1
|
Victor DR, de Oliveira RDAP, de Lucena AGP, Antunes DL, Barros Júnior TDP. The reverse Trendelenburg position in proximal ureteral stone management: A systematic review and meta-analysis. THE FRENCH JOURNAL OF UROLOGY 2024; 34:102668. [PMID: 38849037 DOI: 10.1016/j.fjurol.2024.102668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/09/2024]
Abstract
INTRODUCTION Ureteroscopy lithotripsy (URSL) presents a therapeutic option for patients with proximal ureteral calculi warranting active removal. This systematic review and meta-analysis aimed to assess the efficacy of the reverse Trendelenburg (RT) position during this procedure. MATERIALS A comprehensive literature search was conducted across PubMed, Embase, and Cochrane databases to identify randomized controlled trials and observational studies comparing RT versus standard positioning (STD) in patients undergoing URSL for proximal ureteral stones. Heterogeneity was measured with the Cochran's Q test, I2 statistics, and prediction intervals (PI). A DerSimonian and Laird random-effects model was utilized for all outcomes. RESULTS Four studies encompassing 505 patients undergoing URSL were analyzed. Among the studied participants, 293 (58%) underwent RT positioning. Overall, RT was associated with a lower average incidence of stone retropulsion (RR 0.42; 95% CI 0.27-0.65; I2=48%; PI 0.08-2.10) and a higher mean stone-free rate (RR 1.33; 95% CI 1.18-1.49; I2=0%). However, no significant difference between groups was found in the mean rate of overall complications (RR 0.76; 95% CI 0.40-1.43; I2=51%; PI 0.00-520.22) and operative time (MD -0.65; 95% CI -9.58-8.27; I2=94%; PI -111.95-110.65). In those with proximal ureteral stones undergoing RT positioning at only the 20° angle, there was a reduction in stone retropulsion without any measured heterogeneity (RR 0.35; 95% CI 0.23-0.52; I2=0%). CONCLUSION These findings suggest that RT positioning is effective in improving outcomes for patients with proximal ureteral stones undergoing URSL, and its use should be considered during the procedure.
Collapse
Affiliation(s)
| | | | | | - Dimas Lemos Antunes
- Department of Urology, Hospital dos Servidores do Estado de Pernambuco, Recife, Brazil
| | | |
Collapse
|
2
|
Yamashita S, Inoue T, Imai S, Iwahashi Y, Deguchi R, Muraoka S, Kikkawa K, Kohjimoto Y, Fujisawa M, Hara I. Thermography-Based Comparison of Irrigation Temperatures Between Moses Mode and Virtual Basket Mode: An In Vitro Phantom Study. J Endourol 2023; 37:179-184. [PMID: 36053677 DOI: 10.1089/end.2022.0327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objectives: This study aims to evaluate changes in irrigation fluid temperatures during laser activation by using thermography, with comparison between Moses mode (MM) and virtual basket mode (VBM). Materials and Methods: Experiments were performed using an unroofed pyelocaliceal model. The laser was fired for 60 seconds at 0.4 J/60 Hz. Three runs were tested per setting using short pulse mode, long pulse mode, MM contact, and VBM. The time to reach threshold of thermal injury (43°C) was evaluated using thermometer and thermography, both with and without saline irrigation (25 mL/min). These outcomes were compared between laser pulse modes. Results: In measurement of time to reach the threshold, thermography-based time was significantly shorter than thermometer-based time in all laser modes under the condition of no irrigation. Thermography measurement results indicate that the speed of temperature rise depends on laser pulse modes, and the time to reach the threshold in MM was significantly shorter than that in VBM (9.0 seconds vs 14.3 seconds, p = 0.03). When 25 mL/min saline irrigation was used, the peak temperatures by both thermometer and thermography measurements did not exceed the threshold during laser activation. Conclusions: Thermography-based evaluation suggests that irrigation temperatures near mucosa around stones can rapidly elevate during laser lithotripsy when the irrigation condition is poor. Temperature rise speed in MM may be more rapid than that in VBM. To prevent thermal injury, laser pulse modes must be used selectively according to the condition of irrigation.
Collapse
Affiliation(s)
- Shimpei Yamashita
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| | - Takaaki Inoue
- Department of Urology, Hara Genitourinary Hospital, Hyogo, Japan.,Department of Urology, Kobe University Hospital, Hyogo, Japan
| | - Satoshi Imai
- Department of Urology, Konan Medical Center, Hyogo, Japan
| | - Yuya Iwahashi
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| | - Ryusuke Deguchi
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| | - Satoshi Muraoka
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| | - Kazuro Kikkawa
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yasuo Kohjimoto
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| | - Masato Fujisawa
- Department of Urology, Kobe University Hospital, Hyogo, Japan
| | - Isao Hara
- Department of Urology, Wakayama Medical University Hospital, Wakayama, Japan
| |
Collapse
|
3
|
Kraft L, Petzold R, Suarez-Ibarrola R, Miernik A. In vitro fragmentation performance of a novel, pulsed Thulium solid-state laser compared to a Thulium fibre laser and standard Ho:YAG laser. Lasers Med Sci 2021; 37:2071-2078. [PMID: 34905141 PMCID: PMC8971152 DOI: 10.1007/s10103-021-03495-8] [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: 04/22/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022]
Abstract
The aim of this work was to compare the fragmentation efficiency of a novel, pulsed Thulium solid-state laser (p-Tm:YAG) to that of a chopped Thulium fibre laser (TFL) and a pulsed Holmium solid-state laser (Ho:YAG). During the fragmentation process, we used a silicone mould to fixate the hemispherical stone models under water in a jar filled with room-temperature water. Each laser device registered the total energy applied to the stone model to determine fragmentation efficiency. Our study examined laser settings with single pulse energies ranging from 0.6 to 6 J and pulse frequencies ranging from 5 to 15 Hz. Similar laser settings were applied to explicitly compare the fragmentation efficiency of all three devices. We experimented with additional laser settings to see which of the three devices would perform best. The fragmentation performance of the three laser devices differed statistically significantly (p < 0.05). The average total energy required to fragment the stone model was 345.96 J for Ho:YAG, 372.43 J for p-Tm:YAG and 483.90 J for TFL. To fragment the stone models, both Ho:YAG and p-Tm:YAG needed similar total energy (p = 0.97). TFL’s fragmentation efficiency is significantly lower than that of Ho:YAG and p-Tm:YAG. Furthermore, we found the novel p-Tm:YAG’s fragmentation efficiency to closely resemble that of Ho:YAG. The fragmentation efficiency is thought to be influenced by the pulse duration. TFL’s shortest possible pulse duration was considerably longer than that of Ho:YAG and p-Tm:YAG, resulting in Ho:YAG and p-Tm:YAG exhibiting better fragmenting efficiency.
Collapse
Affiliation(s)
- Lea Kraft
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Ralf Petzold
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Rodrigo Suarez-Ibarrola
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106, Freiburg, Germany.
| |
Collapse
|
4
|
Liu M, Li L, Xu Z, Peng Y, Wang Z, Xie F, Gao X. Stone retropulsion caused by the pulse-duration adjustable Holmium laser: analysis of the whole-process dynamics with a modified method. J Endourol 2021; 36:508-513. [PMID: 34693759 DOI: 10.1089/end.2021.0651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Stone retropulsion was shown to be impacted by pulse duration during Holmium laser lithotripsy, while the whole process of retropulsion was troublesome to study. We developed a modified method to analyze retropulsion using a smartphone and video tracking software. MATERIALS AND METHODS A Holmium laser system was incorporated with a short (200 μs) and long pulse duration (800 μs), and a 272 μm core fiber was attached. A cross-sectional V-shaped rail was submerged in a tank, on which artificial stones were displaced linearly after lasering. Different combinations of pulse energy, frequency and pulse duration were tested for at least four seconds. An iPhone 11 capable of high-definition videoing and video tracking software were used to analyze the stone's displacement and velocity. RESULTS For most settings, the displacement-time graph resembled logarithmic growth and the velocity peaked within the first second after lasering. Higher energy or frequency translated into greater displacement, accompanied by earlier and faster velocity peaks. When the laser power was constant, the stone displacement at the fourth second after lasering was much larger in 0.5 J × 40 Hz than 1.0 J × 20 Hz under the short pulse duration (SP) (13.17 ± 0.92 mm vs. 6.90 ± 1.98 mm, p < 0.05), but this discrepancy was offset by the long pulse duration (LP). The largest stone displacement and velocity were observed in 0.5 J × 40 Hz SP. CONCLUSION The pulse duration plays a dominant role in determining the stone retropulsion and velocity, and a long pulse decreases retropulsion and velocity. Given a constant power, the variable combination of frequency and pulse energy contributes to significantly different retropulsion with a short pulse rather than a long pulse. The modified method offers a feasible solution for the study of stone retropulsion by laser lithotripsy.
Collapse
Affiliation(s)
- Min Liu
- Changhai Hospital, 12520, Department of Urology, Shanghai, China;
| | - Ling Li
- Changhai Hospital, 12520, Department of Urology, Shanghai, China;
| | - Zhipeng Xu
- Shandong Qianfoshan Hospital, 66310, Department of Urology, Jinan, Shandong, China.,First Affiliated Hospital of Shandong First Medical University, 66310, Department of Urology, Jinan, Shandong, China;
| | - Yonghan Peng
- Changhai Hospital, 12520, Department of Urology, Shanghai, China;
| | - Zeyu Wang
- Changhai Hospital, 12520, Department of Urology, Shanghai, China;
| | - Fei Xie
- Changhai Hospital, 12520, Department of Urology, Shanghai, China;
| | - Xiaofeng Gao
- Changhai Hospital, 12520, Department of Urology, Shanghai, China;
| |
Collapse
|
5
|
Karakoyunlu N, Çakıcı MÇ, Sarı S, Hepşen E, Bikirov M, Kısa E, Özbal S, Özok HU, Ersoy H. Efficacy of various laser devices on lithotripsy in retrograde intrarenal surgery used to treat 1-2 cm kidney stones: A prospective randomized study. Int J Clin Pract 2021; 75:e14216. [PMID: 33864337 DOI: 10.1111/ijcp.14216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/05/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS To compare the efficacy of different laser devices and power ranges on lithotripsy in retrograde intrarenal surgery (RIRS) for 1-2 cm kidney stones. METHODS A total of 223 participants undergoing RIRS for 1-2 cm kidney stones at our clinic between January 2015 and January 2017 were recruited for this prospective study (NCT02451319). Two hundred and four participants included in our study were randomly allocated into either ≤20 W with 20 W laser device (group 1) or ≤20 W with 30 W laser device (group 2) or >20 W with 30 W laser device (group 3). RESULTS There was no significant difference between the groups in terms of demographic and stone characteristics. Operation and fluoroscopy times were significantly longer (P = .003 and P < .001, respectively) and stone-free rate (SFR) was significantly lower in group 1 (P = .002). Complications were similar in all three groups (P = .512). However, post-operative pain scores were significantly higher in group 1 (P < .001). The multivariate analysis revealed that stone size (95% CI: 0.654-0.878, OR = 0.758, P < .001), ureteral access sheath use (95% CI: 1.003-20.725, OR = 4.560, P = .049), and lithotripsy with 30 W laser device (95% CI: 1.304-11.632, OR = 3.895, P = .015; 95% CI: 1.738-17.281, OR = 5.480, P = .004, groups 2 and 3, respectively) were independent factors predicting SFR for RIRS used in 1-2 cm kidney stones. CONCLUSION The 30 W laser device used in RIRS for 1-2 cm kidney stones had shorter operation times, higher SFRs, and lower post-operative pain scores compared with the 20 W device. The 30 W laser device is safe and more efficient in RIRS for treatment of 1-2 cm kidney stones.
Collapse
Affiliation(s)
- Nihat Karakoyunlu
- Department of Urology, Health Sciences University, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Mehmet Çağlar Çakıcı
- Department of Urology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Sercan Sarı
- Department of Urology, Faculty of Medicine Hospital, Bozok University, Yozgat, Turkey
| | - Emre Hepşen
- Department of Urology, Yildirim Beyazit University Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - Muslim Bikirov
- Department of Urology, Health Sciences University, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Erdem Kısa
- Department of Urology, Health Sciences University, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Serra Özbal
- Department of Radiology, Health Sciences University, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Hakkı Uğur Özok
- Department of Urology, Faculty of Medicine Hospital, Karabuk University, Karabük, Turkey
| | - Hamit Ersoy
- Department of Urology, Health Sciences University, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
6
|
Petzold R, Miernik A, Suarez-Ibarrola R. Retropulsion force in laser lithotripsy-an in vitro study comparing a Holmium device to a novel pulsed solid-state Thulium laser. World J Urol 2021; 39:3651-3656. [PMID: 33758959 PMCID: PMC8510939 DOI: 10.1007/s00345-021-03668-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/13/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To investigate retropulsion forces generated by two laser lithotripsy devices, a standard Ho:YAG and a new pulsed solid-state Thulium laser device. MATERIALS AND METHODS Two different Dornier laser devices were assessed: a Medilas H Solvo 35 and a pulsed solid-state Thulium laser evaluation model (Dornier MedTech Laser GmbH, Wessling, Germany). We used a 37 °C water bath; temperature was monitored with a thermocouple/data-logger. Representative sets of settings were examined for both devices, including short and long pulse lengths where applicable. For each setting, ten force values were recorded by a low-force precision piezo sensor whereby the laser fibre was either brought into contact with the sensor or placed at a 3 mm distance. RESULTS The mean retropulsion forces resulting from the new Tm:YAG device were significantly lower than those of the Ho:YAG device under all pulse energy and frequency settings, ranging between 0.92 and 19.60 N for Thulium and 8.09-39.67 N for Holmium. The contact setups yielded lower forces than the distance setups. The forces increased with increasing pulse energy settings while shorter pulse lengths led to 12-44% higher retropulsive force in the 2.0 J/5 Hz comparisons. CONCLUSION The Tm:YAG device not only significantly generated lower retropulsion forces in all comparisons to Holmium at corresponding settings but also offers adjustment options to achieve lower energy pulses and longer pulse durations to produce even lower retropulsion. These advantages are a promising add-on to laser lithotripsy procedures and may be highly relevant for improving laser lithotripsy performance.
Collapse
Affiliation(s)
- Ralf Petzold
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Rodrigo Suarez-Ibarrola
- Department of Urology, Faculty of Medicine, University of Freiburg-Medical Centre, Hugstetter Str. 55, 79106 Freiburg, Germany
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent developments in the array of devices which are commonly used by urologists in the surgical management of kidney stones. To accomplish this goal, an extensive review of recent endourology literature, conference abstracts, and publicly available documents from manufacturers and the United States Food and Drug Administration was collected and reviewed. RECENT FINDINGS Recent developments in the holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripsy include the introduction of pulse modulation. This technique delivers the laser energy in an asymmetric manner such that an initial bubble is created (the 'Moses effect') through which the remainder of the energy can then travel through without being absorbed by surrounding water. Even more novel is the thulium fiber laser, which is produced in a fundamentally different way than traditional Ho:YAG lasers and is not yet available for clinical use. Finally, novel mechanical lithotrites which effectively combine ultrasonic energy, ballistic energy, and suction capability appear to be highly effective for stone clearance in recent benchtop and clinical studies. SUMMARY With the introduction of both new modifications of time-tested technologies as well as completely novel modalities, the practicing urologist's armamentarium of devices for the surgical management of kidney stones continues to grow. As the popularity of 'mini' procedures continues to grow, the adaptability of these technologies to these procedures will be critical to maintain maximum relevance.
Collapse
|
8
|
Wu ZH, Liu TZ, Wang XH, Wang YZ, Zheng H, Zhang YG, Zhang XH. Negative-Pressure Ureteroscopic Holmium-YAG Laser Lithotripsy for Ureteral Stones. Urol Int 2020; 104:752-757. [DOI: 10.1159/000507266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/13/2020] [Indexed: 11/19/2022]
|
9
|
Ventimiglia E, Doizi S, Kovalenko A, Andreeva V, Traxer O. Effect of temporal pulse shape on urinary stone phantom retropulsion rate and ablation efficiency using holmium:YAG and super-pulse thulium fibre lasers. BJU Int 2020; 126:159-167. [PMID: 32277557 DOI: 10.1111/bju.15079] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the effects of laser temporal pulse shaping of the super-pulse thulium fibre laser (SPTFL) and to compare these in controlled in vitro conditions with various holmium: yttrium aluminium garnet (Ho:YAG) pulse delivery modes. MATERIALS AND METHODS The SPTFL (Urolase SP, IRE-Polus, Fryazino, Russia), with an emission wavelength of 1.94 μm, and a Ho:YAG laser (P120H; Lumenis, Yokneam, Israel) with Moses technology were compared. Pulse shape, stone retropulsion and ablation efficiency were evaluated using BegoStones and compared for each laser mode: short (SP), long (LP), and Moses pulse (MP) for Ho:YAG, regular pulse (RP) and dual pulse (DP) for SPTFL. RESULTS The Ho:YAG SP mode exhibited an asymmetrical pulse shape, with a steep leading slope and a much more gradual trailing slope, without any flat section. Pulses generated by the SPTFL were significantly longer and therefore had lower peak power than those generated by the Ho:YAG laser at equivalent energy settings. Retropulsion for the holmium:YAG LP and MP modes was similar and lower than that for the SP mode, but higher than for the SPTFL (all P ≤ 0.02), with an average stone displacement approximately four times and two times lower for SPTFL as compared to the Ho:YAG laser. Comparison of ablation volumes indicated that the SPTFL induced significantly higher (twofold) ablation than the Ho:YAG laser. CONCLUSIONS The magnitude and initial velocity of stone retropulsion decreased with longer pulse duration and lower pulse peak power, without sacrificing ablation efficiency. These observations are manifest when comparing the Ho:YAG laser with the SPTFL. The novel SPTFL provides greater versatility and control of pulse variables than the Ho:YAG laser. Further clinical investigation of practical benefits achievable with pulse-shaping SPTFL modes is warranted.
Collapse
Affiliation(s)
- Eugenio Ventimiglia
- GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, Paris, France.,Service d'Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Steeve Doizi
- GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, Paris, France.,Service d'Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | | | | | - Olivier Traxer
- GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, Paris, France.,Service d'Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| |
Collapse
|
10
|
Winship B, Terry R, Boydston K, Carlos E, Wollin D, Peters C, Li J, Preminger G, Lipkin M. Holmium:Yttrium-Aluminum-Garnet Laser Pulse Type Affects Irrigation Temperatures in a Benchtop Ureteral Model. J Endourol 2019; 33:896-901. [PMID: 31418291 DOI: 10.1089/end.2019.0496] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: MOSES™ technology is a holmium:yttrium-aluminum-garnet laser pulse mode shown to minimize stone retropulsion. This may facilitate lithotripsy at higher power settings. However, power and heat production are proportional, and temperatures capable of tissue injury may occur during ureteroscopic lithotripsy. Although previous in vitro studies demonstrate the importance of irrigation and activation time on heat production, the impact of pulse type has not been evaluated. Methods: A flexible ureteroscope with a 365 μm laser fiber was placed in an 11/13 F access sheath inserted into a 50 mL saline bag to simulate a ureter, renal pelvis, and antegrade irrigant flow. A thermocouple was placed adjacent to the laser tip, and the laser fired for 30 seconds at 0.6 J/6 Hz, 0.8 J/8 Hz, 1 J/10 Hz, 1 J/20 Hz, and 0.2 J/70 Hz at irrigation pressure of 100 mmHg. Four runs were tested per setting using short pulse, long pulse (LP), MOSES-contact (MC), and MOSES-distance (MD) modes. The mean temperature changes (dT) were compared and thermal dose was calculated in cumulative equivalent minutes at 43°C (CEM43) using an adjusted baseline of 37°C. CEM43 ≥ 120 minutes was considered the tissue injury threshold. Results: At 0.8 J/8 Hz, LP produced the greatest dT, significantly higher than MC (p = 0.041). CEM43 did not exceed the injury threshold. At 1 J/10 Hz, dT was significantly higher for LP versus MC and MD (p = 0.024 and 0.045, respectively). Thermal dose remained below the injury threshold. No differences in dT were seen between pulse types at 0.6 J/6 Hz, 0.2 J/70 Hz, or 1 J/20 Hz. At 1 J/20 Hz, thermal dose exceeded the injury threshold for all pulse types within 3 seconds. Conclusions: Laser pulse type and length seemed to impact heat production in our ureteral model. LP produced significantly greater temperatures at 0.8 J/8 Hz and 1 J/10 Hz relative to MOSES settings. Fortunately, thermal dose remained safe at these settings. Both LP and MOSES technology have been shown to reduce stone retropulsion. At power ≤10 W, the latter may confer this advantage with decreased heat production.
Collapse
Affiliation(s)
- Brenton Winship
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Russell Terry
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kohldon Boydston
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Evan Carlos
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel Wollin
- Division of Urology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chloe Peters
- Duke University School of Medicine, Durham, North Carolina
| | | | - Glenn Preminger
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael Lipkin
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
11
|
Kronenberg P, Traxer O. The laser of the future: reality and expectations about the new thulium fiber laser-a systematic review. Transl Androl Urol 2019; 8:S398-S417. [PMID: 31656746 PMCID: PMC6790412 DOI: 10.21037/tau.2019.08.01] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/17/2019] [Indexed: 01/08/2023] Open
Abstract
The Holmium:yttrium-aluminum-garnet (Ho:YAG) laser has been the gold-standard for laser lithotripsy over the last 20 years. However, recent reports about a new prototype thulium fiber laser (TFL) lithotripter have revealed impressive levels of performance. We therefore decided to systematically review the reality and expectations for this new TFL technology. This review was registered in the PROSPERO registry (CRD42019128695). A PubMed search was performed for papers including specific terms relevant to this systematic review published between the years 2015 and 2019, including already accepted but not yet published papers. Additionally, the medical sections of ScienceDirect, Wiley, SpringerLink, Mary Ann Liebert publishers, and Google Scholar were also searched for peer-reviewed abstract presentations. All relevant studies and data identified in the bibliographic search were selected, categorized, and summarized. The authors adhered to PRISMA guidelines for this review. The TFL emits laser radiation at a wavelength of 1,940 nm, and has an optical penetration depth in water about four-times shorter than the Ho:YAG laser. This results in four-times lower stone ablation thresholds, as well as lower tissue ablation thresholds. As the TFL uses electronically-modulated laser diodes, it offers the most comprehensive and flexible range of laser parameters among laser lithotripters, with pulse frequencies up to 2,200 Hz, very low to very high pulse energies (0.005-6 J), short to very long-pulse durations (200 µs up to 12 ms), and a total power level up to 55 W. The stone ablation efficiency is up to four-times that of the Ho:YAG laser for similar laser parameters, with associated implications for speed and operating time. When using dusting settings, the TFL outperforms the Ho:YAG laser in dust quantity and quality, producing much finer particles. Retropulsion is also significantly reduced and sometimes even absent with the TFL. The TFL can use small laser fibers (as small as 50 µm core), with resulting advantages in irrigation, scope deflection, retropulsion reduction, and (in)direct effects on accessibility, visibility, efficiency, and surgical time, as well as offering future miniaturization possibilities. Similar to the Ho:YAG laser, the TFL can also be used for soft tissue applications such as prostate enucleation (ThuFLEP). The TFL machine itself is seven times smaller and eight times lighter than a high-power Ho:YAG laser system, and consumes nine times less energy. Maintenance is expected to be very low due to the durability of its components. The safety profile is also better in many aspects, i.e., for patients, instruments, and surgeons. The advantages of the TFL over the Ho:YAG laser are simply too extensive to be ignored. The TFL appears to be a real alternative to the Ho:YAG laser and become a true game-changer in laser lithotripsy. Due to its novelty, further studies are needed to broaden our understanding of the TFL, and comprehend the full implications and benefits of this new technology, as well its limitations.
Collapse
Affiliation(s)
| | - Olivier Traxer
- Hôpital Tenon, Université Pierre et Marie Curie, Paris VI, Paris, France
| |
Collapse
|
12
|
|
13
|
Bayne DB, Chi TL. Assessing Cost-Effectiveness of New Technologies in Stone Management. Urol Clin North Am 2019; 46:303-313. [PMID: 30961862 DOI: 10.1016/j.ucl.2018.12.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease.
Collapse
Affiliation(s)
- David B Bayne
- Urology, University of California San Francisco, San Francisco, CA, USA.
| | - Thomas L Chi
- Urology, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
14
|
Hardy LA, Vinnichenko V, Fried NM. High power holmium:YAG versus thulium fiber laser treatment of kidney stones in dusting mode: ablation rate and fragment size studies. Lasers Surg Med 2019; 51:522-530. [PMID: 30648761 DOI: 10.1002/lsm.23057] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The experimental Thulium fiber laser (TFL) is currently being studied as a potential alternative to the gold standard Holmium:YAG laser for lithotripsy. Recent advances in both Holmium and TFL technology allow operation at similar laser parameters for direct comparison. The use of a "dusting" mode with low pulse energy (0.2-0.4 J) and high pulse rate (50-80 Hz) settings, is gaining popularity in lithotripsy due to the desire to produce smaller residual stone fragments during ablation, capable of being spontaneously passed through the urinary tract. METHODS In this study, Holmium and TFL were directly compared for 'dusting' using three laser groups, G1: 0.2 J/50 Hz/10 W; G2: 0.2 J/80 Hz/16 W; and G3: 0.4 J/80 Hz/32 W. Holmium laser pulse durations ranged from 200 to 350 μs, while TFL pulse durations ranged from 500 to 1,000 μs, due to technical limitations for both laser systems. An experimental setup consisting of 1 × 1 cm cuvette with 1 mm sieve was used with continuous laser operation time limited to ≤5 minutes. Calcium oxalate monohydrate stone samples with a sample size of n = 5 were used for each group, with average initial stone mass ranging from 216 to 297 mg among groups. RESULTS Holmium laser ablation rates were lower than for TFL at all three settings (G1: 0.3 ± 0.2 vs. 0.8 ± 0.2; G2: 0.6 ± 0.1 vs. 1.0 ± 0.4; G3: 0.7 ± 0.2 vs. 1.3 ± 0.9 mg/s). The TFL also produced a greater percentage by mass of stone dust (fragments <0.5 mm) than Holmium laser. For all three settings combined, one out of 15 (7%) stones treated with Holmium laser were completely fragmented in ≤5 minutes compared to nine out of 15 (60%) stones treated with TFL. CONCLUSIONS These preliminary studies demonstrate that the TFL is a promising alternative laser for lithotripsy when operated in dusting mode, producing higher stone ablation rates and smaller stone fragments than the Holmium laser. Clinical studies are warranted. Lasers Surg. Med. 51:522-530, 2019. © 2019 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Luke A Hardy
- Department of Physics and Optical Science, University of North Carolina at Charlotte, Charlotte, North Carolina
| | | | - Nathaniel M Fried
- Department of Physics and Optical Science, University of North Carolina at Charlotte, Charlotte, North Carolina.,McKay Department of Urology, Carolinas Medical Center, Charlotte, North Carolina.,Brady Urological Institute, Johns Hopkins Medical School, Baltimore, Maryland
| |
Collapse
|
15
|
Winship B, Wollin D, Carlos E, Li J, Peters C, Simmons WN, Preminger GM, Lipkin M. Dusting Efficiency of the Moses Holmium Laser: An AutomatedIn VitroAssessment. J Endourol 2018; 32:1131-1135. [DOI: 10.1089/end.2018.0660] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Brenton Winship
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel Wollin
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Evan Carlos
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Chloe Peters
- Duke University, School of Medicine, Durham, North Carolina
| | - W. Neal Simmons
- Department of Mechanical Engineering, Duke University, Durham, North Carolina
| | - Glenn M. Preminger
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael Lipkin
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
16
|
Patel RM, Walia AS, Grohs E, Okhunov Z, Landman J, Clayman RV. Effect of positioning on ureteric stone retropulsion: ‘gravity works’. BJU Int 2018; 123:113-117. [DOI: 10.1111/bju.14510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Roshan M. Patel
- Department of Urology University of California, Irvine OrangeCA USA
| | - Arman S. Walia
- Department of Urology University of California, Irvine OrangeCA USA
| | - Evan Grohs
- Department of Physics University of California, Berkeley Berkeley CAUSA
- Theoretical Division Los Alamos National Laboratory Los Alamos NM USA
| | - Zhamshid Okhunov
- Department of Urology University of California, Irvine OrangeCA USA
| | - Jaime Landman
- Department of Urology University of California, Irvine OrangeCA USA
| | - Ralph V. Clayman
- Department of Urology University of California, Irvine OrangeCA USA
| |
Collapse
|
17
|
Fried NM. Recent advances in infrared laser lithotripsy [Invited]. BIOMEDICAL OPTICS EXPRESS 2018; 9:4552-4568. [PMID: 30615704 PMCID: PMC6157791 DOI: 10.1364/boe.9.004552] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/21/2018] [Indexed: 05/17/2023]
Abstract
The flashlamp-pumped, solid-state, pulsed, mid-infrared, holmium:YAG laser (λ = 2120 nm) has been the clinical gold standard laser for lithotripsy for over the past two decades. However, while the holmium laser is the dominant laser technology in ureteroscopy because it efficiently ablates all urinary stone types, this mature laser technology has several fundamental limitations. Alternative, mid-IR laser technologies, including a thulium fiber laser (λ = 1908 and 1940 nm), a thulium:YAG laser (λ = 2010 nm), and an erbium:YAG laser (λ = 2940 nm) have also been explored for lithotripsy. The capabilities and limitations of these mid-IR lasers are reviewed in the context of the quest for an ideal laser lithotripsy system capable of providing both rapid and safe ablation of urinary stones.
Collapse
Affiliation(s)
- Nathaniel M. Fried
- Department of Physics and Optical Science, University of North Carolina at Charlotte, NC 28223, USA
- McKay Department of Urology, Carolinas Medical Center, Charlotte, NC 28207, USA
- Brady Urological Institute, Johns Hopkins Medical School, Baltimore, MD 21287, USA
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW Laser lithotripsy is increasingly used worldwide and is a continuously evolving field with new and extensive research being published every year. RECENT FINDINGS Variable pulse length Ho:YAG lithotripters allow new lithotripsy parameters to be manipulated, and there is an effort to integrate new technologies into lithotripters. Pulsed thulium lasers seem to be a viable alternative to holmium lasers. The performance of similar laser fibers varies from manufacturer to manufacturer. Special laser fibers and "cleaving only" fiber tip preparation can be beneficial for the lithotripsy procedure. Different laser settings and the surgical technique employed can have significant impact on the success of laser lithotripsy. When safely done, complications of laser lithotripsy are rare and concern the endoscopic nature of procedure, not the technology itself, making laser lithotripsy one of the safest tools in urology. Laser lithotripsy has had several new developments and more insight has been gained in recent years with many more advances expected in the future.
Collapse
Affiliation(s)
| | - Bhaskar Somani
- University Hospital Southampton NHS Trust, Southampton, UK
| |
Collapse
|
19
|
Meria P. Re: Optimal Settings for the Noncontact Holmium:YAG Stone Fragmentation Popcorn Technique. Eur Urol 2018; 74:117. [PMID: 29439819 DOI: 10.1016/j.eururo.2018.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Paul Meria
- St. Louis Hospital of Urology, Paris, France.
| |
Collapse
|