In Vitro Evaluation of LithAssist: A Novel Combined Holmium Laser and Suction Device

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.

Pooled-analysis of efficacy and safety of minimally invasive versus standard percutaneous nephrolithotomy

BACKGROUND

This study aimed to assess the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MPCNL) versus standard percutaneous nephrolithotomy in patients with renal and upper ureteric stones.

METHODS

We conducted a pooled analysis on randomized controlled trials (RCTs). The eligible RCTs were selected from the following databases: MEDLINE, Embase, Web of Science, and the Cochrane Library. The reference lists of retrieved studies were also investigated.

RESULTS

Our analysis included 10 RCTs with 1612 patients. Pooled data from 10 RCTs revealed the following: stone-free rate (odds ratio = 1.46, 95% confidence interval (CI) [1.12,1.88], P = .004), operative time (mean difference [MD]  = 4.10, 95% CI [-1.37,9.56], P = .14), length of hospital stay (MD = -15.31, 95% CI [-29.43,-1.19], P = .03), hemoglobin decrease (MD = -0.86, 95% CI [-1.19,-0.53], P < .00001), postoperative fever (MD = 0.83, 95% CI [0.49,1.40], P = .49), and urine leakage (MD = 0.59, 95% CI [0.25,1.37], P = .22). Besides, we performed sub-group analysis based on vacuum suction effect and multiple kidney stones. For vacuum suction effect, it revealed the following: stone-free rate in vacuum suction group (P = .007) and in non-vacuum suction group (P = .19). Operative time in vacuum suction group (P = .89), non-vacuum suction group (P = .16). Postoperative fever in vacuum suction group (P = .49), non-vacuum suction group (P = .85).

CONCLUSION

This pooled analysis indicated that MPCNL was a safe and effective method for treating renal stones compared with standard percutaneous nephrolithotomy. Besides, the vacuum suction effect in MPCNL played a more important role. When it comes to multiple or staghorn stones, the longer operative time in MPCNL could not be ignored.

Introducing in clinical practice a new laser suction handpiece for percutaneous nephrolithotomy

Objective:

To assess a novel combined laser suction handpiece (LSH) for performing PCNL in a clinical setting.

Methods:

The study comprised 40 consecutive PCNLs performed between May 2019 and February 2020. The first 20 procedures (Group A) were performed with conventional ultrasonic or pneumatic devices and the other 20 (Group B) were performed with the use of the new LSH. All patients were treated by tubeless supine PCNL. The groups were compared for demographics, clinical data, operative time, lithotrite effectiveness, stone clearance rate (SCR), and outcome.

Results:

Groups A and B were similar in age, and in stone size, complexity, and density (Hounsfield units) (p < 0.05). The average operative time was 99 and 78 min, SCR 143 and 200 mm³/min, hospital stay 1.6 and 1.1 days, and stone-free rate 90% and 95%, respectively. Despite a trend toward better results with the new LSH, none of these comparisons reached statistical significance. Ineffective lithotripsy with the initial device (ultrasonic) requiring conversion to another modality (ballistic) occurred in six (30%) procedures in Group A, while all procedures were effectively accomplished with the LSH in Group B (p = 0.02). There were two complications in Group A and none in Group B (p > 0.05).

Conclusions:

The LSH is as effective and safe as the traditional lithotrites for performing PCNLs. This new tool completes the capabilities of the holmium laser high-power machines, enabling them to serve as the sole platform for all endourological treatments.

Suction Use During Endourological Procedures

PURPOSE OF REVIEW

Equipment used in endourology is constantly evolving due to increasing incidence of urolithiasis. Suctioning has been used mainly in PCNL in conjunction with ultrasonic and ballistic devices for stone removal. Recently technological advances permitted the use of suctioning in more endourological techniques. This review aims to summarize the literature regarding these advancements and analyze the upcoming results.

RECENT FINDINGS

Several centers have conducted experimental and clinical studies on suctioning use during PCNL, mPCNL, and ureteroscopy and concluded that it is an effective and safe adjustment that improves stone-free rates and limits complication rates after these procedures. Suctioning use during common endourological procedures led to improved safety and efficacy among several indications. Due to the observational nature and small sample size of many studies, larger RCTs are needed to make safe conclusions.

Intracorporeal lithotripsy

Since the introduction of ESWL, PNL and URS during the early 1980s the application rate of ESWL has declined while those of PNL and URS have increased. This is mainly due to the facts that instruments and techniques for Intracorporeal Lithotripsy (IL) have made a continuous progress. This review shows that today an array of options for IL within the entire urinary tract is available to treat stones in a perfect minimal invasive way. At the same time further improvements of IL are already visible.

A Usability Comparison of Laser Suction Handpieces for Percutaneous Nephrolithotomy

INTRODUCTION

The holmium laser has revolutionized the practice of minimally invasive endoscopy for kidney stones. Recently, a novel, rigid handpiece for use in percutaneous nephrolithotomy (PCNL) that couples the holmium laser with suction has been developed. To date, limited data exist regarding the usability and ergonomics of such treatment systems. We thus sought to compare surgeon-rated usability with three different suction laser handpieces in a porcine model.

MATERIALS AND METHODS

We performed bilateral reverse PCNL on four female domestic farm pigs. After induction of general anesthesia, percutaneous access was obtained into each kidney by using biplanar fluoroscopy and 8 mm stones (plaster of Paris) were inserted into the calix or renal pelvis for treatment. Four surgeons tested the LASER Suction Tube (Karl Storz^®, Germany), LithAssist™ (Cook^® Medical), and Suction Handpiece (HP) (Lumenis^®, Israel) by using a combination of fragmentation (5 Joules/20 Hertz) and dusting (0.8 Joules/80 Hertz) settings on the Lumenis pulse 120 H laser. The primary outcome assessed was the ease of use of the three devices as measured by a surgeon questionnaire.

RESULTS

A total of 15 stones were treated in 8 renal units. The mean time required for stone fragmentation was 8 min. The mean handling and suction efficiency scores were similar between devices. The Suction HP offered the best laser fiber visibility during lithotripsy.

CONCLUSION

Suction laser handpieces offer an option to treat renal stones via PCNL, with limited differences noted in most surgeon ratings between devices.