1
|
Nizzardo M, Albo G, Ripa F, Zino E, De Lorenzis E, Boeri L, Longo F, Montanari E, Zanetti SP. Assessment of Effectiveness and Safety of Aspiration-Assisted Nephrostomic Access Sheaths in PCNL and Intrarenal Pressures Evaluation: A Systematic Review of the Literature. J Clin Med 2024; 13:2558. [PMID: 38731086 PMCID: PMC11084567 DOI: 10.3390/jcm13092558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Different suction-assisted nephrostomic sheaths have been developed for percutaneous nephrolithotomy (PCNL). Objectives: (1) To examine PCNL techniques performed with different aspiration-assisted sheaths (Clear Petra® sheath, Superperc, SuperminiPCNL, and a miniPCNL patented sheath), with specific regard to effectiveness and safety outcomes in adult and paediatric patients; (2) to extrapolate intrarenal pressure (IRP) data during these procedures. Methods: A systematic literature search was performed in accordance with PRISMA guidelines. Relevant articles up to 8 February 2024 were included. Results: Twenty-five studies were selected, thirteen retrospective and twelve prospective. The use of four different aspirating sheaths for miniPCNL was reported: Clear Petra® sheath, Superperc, SuperminiPCNL, and a miniPCNL patented sheath. Stone free rates (SFRs) across techniques ranged from 71.3% to 100%, and complication rates from 1.5% to 38.9%. Infectious complication rates varied from 0 to 27.8% and bleeding complication rates from 0 to 8.9%. Most complications were low grade ones. The trend among studies comparing aspiration- and non-aspiration-assisted miniPCNL was towards equivalent or better SFRs and lower overall infectious and bleeding complication rates in suction techniques. Operation time was consistently lower in suction procedures, with a mean shortening of the procedural time of 19 min. Seven studies reported IRP values during suction miniPCNL. Two studies reported satisfactory SFRs and adequate safety profiles in paediatric patient cohorts. Conclusions: MiniPCNL with aspirating sheaths appears to be safe and effective in both adult and paediatric patients. A trend towards a reduction of overall infectious and bleeding complications with respect to non-suction procedures is evident, with comparable or better SFRs and consistently shorter operative times. The IRP profile seems to be safe with the aid of aspirating sheaths. However, high quality evidence on this topic is still lacking.
Collapse
Affiliation(s)
- Marco Nizzardo
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giancarlo Albo
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Francesco Ripa
- Department of Urology, Whittington Health NHS Trust, London N19 5NF, UK
| | - Ester Zino
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Elisa De Lorenzis
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Luca Boeri
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Fabrizio Longo
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Emanuele Montanari
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Stefano Paolo Zanetti
- Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| |
Collapse
|
2
|
De Stefano V, Castellani D, Somani BK, Giulioni C, Cormio A, Galosi AB, Sarica K, Glover X, da Silva RD, Tanidir Y, Gadzhiev N, Pirola GM, Mulawkar PM, Teoh JYC, Monga M, Herrmann TRW, Gauhar V. Suction in Percutaneous Nephrolithotripsy: Evolution, Development, and Outcomes from Experimental and Clinical studies. Results from a Systematic Review. Eur Urol Focus 2024; 10:154-168. [PMID: 37442721 DOI: 10.1016/j.euf.2023.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/02/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023]
Abstract
CONTEXT Controversy exists regarding the therapeutic benefit of suction use during percutaneous nephrolithotripsy (PCNL). OBJECTIVE To review and highlight the options available in the use of suction for PCNL, and to discuss their strengths and limitations. EVIDENCE ACQUISITION A systematic literature search was performed using Scopus, EMBASE, and PubMed. Thirty four studies were included. There was one ex vivo study. Among clinical studies, 24 used a vacuum/suctioning sheath and nine a handpiece suction device/direct-in-scope suction. The suction technique was employed in standard, mini-PCNL, supermini-PCNL, and enhanced supermini‑PCNL techniques. EVIDENCE SYNTHESIS Handpiece suction devices demonstrated better safety and efficiency in treating large stones than nonsuction PCNL and in a much shorter time. Trilogy and ShockPulse-SE were equally effective, safe, and versatile for standard PCNL and mini-PCNL. The heavier handpiece makes Trilogy less ergonomically friendly. Laser suction handpiece devices can potentiate laser lithotripsy by allowing for better laser control with simultaneous suction of small fragments and dust. Integrated suction-based sheaths are available in reusable and disposable forms for mini-PCNL only. Mini-PCNL with suction reported superior outcomes for operative time and stone-free rate to mini-PCNL. This also helped minimize infectious complications by a combination of intrarenal pressure reduction and faster aspiration of irrigation fluid reducing the risk of sepsis, enhance intraoperative vision, and improve lithotripsy efficiency, which makes it a very attractive evolution for PCNL. CONCLUSIONS Suction devices in PCNL are reforming the way PCNL is being done. Adding suction to mini-PCNL reduces infectious complications and improves the stone-free rate. Our review shows that despite the limited evidence, suction techniques appear to improve PCNL outcomes. PATIENT SUMMARY In this review, we looked at the intra- and perioperative outcomes of percutaneous nephrolithotripsy (PCNL) with the addition of suction. With better stone fragmentation and fewer postoperative infections, this technology is very useful particularly for mini-PCNL.
Collapse
Affiliation(s)
- Virgilio De Stefano
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy.
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Bhaskar K Somani
- Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, UK
| | - Carlo Giulioni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Angelo Cormio
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Kemal Sarica
- Department of Urology, Dr. Lutfi Kirdar Kartal Research and Training Hospital, Istanbul, Turkey
| | - Xavier Glover
- Urology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | | | - Yiloren Tanidir
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | - Nariman Gadzhiev
- Department of Urology, Saint-Petersburg State University Hospital, Petersburg, Russia
| | | | - Prashant Motiram Mulawkar
- Department of Urology, Tirthankar Super Speciality Hospital, Akola, India; Professor of Urology, GMC & SSH, Akola, India; University of Edinburgh, Edinburgh, UK
| | - Jeremy Yuen-Chun Teoh
- S.H.Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Manoj Monga
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Thomas R W Herrmann
- Department of Urology, Kantonspital Frauenfeld, Spital Thurgau AG, Frauenfeld, Switzerland
| | - Vineet Gauhar
- Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Emiliani E, Kanashiro A, Angerri O. Lasers for stone lithotripsy: advantages/disadvantages of each laser source. Curr Opin Urol 2023; 33:302-307. [PMID: 36927702 DOI: 10.1097/mou.0000000000001092] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
PURPOSE The purpose of this article was to make a narrative review of the literature in search of all articles regarding thulium:yttrium-aluminium-garnet (YAG), thulium laser fiber (TFL) and holmium:YAG (Ho:YAG) for lithotripsy from 2020 to 2023. A selection of articles of special interest and best evidence was made in order to give a better perspective on their advantages and disadvantages. RECENT FINDINGS New Ho:YAG technologies of as high power, high frequency and pulsed modulations have shown promising results for lithotripsy by reducing retropulsion with good ablation efficiency. High peak power makes it particularly good for percutaneous nephrolithotomy. High intrarenal temperatures and correct setting are still concerning points.TFL has arrived to be one of the main players in flexible ureteroscopy. Being highly efficient and quick, and by producing micro-dusting the laser is quickly heading to become a gold standard. The new pulsed Thulium YAG is the newest laser. For now, only in-vitro studies show promising results with efficient lithotripsy. As the peak power lies between Ho:YAG and TFL it may be able to adequately perform when needing and low power lithotripsy. SUMMARY Several new technologies have been developed in the last years for stone lithotripsy. All being efficient and safe if well used. Different advantages and disadvantages of each laser must be taken into consideration to give each laser the proper indication.
Collapse
Affiliation(s)
- Esteban Emiliani
- Fundació Puigvert. Autonomous University of Barcelona. Barcelona, Spain
| | | | | |
Collapse
|
5
|
Mykoniatis I, Pyrgidis N, Tzelves L, Pietropaolo A, Juliebø-Jones P, De Coninck V, Hameed BMZ, Chaloupka M, Schulz GB, Stief C, Kallidonis P, Somani BK, Skolarikos A. Assessment of single-probe dual-energy lithotripters in percutaneous nephrolithotomy: a systematic review and meta-analysis of preclinical and clinical studies. World J Urol 2023; 41:551-565. [PMID: 36656331 DOI: 10.1007/s00345-023-04278-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of single-probe dual-energy (SPDE) lithotripters in patients undergoing percutaneous nephrolithotripsy (PCNL) through a systematic review and meta-analysis. METHODS We searched PubMed, Cochrane Library, Scopus and Embase databases until July 2022 for any preclinical or clinical studies, exploring the safety and efficacy of different SPDE lithotripters in patients undergoing PCNL. We performed a meta-analysis to compare stone-free rate, bleeding, or other complications and mean operative time between SPDE lithotripters and other lithotripters (PROSPERO: CRD42021285631). RESULTS We included 16 studies (six preclinical, seven observational and three randomized with 625 participants) in the systematic review and four in the meta-analysis. Preclinical studies suggest that SPDE lithotripters are safe and effective for the management of renal stones. Among clinical studies, four studies assessed Trilogy with no comparative arm, two compared Trilogy or ShockPulse with a dual-probe dual-energy lithotripter, two compared Trilogy with a laser, one compared ShockPulse with a pneumatic lithotripter, and one directly compared Trilogy with ShockPulse. Comparing SPDE lithotripters to other lithotripters, no significant differences were demonstrated in stone free rate (OR 1.13, 95% CI 0.53-2.38, I2 = 0%), postoperative blood transfusion (OR 1.33, 95% CI 0.34-5.19, I2 = 0%), embolization (OR 0.45, 95% CI 0.02-12.06), operative time (WMD: 2.82 min, 95% CI -7.31-12.95, I2 = 78%) and postoperative complications based on the Clavien-Dindo classification. CONCLUSIONS SPDE lithotripters represent a promising treatment modality for patients requiring PCNL. Despite the initial encouraging findings of preclinical and isolated clinical studies, it seems that Trilogy or ShockPulse provide similar efficiency compared to older generation devices.
Collapse
Affiliation(s)
- Ioannis Mykoniatis
- First Department of Urology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Young Academic Urologists (YAU), Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Nikolaos Pyrgidis
- Department of Urology, University Hospital, LMU Munich, Munich-Marchioninistr. 15, 81377, Munich, Germany
| | - Lazaros Tzelves
- Second Department of Urology, Sismanoglio Hospital, Sismanogliou 37, Athens, Greece.,University College of London Hospitals NHS Foundation Trust, London, UK.,Young Academic Urologists (YAU), Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Amelia Pietropaolo
- Department of Urology, University of Hospital Southampton NHS Trust, Southampton, UK.,Young Academic Urologists (YAU), Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Patrick Juliebø-Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Young Academic Urologists (YAU), Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Vincent De Coninck
- Department of Urology, AZ Klina, Brasschaat, Belgium.,Young Academic Urologists (YAU), Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Belthangady M Zeeshan Hameed
- Department of Urology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India.,Young Academic Urologists (YAU), Urolithiasis and Endourology Working Party, Arnhem, the Netherlands
| | - Michael Chaloupka
- Department of Urology, University Hospital, LMU Munich, Munich-Marchioninistr. 15, 81377, Munich, Germany
| | - Gerald Bastian Schulz
- Department of Urology, University Hospital, LMU Munich, Munich-Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Stief
- Department of Urology, University Hospital, LMU Munich, Munich-Marchioninistr. 15, 81377, Munich, Germany
| | | | - Bhaskar K Somani
- Department of Urology, University of Hospital Southampton NHS Trust, Southampton, UK
| | - Andreas Skolarikos
- Second Department of Urology, Sismanoglio Hospital, Sismanogliou 37, Athens, Greece.
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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.
Collapse
|
8
|
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.
Collapse
|