID: 36710593 DOI: 10.1097/mou.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To review and summarize preclinical and clinical data on thulium fiber laser's (TFL) effectiveness (ablation rate, stone-free rate etc.) and safety in terms of laser injuries and thermal damage. This enables us to assess how the in-vitro evidence translates into the clinical real-life scenario. RECENT FINDINGS In this analysis, a total of 21 preclinical trials have been included. Most of the trials use conventional Holmium:YAG laser as a comparator, with only a few assessing lasers with pulse modulation. Most of the trials focus on the superior ablation rate and superior dusting features of TFL, as well as comparison of retropulsion (both in conventional Ho:YAG and in a pulse modulation), with a few studies assessing safety aspects. A total of 13 trials assessed TFL, clinically, in percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). The clinical data obtained suggest that lithotripsy by TFL is safe, facilitates effective stone fragmentation, and results in a reduction of retropulsion. Unfortunately, most of the clinical trials lack a direct comparator, and so no clear-cut comparisons are possible. SUMMARY During in-vitro studies, TFL demonstrated to be a new energy source with a great potential for improved ablation, lower retropulsion and improved dusting. These claims are supported in contemporary clinical studies, reporting superior ablation and negligible retropulsion in both PCNL and RIRS. However, it should be noted that the data regarding clinical results compared with conventional Ho:YAG is still limited.
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Affiliation(s)
- Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Thomas R W Herrmann
- Department of Urology, Spital Thurgau AG, Kantonspital Frauenfeld, Frauenfeld, Switzerland
- Hannover Medical School, Hannover, Germany
- Division of Urology, Department of Surgical Sciences, Stellenbosch University, Western Cape, South Africa
| | - Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Camilla Azilgareeva
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Anastasia Borodina
- Institute for clinical medicine named after N.V.Sklifosovsky, Sechenov University, Moscow, Russia
| | - Olivier Traxer
- Service d'Urologie, AP-HP, Hôpital Tenon, Sorbonne Université
- GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, Paris, France
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13
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Markom AM, Ghafar NAMA, Batumalay M, Yusof Y, Rosol AHA, Zulkipli NF, Muhammad AR, Haris H, Saad I, Harun SW. Dissipative Soliton Mode-Locked Erbium-Doped Fiber Laser Using Nb 2AlC Nanomaterial Saturable Absorber. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 13:810. [PMID: 36903689 PMCID: PMC10005740 DOI: 10.3390/nano13050810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/26/2023] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
We report the fabrication of an erbium-doped fiber-based saturable absorber (SA) of niobium aluminium carbide (Nb2AlC) nanomaterial that can generate a dissipative soliton mode-locked pulse. Stable mode-locked pulses operating at 1530 nm with repetition rates of 1 MHz and pulse widths of 6.375 ps were produced using polyvinyl alcohol (PVA) and the Nb2AlC nanomaterial. A peak pulse energy of 7.43 nJ was measured at 175.87 mW pump power. In addition to providing some useful design suggestions for manufacturing SAs based on MAX phase materials, this work shows the MAX phase materials' immense potential for making ultra-short laser pulses.
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Affiliation(s)
- Arni Munira Markom
- School of Electrical Engineering, College of Engineering, Universiti Teknologi MARA, Shah Alam 40450, Selangor, Malaysia
| | | | - Malathy Batumalay
- Faculty of Data Science and IT, INTI International University, Nilai 71800, Selangor, Malaysia
| | - Yusrina Yusof
- School of Electrical Engineering, College of Engineering, Universiti Teknologi MARA, Shah Alam 40450, Selangor, Malaysia
| | - Ahmad Haziq Aiman Rosol
- Department of Electronic Systems Engineering, Malaysia–Japan International Institute of Technology, Universiti Teknologi Malaysia, Jalan Sultan Yahya, Kuala Lumpur 54100, Selangor, Malaysia
| | - Nur Farhanah Zulkipli
- Department of Engineering and Built Environment, Tunku Abdul Rahman University College (TARUC) Penang Branch Campus, Tanjong Bungah 11200, Pulau Pinang, Malaysia
| | - Ahmad Razif Muhammad
- Institute of Microengineering and Nanoelectronics (IMEN), Universiti Kebangsaan Malaysia (UKM), Bangi 43600, Selangor, Malaysia
| | - Hazlihan Haris
- Faculty of Engineering, Universiti Malaysia Sabah (UMS), Kota Kinabalu 88400, Sabah, Malaysia
| | - Ismail Saad
- Faculty of Engineering, Universiti Malaysia Sabah (UMS), Kota Kinabalu 88400, Sabah, Malaysia
| | - Sulaiman Wadi Harun
- Department of Electrical Engineering, University of Malaya, Kuala Lumpur 50603, Selangor, Malaysia
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14
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Basulto-Martínez M, Proietti S, Pavia MP, Yeow Y, Eisner BH, Giusti G. Understanding the ablation rate of Holmium:YAG and thulium fiber lasers. Perspectives from an in vitro study. Urolithiasis 2023; 51:32. [PMID: 36648558 PMCID: PMC9845154 DOI: 10.1007/s00240-022-01402-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/30/2022] [Indexed: 01/18/2023]
Abstract
This study sought to analyze the ablation rates of Holmium:YAG (Ho:YAG) and thulium fiber laser (TFL) under different settings combinations. Lasering was carried out by a computed spiral pattern through a stepper motor bearing a laser fiber. BegoStones were placed inside a water container and lasered therein and the ablation rate was calculated. Different combinations were tested for ~12 Watts (W) for Ho:YAG and TFL lasers. Further 25 W combination for TFL were conducted testing higher frequencies. One-hundred-one experiments were conducted. Under ~12 W, the highest ablation rate for Ho:YAG was obtained with 40 Hz/0.3 J, and Virtual Basket™ (VB) emission mode [114.35 (88.30 - 126.40) mg/min] whereas for TFL, using 40 Hz/0.3 J, and long pulse [143.40 (137.40 - 146) mg/min]. A matched-comparison for 12 Hz/1 J settings showed that TFL outperformed Ho:YAG using medium pulse [63.30 (55.30 - 81.30) vs 132.00 (115.70 - 228.60) mg/min, p=0.016] and long pulse [62.90 (51.60 - 78.90) vs 134.70 (110.60 - 149.30) mg/min, p=0.016]. In the 40 Hz/0.3 J settings, TFL outperformed Ho:YAG (p=0.034). Nonetheless, Ho:YAG with VB's ablation rate increased [114.35 (88.30 - 126.40)], being comparable to that of TFL with medium pulse [127.5 (88.90 - 141.70)] (p=0.400). In TFL 25 W experiments, the ablation rate of 500 Hz / 0.05 J, was higher than those of 1000 Hz / 0.025 J (p=0.049). TFL ablation rate is higher than that of Ho:YAG. Moreover, the Virtual Basket™ emission mode, increased Ho:YAG ablation rates, resulting reaching similar to that of TFL in certain modalities.
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Affiliation(s)
- Mario Basulto-Martínez
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
- European Training Center in Endourology, Milan, Italy
- Department of Urology, Hospital Regional de Alta Especialidad de la Península de Yucatán, Merida, Mexico
| | - Silvia Proietti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
- European Training Center in Endourology, Milan, Italy
| | - Maria Pia Pavia
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
- European Training Center in Endourology, Milan, Italy
- Department of Urology, "Ospedale Riuniti" University Hospital, Marche Polytechnic University, Ancona, Italy
| | - Yuyi Yeow
- European Training Center in Endourology, Milan, Italy
| | - Brian H Eisner
- Department of Urology, Massachusetts General Hospital, Boston, MA, USA
| | - Guido Giusti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.
- European Training Center in Endourology, Milan, Italy.
- Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale San Raffaele S.r.l., Via Olgettina 60, 20132, Milan, MI, Italy.
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15
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Laser Efficiency and Laser Safety: Holmium YAG vs. Thulium Fiber Laser. J Clin Med 2022; 12:jcm12010149. [PMID: 36614950 PMCID: PMC9821183 DOI: 10.3390/jcm12010149] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/28/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
(1) Objective: To support the efficacy and safety of a range of thulium fiber laser (TFL) pre-set parameters for laser lithotripsy: the efficiency is compared against the Holmium:YAG (Ho:YAG) laser in the hands of juniors and experienced urologists using an in vitro ureteral model; the ureteral damage of both lasers is evaluated in an in vivo porcine model. (2) Materials and Methods: Ho:YAG laser technology and TFL technology, with a 200 µm core-diameter laser fibers in an in vitro saline ureteral model were used. Each participant performed 12 laser sessions. Each session included a 3-min lasering of stone phantoms (Begostone) with each laser technology in six different pre-settings retained from the Coloplast TFL Drive user interface pre-settings, for stone dusting: 0.5 J/10 Hz, 0.5 J/20 Hz, 0.7 J/10 Hz, 0.7 J/20 Hz, 1 J/12 Hz and 1 J/20 Hz. Both lasers were also used in three in vivo porcine models, lasering up to 20 W and 12 W in the renal pelvis and the ureter, respectively. Temperature was continuously recorded. After 3 weeks, a second look was done to verify the integrity of the ureters and kidney and an anatomopathological analysis was performed. (3) Results: Regarding laser lithotripsy efficiency, after 3 min of continuous lasering, the overall ablation rate (AR) percentage was 27% greater with the TFL technology (p < 0.0001). The energy per ablated mass [J/mg] was 24% lower when using the TFL (p < 0.0001). While junior urologists performed worse than seniors in all tests, they performed better when using the TFL than Ho:YAG technology (36% more AR and 36% fewer J/mg). In the in vivo porcine model, no urothelial damage was observed for both laser technologies, neither endoscopically during lasering, three weeks later, nor in the pathological test. (4) Conclusions: By using Coloplast TFL Drive GUI pre-set, TFL lithotripsy efficiency is higher than Ho:YAG laser, even in unexperienced hands. Concerning urothelial damage, both laser technologies with low power present no lesions.
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16
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Abstract
Objective The holmium:yttrium-aluminium-garnet laser (Ho:YAG) has been the gold standard for laser lithotripsy over the last three decades. After demonstrating good in vitro efficacy, the thulium fiber laser (TFL) has been recently released in the market and the initial clinical results are encouraging. This article aims to review the main technology differences between the Ho:YAG laser and the TFL, discuss the initial clinical results with the TFL as well as the optimal settings for TFL lithotripsy. Methods We reviewed the literature focusing on the technological aspects of the Ho:YAG laser and TFL as well as the results of in vitro and in vivo studies comparing both technologies. Results In vitro studies show a technical superiority of TFL compared to the Ho:YAG laser and encouraging results have been demonstrated in clinical practice. However, as TFL is a new technology, limited studies are currently available, and the optimal settings for lithotripsy are not yet established. Conclusion TFL has the potential to be an alternative to the Ho:YAG laser, but more reports are still needed to determine the optimal laser for lithotripsy of urinary tract stones when considering all parameters including effectiveness, safety, and costs.
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17
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Zeng G, Zhong W, Mazzon G, Choong S, Pearle M, Agrawal M, Scoffone CM, Fiori C, Gökce MI, Lam W, Petkova K, Sabuncu K, Gadzhiev N, Pietropaolo A, Emiliani E, Sarica K. International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy. Minerva Urol Nephrol 2022; 74:653-668. [PMID: 35099162 DOI: 10.23736/s2724-6051.22.04752-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.
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Affiliation(s)
- Guohua Zeng
- Department of Urology, Guangdong Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wen Zhong
- Department of Urology, Guangdong Key Laboratory of Urology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Giorgio Mazzon
- Department of Urology, San Bassiano Hospital, Vicenza, Italy
| | - Simon Choong
- University College Hospital of London, Institute of Urology, London, UK
| | - Margaret Pearle
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Madhu Agrawal
- Department of Urology, Center for Minimally Invasive Endourology, Global Rainbow Healthcare, Agra, India
| | | | - Cristian Fiori
- Department of Urology, San Luigi Hospital, University of Turin, Turin, Italy
| | - Mehmet I Gökce
- Department of Urology, Faculty of Medicine, University of Ankara, Ankara, Turkey
| | - Wayne Lam
- Division of Urology, Queen Mary Hospital, Hong Kong, China
| | - Kremena Petkova
- Military Medical Academy, Department of Urology and Nephrology, Sofia, Bulgaria
| | - Kubilay Sabuncu
- Department of Urology, Karacabey State Hospital, Karacabey-Bursa, Turkey
| | - Nariman Gadzhiev
- Department of Urology, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Amelia Pietropaolo
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Esteban Emiliani
- Department of Urology, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Kemal Sarica
- Medical School, Department of Urology, Biruni University, Istanbul, Turkey -
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De Lorenzis E, Zanetti SP, Boeri L, Montanari E. Is There Still a Place for Percutaneous Nephrolithotomy in Current Times? J Clin Med 2022; 11:jcm11175157. [PMID: 36079083 PMCID: PMC9457409 DOI: 10.3390/jcm11175157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/20/2022] [Accepted: 08/29/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Percutaneous nephrolithotomy (PCNL) and its miniaturized modifications are usually considered the standard surgical options for large (>20 mm) staghorn and infected stones. Moreover, PCNL is a viable alternative to retrograde intrarenal surgery (RIRS) for smaller stones (<20 mm) in the presence of anatomical malformations or inaccessible lower pole stones. However, due to the advancements in laser and scope technology, RIRS is expanding its indications with the potential benefits of lower complications and a shorter hospital stay. Methods: A literature search using the PUBMED database from inception to June 2022 was performed to explore the current role of PCNL in endourology. The analysis involved a narrative synthesis. Results: PCNL confirmed its role in the treatment of large and complex stones; moreover, miniaturized PCNL has become more competitive, gaining space among classic indications of flexible ureteroscopy. Conclusions: considering all the evaluated subgroups, we can conclude that PCNL is an old fascinating procedure and is here to stay.
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Affiliation(s)
- Elisa De Lorenzis
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda 15, 20122 Milan, Italy
- Correspondence:
| | - Stefano Paolo Zanetti
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda 15, 20122 Milan, Italy
| | - Luca Boeri
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda 15, 20122 Milan, Italy
| | - Emanuele Montanari
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda 15, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Lithotripsy devices for percutaneous nephrolithotomy (PNL) - new developments. Curr Opin Urol 2022; 32:405-410. [PMID: 35674683 DOI: 10.1097/mou.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Percutaneous nephrolithotomy (PNL) is the mainstay of surgery for renal calculi>2 cm or complex multiple calculi and is a technique that has been around since 1976. We review recent literature surrounding novel lithotripsy devices and technology used in PNL. RECENT FINDINGS At present, the Holmium:yttrium-aluminum-garnet (Ho:YAG) laser is widely accepted as the gold standard laser lithotripsy for PNL. SwissLithoClast Trilogy offers a range of probes with a trifecta of electromagnetic, ultrasonic energy with surgeon-controlled suction. The Olympus Shockpulse-SE is a similar lithotripter that relies on continuous ultrasonic energy with pulsed ballistic energy to break stones. Thulium Fiber Laser (TFL) offers an alternative laser energy source to the Holmium laser, which has been shown to be very effective at producing small stone fragments and dust. The Moses technology is another addition in a long list of improvements to the Ho:YAG laser, forming vaporization bubble through which more effective energy can be applied to stones. SUMMARY Trilogy, Shockpulse, TFL and Moses pulse modulation technology for the Holmium laser all provide improvements compared with older lithotripsy devices. In particular, they convey a safer, efficient and more effective way to manage and clear stones.
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Abstract
PURPOSE OF REVIEW The aim of this study was to present the recent and promising innovations of the new laser technologies used for the treatment of renal stones. RECENT FINDINGS Taking advantage of pulse modulation, new technologies such as the Moses effect, the Virtual basket and the Vapor tunnel have been introduced. These technologies seem to improve lithotripsy efficacy by reducing retropulsion and increasing the stone ablation rate.High-power laser lithotripsy has arisen in everyday clinical practice in some centres. The combination of equal efficacy and safety levels compared with the low-power laser lithotripsy and significantly reduced operative time could explain this trend.Thulium fibre laser is an innovative type of laser-emitting machine that offers a lot of advantages compared with its predecessors. The different mechanism of creating the laser pulse offers new possibilities in laser lithotripsy and perhaps in the future thulium fibre laser could replace Ho:YAG as the golden standard for laser lithotripsy. SUMMARY Laser lithotripsy is heavily based on technological equipment. The continuous improvement of available lasers increases the endoscopic lithotripsy levels of efficacy and safety.
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21
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Patil A, Reddy M NK, Shah D, Singh A, Ganpule A, Sabnis RB, Desai M. Holmium with MOSES technology or Thulium Fiber Laser in Miniperc with suction - A new curiosity. J Endourol 2022; 36:1348-1354. [PMID: 35331003 DOI: 10.1089/end.2021.0915] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To present initial clinical comparison between high-power Holmium with MOSES technology(HPH-M) and Thulium Fiber laser(TFL) during mini-PCNL for renal calculi with specific emphasis on fragmentation efficiency, fragment size distribution and stone-free rates(SFR). MATERIAL AND METHODS Between Aug2018-Dec2019, we performed mini-PCNL for renal calculi <3cm using HPH-M(Lumenis, Israel) or TFL(Urolase SP, IPG Photonics). Data was collected prospectively in our institutional stone registry. Propensity score matching(1:1) was performed using stone size and density as predictors resulting in matched cohort of 51 patients in each group. MiniPCNL with active suction sheath was standard across all patients. Primary end-point was SFR at immediate post-procedure and 1month using CT/Xray KUB. Stone fragments were retrieved and segregated to assess proportion of dust(<1mm), small(1-3mm) and large(>3mm) fragments. RESULT Both groups were comparable in terms of stone size(p=0.74), volume(p=0.17) and density(p=0.69). SFR at 48 hours was 78.43% in HPH-M group and 68.63 % in TFL group. Patients with residual fragments were completely clear at 1month. Lasing time(678.6v/s551.95 seconds;p=0.17), stone fragmentation rate(4.6v/s5.2 mm3/s;p=0.23) and total laser energy(21.9v/s16.3KJ;p=0.09) were comparable in both arms. Both groups produced similar dusting (46.8v/s46.41%;p=0.93). TFL produced a greater proportion of fragments >3mm(36%v/s22.68%, p=0.002). On sub-set analysis based on stone density, all outcome parameters were comparable except a shorter total operative time with TFL (p=<0.05). CONCLUSION HPH-M and TFL showed similar SFR. Within constraints of the laser fiber size and energy settings, both modalities were equivalent in terms of fragmentation efficiency and proportion of dusting across stone densities.
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Affiliation(s)
- Abhijit Patil
- Muljibhai Patel Urological Hospital, 29025, Urology, Muljibhai Patel Urological Hospital, V V Desai Road, Nadiad, India, 387001;
| | - Naveen Kumar Reddy M
- Muljibhai Patel Urological Hospital, 29025, Urology, Dr V V Desai Road, Nadiad, Gujarat, India, 387001;
| | - Darshit Shah
- Muljibhai Patel Urological Hospital Department of Urology, 537606, Nadiad, Gujarat, India;
| | - Abhishek Singh
- Muljibhai Patel Urological Hospital, 29025, Urology, Nadiad, Gujarat, India;
| | - Arvind Ganpule
- Muljibhai Patel Urological Hospital, 29025, Department of Urology, Nadiad, Gujarat, India;
| | - R B Sabnis
- Muljibhai Patel Urological Hospital, 29025, Urology, Nadiad, Gujarat, India;
| | - Mahesh Desai
- Muljibhai Patel Urological Hospital, 29025, Urology, Nadiad, Gujarat, India;
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22
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Rice P, Somani BK. Percutaneous laser nephrolithotripsy: is it here to stay? Results of a systematic review. Curr Opin Urol 2022; 32:185-191. [PMID: 34930884 DOI: 10.1097/mou.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW PCNL (percutaneous nephrolithotomy) and its miniaturized variants are being widely employed in stone surgery, owing to their high-stone-free rates (SFRs) and efficacy for large (>20 mm) stones. With advances in laser technology, it has been readily utilized in PCNL, with the potential for lower complication rates at similar SFR. We aimed to perform a systematic literature review with a focus on recent prospective clinical data that compares laser PCNL to either nonlaser PCNL, different PCNL sizes or other current standards of care such as shockwave lithotripsy (ESWL) or flexible ureteroscopy (FURS). RECENT FINDINGS Of the 294 studies initially identified through database searching, nine papers published between 2019 and 2021 were included which compared laser PCNL (Standard PCNL in three, mini-PCNL in four, ultra-mini PCNL in one, micro-PCNL in one study) to other nonlaser lithotripsy, ESWL, FURS, and different PCNL sizes. Complications for laser PCNL ranged from bleeding (4.4%), perirenal haematoma (1.1%), fever (4.6%), ureteric/renal pelvic injury (2.3%), haematuria (2.7%), and infection (2.6%). The mean SFR for laser PCNL was 91.5% at 3 months. SUMMARY Percutaneous laser nephrolithotripsy is well tolerated and effective, with high-SFRs at 3 months and relatively low intraoperative and postoperative complication rates. Further research is required to assess the role of intraoperative techniques and suction to improve outcomes further.
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Affiliation(s)
- Patrick Rice
- Department of Urology, University Hospitals Southampton
- Department of Urology, University of Southampton, Southampton, UK
| | - Bhaskar K Somani
- Department of Urology, University Hospitals Southampton
- Department of Urology, University of Southampton, Southampton, UK
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23
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Corrales M, Traxer O. Retrograde intrarenal surgery: laser showdown (Ho:YAG vs thulium fiber laser). Curr Opin Urol 2022; 32:179-184. [PMID: 35013078 DOI: 10.1097/mou.0000000000000971] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Retrograde intrarenal surgery (RIRS) has always been recommended for large stones > 20 mm, using the Ho:YAG laser. The introduction of a new technology in the urological market, the thulium fiber laser (TFL) has revolutionized the endourology world because of its characteristics and significantly shorter laser-on time (LOT) and operative time, without scarifying the champ vision. The aim of this review is to evaluate the most relevant findings of the last 2 years of each laser technology, confronting Ho:YAG vs TFL, analyzing who is more suitable for performing an efficient RIRS. RECENT FINDINGS Five full clinical trials using TFL for RIRS were found. Median LOT was between 2.8 and 34 min. All stones were similar in terms of stone volume, >500 mm3, and stone density, > 800 HU. Low complication rate, mostly Clavien-Dindo grade I and II and not related to the laser itself. One clinical trial only analyzed the efficacy of TFL for > 20 mm renal stones. SUMMARY Based on this review, TFL performs a more efficient RIRS than the Ho:YAG laser with similar safety.
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Affiliation(s)
- Mariela Corrales
- Sorbonne University GRC Urolithiasis no. 20-Tenon Hospital, Paris, France
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24
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Taratkin M, Azilgareeva C, Cacciamani GE, Enikeev D. Thulium fiber laser in urology: physics made simple. Curr Opin Urol 2022; 32:166-172. [PMID: 34954703 DOI: 10.1097/mou.0000000000000967] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In this narrative review, we will focus on a novel thulium fiber laser's physical properties in terms of its clinical applicability. RECENT FINDINGS TFL has successfully moved forward from the preclinical trials into clinical practice and now is being widely used in clinics around the world. The available data suggest that the device effectively operates in soft tissues - benign prostate hyperplasia (BPH) and bladder tumors, as well as in lithotripsy. Also, the first promising results were obtained from laparoscopic surgery showing its possible applicability in the management of renal cell carcinoma. The constructional changes in fiber laser's design, lead to alteration of laser-tissue interactions, which resulted in clinical advantages of the device. Yet, the exact mechanism often is considered complex for understanding. With this work, we are aiming to build a bridge between biophysics and clinical practice and give a simple explanation of how the devices is working and why the knowledge of it is important for a clinician. SUMMARY The more effective wavelength (closer to the water absorption peak), favorable beam profile, different modes of action allowing to decrease carbonization on one hand and retropulsion on the other, all this makes TFL an evolution in urologic surgery. Further trials investigating on the possible pros and cons of the device are awaited.
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Affiliation(s)
- Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Camilla Azilgareeva
- International School 'Medicine of the Future', Sechenov University, Moscow, Russia
| | - Giovanni E Cacciamani
- USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine
- Artificial Intelligence Center at USC Urology, USC Institute of Urology, University of Southern California, Los Angeles, California, USA
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
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25
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Mahajan S, Mahajan A. Author reply Re: Mahajan AD, Mahajan SA. Thulium fiber laser versus holmium:yttrium aluminum garnet laser for stone lithotripsy during mini-percutaneous nephrolithotomy: A prospective randomized trial. Indian J Urol 2022;38:42-7. Indian J Urol 2022; 38:160-161. [PMID: 35400874 PMCID: PMC8992714 DOI: 10.4103/iju.iju_42_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/03/2022] [Indexed: 11/04/2022] Open
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26
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Dheeroo DK, Mandal S, Das MK, Tripathy S, Nayak P. Re: Vaddi CM, Ramakrishna P, Ganeshan S, Swamy S, Anandan H, Babu M, et al. The clinical efficiency and safety of 60W superpulse thulium fiber laser in retrograde intrarenal surgery. Indian J Urol 2022; 38:191-6. Indian J Urol 2022; 38:330-331. [PMID: 36568458 PMCID: PMC9787440 DOI: 10.4103/iju.iju_230_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/17/2022] [Indexed: 12/27/2022] Open
Affiliation(s)
- Dheeraj Kumar Dheeroo
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Swarnendu Mandal
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India,
E-mail:
| | - Manoj K. Das
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sambit Tripathy
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Prasant Nayak
- Department of Urology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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27
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Mahajan S, Mahajan A. Authors reply Re: Mahajan AD, Mahajan SA. Thulium fiber laser versus holmium:yttrium aluminum garnet laser for stone lithotripsy during mini-percutaneous nephrolithotomy: A prospective randomized trial. Indian J Urol 2022;38:42-7. Indian J Urol 2022; 38:163-164. [PMID: 35400873 PMCID: PMC8992721 DOI: 10.4103/iju.iju_85_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 11/20/2022] Open
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28
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Patil A, Sharma R, Shah D, Gupta A, Singh A, Ganpule A, Sabnis R, Desai M. A prospective comparative study of mini-PCNL using Trilogy™ or thulium fibre laser with suction. World J Urol 2021; 40:539-543. [PMID: 34839407 DOI: 10.1007/s00345-021-03881-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/03/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION There has been recent introduction of novel lithotripters and high-power lasers for stone disintegration. With miniaturization of PCNL, there is need of effective disintegration and faster stone-clearance. This study aimed to evaluate efficiency of Trilogy™ and Thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (mini-PCNL). METHODS This is prospective study comparing efficiency and outcomes of Trilogy™ and TFL in mini-PCNL between January 2019 and February 2020. Primary objective was to compare stone fragmentation rates, with secondary objectives beings stone-free rates and complications. RESULTS There were 60 mini-PCNL with suction using either Trilogy™ or TFL energy source. Mean stone size and density were 27.60 ± 10.17 mm, 22.04 ± 9.69 mm (p = 0.05) and 1172.9 ± 313.5HU, 1308.9 ± 333.9HU (p = 0.10) for Trilogy™ and TFL, respectively. Using 3D doctor imaging software from CT images, mean stone volumes were 3718.9 ± 3038.7mm3 for Trilogy™ and 3425.9 ± 3096.1mm3 for TFL(p = 0.77). Using probe-activation time or lasing time, stone-fragmentation rate was 5.98 ± 4.25mm3/sec for Trilogy™ and 3.95 ± 1.00mm3/sec for TFL(p = 0.015). Treatment time (puncture to complete clearance) was 32.48 ± 15.39 min for Trilogy™ and 28.63 ± 18.56 min for TFL(p = 0.38). Haemoglobin drop was 1.19 ± 0.76gm/dl for Trilogy™ and 0.99 ± 0.74gm/dl for TFL (p = 0.30). Trilogy™ arm had 96.6% complete clearance and TFL had 76.6% in TFL at 48 h. One patient in Trilogy™ arm required auxiliary RIRS for residual stone. Both arms had complete stone clearance at 1 month follow-up. Trilogy™ arm had 3 Clavien-Dindo grade-II complications while TFL had 2 Clavien-Dindo grade-II complications (UTI requiring antibiotics). There was no blood transfusion in either of arm. CONCLUSION Trilogy™ had significantly better stone fragmentation rate than TFL in managing renal stones. However, stone-free rates and complications were comparable for Trilogy™ and TFL.
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Affiliation(s)
- Abhijit Patil
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Rohan Sharma
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Darshit Shah
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Ankit Gupta
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Abhishek Singh
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Arvind Ganpule
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - Ravindra Sabnis
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India.
| | - Mahesh Desai
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
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29
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Abstract
Laser technology has been a breakthrough in urology. The new era in endocorporeal laser lithotripsy has recently begun in mid-2020, where promising technologies tested in vitro have reached their approval for clinical use and, in that way, have made it possible to confirm their safety and advantages in the real world, for the patient and for the urologist.
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Affiliation(s)
- Olivier Traxer
- Sorbonne University, GRC Urolithiasis no. 20, Tenon Hospital, Paris F-75020, France; Sorbonne University, Department of Urology AP-HP, Tenon Hospital, Paris F-75020, France.
| | - Mariela Corrales
- Sorbonne University, GRC Urolithiasis no. 20, Tenon Hospital, Paris F-75020, France; Sorbonne University, Department of Urology AP-HP, Tenon Hospital, Paris F-75020, France
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30
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Jones P, Beisland C, Ulvik Ø. Current status of thulium fibre laser lithotripsy: an up-to-date review. BJU Int 2021; 128:531-538. [PMID: 34273234 DOI: 10.1111/bju.15551] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To perform an up-to-date review to scope the current status of the thulium fibre laser (TFL) in the setting of stone lithotripsy and provide a guide for the clinical urologist. METHODS A review of world literature was performed to identify original articles on TFL for stone lithotripsy. Our clinical experiences of using the technology have also been shared. RESULTS To date there have been 11 clinical studies published on TFL for stone lithotripsy. Three of these have been in the setting of miniaturised percutaneous nephrolithotomy (mini-PCNL) and the remainder have been on ureteroscopy (URS). There has only been one randomised study on this technology, which has been for URS. For URS, the range of settings has been 0.1-4 J × 7-300 Hz for both URS and mini-PCNL. Stones ranging from 0.4-3.2 and 1.5-3 cm have been treated with URS and mini-PCNL, respectively. The final stone-free rate for TFL has ranged from 66.6% to 100% and 85-100% for URS and mini-PCNL, respectively. The average length of stay ranged from 0.5 to 2.4 days in the URS group, but no studies have been reported this for mini-PCNL. Operative times in all the studies (both URS and mini PCNL) were <60 min. CONCLUSION Initial clinical studies reveal that TFL appears to be efficacious in the setting of stone lithotripsy. However, further randomised trials are warranted to delineate its formal position, as well as determine the optimal settings for use in clinical practice.
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Affiliation(s)
- Patrick Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Beisland
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Ulvik
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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31
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Werner H, Bapat S, Schobesberger M, Segets D, Schwaminger SP. Calcium Oxalate Crystallization: Influence of pH, Energy Input, and Supersaturation Ratio on the Synthesis of Artificial Kidney Stones. ACS OMEGA 2021; 6:26566-26574. [PMID: 34661011 PMCID: PMC8515601 DOI: 10.1021/acsomega.1c03938] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/10/2021] [Indexed: 05/13/2023]
Abstract
The removal of kidney stones can lead to small residual fragments remaining in the human body. Residual stone fragments can act as seeds for kidney stone crystallization and may necessitate another intervention. Therefore, it is important to create a consistent model with a particle size comparable to the range of kidney stone fragments. Thus, the size-determining parameters such as supersaturation ratio, energy input, and pH value are examined. The batch crystallizations were performed with supersaturation ratios between 5.07 and 6.12. The compositions of the dried samples were analyzed with Raman spectroscopy, infrared spectroscopy, and X-ray diffraction (XRD). The samples were identified as calcium oxalate monohydrate with spectroscopic analysis, while calcium oxalate dihydrate being the most prominent crystalline species at all supersaturation ratios for the investigated conditions. The aggregate size, obtained with analytical centrifugation, varied between 2.9 and 4.3 μm, while the crystallite domain size, obtained from XRD, varied from 40 to 61 nm. Our results indicate that particle sizes increase with increasing supersaturation, energy input, and pH. All syntheses yield a high particle heterogeneity and represent an ideal basis for reference materials of small kidney stone fragments. These results will help better understand and control the crystallization of calcium oxalate and the aggregation of such pseudopolymorphs.
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Affiliation(s)
- Helen Werner
- Bioseparation
Engineering Group, Department of Mechanical Engineering, Technical University of Munich, 85748 Garching, Germany
| | - Shalmali Bapat
- Process
Technology for Electrochemical Functional Materials, Institute for
Combustion and Gas Dynamics—Reactive Fluids (IVG-RF), University of Duisburg-Essen (UDE), 47057 Duisburg, Germany
| | - Michael Schobesberger
- Bioseparation
Engineering Group, Department of Mechanical Engineering, Technical University of Munich, 85748 Garching, Germany
| | - Doris Segets
- Process
Technology for Electrochemical Functional Materials, Institute for
Combustion and Gas Dynamics—Reactive Fluids (IVG-RF), University of Duisburg-Essen (UDE), 47057 Duisburg, Germany
- Center
for Nanointegration Duisburg-Essen (CENIDE), 47057 Duisburg, Germany
| | - Sebastian P. Schwaminger
- Bioseparation
Engineering Group, Department of Mechanical Engineering, Technical University of Munich, 85748 Garching, Germany
- Department
of Chemical Engineering, Massachusetts Institute
of Technology, Cambridge, Massachusetts 02139, United States
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32
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Yu Y, Pu J, Wu T, Hu L. The characteristics and influencing factors of fever in postoperative patients undergoing percutaneous nephrolithotomy: A retrospective analysis. Medicine (Baltimore) 2021; 100:e26485. [PMID: 34397870 PMCID: PMC8360468 DOI: 10.1097/md.0000000000026485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
Percutaneous nephrolithotomy (PCNL) is commonly used for the treatment of upper urinary calculi in clinical setting, and fever is a common complication after PCNL. It is necessary to evaluate the risk factors of fever in patients undergoing PCNL, to provide insights into the management of PCNL.Patients who underwent PCNL in our hospital from January 2018 to August 2020 were included. The clinical data of postoperative fever and no fever patients were collected and assessed. Logistic regression analyses were conducted to analyze the risk factors for fever in patients undergoing PCNL.A total of 276 patients undergoing PCNL were included, the incidence of postoperative fever for patients undergoing PCNL was 19.39%. No significant differences in the gender, body mass index, alcohol drinking, smoking, hypertension, hyperlipidemia, intraoperative blood infusion, length of hospital stay between fever patients, and no fever patients were found (all P > .05). There were significant differences in the age, diabetes, size of stones, duration of surgery between fever patients, and no fever patients (all P < .05). Age ≥60 years (odds ratio [OR] 2.143, 95% confidence interval [CI] 1.101∼3.264), diabetes (OR 2.218, 95% CI 1.176∼4.642), size of stone ≥2 cm (OR 1.428, 95%CI 1.104∼2.055), duration of surgery ≥100 minutes (OR 1.334, 95% CI 1.015∼1.923) were the risk factors for fever in patients with PCNL (all P < .05). Escherichia coli (48.44%), Staphylococcus aureus (18.75%), and Candida albicans (10.93%) were the top 3 pathogenic bacteria of urine culture.Fever is one of the common complications after PCNL. Patients with high-risk factors should be given full attentions and take corresponding preventive measures targeted on risks.
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33
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Traxer O, Corrales M. Managing Urolithiasis with Thulium Fiber Laser: Updated Real-Life Results-A Systematic Review. J Clin Med 2021; 10:3390. [PMID: 34362169 PMCID: PMC8347545 DOI: 10.3390/jcm10153390] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 01/02/2023] Open
Abstract
Thirty-three years ago, pulsed lasers marked the beginning of a new era in endoscopic lithotripsy, and the one that was highlighted because of its potential was the Holmium: YAG laser, which became and still is the gold standard in endourology. Recently, a new laser technology has been accepted for clinical use in lithotripsy: the thulium fiber laser (TFL), showing appealing characteristics not seen before in several preclinical studies. A review of the literature was performed and all relevant in vitro studies and clinical trials until April 2021 were selected. The search came back with 27 clinical experiences (7 full-text clinical trials and 20 peer-reviewed abstracts) and 33 laboratory studies (18 full-text articles and 15 peer-reviewed abstracts). The clinical experiences confirmed the clinical safety of using the wide parameter range of the TFL. This technology demonstrated the performance at a higher ablation speed, the higher ablation efficiency, and the better dust quality of the TFL, as well as reduced stone retropulsion, thus helping to maintain an optimal visibility. No thermal or radiation damage was found. Given the current evidence, we may be facing the future gold standard laser in endoscopic lithotripsy.
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Affiliation(s)
- Olivier Traxer
- Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F-75020 Paris, France;
- Sorbonne Université, Service d’Urologie, AP-HP, Hôpital Tenon, F-75020 Paris, France
| | - Mariela Corrales
- Sorbonne Université, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, F-75020 Paris, France;
- Sorbonne Université, Service d’Urologie, AP-HP, Hôpital Tenon, F-75020 Paris, France
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34
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Castellani D, Corrales M, Lim EJ, Cracco C, Scoffone C, Teoh JYC, Traxer O, Gauhar V. The impact of lasers in percutaneous nephrolithotomy outcomes: results from a systematic review and meta-analysis of randomized comparative trials. J Endourol 2021; 36:151-157. [PMID: 34314230 DOI: 10.1089/end.2021.0507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Percutaneous nephrolithotomy (PCNL) is the first choice treatment of renal stones larger than 2 cm. We aimed to evaluate if lasers perform as equal as non-laser devices in patients with kidney stones candidate to PCNL. Materials and methods A comprehensive literature search was performed in MEDLINE via PubMed, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) to assess the differences in the perioperative course, incidence of postoperative complications, and stone free-rate (SFR) in patients with kidney stones undergoing laser versus non-laser PCNL in randomized studies. The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios (RR), 95% Confidence Intervals (CI), and p-values. Surgical time and length of stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% CI, and p-values. Analyses were two-tailed, with a significance set at p ≤0.05. Results Six papers including 732 patients (311 patients undergoing holmium laser and 421 non-laser PCNL) were included in meta-analysis. Surgical time and postoperative stay were shorter in the non-laser group (MD:11.14, 95% CI:2.32-19.96, p=0.002; MD:-0.81, 95%CI:-2.18-0.57 p=0.25, respectively). SFR was significantly higher in the non-laser group (RR:1.08, 95% CI:1.01-1.15, p=0.03). Patients undergoing laser PCNL had a non-significant higher risk of postoperative fever >38°C (RR:0.64, 95%CI: .31-1.30, p=0.22). Transfusion rate did not differ between the two groups (RR:1.02, 95% CI:0.50-2.11 p=0.95). The need for stent positioning due to urine extravasation was higher risk in the laser group but the difference did not reach significance (RR:0.49, 95% CI:0.17-1.41 p=0.19). Conclusions Non-laser PCNL showed better perioperative outcomes and SFR as compared to holmium laser PCNL.
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Affiliation(s)
- Daniele Castellani
- AOU Ospedali Riuniti di Ancona, 18494, via conca 71, Ancona, Italy, 60126;
| | - Mariela Corrales
- Hospital Tenon, 55705, Urology, 4 Rue de la Chine, Paris, Île-de-France, France, 75020;
| | - Ee Jean Lim
- Singapore General Hospital, Department of Urology, Academia Level 5, 20 College Rd, Singapore 169856, Singapore, Singapore, 169856;
| | - Cecilia Cracco
- San Luigi Hospital, University of Turin, Department of Urology, regione gonzole 10, Orbassano (Torino), Italy, 10043.,Ospedale Cottolengo, 46961, Department of Urology, via Cottolengo 9, Torino, Italy, 10152;
| | - Cesare Scoffone
- Cottolengo Hospital, Division of Urology, via Cottolengo 9, Torino, Torino, Italy, 10152;
| | - Jeremy Y C Teoh
- Prince of Wales Hospital, Surgery, 30-32 Ngan Shing Street, Shatin, New Territories., Hong Kong, Hong Kong;
| | - Olivier Traxer
- Tenon Hospital, Assitance Publique-Hopitaux De Paris. Pierre Et Marie Curie University, Paris 6, Urology, 4 rue de la Chine, Paris, France, 75020;
| | - Vineet Gauhar
- Ng Teng Fong General Hospital, 242949, Urology, Singapore, Singapore;
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35
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Rice P, Somani BK. A Systematic Review of Thulium Fiber Laser: Applications and Advantages of Laser Technology in the Field of Urology. Res Rep Urol 2021; 13:519-527. [PMID: 34327179 PMCID: PMC8314925 DOI: 10.2147/rru.s233979] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/02/2021] [Indexed: 12/11/2022] Open
Abstract
Laser technology is widely used in urological surgery, from lithotripsy, prostate surgery to en-bloc resection of tumours. While Holmium:YAG has been widely employed over the last two decades, in recent years, there has been a surge of interest in Thulium Fiber Laser (TFL), which offers theoretical advantages of better water absorption and lower stone ablation thresholds. A systematic review was conducted to assess the evidence from clinical research on TFL's application for lithotripsy and prostate surgery. It identified 357 articles and 8 (1506 patients) were selected, of which 4 clinical studies each investigated TFL enucleation of prostate (ThuFLEP) and TFL lithotripsy. For flexible ureteroscopic lithotripsy (FURSL), stone ablation settings ranged from 0.1-4 J, and 7-300 Hz, mean operative time ranged from 23.4-39.8 minutes and lasing time ranged from 1.2-10 minutes. For stone dusting in percutaneous nephrolithotomy (PCNL), settings of 0.2 J and 125-200 Hz were found to be optimal. For ThuFLEP, all studies showed a significant improvement in IPSS (International Prostate Symptom Score), urinary flow rate (Qmax), quality of life measures, and post-void residual volume, with mean operative time ranging from 67-104.5 minutes. Our review shows that there is limited evidence on the use and clinical outcomes of TFL. ThuFLEP might suggest equivalence to the widely used HoLEP in the available evidence so far. TFL lithotripsy shows promising results but further prospective, randomized trials are required to properly assess its usability, clinical effectiveness and standardisation of the settings for successful adoption of the technology.
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Affiliation(s)
- Patrick Rice
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Bhaskar K Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
- Manipal Academy of Higher Education, Manipal, India
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Carrera RV, Randall JH, Garcia-Gil M, Knudsen BE, Chew BH, Thompson JA, Humphreys MR, Molina WR. Ureteroscopic Performance of High Power Super Pulse Thulium Fiber Laser for the Treatment of Urolithiasis: Results of the First Case Series in North America. Urology 2021; 153:87-92. [PMID: 33621583 DOI: 10.1016/j.urology.2020.12.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/30/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To report the first case series of ureterorenoscopy in North America using the High Power Super Pulse Thulium Fiber Laser for the treatment of upper urinary tract stones. METHODS After Institutional Review Board approval, a multicentric retrospective chart review of patients treated with the High Power Super Pulse Thulium Fiber Laser from October 2019 to March 2020 was conducted. Basic demographic information, pre-operative, and peri-operative data were recorded. RESULTS Seventy-six patients were included with a mean age of 60.9 ± 13.3 years. 118 stones were treated including 32 within the ureter, 49 in the lower pole, 37 in mid or upper poles. Dusting technique was commonly used (67.1%) with pulse frequencies up to 2400 Hz. Mean operative time was 59.4 ± 31.5 minutes. Mean laser time and total laser energy were 10.8 ± 14.1 minutes and 12.5 ± 19.1 KJ, respectively. Intraoperative complications were limited to 7 grade 1, 3 grade 2, and 1 grade 3 ureteral injuries and one case of renal collecting system bleeding that was adequately managed with laser coagulation settings (1J-20Hz). CONCLUSION This initial case series in North America of the High Power Super Pulse Thulium Fiber Laser is promising for the treatment of urolithiasis. Sub-200 μm fibers and dusting settings up to 2400 Hz were utilized successfully. No specific complications related to use of the laser were seen.
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Affiliation(s)
- Raphael V Carrera
- University of Kansas Medical Center, Department of Urology, Kansas City, KS, United States
| | - J Hogan Randall
- University of Kansas Medical Center, Department of Urology, Kansas City, KS, United States
| | - Maurilio Garcia-Gil
- The Ohio State University Wexner Medical Center, Department of Urology, Columbus, OH, United States
| | - Bodo E Knudsen
- The Ohio State University Wexner Medical Center, Department of Urology, Columbus, OH, United States
| | - Ben H Chew
- University of British Columbia, Department of Urologic Sciences, Vancouver, BC, Canada
| | - Jeffrey A Thompson
- Department of Biostatistics & Data Science, Kansas City, KS, United States
| | | | - Wilson R Molina
- University of Kansas Medical Center, Department of Urology, Kansas City, KS, United States.
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Enikeev D. Re: Panthier et al., Pulsed lasers and endocorporeal laser lithotripsy, Progrès en Urologie, 2021. Prog Urol 2021; 31:449-450. [PMID: 33941455 DOI: 10.1016/j.purol.2020.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/18/2022]
Affiliation(s)
- D Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.
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Abstract
PURPOSE OF REVIEW To describe and critically discuss the most recent evidence regarding the percutaneous nephrolithotomy (PCNL) techniques. RECENT FINDINGS Three-dimensional printing and virtual reality are promising tools to improve surgeon experience and operative performance. Totally ultrasound-guided PCNL is feasible and can reduce the radiological risk. Growing evidence highlights the safety and advantages of the use of miniaturized instrumentations, although some related limitations place the mini PCNL (mPCNL) in direct challenge with the retrograde intrarenal surgery. LithoClast Trilogy and ClearPetra system can improve the stone clearance. Thulium laser is a new source of energy with growing expectations and promising in-vitro results. SUMMARY Significant advances have recently been recorded in PCNL techniques. Thulium fiber laser, LithoClast Trilogy, new suction devices, and the development of novel technologies for teaching and planning procedures may overcome mPCNL drawbacks. Further studies are needed to confirm the promising preliminary results available on the topic.
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Abstract
PURPOSE OF REVIEW Recent years witnessed significant changes in the endourological management of renal tones because of the development of new, more advanced instruments. Retrograde intrarenal surgery (RIRS) has gained particular advantage from such technological progress and now tends to be considered the gold standard treatment for uncomplicated less than 20 mm renal stones. Using a step-by-step approach, this review aims to highlight current achievements but also unsolved problems in RIRS. RECENT FINDINGS Several technical details of RIRS, including preoperative stenting, use of ureteral access sheets, lithotripsy method, and renal drainage, remain open to discussion and linked to surgeon's preference. Moreover, there is a wide range of variation in efficacy and safety data, with major complications being episodic but often under-reported. SUMMARY RIRS has gained increased popularity among the urological community. This is certainly because of the continuous technological advancements, which have continuously improved the RIRS performance but also to the perception of ease and safety of this procedure when compared with the other available treatment modalities, particularly percutaneous nephrolitotomy. Indeed, the reported advances in RIRS technique have significantly improved the outcomes of this procedure but care should be taken not to underestimate its potential challenges.
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Liu M, Peng Y, Wang Z, Li L, Ming S, Fang Z, Dong H, Li R, Gao X. Ablation Efficiency of a Novel Thulium Fiber Laser: An In Vitro Study on Laser Setting and Fiber Usage. J Endourol 2021; 35:1211-1216. [PMID: 33403925 DOI: 10.1089/end.2020.1116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: To investigate the ablation efficiency of super-pulse thulium fiber laser (SPTFL) with different laser settings and fiber usage. Materials and Methods: SPTFL machine was attached with different fibers. Artificial stones were fixed in water, whereas laser fiber was driven on a platform for ablation. Pulse energy, frequency, fiber-moving speed, fiber-to-stone distance, and fiber size were adjusted in each trial. The cross-sectional area of craters on the lateral stone surface was measured for comparison of ablation rate, combined with fiber-moving speed. Results: There was a trend that the ablation rate increased as pulse energy or frequency increased. When pulse energy was set as 0.2 J and frequency was increased from 50 to 150 Hz, the cross-sectional area of the crater was enlarged from 0.21 to 0.37 mm2 (p < 0.05); when the frequency was set as 100 Hz and pulse energy was increased from 0.1 to 0.3 J, the crater was enlarged from 0.10 to 0.45 mm2 (p < 0.05). Furthermore, energy demonstrated greater impact on ablation rate and the crater was enlarged from 0.20 mm2 in the 0.1 J × 300 Hz group to 0.44 mm2 in the 0.3 J × 100 Hz group (p < 0.05). Then fiber was set at different moving speeds with the same laser setting; the ablation rate of 3 mm/second group was 3.64 times higher than 0.5 mm/second group (p < 0.05). Ablation diminished as fiber-to-stone distance grew. A 200 μm fiber produced thinner and deeper fissure than 272 and 550 μm fibers, and the ablation rate was the highest for the 200 μm fiber. Conclusion: Pulse energy is a more important factor in influencing ablation efficiency compared with frequency. Closer fiber-to-stone distance, faster fiber movement, and smaller fiber size increase ablation efficiency.
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Affiliation(s)
- Min Liu
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Yonghan Peng
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Zeyu Wang
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Ling Li
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Shaoxiong Ming
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Ziyu Fang
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Hao Dong
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Rui Li
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
| | - Xiaofeng Gao
- Department of Urology, Shanghai Changhai Hospital, Shanghai, China
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Taratkin M, Azilgareeva C, Chinenov D, Mikhailov V, Inoyatov J, Ali S, Korolev D, Tsarichenko D, Corrales M, Enikeev D. Retrograde intrarenal surgery versus percutaneous nephrolithotomy in larger kidney stones. Could SuperPulsed Thulium-fiber laser change the game? Cent European J Urol 2021; 74:229-234. [PMID: 34336243 PMCID: PMC8318030 DOI: 10.5173/ceju.2021.0133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction The aim of this article was to compare retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) efficacy and safety with SuperPulsed Thulium-fiber laser (SP TFL) for stones 20 mm and larger. Material and methods Patients with large kidney stones (20 mm and larger) were recruited to undergo PCNL or RIRS with SP TFL lithotripsy. Both groups were comparable in terms of stone size and density, operation time, laser-on time (LOT), stone-free rate, residual fragments and complication rate. Stone retropulsion and visibility were assessed based on the surgeon's feedback using Likert scales. Results A total of 14 and 56 patients were included in the RIRS and PCNL groups, respectively. The mean stone density was 833.8 ±298.3 HU in the RIRS group and 882.3 ±408.5 HU in the PCNL group (p = 0.072). The median LOT was 11.7 (10.0-15.5) min for RIRS and 10.0 (6.0-12.1) min for PCNL (p = 0.207). The median total energy for stone ablation was 13.8 (11.8-25.0) kJ for RIRS and 12.0 (7.0-20.1) kJ for PCNL (p = 0.508). The median ablation speed was 3.9 (3.9-5.7) mm3/sec for RIRS and 5.0 (4.6-11.3) mm3/sec for PCNL (p = 0.085). We found a significant correlation between retropulsion and the type of surgery performed: with higher retropulsion in the PCNL (r = 0.298 with p = 0.012). The stone-free rate at 3-months was 85.7% in RIRS and 89.3% in PCNL (p = 0.505). Conclusions SP TFL is a safe and effective modality for lithotripsy for both, RIRS and PCNL, achieving minimal retropulsion and good visibility. No discrepancies in procedure duration, complications, or LOT were identified between the different modalities.
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Affiliation(s)
- Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Camilla Azilgareeva
- International School 'Medicine of the Future', Sechenov University, Moscow, Russian Federation
| | - Denis Chinenov
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | | | - Jasur Inoyatov
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Stanislav Ali
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Dmitry Korolev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Dmitry Tsarichenko
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
| | - Mariela Corrales
- GRC #20 Lithiase Urinaire, Sorbonne University, Hôpital Tenon, Paris, France
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russian Federation
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Okhunov Z, Jiang P, Afyouni AS, Ayad M, Arada RB, Brevik A, Akopian G, Patel RM, Landman J, Clayman RV. Caveat Emptor: The Heat Is "ON": An In Vivo Evaluation of the Thulium Fiber Laser and Temperature Changes in the Porcine Kidney during Dusting and Fragmentation Modes. J Endourol 2021; 35:1716-1722. [PMID: 33906433 DOI: 10.1089/end.2021.0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION We sought to examine the intrarenal fluid and tissue temperature during dusting and fragmentation with the Thulium fiber laser (TFL) in an in vivo porcine kidney. METHODS In two pigs, temperature was continuously measured within the upper, middle, and lower calyces and at the tip of the ureteroscope. Four experimental protocols were performed: dual lumen ureteroscope with both warmed (37°C) and room temperature (20-22ºC) irrigation and single lumen ureteroscope with warmed and room temperature irrigation. In each pig, one kidney had a 14F ureteral access sheath (UAS), other kidney had no UAS. A 200µm TFL was fired at three settings: dusting (0.5J, 80Hz, 40W) with continuous activation for 5 minutes or until a temperature reached 44⁰C; low power (1J, 10Hz, 10W) and high-power fragmentation (1.5J, 20Hz, 30W). For fragmentation, the laser was activated for 10 seconds with a 2 second intermission for 1 minute. RESULTS In the absence of an UAS, in all but one circumstance, temperatures exceeded 44ºC at all settings with the use of either warm or room temperature irrigation, regardless of the type of ureteroscope. Temperatures recorded at the ureteroscope tip were 4ºC - 22ºC less than the temperatures recorded in the renal calyces. In contrast, with a 14F UAS in place, 6 distinct groups had temperatures that did not exceed 44ºC, specifically at low and high-power fragmentation settings with room temperature irrigation for both sets of ureteroscopes and at dusting and low-power fragmentation settings with warm temperature irrigation solely for the single lumen ureteroscope. Temperatures at the ureteroscope tip with an UAS yielded temperature differences from 17ºC less to 19ºC more than the renal calyces. CONCLUSIONS Thulium fiber laser is a novel technology for lithotripsy. In the absence of a UAS, high-power TFL fragmentation settings, may create temperatures that could result in urothelial tissue injury.
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Affiliation(s)
- Zhamshid Okhunov
- University of California, Irvine, Urology, 333 City Boulevard, Suite 2100, 333 City Boulevard, Suite 2100, Orange, California, United States, 92868;
| | - Pengbo Jiang
- University of California Irvine, 8788, Urology, Irvine, California, United States;
| | - Andrew Shea Afyouni
- University of California Irvine, 8788, Department of Urology, 333 City Blvd W, Orange, California, United States, 92868;
| | - Maged Ayad
- University of California Irvine, 8788, Urology, 101 The City Drive S, Orange, California, United States, 92868;
| | - Raphael B Arada
- University of California Irvine Department of Urology, 481083, 101 The City Dr S, Orange, California, United States, 92868-2987;
| | - Andrew Brevik
- University of California Irvine, 8788, Urology, 333 City Blvd West, Orange, California, United States, 92868.,Kansas City University of Medicine and Biosciences, 32959, Kansas City, Missouri, United States, 64106-1453;
| | - Gagik Akopian
- I M Sechenov First Moscow State Medical University, 68477, Research Institute of Uronephrology and Reproductive Health, Moskva, Moskva, Russian Federation;
| | - Roshan M Patel
- University of California Irvine, 8788, Urology, Orange, California, United States;
| | - Jaime Landman
- University of California Irvine, Urology, 333 City Blvd West, Orange, California, United States, 92868;
| | - Ralph V Clayman
- Univ. of California, Irvine, Urology, 101 The City Drive South, Bldg. 55, Room 304, Route 81, Irvine, California, United States, 92868;
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El-Nahas AR, Khadgi S, Diab M, Al-Terki A. Definition and Unfavorable Risk Factors of Trifecta in Mini-Percutaneous Nephrolithotomy. J Endourol 2021; 35:1140-1145. [PMID: 33554728 DOI: 10.1089/end.2020.1192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objectives: In performing mini-percutaneous nephrolithotomy (PCNL), we aimed at achieving the trifecta of stone-free status and no complications in a single treatment session. We analyzed our experience to determine negative predictors for achieving these three-fold goals. Patients and Methods: The data of all consecutive patients who underwent tubeless mini-PCNL between July 2015 and March 2020 in two hospitals were retrospectively reviewed. Stone-free was defined as no residual stones. Complications were recorded and graded according to modified Clavien classification. Patients were divided into two groups according to the outcome (trifecta and non-trifecta). Factors affecting the outcome were compared between both groups by using univariate and multivariate analyses to detect independent unfavorable risk factors. Results: The study included 944 patients with mean age 40.2 years (standard deviation: 13.6). The stone-free rate after one session of mini-PCNL was 90.7%. Auxiliary procedures were needed in 14 patients (1.5%). Complications were observed in 76 patients (8.1%). Trifecta was achieved in 792 patients (84%). Independent unfavorable risk factors in multivariate analysis were number of caliceal groups affected by the stones (relative risks were 1.95 to 2.27 and 5.7 for one, two, and three caliceal groups respectively) and number of percutaneous tracts (relative risk was 2.2). Stone size and complexity were not significant predictors of missing trifecta in multivariate analysis. Conclusions: Mini-PCNL can achieve a high rate of trifecta (84%) for different stone sizes and complexities. Stones distribution in multiple caliceal groups and multiple tracts are the independent unfavorable risk factor.
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Affiliation(s)
- Ahmed R El-Nahas
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.,Urology Unit, AL-Amiri Hospital, Kuwait, Kuwait
| | - Sanjay Khadgi
- Department of Urology, Vayodha Hospital, Kathmandu, Nepal
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Minimally invasive percutaneous nephrolithotomy with SuperPulsed Thulium-fiber laser. Urolithiasis 2021; 49:485-491. [PMID: 33655346 DOI: 10.1007/s00240-021-01258-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/18/2021] [Indexed: 12/19/2022]
Abstract
We aimed to assess the efficacy and safety of minimally invasive percutaneous nephrolithotomy (PCNL) with SuperPulsed Thulium-fiber laser (SP TFL) using different frequency settings. 125 patients with solitary kidney calculi of up to 55 mm in the maximum diameter underwent mini-PCNL with the SP TFL. Stone-free rate, laser-on time, ablation efficacy, energy consumption, ablation speed and complications were all analyzed. Negative low-dose computed tomography scan or asymptomatic patients with stone fragments < 2 mm were the criteria for assessing the stone-free status. In 36 patients (28.8%) low frequency regimens were used (LF: 3-19 Hz-0.5-6 J), in 75 patients (60%) high frequency regimens were chosen (HF: 20-49 Hz-0.2-2 J) and in 14 (11.2%) patients higher frequency (HRF: 50-200 Hz-0.1-0.5 J) regimens were preferred. The mean age was 52 ± 1.8 years. Median stone diameter and median stone volume were larger at low frequency regimens compared to high frequency regimens. Ablation efficacy (J/mm3) was lower at low rather than at high frequency regimens. Ablation speed (mm3/sec) was higher at low compared to high frequency regimens. Surgeons reported minimal and absent retropulsion at higher frequency regimens. The best visibility was observed at high frequency regimens. The overall stone free rate (SFR) at 3 months was 85%. The majority of the postoperative complications were classified between Clavien grades I-II. SP TFL is an effective and safe tool for performing mini-PCNL regardless of the laser settings.
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Kronenberg P, Hameed BMZ, Somani B. Outcomes of thulium fibre laser for treatment of urinary tract stones: results of a systematic review. Curr Opin Urol 2021; 31:80-86. [PMID: 33470684 PMCID: PMC7879830 DOI: 10.1097/mou.0000000000000853] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Lasers have become a fundamental aspect of stone treatment. Although Holmium:Yttrium-Aluminum-garnet (Ho:YAG) laser is the current gold-standard in endoscopic laser lithotripsy, there is a lot of buzz around the new thulium fibre laser (TFL). We decided to evaluate the latest data to help create an objective and evidence-based opinion about this new technology and associated clinical outcomes. RECENT FINDINGS Sixty full-text articles and peer-reviewed abstract presentations were included in the qualitative synthesis of this systematic review performed over the last 2 years. Current super pulsed TFL machines are capable of achieving peak powers of 500W and emit very small pulse energies of 0.025 Joules going up to 6 Joules, and capable of frequency over 2000 Hz. This makes the TFL ablate twice as fast for fragmentation, 4 times as fast for dusting, more stone dust of finer size and less retropulsion compared to the Ho:YAG laser. Because of the smaller laser fibres with the TFL, future miniaturization of instruments is also possible. SUMMARY Based on the review, the TFL is a potential game-changer for kidney stone disease and has a promising role in the future. However larger multicentric prospective clinical studies with long-term follow-up are needed to establish the safety and efficacy of the TFL in endourology.
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Affiliation(s)
| | - BM Zeeshan Hameed
- Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Bhaskar Somani
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Gao B, Bobrowski A, Lee J. A scoping review of the clinical efficacy and safety of the novel thulium fiber laser: The rising star of laser lithotripsy. Can Urol Assoc J 2021; 15:56-66. [PMID: 32744995 PMCID: PMC7864720 DOI: 10.5489/cuaj.6804] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the gold standard for intracorporeal lithotripsy. Preclinical reports suggest the thulium laser fibre (TFL) may possess advantages over the Ho:YAG laser, including improved lithotripsy efficacy, enhanced safety, and lower costs. Although the TFL is well-characterized in-vitro, there are no reviews examining TFL lithotripsy in a clinical setting. METHODS A review of the literature was conducted using a systematic search of MEDLINE, PubMed, and Embase, yielding a total of 130 manuscripts published up to May 2020. Two independent reviewers selected studies for screening, eligibility, and inclusion into the scoping review. Following the title, abstract, and full-text review, 14 articles were analyzed. RESULTS Within these articles, there were 13 prospective cohort studies and one case series. The average sample size was 100 participants. Study followup durations ranged from four weeks to three months. TFL had comparable stone-free rates to Ho:YAG lasers and improved operating time. TFL was subjectively favorable in terms of stone retropulsion, stone fragmentation, endoscopic maneuverability, and endoscopic visibility. TFL appeared clinically safe and did not result in any major complications. Many studies were underpowered and non-peer-reviewed, demonstrating the need for additional research in this field. CONCLUSIONS The TFL has the potential to catalyze a paradigm shift in laser lithotripsy. While the objective of this scoping review was to describe the contemporary landscape of the literature, it is important to consider that inferences posed by the studies described herein must be tempered by the low quality of available evidence.
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Affiliation(s)
- Bruce Gao
- Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Adam Bobrowski
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jason Lee
- Division of Urology, University of Toronto, Toronto, ON, Canada
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Khusid JA, Khargi R, Seiden B, Sadiq AS, Atallah WM, Gupta M. Thulium fiber laser utilization in urological surgery: A narrative review. Investig Clin Urol 2021; 62:136-147. [PMID: 33660440 PMCID: PMC7940849 DOI: 10.4111/icu.20200467] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/02/2020] [Accepted: 12/15/2020] [Indexed: 11/18/2022] Open
Abstract
The thulium fiber laser (TFL) is a novel technology under active investigation as an conceivable alternative to the Holmium:yttrium-aluminum-garnet (Ho:YAG) laser, which is currently the gold standard for an array of urologic procedures. The purpose of this review is to discuss the existing literature on the functionality and effectiveness of TFL in urological practice. We conducted a search of the PubMed, Medline, Web of Science Core Collection, SCOPUS, Embase (OVID), and Cochrane Databases for all full articles and systematic reviews on the TFL. We found a total of 35 relevant pieces of literature. The early research findings pertaining to the TFL exhibit numerous potential advantages over the Ho:YAG laser. In vitro and ex vivo studies have highlighted the TFL's ability to utilize smaller laser fibers, obtain faster stone ablation rates, and achieve less retropulsion when tested against the Ho:YAG laser in lithotripsy. Currently, there is limited in vivo research that investigates the utilization of the TFL. The in vivo results that are available, however, look promising both for laser lithotripsy and soft tissue ablation. Indeed, the existing literature suggests that the TFL has great potential and may possess numerous technological advantages over the Ho:YAG laser, especially in laser lithotripsy. Although these early studies are promising, randomized control trials are needed to assess the full applicability of the TFL in urology.
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Affiliation(s)
- Johnathan A Khusid
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Raymond Khargi
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Benjamin Seiden
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Areeba S Sadiq
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William M Atallah
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mantu Gupta
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Taguchi K. Editorial Comment from Dr Taguchi to Endoscopic lithotripsy with a SuperPulsed thulium-fiber laser for ureteral stones: A single-center experience. Int J Urol 2020; 28:266-267. [PMID: 33269479 DOI: 10.1111/iju.14459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kazumi Taguchi
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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Enikeev D, Grigoryan V, Fokin I, Morozov A, Taratkin M, Klimov R, Kozlov V, Gabdullina S, Glybochko P. Endoscopic lithotripsy with a SuperPulsed thulium-fiber laser for ureteral stones: A single-center experience. Int J Urol 2020; 28:261-265. [PMID: 33258271 DOI: 10.1111/iju.14443] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/25/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To estimate the efficacy and safety of SuperPulsed thulium-fiber laser ureteral lithotripsy and to identify optimal laser settings. METHODS Patients with solitary stones were prospectively included. Lithotripsy was performed with a SuperPulsed thulium-fiber laser (NTO IRE-Polus, Fryazino, Russia) using a rigid ureteroscope 7.5 Ch (Richard Wolf, Knittlingen, Germany). We analyzed the efficacy of lithotripsy by measuring total energy required for stone disintegration, "laser-on" time, ablation speed, ablation efficacy, and energy consumption. Stone retropulsion and visibility were assessed using a three-point Likert scale. Complications were assessed using the Clavien-Dindo classification system. RESULTS A total of 149 patients were included. The mean stone density was 985 ± 360 Hounsfield units, the median (interquartile range) stone volume was 179 (94-357) mm3 . The median (interquartile range) total energy was 1 (0.4-2) kJ, and laser-on time 1.2 (0.5-2.7) min. The median (interquartile range) stone ablation speed was 140 (80-279) mm3 /min, energy for ablation of 1 mm3 was 5.6 (3-9.9) J/mm3 and energy consumption was 0.9 (0.6-1) J/min. A correlation was found between retropulsion and the energy used (r = 0.5, P < 0.001). Multivariable analysis showed energy to be a predictor of increased retropulsion (odds ratio 65.7, 95% confidence interval 1.6-2774.1; P = 0.028). No predictors for worse visibility were identified. CONCLUSION The SuperPulsed thulium-fiber laser provides effective and safe lithotripsy during ureteroscopy regardless of stone density. Fiber diameter and laser frequency do not influence visibility or safety. Optimal laser settings are 0.5 J × 30 Hz for fragmentation and 0.15 J × 100 Hz for dusting.
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Affiliation(s)
- Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Vagarshak Grigoryan
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Igor Fokin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Andrey Morozov
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Roman Klimov
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Vasiliy Kozlov
- Department of Public Health and Healthcare, Sechenov University, Moscow, Russia
| | - Svetlana Gabdullina
- Institute of Linguistics and Intercultural Communication, Sechenov University, Moscow, Russia
| | - Petr Glybochko
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
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Taratkin M, Kovalenko A, Laukhtina E, Paramonova N, Spivak L, Wachtendorf LJ, Eminovic S, Afyouni AS, Okhunov Z, Karagezyan M, Mikhailov V, Strakhov Y, Herrmann TR, Enikeev D. Ex vivo study of Ho:YAG and thulium fiber lasers for soft tissue surgery: which laser for which case? Lasers Med Sci 2020; 37:149-154. [PMID: 33175250 DOI: 10.1007/s10103-020-03189-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
The goal of this study was to assess the ablation, coagulation, and carbonization characteristics of the holmium:YAG (Ho:YAG) laser and thulium fiber lasers (TFL). The Ho:YAG laser (100 W av.power), the quasi-continuous (QCW) TFL (120 W av.power), and the SuperPulsed (SP) TFL (50 W av.power) were compared on a non-frozen porcine kidney. To control the cutting speed (2 or 5 mm/s), an XY translation stage was used. The Ho:YAG was tested using E = 1.5 J and Pav = 40 W or Pav = 70 W settings. The TFL was tested using E = 1.5 J and Pav = 30 W or Pav = 60 W settings. After ex vivo incision, histological analysis was performed in order to estimate thermal damage. At 40 W, the Ho:YAG displayed a shallower cutting at 2 and 5 mm/s (1.1 ± 0.2 mm and 0.5 ± 0.2 mm, respectively) with virtually zero coagulation. While at 70 W, the minimal coagulation depth measured 0.1 ± 0.1 mm. The incisions demonstrated zero carbonization. Both the QCW and SP TFL did show effective cutting at all speeds (2.1 ± 0.2 mm and 1.3 ± 0.2 mm, respectively, at 30 W) with prominent coagulation (0.6 ± 0.1 mm and 0.4 ± 0.1 mm, respectively, at 70 W) and carbonization. Our study introduced the TFL as a novel efficient alternative for soft tissue surgery to the Ho:YAG laser. The SP TFL offers a Ho:YAG-like incision, while QCW TFL allows for fast, deep, and precise cutting with increased carbonization.
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Affiliation(s)
- Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.
| | - Anastasia Kovalenko
- NTO "IRE-Polus", One Vvedenskogo Sq, Fryazino, Moscow Region, Russia, 141120
| | - Ekaterina Laukhtina
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Nina Paramonova
- Centralized Pathology Department, Sechenov University, Moscow, Russia
| | - Leonid Spivak
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | | | - Semil Eminovic
- Faculty of Medicine, Philipps University Marburg, Marburg, Germany
| | | | - Zhamshid Okhunov
- Department of Urology, University of California, Irvine, CA, USA
| | - Marina Karagezyan
- Institute of Linguistics and Intercultural Communication, Sechenov University, Moscow, Russia
| | - Vasily Mikhailov
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Yuriy Strakhov
- Centralized Pathology Department, Sechenov University, Moscow, Russia
| | - Thomas Rw Herrmann
- Department of Urology, Spital Thurgau AG, Pfaffenholzstrasse 4, 8501, Frauenfeld, Switzerland
- Department of Urology, Hannover Medical School, Hannover, Germany
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
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