Stone technology: intracorporeal lithotripters

Trilogy vs 100 W Ho:YAG Laser for Lithotripsy in Mini-Percutaneous Nephrolithotomy: Superior Stone-Free Rates in a Randomized Controlled Trial

OBJECTIVE

To compare the clinical outcomes of lithotripsy using the 100 W Ho:YAG laser and the Trilogy lithotripter in Mini-percutaneous nephrolithotomy (PCNL), and to determine the most effective method for stone clearance through a miniaturized percutaneous tract.

METHODS

This double-blind, randomized, single-center controlled trial (Clinicaltrials.gov ID: NCT04559321) enrolled patients with GUY's grade 1-2 kidney stones. Participants were randomly assigned to undergo Mini-PCNL using either the 100 W Ho:YAG laser (Lumenis Pulsed 100H) or the 1.5 mm Trilogy lithotripter (EMS-Nyon). Primary endpoints were stone lithotripsy time (SLT), lithotripsy rate (SLR), and stone-free rate (SFR). SLT was defined as the time from first activation of the lithotripter/laser until no further activations were needed. The study was terminated early in August 2023 following DSMB recommendations due to evidence of efficacy in one arm.

RESULTS

Eighty-three patients were analyzed (Laser, n=40; Trilogy, n=43), with comparable demographic and stone characteristics. Mean SLT was 8.02 minutes (Laser) vs 5.7 minutes (Trilogy, P=.199). SLR was 179 vs 212 mm³/min (P=.218), and operative time was 75.1±26.6 vs 85.9±28.1 minutes (P=.077). Trilogy achieved a significantly higher SFR (88.4% vs 70%, P=.038). Complication rates were low (2.3% Trilogy vs 10% laser, P=.142). Residual stone volume did not differ significantly between groups.

CONCLUSION

Trilogy lithotripsy resulted in higher SFR without increasing operative time or complications, supporting its use as an effective alternative to high-power laser lithotripsy in Mini-PCNL, especially where active suction is unavailable.

A prospective comparative study of mini-PCNL using Trilogy™ or thulium fibre laser with suction

INTRODUCTION

There has been recent introduction of novel lithotripters and high-power lasers for stone disintegration. With miniaturization of PCNL, there is need of effective disintegration and faster stone-clearance. This study aimed to evaluate efficiency of Trilogy™ and Thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (mini-PCNL).

METHODS

This is prospective study comparing efficiency and outcomes of Trilogy™ and TFL in mini-PCNL between January 2019 and February 2020. Primary objective was to compare stone fragmentation rates, with secondary objectives beings stone-free rates and complications.

RESULTS

There were 60 mini-PCNL with suction using either Trilogy™ or TFL energy source. Mean stone size and density were 27.60 ± 10.17 mm, 22.04 ± 9.69 mm (p = 0.05) and 1172.9 ± 313.5HU, 1308.9 ± 333.9HU (p = 0.10) for Trilogy™ and TFL, respectively. Using 3D doctor imaging software from CT images, mean stone volumes were 3718.9 ± 3038.7mm³ for Trilogy™ and 3425.9 ± 3096.1mm³ for TFL(p = 0.77). Using probe-activation time or lasing time, stone-fragmentation rate was 5.98 ± 4.25mm³/sec for Trilogy™ and 3.95 ± 1.00mm³/sec for TFL(p = 0.015). Treatment time (puncture to complete clearance) was 32.48 ± 15.39 min for Trilogy™ and 28.63 ± 18.56 min for TFL(p = 0.38). Haemoglobin drop was 1.19 ± 0.76gm/dl for Trilogy™ and 0.99 ± 0.74gm/dl for TFL (p = 0.30). Trilogy™ arm had 96.6% complete clearance and TFL had 76.6% in TFL at 48 h. One patient in Trilogy™ arm required auxiliary RIRS for residual stone. Both arms had complete stone clearance at 1 month follow-up. Trilogy™ arm had 3 Clavien-Dindo grade-II complications while TFL had 2 Clavien-Dindo grade-II complications (UTI requiring antibiotics). There was no blood transfusion in either of arm.

CONCLUSION

Trilogy™ had significantly better stone fragmentation rate than TFL in managing renal stones. However, stone-free rates and complications were comparable for Trilogy™ and TFL.

Principles of Intravascular Lithotripsy for Calcific Plaque Modification

A significant proportion of lesions treated with transcatheter interventions in the coronary and peripheral vascular beds exhibit moderate to severe calcific plaques known to portend lower procedural success rates, increased peri-procedural adverse events, and unfavorable clinical outcomes compared with noncalcific plaques. Adapted from lithotripsy technology used for treatment of ureterorenal calculi, intravascular lithotripsy (IVL) is a novel technique for the treatment of severely calcific plaque lesions that uses acoustic shockwaves in a balloon-based delivery system. Shockwaves induce calcium fractures, which facilitate stent expansion and luminal gain. In this review, the authors summarize the physics, preclinical and clinical data on IVL use in the coronary and peripheral vasculature, and future directions of IVL in transcatheter cardiovascular therapies.

15 and 30 W Holmium:YAG Laser Lithotriptor in Ureteroscopic Lithotripsy: Which One Is More Effective and Safe?

Background: Holmium:yttrium-aluminium-garnet (Ho:YAG) laser lithotripsy with ureteroscopy (URS) was a safe and successful treatment option for pediatric ureteral stones. We aimed to comparatively evaluate the outcomes of 15 and 30 W Ho:YAG laser lithotriptors in pediatric ureter stones. Materials and Methods: We retrospectively evaluated 55 children who underwent ureteroscopic laser lithotripsy to treat ureter stone size up to 15 mm between September 2009 and March 2020. Groups were formed according to the laser lithotriptor power 15 W (Group 15: n = 32), 30 W (Group 30: n = 23). The efficiency of laser lithotriptors was compared between the groups. Results: The age, gender, and stone characteristics (longest stone diameter, density, location and multiple stones) were similar between the groups. In the postop first month, stone-free status was achieved in all cases except one child in Group 15. The median operative time was significantly shorter in Group 30 (40 minutes) than in Group 15 (52.5 minutes) (P = .010). Clavien-Dindo class (CDC) 2 complications occurred in 2 children in both groups (P = .597). Although ureteric stenosis was observed in 1 patient in Group 15, no ureteric stenosis was seen in Group 30 during follow-up (median 16.1 months). Length of hospital stay (LoHS) and stone-free rates were similar between groups. Conclusion: URS with 15 and 30 W Ho:YAG laser lithotriptors is an effective treatment option for pediatric ureteral stones with a high success rate and low complication rates. In brief, 30 W Ho:YAG laser lithotriptors should be preferred over 15 W lithotriptors due to their shorter operative time with similar success rate.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy

CONTEXT

Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol.

OBJECTIVE

To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up.

EVIDENCE ACQUISITION

An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL.

EVIDENCE SYNTHESIS

The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus.

CONCLUSIONS

Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL.

PATIENT SUMMARY

Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

A case of fatal embolization during laser lithotripsy

PURPOSE

To report in literature the first case of fatal multi-organ embolization of ureteral stones fragments during laser lithotripsy.

CASE PRESENTATION

A tetraplegic 43-year-old woman was admitted to the hospital to undergo laser lithotripsy because of bilateral ureteral stones and right ureteral infected stent. During the removal of the right ureteral stent, the patient developed a sudden severe bradycardia followed by a reduction in the arterial oxygen saturation. In spite of a rapid and intensive medical intervention, the clinical picture did not improve; the woman was therefore transferred to the nearest Emergency Room where she was rescued but a cardiocirculatory arrest occurred. A claim of alleged medical malpractice was brought against the urologists. A complete autopsy was performed 8 days after death.

AUTOPSY FINDINGS

The diagnosis was determined by the microscopic findings: they have unequivocally shown a massive embolization of calculus fragments in the lungs and in the heart. In the light of all these findings, the cause of death was attributable to a disseminated intravascular coagulation due to this unforeseeable embolization of calcified amorphous material.

CONCLUSION

Embolization of calculus fragments represents an important challenge because it is extremely unpredictable. Indeed, a prompt diagnosis of non-thrombotic pulmonary embolism, during the urologic procedure, is extremely difficult because the condition presents with no specific clinical signs: this life-threatening pathology is often underestimated. For this reason, the autopsy and the subsequent histopathological examination are indispensable in order to prove lethal embolization: microscopic findings play a key role in the final diagnosis of death.

The Effect of Propofol on the Success Rate of Transurethral Lithotripsy by Holmium Laser: A Randomized Clinical Trial

Introduction: Urinary stone disease is the third most common affliction of the urinary tract that has been associated with an increasing incidence. Over decades, great advances have been made in the minimally invasive treatment of urinary stones. Recently, transurethral lithotripsy (TUL) by holmium laser was introduced as a possible therapeutic option. This study evaluated the effect of propofol on the success rate of TUL by holmium laser. Methods: A double-blind randomized controlled trial was conducted on 180 patients to investigate the effect of propofol on the success and complication rate of TUL by holmium laser. The enrolled patients were divided into two groups: the first group received sodium thiopental (n=89) while the second group received propofol (n=91). The two groups were compared in terms of the fluctuations of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), operation time, future stone-free rate (SFR), stone migration, post-operative fever, and ureteral complications such as perforation and mucosal damage. Other developed complications were also recorded. After data gathering, statistical analysis was performed with SPSS version 21. Results: the patients' data such as age, sex, stone diameter, stone laterality, duration of stone impaction, primary SBP, DBP and HR were not significantly different between the two groups (P>0.05). TUL and anesthesia duration, first-minute and fifth-minute SBP and DBP, and also changes of HR were significantly lower in the propofol group compared with the sodium thiopental group (P <0.001). Moreover, SFR of TUL was more evident in the propofol group. Ureteral mucosal damage was significantly less in the propofol group. Conclusion: Propofol was associated with a higher reduction in SBP and DBP, decreased duration of TUL, fewer fluctuations in HR, and an increased success rate of stone removal by TUL with holmium laser.

Ho:YAG laser versus pneumatic lithotripsy for management of pediatric ureteral stones: a prospective-comparative analysis with adults

BACKGROUND

There are limited number of studies comparing the results of Holmium:YAG laser lithotripsy (LL) and pneumatic lithotripsy (PL) for pediatric ureteral stones.

OBJECTIVES

To perform a comparative analysis of LL and PL in the management of ureteral stones in children and adults.

STUDY DESIGN

Ninety-eight children (56 boys and 42 girls) and 623 adults (360 men and 263 women), who were treated for ureteral stones at our clinic between 2017 and 2019, were the subjects of this study. Patients were grouped according to their age as group 1 (n:98, pediatric [<18 age]) and group 2 (n:623, adult [≥18 age]). The patients were then grouped according to lithotripter type as laser (n:580) and pneumatic (n:141). The effects of lithotripter type, stone size and location, and operative times on success and complication rates were investigated.

RESULTS

In both groups, mean operation time was in favor of PL (14.6 vs 22.8 min, p = 0.042 and 26.4 vs 36.3 min, p = 0.013, respectively). In both groups, overall stone-free rates (SFR) were in favor of LL (86.8% vs 66.7%, p < 0.001, and 83% vs 73.9%, p = 0.005, respectively), but there was no significant difference in overall SFRs between adults and children (78.4% vs 76.7, p = 0.390). Retreatment rates were higher in the pneumatic group in both children and adults (p = 0.026 and p = 0.041, respectively). While there was no significant difference in the overall complication rates between adults and children (53.5% vs 40.6%, p = 0.816), the rate of complications with LL was lower in adults (37.7% vs 69.4%, p < 0.001) (TABLE).

DISCUSSION

This paper is the first to report a comparative analysis of factors affecting URS success in adults and children. SFRs were higher in all ureteral locations for LL. LL, lower ureteral location, and <6 mm ureteral stone were determined as the predictors of success for both pediatric and adult patients. The presence of multiple surgeons with different levels of experience is the main limitation of this study.

CONCLUSION

Both LL and PL are safe in children and adults with similar clinically insignificant complication rates. However, in the short term, LL provides better SFRs in both children and adults, especially in the upper ureteral stones. Surgeons should decide the energy technique to be used in URS according to the characteristics of the stone rather than the patient's age group.

Initial Clinical Experience with Swiss LithoClast Trilogy During Percutaneous Nephrolithotomy

Introduction and Objective: Current available lithotrites have clinical stone clearance rates averaging 24 to 32 mm²/minute. The objective of this study was to critically evaluate the initial experience with the Swiss LithoClast^® Trilogy lithotrite during percutaneous nephrolithotomy (PCNL). Methods: We prospectively enrolled patients with a minimum of 15 mm of stone in axial diameter at three locations (Indiana University, University of California Davis, and University of California San Diego) scheduled to undergo PCNL for nephrolithiasis over a 60-day trial period. We assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rate, and complications. Each surgeon also evaluated subjective parameters from each case related to the use of Trilogy on a 1 to 10 scale (10 = extremely effective), and compared it with their usual lithotrite on a 1 to 5 scale (5 = much better). Results: We included 43 patients and had 7 bilateral (16.3%) cases, for a total of 50 renal units. One case was a mini-PCNL. Two cases experienced device malfunctions requiring troubleshooting but no transition to another lithotrite. The mean stone clearance rate was 68.9 mm²/minute. The stone-free rate on postoperative imaging was 67.6% (25 of 37 patients with available imaging). The lowest subjective rating was the ergonomic score of 6.7, and the highest subjective rating was the ease of managing settings score of 9.2. The surgeon impressions of ultrasound (7.3), ballistics (8.1), combination of ultrasound and ballistics (8.7), and suction (8.4) were high. One patient experienced an intraoperative renal pelvis perforation, one patient required a blood transfusion, one patient had a pneumothorax requiring chest tube placement, and one patient had a renal artery pseudoaneurysm requiring endovascular embolization. Conclusions: This multi-institutional study evaluated a new and efficient combination lithotrite that was perceived by surgeons to be highly satisfactory, with an excellent safety and durability profile.

Comparative evaluation of tissue damage induced by ultrasound and impact dual-mode endoscopic lithotripsy versus conventional single-mode ultrasound lithotripsy

OBJECTIVE

The aim of our study was to perform comparative investigation of the tissue safety of three different endoscopic lithotripter devices including a new single-probe/dual-energy lithotripter in an in vivo animal model. The Swiss LithoClast Trilogy was compared to the Storz Calcuson and the Swiss LithoClast Vario. The safety test simulated the accidental direct contact between lithotripter probes and the urothelium, which can occur when sliding off a stone or drilling through a calculus during lithotripsy. The safety test included a smallest (1.5 mm) and largest (3.3/3.4 mm) probe diameter per device.

METHODS

Testing was performed in nine pigs (three animals per device). The bladder tissue was exposed to direct lithotripter probe contact at maximum power for 10 s to produce visible tissue lesions. Acute tissue trauma was evaluated using a simplified scoring model describing the expected bladder wall injuries for histological examination. After 7 days, all animals were killed, necropsied and examined post mortem. For between-group comparisons regarding microscopic histopathologic features, a Chi-square test was used. A p value < 0.05 was considered to be statistically significant.

RESULTS

Irrespective of the lithotripter used, no systemic signs of toxicity were observed. Histologically, signs of normal ongoing healing were observed on the bladder mucosa. There were no significant differences in histological findings taking changes of the epithelium (p = 0.360), the leucocyte infiltration (p = 0.123), the vascular congestion (p = 0.929) and the edema (p = 1.0) between the groups into account.

CONCLUSIONS

The results of this study demonstrated a comparable safety between all lithotripsy devices.

Minimally Invasive Management of Uroliths in Cats and Dogs

Urolithiasis commonly affects cats and dogs. The American College of Veterinary Internal Medicine established guidelines for the treatment of uroliths that reflect modern techniques prioritizing minimally invasive procedures with an emphasis on prevention strategies to limit morbidity and mortality. Extracorporeal shockwave lithotripsy and endoscopic nephrolithotomy constitute some of the minimally invasive treatment modalities available for upper urinary tract uroliths. Cystoscopic-guided basket retrieval, cystoscopic-guided laser lithotripsy, and percutaneous cystolithotomy are minimally invasive options for the management of lower urinary tract uroliths. Following stone removal, prevention strategies are essential to help reduce morbidity and mortality associated with stone recurrence.

Endoscopic intact removal of medium-size- or multiple bladder stones with the use of transvesical laparoendoscopic single-site surgery

Objectives

To determine the feasibility and safety of performing transvesical laparoendoscopic single-site surgery (T-LESS) in patients with medium-size, hard stones or multiple stones with high burden.

Methods

In this case series study, 12 patients (11 males and one female) with a mean age of 66.8 years were operated on from February 2016 to May 2017 due to bladder calculi, using the T-LESS approach with a single-port device (Tri-Port + , Olympus, Germany). Indications for this procedure were hard, medium-size, solitary stones after previous unsuccessful endoscopic lithotripsy or the presence of multiple high-burden stones. In two patients, additional procedures (diverticulectomy or a ureterocele incision) were performed simultaneously.

Results

All stones were removed intact. No serious complications were observed. The mean operative time was 46 min and the postoperative hospital stay was 22 h. The mean diameter of the largest stone and the mean stone volume of each case were 24 mm and 11 cm³, respectively. At the mean follow-up time of 15 months, there was significant improvement of the symptoms.

Conclusions

The T-LESS technique is an efficient, safe and minimally invasive procedure for intact bladder stone removal in selected patients. The method avoids the risk of urethral injury. Nevertheless, further investigation is needed to assess the wider applicability of the procedure.