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Li P, Wang K, Luo L, Xie Q, Wu Y, Liao Q. Construction of a Risk Prediction Model for Ureteral Stricture after Ureteroscopic Holmium Laser Lithotripsy. J Endourol 2024. [PMID: 39283828 DOI: 10.1089/end.2023.0638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024] Open
Abstract
Introduction: To analyze the influencing factors of ureteral stenosis after ureteroscopic holmium laser lithotripsy. Methods: The clinical data of 427 patients treated with ureteroscopic holmium laser lithotripsy were selected, and the patients were divided into two groups based on the presence or absence of ureteral stenosis after the operation. Univariate and multivariate logistic regression were used to analyze the independent risk factors for postoperative ureteral stenosis, and R software and regression coefficients were used to construct a predictive model. Results: After a 1-year follow-up of 427 patients, 28 patients (6.56%) developed ureteral stenosis; univariate analysis showed that the occurrence of ureteral stenosis after subureteral holmium laser lithotripsy was related to stone diameter, stone incarceration, degree of hydronephrosis, holmium laser injury of mucosa, and operation time (p < 0.05); further logistic regression analysis showed that a large stone diameter, stone incarceration, and moderate to severe hydronephrosis were independent risk factors for ureteral stenosis after ureteroscopic holmium laser lithotripsy (p < 0.05); According to H-L deviation degree and area under receiver operating characteristic curve test, the results show that the model has high accuracy (χ2 = 2.475, p = 0.613) and differentiation (0.875 [95% confidence interval or CI: 0.817-0.919]), and the external verification of the nomogram prediction model was carried out by the verification group. The results showed that the prediction probability of the calibration curve was close to the actual probability and had a good consistency (area under the curve: 0.873 [95 CI: 0.822-0.914]). Conclusion: The established nomogram model exhibits high accuracy and discriminative ability. It can effectively identify high-risk groups, enabling timely prevention of ureteral stenosis and minimizing the risk of postoperative ureteral stenosis.
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Affiliation(s)
- Ping Li
- Department of Urology Surgery, The First Affiliated Hospital of Shaoyang University, Shaoyang, P.R. China
| | - Kangning Wang
- Department of Urology Surgery, Xiangya Hospital Central South University, Changsha, P.R. China
| | - Lin Luo
- Department of Urology Surgery, The First Affiliated Hospital of Shaoyang University, Shaoyang, P.R. China
| | - Qingzhi Xie
- Department of Urology Surgery, The First Affiliated Hospital of Shaoyang University, Shaoyang, P.R. China
| | - Yunchou Wu
- Department of Urology Surgery, The First Affiliated Hospital of Shaoyang University, Shaoyang, P.R. China
| | - Qiuling Liao
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, P.R. China
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Jia X, Wang M. The application of intravenous general anesthesia under nasopharyngeal airway assisted ventilation undergoing ureteroscopic holmium laser lithotripsy: A prospective, single-center, controlled trial. Open Med (Wars) 2024; 19:20241046. [PMID: 39329144 PMCID: PMC11426383 DOI: 10.1515/med-2024-1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/28/2024] Open
Abstract
To observe the effect of intravenous general anesthesia under nasopharyngeal airway-assisted ventilation on patients undergoing ureteroscopic holmium laser lithotripsy. One hundred and twenty patients who underwent ureteroscopic holmium laser lithotripsy in our hospital were selected and randomly divided into nasopharyngeal airway group (research group) and laryngeal mask group (control group). These patients, respectively, received intravenous anesthesia under nasopharyngeal airway and laryngeal mask-assisted ventilation. The following evaluation indexes were compared and analyzed between the two groups, including anesthetic effect, hemodynamics, stress response, postoperative recovery, adverse reactions, etc. There were no significant differences in Visual Analog Scale, hemodynamics, and stress response between the two groups at each time point (P > 0.05). There were no significant differences in residence time and postoperative recovery time between the two groups (P > 0.05). The difference in airway establishment time between the two groups was statistically significant (P < 0.05), and cases with blood in the research group was significantly lower than those in the control group (P < 0.05). Patient satisfaction in research group was significantly higher than those in the control group (P < 0.05). The clinical effect of intravenous general anesthesia under nasopharyngeal airway-assisted ventilation in ureteroscopic holmium laser lithotripsy is significant, which helps to stabilize patients' hemodynamics, reduce their stress response and adverse reactions, and improve the satisfaction rate of patient.
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Affiliation(s)
- Xuandong Jia
- Department of Anesthesiology, The 904th Hospital of the Joint Logistic Support Force of PLA, Wuxi, 214000, Jiangsu, China
| | - Min Wang
- Department of Anesthesiology, The 904th Hospital of the Joint Logistic Support Force of PLA, Wuxi, 214000, Jiangsu, China
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Wanderling C, Saxton A, Phan D, Doersch K, Shepard L, Schuler N, Osinski T, Quarrier S, Ghazi A. Turning up the HEAT Surgical simulation of the Moses 2.0 laser in an anatomic model. Can Urol Assoc J 2024; 18:E220-E227. [PMID: 39074990 PMCID: PMC11286189 DOI: 10.5489/cuaj8673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
INTRODUCTION With advancements in laser technology, urologists have been able to treat urinary calculi more efficiently by increasing the energy delivered to the stone. With increases in power used, there is an increase in temperatures generated during laser lithotripsy. The aim of this study was to evaluate the thermal dose and temperatures generated with four laser settings at a standardized power in a high-fidelity, anatomic model. METHODS Using high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system with a synthetic BegoStone implanted in the renal pelvis, surgical simulation of ureteroscopic laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations: at the stone and ureteropelvic junction. RESULTS Greater cumulative thermal doses and maximal temperatures were achieved with greater ODCs and longer laser activation periods. There were statistically significant differences between the thermal doses and temperature profiles of the laser settings evaluated. Temperatures were greater closer to the tip of the laser fiber. CONCLUSIONS Laser energy and frequency play an important role in the thermal loads delivered during laser lithotripsy. Urologists must perform laser lithotripsy cautiously when aggressively treating large renal pelvis stones, as dangerous temperatures can be reached. To reduce the risk of causing thermal tissue injury, urologists should consider reducing their ODC and laser-on time.
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Affiliation(s)
- Christopher Wanderling
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Aaron Saxton
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Dennis Phan
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Karen Doersch
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Lauren Shepard
- Brady Urologic Institute, Johns Hopkins University, Baltimore, MD, United States
| | - Nathan Schuler
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Thomas Osinski
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Scott Quarrier
- University of Rochester Medical Center, Department of Urology, Rochester, NY, United States
| | - Ahmed Ghazi
- Brady Urologic Institute, Johns Hopkins University, Baltimore, MD, United States
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He M, Dong Y, Cai W, Cai J, Xie Y, Yu M, Li C, Wen L. Recent advances in the treatment of renal stones using flexible ureteroscopys. Int J Surg 2024; 110:4320-4328. [PMID: 38477158 PMCID: PMC11254199 DOI: 10.1097/js9.0000000000001345] [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: 12/21/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024]
Abstract
Upper urinary tract stones are a common urological disease that can be treated by flexible ureteroscopy (FURS) through the natural urinary tract, in addition to extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. The advantages of FURS are less trauma, faster recovery, and fewer complications, while its disadvantages include poor results of lithotripsy and stone extraction when dealing with larger stones, and prolonged operation time. Over the last two decades, the emergence of new technologies such as FURS combined with negative pressure suction, robot-assisted FURS, and artificially intelligent FURS, coupled with improvements in laser technology (the use of thulium fiber lasers and the invention of single-use flexible ureteroscopes (su-fURS) suitable for primary level application, have significantly increased the global adoption of FURS. This surge in usage holds a promising future in clinical application, benefiting a growing number of patients with renal calculi. Accompanied by changes in technical concepts and therapeutic modalities, the scope of indications for FURS is broadening, positioning it as a potential primary choice for urolithiasis treatment in the future. This review outlines the progress in employing FURS for the treatment of renal calculi in order to generate insights for further research.
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Affiliation(s)
- Min He
- School of the Second Clinical Medical College, Zhejiang Chinese Medical University
- First People’s Hospital of Fuyang
| | - Yonghui Dong
- School of the Second Clinical Medical College, Zhejiang Chinese Medical University
- Department of Urology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University
| | | | - Jiale Cai
- School of the Second Clinical Medical College, Zhejiang Chinese Medical University
- First People’s Hospital of Fuyang
| | - Yaming Xie
- General Surgery, Department of Hepatobiliary and Pancreatic Surgery and Minimal Invasive Surgery, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College
| | - Mingke Yu
- Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Changjiu Li
- Department of Urology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University
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Kose E, Bostanci Y, Gulsen M, Sahin F, Kalayci O, Ozden E, Yakupoglu YK, Sarikaya S. Monitoring Intrarenal temperature changes during Ho: YAG laser lithotripsy in patients undergoing retrograde intrarenal surgery: a novel pilot study. Urolithiasis 2024; 52:86. [PMID: 38869637 DOI: 10.1007/s00240-024-01592-1] [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: 04/01/2024] [Accepted: 06/06/2024] [Indexed: 06/14/2024]
Abstract
Ho: YAG laser lithotripsy is widely used for urinary stone treatment, but concerns persist regarding its thermal effects on renal tissues. This study aimed to monitor intrarenal temperature changes during kidney stone treatment using retrograde intrarenal surgery with Ho: YAG laser. Fifteen patients were enrolled. Various laser power settings (0.8 J/10 Hz, 1.2 J/12 Hz) and irrigation modes (10 cc/min, 15 cc/min, 20 cc/min, gravity irrigation, and manual pump irrigation) were used. A sterile thermal probe was attached to a flexible ureterorenoscope and delivered into the calyceal system via the ureteral access sheath. Temperature changes were recorded with a T-type thermal probe with ± 0.1 °C accuracy. Laser power significantly influenced mean temperature, with a 4.981 °C difference between 14 W and 8 W laser power (p < 0.001). The mean temperature was 2.075 °C higher with gravity irrigation and 2.828 °C lower with manual pump irrigation (p = 0.038 and p = 0.005, respectively). Body mass index, laser power, irrigation model, and operator duty cycle explained 49.5% of mean temperature variability (Adj. R2 = 0.495). Laser power and operator duty cycle positively impacted mean temperature, while body mass index and specific irrigation models affected it negatively. Laser power and irrigation rate are critical for intrarenal temperature during Ho: YAG laser lithotripsy. Optimal settings and irrigation strategies are vital for minimizing thermal injury risk. This study underscores the need for ongoing research to understand and mitigate thermal effects during laser lithotripsy.
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Affiliation(s)
- Ertugrul Kose
- Department of Urology, Gazi State Hospital, Ilkadım, Samsun, Turkey.
| | - Yakup Bostanci
- Department of Urology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Murat Gulsen
- Department of Urology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Fevzi Sahin
- Department of Mechanical Engineering, Faculty of Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Onur Kalayci
- Department of Urology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Ender Ozden
- Department of Urology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | | | - Saban Sarikaya
- Department of Urology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
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Marom R, Dau JJ, Ghani KR, Hall TL, Roberts WW. Assessing renal tissue temperature changes and perfusion effects during laser activation in an in vivo porcine model. World J Urol 2024; 42:197. [PMID: 38530484 DOI: 10.1007/s00345-024-04896-4] [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: 09/09/2023] [Accepted: 02/21/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION High fluid temperatures have been seen in both in vitro and in vivo studies with laser lithotripsy, yet the thermal distribution within the renal parenchyma has not been well characterized. Additionally, the heat-sink effect of vascular perfusion remains uncertain. Our objectives were twofold: first, to measure renal tissue temperatures in response to laser activation in a calyx, and second, to assess the effect of vascular perfusion on renal tissue temperatures. METHODS Ureteroscopy was performed in three porcine subjects with a prototype ureteroscope containing a temperature sensor at its tip. A needle with four thermocouples was introduced percutaneously into a kidney with ultrasound guidance to allow temperature measurement in the renal medulla and cortex. Three trials of laser activation (40W) for 60 s were conducted with an irrigation rate of 8 ml/min at room temperature in each subject. After euthanasia, three trials were repeated without vascular perfusion in each subject. RESULTS Substantial temperature elevation was observed in the renal medulla with thermal dose in two of nine trials exceeding threshold for tissue injury. The temperature decay time (t½) of the non-perfused trials was longer than in the perfused trials. The ratio of t½ between them was greater in the cortex than the medulla. CONCLUSION High-power laser settings (40W) can induce potentially injurious temperatures in the in vivo porcine kidney, particularly in the medullary region adjacent to the collecting system. Additionally, the influence of vascular perfusion in mitigating thermal risk in this susceptible area appears to be limited.
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Affiliation(s)
- Ron Marom
- Department of Urology, University of Michigan, 4432 Medical Science I, 1301 Catherine Street, Ann Arbor, MI, 48109-5330, USA.
| | - Julie J Dau
- Department of Urology, University of Michigan, 4432 Medical Science I, 1301 Catherine Street, Ann Arbor, MI, 48109-5330, USA
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, 4432 Medical Science I, 1301 Catherine Street, Ann Arbor, MI, 48109-5330, USA
| | - Timothy L Hall
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - William W Roberts
- Department of Urology, University of Michigan, 4432 Medical Science I, 1301 Catherine Street, Ann Arbor, MI, 48109-5330, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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Wanderling C, Saxton A, Phan D, Doersch KM, Shepard L, Schuler N, Hassig S, Quarrier S, Osinski T, Ghazi A. Getting hot in here! Comparison of Holmium vs. thulium laser in an anatomic hydrogel kidney model. Urolithiasis 2024; 52:49. [PMID: 38520506 DOI: 10.1007/s00240-024-01541-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: 11/27/2023] [Accepted: 02/05/2024] [Indexed: 03/25/2024]
Abstract
As laser technology has advanced, high-power lasers have become increasingly common. The Holmium: yttrium-aluminum-garnet (Ho:YAG) laser has long been accepted as the standard for laser lithotripsy. The thulium fiber laser (TFL) has recently been established as a viable option. The aim of this study is to evaluate thermal dose and temperature for the Ho:YAG laser to the TFL at four different laser settings while varying energy, frequency, operator duty cycle (ODC). Utilizing high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system (PCS) with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Ho:YAG laser or TFL. At a standard power (40W) and irrigation (17.9 ml/min), we evaluated four different laser settings with ODC variations with different time-on intervals. Temperature was measured at two separate locations. In general, the TFL yielded greater cumulative thermal doses than the Ho:YAG laser. Thermal dose and temperature were typically greater at the stone when compared away from the stone. Regarding the TFL, there was no general trend if fragmentation or dusting settings yielded greater thermal doses or temperatures. The TFL generated greater temperatures and thermal doses in general than the Ho:YAG laser with Moses technology. Temperatures and thermal doses were greater closer to the laser fiber tip. It is inconclusive as to whether fragmentation or dusting settings elicit greater thermal loads for the TFL. Energy, frequency, ODC, and laser-on time significantly impact thermal loads during ureteroscopic laser lithotripsy, independent of power.
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Affiliation(s)
| | - Aaron Saxton
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Dennis Phan
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen M Doersch
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Lauren Shepard
- Johns Hopkins Brady Institute of Urologic Surgery, Baltimore, MD, USA
| | - Nathan Schuler
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Stephen Hassig
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott Quarrier
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas Osinski
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ahmed Ghazi
- Johns Hopkins Brady Institute of Urologic Surgery, Baltimore, MD, USA
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Wanderling C, Saxton A, Phan D, Doersch K, Shepard L, Schuler N, Osinski T, Quarrier S, Ghazi A. WATTS happening? Evaluation of thermal dose during holmium laser lithotripsy in a high-fidelity anatomic model. World J Urol 2024; 42:157. [PMID: 38483596 DOI: 10.1007/s00345-024-04821-9] [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: 08/20/2023] [Accepted: 01/16/2024] [Indexed: 03/19/2024] Open
Abstract
PURPOSE To evaluate the thermal profiles of the holmium laser at different laser parameters at different locations in an in vitro anatomic pelvicalyceal collecting system (PCS) model. Laser lithotripsy is the cornerstone of treatment for urolithiasis. With the prevalence of high-powered lasers, stone ablation efficiency has become more pronounced. Patient safety remains paramount during surgery. It is well recognized that the heat generated from laser lithotripsy has the potential to cause thermal tissue damage. METHODS Utilizing high-fidelity, 3D printed hydrogel models of a PCS with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations-at the stone and away from the stone. RESULTS Temperatures were highest closest to the laser tip with a decrease away from the laser. Fluid temperatures increased with longer laser-on times and higher ODCs. Thermal doses were greater with increased ODCs and the threshold for thermal injury was reached for ODCs of 75% and 100%. CONCLUSION Temperature generation and thermal dose delivered are greatest closer to the tip of the laser fiber and are not dependent on power alone. Significant temperature differences were noted between four laser settings at a standardized power (40 W). Temperatures can be influenced by a variety of factors, such as laser-on time, operator duty cycle, and location in the PCS.
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Affiliation(s)
| | - Aaron Saxton
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Dennis Phan
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen Doersch
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Lauren Shepard
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Urology, Johns Hopkins University, Baltimore, MD, USA
| | - Nathan Schuler
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Urology, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas Osinski
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott Quarrier
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ahmed Ghazi
- Department of Urology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Urology, Johns Hopkins University, Baltimore, MD, USA
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He Z, Xun Y, Wang S. Evaluation of a novel circulation system for ureteroscopic laser lithotripsy in vitro. World J Urol 2024; 42:62. [PMID: 38285266 DOI: 10.1007/s00345-023-04705-4] [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: 04/08/2023] [Accepted: 11/01/2023] [Indexed: 01/30/2024] Open
Abstract
PURPOSE To evaluate the cooling effect and other advantages of a novel circulation system for ureteroscopic holmium laser lithotripsy (URSL) in a standardized in vitro model. MATERIALS AND METHODS The novel circulation system was assembled by connecting a 4Fr ureteral catheter and a filter. Trails were divided into a new URSL group and a conventional URSL group. First, different power settings (18-30 W) of the holmium laser and irrigation flow rates (20-50 mL/min) were used to evaluate the thermal effect on the lithotripsy site of all groups. Then, renal pelvic temperature and pressure were assessed during URSL at a power of 1.5 J/20 Hz and irrigation flow rates of (20-50 mL/min). Finally, the whole process of lithotripsy was performed at 1.5 J/20 Hz (operator duty cycle ODC: 50%) with an irrigation flow rate of 30 mL/min. The time required for lithotripsy, visual field clarity, and stone migration were observed. RESULTS Temperature of the lithotripsy point was significantly lower in the new URSL group than in the conventional group (P < 0.05) with irrigation rates (20, 30 mL/min). The renal pelvic pressure of the new group was significantly lower than that of the conventional group in which intrarenal hypertension developed at an irrigation rate of 50 ml/min. The new group had better visual clarity and lesser stone upward migration when lithotripsy was performed at 1.5 J/20 Hz and 30 ml/min. CONCLUSION The novel circulation system is more effective in reducing the thermal effects of URSL, pelvic pressure, stone upward migration, and improving the visual clarity of the operative field.
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Affiliation(s)
- Zonghai He
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, Hubei, People's Republic of China
- Department of Urology, Hospital of Kunming Medical University, Kunming, People's Republic of China
| | - Yang Xun
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, Hubei, People's Republic of China.
| | - Shaogang Wang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, Hubei, People's Republic of China.
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10
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Tonyali S, von Bargen MF, Ozkan A, Gratzke C, Miernik A. The heat is on: the impact of excessive temperature increments on complications of laser treatment for ureteral and renal stones. World J Urol 2023; 41:3853-3865. [PMID: 38010538 PMCID: PMC10693507 DOI: 10.1007/s00345-023-04652-0] [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: 05/20/2023] [Accepted: 09/21/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Technological advancements in the field of urology have led to a paradigm shift in the management of urolithiasis towards minimally invasive endourological interventions, namely ureteroscopy and percutaneous nephrolithotomy. However, concerns regarding the potential for thermal injury during laser lithotripsy have arisen, as studies have indicated that the threshold for cellular thermal injury (43 °C) can be exceeded, even with conventional low-power laser settings. This review aims to identify the factors that contribute to temperature increments during laser treatment using current laser systems and evaluate their impact on patient outcomes. MATERIALS AND METHODS To select studies for inclusion, a search was performed on online databases including PubMed and Google Scholar. Keywords such as 'temperature' or 'heat' were combined with 'lithotripsy', 'nephrolithotomy', 'ureteroscopy', or 'retrograde intrarenal surgery', both individually and in various combinations. RESULTS Various strategies have been proposed to mitigate temperature rise, such as reducing laser energy or frequency, shortening the duration of laser activation, increasing the irrigation fluid flow rate, and using room temperature or chilled water for irrigation. It is important to note that higher irrigation fluid flow rates should be approached cautiously due to potential increases in intrarenal pressure and associated infectious complications. The utilization of a ureteral access sheath (UAS) may offer benefits by facilitating irrigation fluid outflow, thereby reducing intrapelvic pressure and intrarenal fluid temperature. CONCLUSION Achieving a balance between laser power, duration of laser activation, and irrigation fluid rate and temperature appears to be crucial for urologists to minimize excessive temperature rise.
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Affiliation(s)
- Senol Tonyali
- Department of Urology, Faculty of Medicine, University of Freiburg Medical Center, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Maximilian Ferry von Bargen
- Department of Urology, Faculty of Medicine, University of Freiburg Medical Center, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arif Ozkan
- Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Christian Gratzke
- Department of Urology, Faculty of Medicine, University of Freiburg Medical Center, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, Faculty of Medicine, University of Freiburg Medical Center, Hugstetter Str. 55, 79106, Freiburg, Germany
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11
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Villena JM, Elorrieta V, Salvadó JA. Temperature effect of Moses™ 2.0 during flexible ureteroscopy: an in vitro assessment. Cent European J Urol 2023; 76:331-335. [PMID: 38230319 PMCID: PMC10789270 DOI: 10.5173/ceju.2023.127] [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: 07/04/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 01/18/2024] Open
Abstract
Introduction One of the main issues related to the use of high-power lasers is the associated rise in temperature. The aim of this study was to characterize temperature variations with activation of the Moses™ 2.0 laser. Material and methods An in vitro experimental study was designed using a high-fidelity uretero-nephroscope simulation model to assess changes in temperature during intracorporeal laser lithotripsy. Renal and ureteral temperature records were obtained from the treatment of BegoStones positioned in the renal pelvis. Different laser settings over three time periods and two possible irrigation flow speeds were evaluated. We considered 43°C as the threshold since it is associated with denaturation of proteins. The Wilcoxon-Mann-Whitney test was used to assess quantitative variables and the Kruskal-Wallis test for categorical variables. Results The highest increase in intrarenal temperature was reached with 30 seconds of laser activation at a laser setting of 0.5 J/100 Hz (50 W) and a flow of 10 mL/min. Only 15 seconds of activation was sufficient for most settings to exceed 43°C. The ureteral temperature did not increase significantly, regardless of the combination of laser setting, time, or irrigation flow, except when 30 W was used for a 30 second period. Multivariate analysis showed that an irrigation flow of 20 mL/min produced an intrarenal temperature decrease of 4.7-9.2°C (p <0.001). Conclusions Use of high-power lasers, both for the ureter and kidney, should involve consideration of temperature increases evidenced in this study, due to the potential biological risk entailed.
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Affiliation(s)
- José M. Villena
- Faculty of Medicine, Finis Terrae University, Santiago, Chile
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12
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Marom R, Dau JJ, Hall TL, Ghani KR, Louters MM, Kim HJ, Khajeh NR, Roberts WW. Thermal Safety Boundaries for Laser Power and Irrigation Rate During Ureteroscopy: In Vivo Porcine Assessment With a Ho:YAG Laser. Urology 2023; 180:81-85. [PMID: 37482102 DOI: 10.1016/j.urology.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To map thermal safety boundaries during ureteroscopy (URS) with laser activation in two in vivo porcine subjects to better understand the interplay between laser power, irrigation rate, and fluid temperature in the collecting system. METHODS URS was performed in two in vivo porcine subjects with a prototype ureteroscope containing a thermocouple at its tip. Up to 6 trials of 60 seconds laser activation were carried out at each selected power setting and irrigation rate. Thermal dose was calculated for each trial, and laser power-irrigation rate parameter pairs were categorized based on number of trials that exceeded a thermal dose of 120 equivalent minutes. RESULTS The collecting fluid temperature was increased with greater laser power and slower irrigation rate. In the first porcine subject, 25 W of laser power could safely be applied if irrigation was at least 15 mL/min, and 48 W with at least 30 mL/min. Intermediate values followed a linear curve between these bounds. For the second subject, where the calyx appeared larger, 15 W laser power required 9 mL/min irrigation, 48 W required 24 mL/min, and intermediate points also followed a near-linear curve. CONCLUSION This study validates previous bench research and provides a conceptual framework for selection of safe laser lithotripsy settings and irrigation rates during URS with laser lithotripsy. Additionally, it provides insight and guidance for future development of thermal mitigation strategies and devices.
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Affiliation(s)
- Ron Marom
- Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Julie J Dau
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Timothy L Hall
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | | | | | - Hyung Joon Kim
- Department of Urology, Konyang University College of Medicine, Daejeon, South Korea
| | | | - William W Roberts
- Department of Urology, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
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13
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O’Meara S, Croghan S, O’Brien FJ, Davis NF. A Good Craftsperson Knows Their Tools: Understanding of Laser and Ureter Mechanics in Training Urologists. J Lasers Med Sci 2023; 14:e29. [PMID: 37744011 PMCID: PMC10517579 DOI: 10.34172/jlms.2023.29] [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: 04/12/2023] [Accepted: 06/27/2023] [Indexed: 09/26/2023]
Abstract
Introduction: Recent decades have seen a move to minimally invasive techniques to manage urolithiasis. Trainees are expected to develop competency in common endourology procedures. Knowledge of ureter mechanics and the theory behind new technologies is important to ensure safe and efficient techniques. We aim to evaluate the exposure to endourology, self-reported competency in common techniques and knowledge of basic ureter biomechanics and technology in training urologists. Methods: An online survey was circulated to all training urologists in the Republic of Ireland. Questions focused on self-reported competency, clinical knowledge, ureter mechanical properties and laser technology. Results: Thirty responses were received with a range of 1-8 years of urology experience (mean=4 years). The respondents reported high levels of exposure to endourology with the majority reporting competency in flexible ureterorenoscopy (FURS) (n=18, 60%) and semi-rigid ureteroscopy (URS) (n=21, 70%). The respondents demonstrated good clinical knowledge but variable knowledge of laser settings, laser thermodynamics and ureter mechanics. Half of the respondents (n=15, 50%) correctly described fragmentation laser settings, with 10 trainees (n=33%) accurately identifying both factors that increase ureteral access sheath (UAS) insertion force. Most of the respondents (n=20, 67%) described the proximal ureter as the site with the greatest compliance, while the site of the greatest force during ureteroscope insertion was correctly identified by 17% (n=5). Conclusion: To our knowledge, this represents the first study evaluating urologist understanding of laser technology and the mechanical properties of the human ureter. Despite trainees reporting high levels of experience in endourology, there is a variable understanding of the principles of laser technology and ureter mechanics. Further research and education are needed with a focus on laser safety, suitable laser settings and the safe limit of insertion forces.
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Affiliation(s)
- Sorcha O’Meara
- Department of Surgery, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Stefanie Croghan
- Department of Surgery, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Fergal J. O’Brien
- Tissue Engineering Research Group (TERG), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Niall F. Davis
- Department of Surgery, Royal College of Surgeons of Ireland, Dublin, Ireland
- Department of Urology and Transplant Surgery, Beaumont Hospital, Dublin, Ireland
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14
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Panthier F, Pauchard F, Traxer O. Retrograde intra renal surgery and safety: pressure and temperature. A systematic review. Curr Opin Urol 2023; 33:308-317. [PMID: 37140545 DOI: 10.1097/mou.0000000000001102] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PURPOSE OF REVIEW Retrograde intra renal surgery (RIRS) with laser lithotripsy represents the gold-standard to treat renal stones up to 20 mm. Controlling intraoperative parameters such as intrarenal pressure (IRP) and temperature (IRT) is mandatory to avoid complications. This article reviews advances in IRP and IRT over the last 2 years. RECENT FINDINGS We conducted a PubMed/Embase search and reviewed publications that include temperature and pressure during RIRS. Thirty-four articles have been published which met the inclusion criteria. Regarding IRP, a consensus has emerged to control IRP during RIRS, in order to avoid (barotraumatic and septic) complications. Several monitoring devices are under evaluation but none of them are clinically approved for RIRS. Ureteral access sheath, low irrigation pressure and occupied working channel help to maintain a low IRP. Robotic systems and suction devices would improve IRP intraoperative management and monitoring. IRT determinants are the irrigation flow and laser settings. Low power settings(<20 W) with minimal irrigation flow (5-10 ml/min) are sufficient to maintain low IRT and allows continuous laser activation. SUMMARY Recent evidence suggests that IRP and IRT are closely related. IRP depends on inflow and outflow rates. Continuous monitoring would help to avoid surgical and infectious complications. IRT depends on the laser settings and the irrigation flow.
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Affiliation(s)
- Frédéric Panthier
- GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université
- Service d'Urologie, Assistance-Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université
- PIMM, UMR 8006 CNRS-Arts et Métiers ParisTech, Paris, France
- Progressive Endourological Association for Research and Leading Solutions (PEARLS)
| | - Felipe Pauchard
- Progressive Endourological Association for Research and Leading Solutions (PEARLS)
- Urology Department, Hospital Naval Almirante Nef, Viña del Mar, Chile
| | - Olivier Traxer
- GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université
- Service d'Urologie, Assistance-Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université
- Progressive Endourological Association for Research and Leading Solutions (PEARLS)
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15
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Wu Z, Wei J, Sun C, Huangfu Q, Wang B, Huang G, Qi K, Jiang Z, Zhu W, Wen J. Temperature changes of renal calyx during high-power flexible ureteroscopic Moses holmium laser lithotripsy: a case analysis study. Int Urol Nephrol 2023:10.1007/s11255-023-03611-3. [PMID: 37145376 DOI: 10.1007/s11255-023-03611-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/21/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE The risk of thermal damage increases with the introduction of high-power lasers during holmium laser lithotripsy. This study aimed to quantitatively evaluate the temperature change of renal calyx in the human body and the 3D printed model during high-power flexible ureteroscopic holmium laser lithotripsy and map out the temperature curve. METHODS The temperature was continuously measured by a medical temperature sensor secured to a flexible ureteroscope. Between December 2021 and December 2022, willing patients with kidney stones undergoing flexible ureteroscopic holmium laser lithotripsy were enrolled. High frequency and high-power settings (24 W, 80 Hz/0.3 J and 32 W, 80 Hz/0.4 J) were performed for each patient with room temperature (25 °C) irrigation. In the 3D printed model, we studied more holmium laser settings (24 W, 80 Hz/0.3 J, 32 W, 80 Hz/0.4 J and 40 W, 80 Hz/0.4 J) with warmed (37 °C) and room temperature (25 °C) irrigation. RESULTS Twenty-two patients were enrolled in our study. With 30 ml/min or 60 ml/min irrigation, the local temperature of the renal calyx did not reach 43 °C in any patient under 25 °C irrigation after 60 s laser activation. There were similar temperature changes in the 3D printed model with the human body under the irrigation of 25 °C. Under the irrigation of 37 °C, the temperature rise slowed down, but the temperature in the renal calyces was close to or even exceeded the 43 °C at the setting of 32 W, 30 ml/min and 40 W, 30 ml/min after continuing laser activation. CONCLUSION In the irrigation of 60 ml/min, the temperature in the renal calyces can still be maintained within a safe range after continuous activation of a holmium laser up to 40 W. However, continuous activation of 32 W or higher power holmium laser in the renal calyces for more than 60 s in the limited irrigation of 30 ml/min can cause excessive local temperature, in such situation room temperature perfusion at 25 ℃ may be a relatively safer option.
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Affiliation(s)
- Zhiyue Wu
- Department of Urology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, Zhejiang, China
| | - Jingchao Wei
- Department of Urology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Chengfang Sun
- Department of Urology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qi Huangfu
- Department of Urology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Bohan Wang
- Department of Urology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Guangyi Huang
- Department of Urology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, Zhejiang, China
| | - Kai Qi
- Department of Urology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, Zhejiang, China
| | - Zeping Jiang
- Department of Urology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, Zhejiang, China
| | - Wuan Zhu
- Department of Urology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, Zhejiang, China
| | - Jiaming Wen
- Department of Urology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China.
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16
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Tokas T, Rice P, Seitz C, Gauhar V, Somani B. Temperature change during laser upper-tract endourological procedures: current evidence and future perspective. Curr Opin Urol 2023; 33:108-115. [PMID: 36226721 DOI: 10.1097/mou.0000000000001048] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW To examine the most recent data on temperatures produced during laser lithotripsy and to provide several strategies for maintaining lower values and reducing the risk of complications during endourological treatment. RECENT FINDINGS Endourologists have access to a wide range of alternatives with the help of the holmium: yttrium-aluminum-garnet (Ho:YAG), thulium: yttrium-aluminum-garnet (TM:YAG), and thulium fiber laser (TFL) that compose a robust and adaptable laser lithotripsy armamentarium. Nevertheless, the threat of thermal damage increases as the local temperature rises with high total power. Most endourologists are not familiar with normal and pathological temperature ranges, how elevated temperatures affect perioperative problems, or how to avoid them. SUMMARY Increased temperatures experienced during laser lithotripsy may affect the course of the healing process. All lasers display a safe temperature profile at energies below 40 W. At equal power settings, Ho:YAG, Tm:YAG, and TFL lasers change the temperature comparably. Shorter on/off laser activation intervals, chilled irrigation, open irrigation systems, and UASs all aid in maintaining acceptable temperatures.
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Affiliation(s)
- Theodoros Tokas
- Department of Urology and Andrology, General Hospital Hall in Tirol, Hall in Tirol
- Training and Research in Urological Surgery and Technology (T.R.U.S.T.)-Group, Austria
| | - Patrick Rice
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Christian Seitz
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Vineet Gauhar
- Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Bhaskar Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
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17
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Tissue thermal effect during lithotripsy and tissue ablation in endourology: a systematic review of experimental studies comparing Holmium and Thulium lasers. World J Urol 2023; 41:1-12. [PMID: 36515722 DOI: 10.1007/s00345-022-04242-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE We looked into the Thulium: yttrium-aluminum-garnet (TM:YAG), Thulium Fibre laser (TFL) and Holmium: yttrium-aluminum-garnet (Ho:YAG) thermal laser tissue effect during lithotripsy and tissue ablation. METHODS We performed a PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) search. RESULTS During lithotripsy, the Ho:YAG generated temperatures from 24 to 68.7 °C at powers < 20 W, the Tm:YAG from 43.7 °C at 30 W to 68 °C at powers < 20 W, and the TFL from 33 to 40.46 °C. During ablation, the Ho:YAG and continuous wave (cw) Tm:YAG tissue incision depths ranged from 0.08 to 2.26 mm, and from 0.28 to 3.22 mm. The Ho:YAG and Tm:YAG vaporization areas ranged from 0.044 to 0.078 mm2 and from 0.050 to 0.078 mm3 and their coagulation zones were 0.075 mm2 and 0.125 mm3 respectively. Ho:YAG and Tm:YAG laser damage zones ranged from 0.093 to 2.6 mm3 and from 0.207 to 0.98 mm3 respectively. The TFL incision depth ranged from 0.04 to 5.7 mm. The cw and SuperPulsed (SP) vaporization volumes ranged from 8 to 28.2 mm3/s and from 4 to 11 mm3/s. TFL coagulation depth and coagulation zone ranged from zero to 1.1 mm, 2.2 to 5.1 mm3 in SP mode and from 7.7 to 18.1 mm3 in cw mode. CONCLUSION During lithotripsy all lasers caused similar temperature changes and had a safe temperature profile at < 40 W. During tissue ablation, Ho:YAG has a deeper incision depth, while cwTm:YAG and cwTFL have broader coagulation and total laser areas.
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18
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Azal W, de Salles LC, di Domenico B, Miyaoka R, Reis LO. Will the advances in retrograde intrarenal surgery extinguish percutaneous nephrolithotomy for stones larger than 2 cm? Int Braz J Urol 2023; 49:143-149. [PMID: 36512462 PMCID: PMC9881800 DOI: 10.1590/s1677-5538.ibju.2022.0533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/26/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Wilmar Azal
- Universidade Estadual de CampinasCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Lukas Costa de Salles
- Universidade Estadual de CampinasCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Bruno di Domenico
- Universidade Estadual de CampinasCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Ricardo Miyaoka
- Universidade Estadual de CampinasCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Leonardo O. Reis
- Universidade Estadual de CampinasCampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
- Pontifícia Universidade Católica de CampinasCampinasSPBrasilUroScience, Pontifícia Universidade Católica de Campinas (PUC-Campinas), Campinas, SP, Brasil
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19
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Thulium Fiber Laser Behavior on Tissue During Upper- and Lower-Tract Endourology. Curr Urol Rep 2022; 23:271-278. [PMID: 36178569 DOI: 10.1007/s11934-022-01117-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW To present the latest evidence on thulium fiber laser (TFL) effects on tissue, during lithotripsy and ablation, emphasizing on generated temperatures, thermal damage thresholds, incision depths, areas of coagulation, and laser damage. RECENT FINDINGS Lasers are frequently utilized during endoscopic treatment of different urological conditions. The holmium:yttrium-aluminum-garnet (Ho:YAG) is most frequently used for various types of stones and soft tissue. The TFL has been recently introduced, offering several advantages. However, its activity on tissue during upper and lower tract endourology is poorly understood. At equivalent power settings, TFL and Ho:YAG generate similar temperature changes during lithotripsy. TFL has a shallow incision depth during tissue ablation. Compared to SP TFL, (cw) TFL results in a broader coagulation zone, whereas SP TFL gives of Ho:YAG-similar incision, and (cw) TFL offers a quick, precise cut with more carbonization.
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20
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Æsøy MS, Juliebø-Jones P, Beisland C, Ulvik Ø. Temperature profiles during ureteroscopy with thulium fiber laser and holmium:YAG laser: Findings from a pre-clinical study. Scand J Urol 2022; 56:313-319. [PMID: 35924316 DOI: 10.1080/21681805.2022.2104367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE The aim of this study was to investigate temperature profiles in both the renal pelvis and parenchyma during Thulium Fiber Laser (TFL) and Holmium:yttrium-aluminium-garnet (Ho:YAG) laser activation in an ex-vivo porcine model. METHODS Three porcine kidneys with intact renal pelvis and proximal ureters were used in the study. A temperature sensor was inserted through a nephrostomy tube into the renal pelvis and a second sensor was inserted directly into the renal parenchyma. Temperatures were recorded during continuous laser activation for 180 s, and for an additional 60 s after deactivation. TFL (150 μm and 200 μm) and Ho:YAG (270 μm) laser delivered power at settings of 2.4 W, 8 W, 20 W and 30 W. RESULTS Intrapelvic temperatures correlated directly to power settings. Higher power produced higher temperatures. For example, using a 150 μm fiber at 2.4 W resulted in a 2.6 °C rise from baseline (p = 0.008), whereas using the same fiber at 20 W produced a rise in temperature of 19.9 °C (p = 0.02). Larger laser fibers caused significantly higher temperatures compared to smaller fibers using equivalent power settings, e.g. mean temperature at 20 W using 150 μm was 39.6 °C compared to 44.9 °C using 200 μm, p < 0.001. There was a significant increase in parenchymal temperatures when applying 20 W and 30 W of laser power with the two larger fibers. CONCLUSION In this ex-vivo study, renal temperatures correlated directly to power settings. Higher power produced higher temperatures. Furthermore, larger laser fibers caused higher temperatures. These findings could help guide selection of safe power settings for ureteroscopic lithotripsy, but future clinical studies are needed for confirmation.
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Affiliation(s)
- M S Æsøy
- Department of Urology, Haukeland University Hospital, Bergen, Norway
| | - P Juliebø-Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - C Beisland
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Ø Ulvik
- Department of Urology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
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21
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Pauchard F, Ventimiglia E, Corrales M, Traxer O. A Practical Guide for Intra-Renal Temperature and Pressure Management during Rirs: What Is the Evidence Telling Us. J Clin Med 2022; 11:jcm11123429. [PMID: 35743499 PMCID: PMC9224584 DOI: 10.3390/jcm11123429] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION One of the main limitations of Ho:YAG lithotripsy is represented by its advancement speed. The need for faster lithotripsy has led to the introduction of high-power laser equipment. This general trend in increasing Ho:YAG lithotripsy power has certain points that deserve to be considered and analyzed. The objective is to carry out a narrative review on intrarenal temperature and pressure during ureteroscopy. METHODS A literature search using PUBMED database from inception to December 2021 was performed. The analysis involved a narrative synthesis. RESULTS Using more power in the laser correlates with an increase in temperature that can be harmful to the kidney. This potential risk can be overcome by increasing either the irrigation inflow or outflow. Increasing irrigant flow can lead to high intrarenal temperature (IRP). The factors that allow the reduction of intrarenal pressure are a low irrigation flow, the use of a ureteral access sheath of adequate diameter according to the equipment used, and the occupation of the working channel by the laser or basket. CONCLUSION To maintain a safe temperature profile, it has been proposed to use chilled irrigation fluid, intermittent laser activation or to increase irrigation flow. This last recommendation can lead to increased IRP, which can be overcome by using a UAS. Another option is to use low power laser configurations in order to avoid temperature increases and not require high irrigation flows.
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Affiliation(s)
- Felipe Pauchard
- Urology Department, Hospital Naval Almirante Nef, Viña del Mar 2520000, Chile;
| | - Eugenio Ventimiglia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Mariela Corrales
- Groupe de Recherche Cliniques sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, F-75020 Paris, France;
| | - Olivier Traxer
- Groupe de Recherche Cliniques sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, F-75020 Paris, France;
- Service d’Urologie, Assitance-Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, F-75020 Paris, France
- Correspondence: ; Tel.: +33-1-56-01-61-53; Fax: +33-1-56-01-63-77
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22
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Tsaturyan A, Peteinaris A, Pantazis L, Farsari E, Pagonis K, Adamou C, Vagionis A, Natsos A, Liatsikos E, Kallidonis P. The effect of prolonged laser activation on irrigation fluid temperature: an in vitro experimental study. World J Urol 2022; 40:1873-1878. [PMID: 35445335 DOI: 10.1007/s00345-022-04000-8] [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: 12/23/2021] [Accepted: 03/18/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To investigate the effect of prolonged laser activation on irrigation fluid temperature by varying the power settings flow rate (10-30 ml/min). MATERIALS AND METHODS An experimental study using a 20 ml syringe, 12/14 ureteral access sheath, a dual-lumen catheter and a thermocouple was performed. The laser was fired with 12 W (0.3 J × 40 Hz), 40 W (1 J × 40 Hz), 60 W (1.5 J × 40 Hz) using Quanta Ho 150 W (Quanta System, Samarate, Italy). All trials were performed with fluid outflow rate of 10, 20 and 30 ml/min with the fixed fluid volume at 10 ml. RESULTS Continuous laser activation for 10 min with the outflow rate of 10 ml/min using only 12 W resulted to continuous temperature rise to as high as 83 °C. Similar rise of temperatures were observed for 40 W and 60 W with 10 ml/min outflow rate with intermittent laser activation. With 20 and 30 ml/min outflow rates the maximum temperatures for all power settings were below the threshold (< 43 °C). However, the time to reach the same total emitted energy was 60% and 40% shorter 60 W and 40 W, respectively. CONCLUSION Our study found that continuous laser activation with as less as 12 W using 10 ml/min outflow rate increased the irrigation fluid temperature above the threshold only after 1 min. In the current experimental setup, with the fluid outflow rate of 20 and 30 ml/min safe laser activation with 60 W and 40 W (temperature < 43 °C) can be achieved reaching the same total emitted energy as with 12 W in significantly shorter time period.
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Affiliation(s)
- Arman Tsaturyan
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece.
| | - Angelis Peteinaris
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
| | - Lampros Pantazis
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
| | - Ergina Farsari
- Plasma Technology Laboratory, Department of Chemical Engineering, University of Patras, Patras, Greece
| | - Konstantinos Pagonis
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
| | - Constantinos Adamou
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
| | - Athanasios Vagionis
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
| | - Anastasios Natsos
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
| | - Evangelos Liatsikos
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece.,Department of Urology, Medical University of Vienna, Vienna, Austria.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Panagiotis Kallidonis
- Department of Urology, University of Patras Medical School, Rio, 26500, Patras, Greece
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23
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Rice P, Somani BK, Nagele U, Herrmann TRW, Tokas T. Generated temperatures and thermal laser damage during upper tract endourological procedures using the holmium: yttrium-aluminum-garnet (Ho:YAG) laser: a systematic review of experimental studies. World J Urol 2022; 40:1981-1992. [PMID: 35355103 DOI: 10.1007/s00345-022-03992-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/14/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To perform a review on the latest evidence related to generated temperatures during Ho:YAG laser use, and present different tools to maintain decreased values, and minimize complication rates during endourological procedures. METHODS We performed a literature search using PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials-CENTRAL, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were URS, RIRS, ureteroscopy, percutaneous, PCNL, and laser. RESULTS Thermal dose (t43) is an acceptable tool to assess possible thermal damage using the generated temperature and the time of laser exposure. A t43 value of more than 120 min leads to a high risk of thermal tissue injury and at temperatures higher than 43 °C Ho:YAG laser use becomes hazardous due to an exponentially increased cytotoxic effect. Using open continuous flow, or chilled irrigation, temperatures remain lower than 45 °C. By utilizing high-power (> 40 W) or shorter laser pulse, temperatures rise above the accepted threshold, but adding a ureteral access sheath (UAS) helps to maintain acceptable values. CONCLUSIONS Open irrigation systems, chilled irrigation, UASs, laser power < 40 W, and shorter on/off laser activation intervals help to keep intrarenal temperatures at accepted values during URS and PCNL.
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Affiliation(s)
- Patrick Rice
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Bhaskar Kumar Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Udo Nagele
- Department of Urology and Andrology, General Hospital Hall i.T., Milser Str. 10, 6060, Hall in Tirol, Austria
- Training and Research in Urological Surgery and Technology (T.R.U.S.T.)-Group, Hall in Tirol, Austria
| | - Thomas R W Herrmann
- Training and Research in Urological Surgery and Technology (T.R.U.S.T.)-Group, Hall in Tirol, Austria
- Department of Urology, Kantonspital Frauenfeld, Spital Thurgau AG, Frauenfeld, Switzerland
| | - Theodoros Tokas
- Department of Urology and Andrology, General Hospital Hall i.T., Milser Str. 10, 6060, Hall in Tirol, Austria.
- Training and Research in Urological Surgery and Technology (T.R.U.S.T.)-Group, Hall in Tirol, Austria.
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Laser operator duty cycle effect on temperature and thermal dose: in-vitro study. World J Urol 2022; 40:1575-1580. [DOI: 10.1007/s00345-022-03967-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/14/2022] [Indexed: 11/26/2022] Open
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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.
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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.
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Dau JJ, Rezakahn Khajeh N, Hall TL, Roberts WW. Chilled irrigation for control of temperature elevation during ureteroscopic laser lithotripsy: in vivo porcine model. J Endourol 2021; 36:403-409. [PMID: 34569294 DOI: 10.1089/end.2021.0537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Multiple studies have shown significant heating of fluid within the urinary collecting system with high-power laser settings. Elevated fluid temperatures may cause thermal injury and tissue damage unless appropriately mitigated. A previous in vitro study demonstrated that chilled (4 °C) irrigation slowed temperature rise, decreased plateau temperature, and lowered thermal dose during laser activation with high-power settings. We sought to evaluate the thermal effects of chilled, room temperature, and warmed irrigation during ureteroscopy with laser activation in an in vivo porcine model. MATERIALS AND METHODS Seven female Yorkshire cross pigs (45-55 kg) were anesthetized and positioned supine. Retrograde ureteroscopy was performed with a thermocouple affixed 5 mm from the distal end of the ureteroscope. In two pigs a holmium:YAG laser was activated for 60 seconds at irrigation rates of 8 ml/min, 12 ml/min, and 15 ml/min with chilled, room temperature, or warmed irrigation. In five pigs core body temperature was recorded for one hour with or without continuous chilled irrigation at 15 ml/min. RESULTS At irrigation rates ≥ 12 ml/min, temperature curves appeared uniformly offset, warmed > room temperature > chilled irrigation. The threshold of thermal tissue injury was reached during laser activation for all irrigation temperatures at 8 ml/min. The threshold was not reached with chilled irrigation at 12 ml/min or 15 ml/min, or with room temperature irrigation at 15 ml/min. The threshold was exceeded at all irrigation rates with warmed irrigation. There was no significant change in core body temperature after delivering chilled irrigation at 15 ml/min compared with no irrigation for 60 minutes. CONCLUSION Irrigation with chilled saline solution during ureteroscopic laser lithotripsy slows temperature rise, lowers peak temperature, and lengthens the time to thermal injury compared to irrigation with room temperature or warmed saline solutions. Core body temperature was not significantly impacted by chilled irrigation.
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Affiliation(s)
- Julie J Dau
- University of Michigan, 1259, Urology, 4432 Medical Sciences Bldg I, 1301 Catherine St, Ann Arbor, Michigan, United States, 48109-1382;
| | | | - Timothy L Hall
- University of Michigan, Biomedical Engineering, 2200 Bonisteel Blvd, Ann Arbor, Michigan, United States, 48109;
| | - William W Roberts
- University of Michigan, Urology, 3879 Taubman Center, 1500 East Medical Center Dr,, Ann Arbor, Michigan, United States, 48109-5330.,University of Michigan, Biomedical Engineering, Ann Arbor, Michigan, United States;
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Rezakahn Khajeh N, Hall TL, Ghani KR, Roberts WW. Pelvicalyceal Volume and Fluid Temperature Elevation During Laser Lithotripsy. J Endourol 2021; 36:22-28. [PMID: 34254838 DOI: 10.1089/end.2021.0383] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND While high-power laser systems facilitate successful ureteroscopic treatment of larger and more complex stones, they can substantially elevate collecting system fluid temperatures with potential thermal injury of adjacent tissue. The volume of fluid in which laser activation occurs is an important factor when assessing temperature elevation. The aim of this study was to measure fluid temperature elevation and calculate thermal dose from laser activation in fluid-filled glass bulbs simulating varying calyx/pelvis volumes. MATERIALS AND METHODS Glass bulbs of volumes 0.5, 2.8, 4.0, 7.0, 21.0, and 60.8 ml were submerged in a 16 L tank of 37˚C deionized water. A 230-µm laser fiber extending 5mm from the tip of a ureteroscope was positioned in the center of each glass bulb. Irrigation with 0, 8, 15, and 40 ml/min of room temperature DI water was applied. Once steady state temperature was achieved, a Ho:YAG laser was activated for 60 seconds at 40W (0.5J x 80Hz, SP). Temperature was measured from a thermocouple affixed to the external tip of the ureteroscope. Thermal dose was calculated using the Dewey and Sapareto t43 methodology. RESULTS The extent of temperature elevation and thermal dose from laser activation were inversely related to the volume of fluid in each model and the irrigation rate. The time to threshold of thermal injury was only 3 seconds for the smallest model (0.5ml) without irrigation but was not reached in the largest model (60.8ml) regardless of irrigation rate. Irrigation delivered at 40 ml/min maintained safe temperatures below the threshold of tissue injury in all models with 1 minute of continuous laser activation. CONCLUSIONS The volume of fluid in which laser activation occurs is an important factor in determining the extent of temperature elevation. Smaller volumes receive greater thermal dose and reach threshold of tissue injury more rapidly than larger volumes.
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Affiliation(s)
- Nikta Rezakahn Khajeh
- University of Michigan, 1259, Urology, 4432 Med Sci I, 1301 Catherine St., Ann Arbor, Michigan, United States, 48109-1382;
| | - Timothy L Hall
- University of Michigan, Biomedical Engineering, 2200 Bonisteel Blvd, Ann Arbor, Michigan, United States, 48109;
| | - Khurshid R Ghani
- University of Michigan, Urology, 3448 Riverbend Drive, Ann Arbor, Michigan, United States, 48105.,University of Michigan, 1259, Ann Arbor, Michigan, United States, 48109-1382;
| | - William W Roberts
- University of Michigan, Urology, 3879 Taubman Center, 1500 East Medical Center Dr,, Ann Arbor, Michigan, United States, 48109-5330.,University of Michigan, Biomedical Engineering, Ann Arbor, Michigan, United States;
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