Caliceal Fluid Temperature During High-Power Holmium Laser Lithotripsy in an In Vivo Porcine Model

Temperature variations with Ho: YAG and thulium fiber lasers, including advanced fragmentation pulse (AFP) technology: an experimental analysis

PURPOSE

Recent developments in high-power systems and the super-pulsed thulium fiber laser (TFL) promise enhanced efficiency but raise concerns about thermal safety. This study examines the intrarenal temperature profiles of Ho: YAG and TFL systems including the advanced fragmentation pulse (AFP) mode under simulated conditions.

METHODS

A custom-designed kidney and ureter model was used to measure intrarenal temperature changes during laser activation. Real-time temperature data were recorded via thermocouples placed in collecting system. Results were analyzed to compare water temperature increases with the safety threshold of 43 °C.

RESULTS

At an irrigation flow rate of 23 mL/min and an initial water temperature of 22 ± 1 °C, WTIs for all laser systems remained below the safety threshold of temperature increase (STTI) during 60 s of laser activation. Ho: YAG consistently demonstrated the lowest WTIs, whereas TFL in AFP mode showed higher WTIs comparable to Ho: YAG but lower compared to TFL standard mode. Across all settings, WTIs were highest in the pelvis due to proximity to the laser fiber, with lower values in the upper and lower poles. The rapid temperature rise observed in the first 10-15 s was followed by a slower, steady increase. These findings confirm that with proper irrigation, even high-power laser lithotripsy systems, including TFL with AFP, operate within thermally safe limits.

CONCLUSION

This study confirms that both Ho: YAG and TFL systems, including AFP mode, remain thermally safe with adequate irrigation (23 mL/min) during 60-second activation sessions.

Optimizing Fragmentation while Minimizing Thermal Injury Risk with the Thulium Fiber Laser in Ureteral Stone Lithotripsy: An In Vitro Study

Objective: To optimize thulium fiber laser (TFL) settings for effective stone fragmentation although minimizing thermal injury in confined ureteral spaces using a three-dimensional ureter model. Materials and Methods: A hydrogel-based ureter model was maintained at 37.2 ± 0.5°C, with a cylindrical BegoStone (10 × 10 mm, 1.00 ± 0.07 gm) occluding the ureter. Ureteroscopy was performed using a 150 µm TFL fiber for 3 minutes with room temperature irrigation and differing rates (0, 20, 40 mL/min) and power settings (6.4 to 20 W). Maximum sustained temperature (MST) and cumulative thermal dose (cumulative equivalent minutes at 43°C) were assessed against a 120-minute safety threshold. We also evaluated the effects of ureter volume and irrigation temperature. Stone mass treated was calculated by subtracting the mass of residual fragments >3 mm from the initial mass. Results: At 6.4 and 10 W, MSTs were below body temperature, and thermal doses were under 1 minute, indicating minimal thermal risk. At 20 W with 20 mL/min irrigation, MST exceeded 43°C within seconds, and thermal doses surpassed 120 minutes. Treatment efficiency was highest at 20 W (1.58 mg/s), followed by 10 W (1.15 mg/s) and 6.4 W (0.78 mg/s). Among 10 W settings, 1.0 J/10 Hz was more efficient than 2.0 J/5 Hz and 3.0 J/3 Hz. Safe settings produced 95.5% fine dust, whereas high-energy pulses 2-3 J produced significantly more fragments (1-3 mm) compared with settings with pulse energy 0.5-1.0 J. Increasing irrigation to 40 mL/min or using 15°C irrigation effectively reduced MST and improved efficiency, particularly at 20 W. Conclusion: Our study demonstrates the risk of thermal injury with 20 W TFL treatment. Conversely, 10 W settings at 2.0 J/5 Hz are safe and effective for fragmentation. Future research will focus on validating these optimal settings for human stone treatment.

Stone dust in endourology: a systematic review of its definition, management, and clinical impact

OBJECTIVE

To evaluate and synthesise the existing literature on stone dust (DUST) in endourology, focusing on its definition, creation methods, and removal techniques.

METHODS

A comprehensive electronic literature search was conducted using the PubMed/Medline, Web Of Science, and Embase databases to identify reports published until October 2024. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The outcomes assessed included the definition of DUST, the method by which DUST was created, and how it was removed, evaluating both in vitro and in vivo studies. The review also assessed the efficacy of different laser technologies, including holmium-yttrium-aluminium-garnet (Ho:YAG) laser, thulium fibre laser (TFL), and pulsed thulium-YAG laser (p-Tm:YAG) laser, in generating DUST and their clinical relevance in stone management.

RESULTS

The systematic review identified 43 eligible studies, revealing significant variability in the definition and evaluation of DUST. Criteria for DUST ranged from sub-millimetre particle sizes to functional properties like floatability and aspiration capability. While Ho:YAG lasers remain widely used for stone dusting, emerging technologies such as TFL and p-Tm:YAG lasers have shown superior efficiency in producing finer particles and reducing retropulsion. No consensus emerged regarding the settings used by surgeons and the pre-settings provided by laser manufacturers.

CONCLUSIONS

Despite the widespread use of dusting techniques in endourology, a standardised definition of DUST remains lacking, with significant variability in laser settings, particle sizes, and evacuation methods. It must be clarified whether DUST should be defined as a noun-representing a distinct entity with a precise definition-or as the result of the dusting process, in which case clear criteria are needed to characterise it accurately. Establishing standardised definitions and protocols through international consensus is crucial to optimising clinical outcomes and ensuring consistency in future research.

Application of Catheter-Assisted Circulation System in Ureteroscopic Holmium Laser Lithotripsy

Objective: Ureteroscopic lithotripsy (URSL) is the main method for treating ureteral calculi. The scholars used ureteroscopes with dual channels and access sheath to reduce the local temperature and flushing fluid pressure. This study compares the efficacy and safety of ureteral catheter-assisted URSL (UCA-URSL) and traditional URSL in treating ureteral calculi. Patients and Methods: A cross-regional retrospective case-control study in China, including 217 intention-to-treat patients from the First Affiliated Hospital of Kunming Medical University and Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, from August 2023 to July 2024. The primary outcome was the temperature of the lithotripsy point. The secondary outcomes included stone-free rate (SFR), operation time, hospital stay, and postoperative complications. Results: Compared with the traditional URSL group, the catheter-assisted URSL group had a significantly lower lithotripsy point temperature (max, 37.9 ± 2.60°C vs 49.98 ± 5.04°C, p < 0.0001; mean, 32.3 ± 3.25°C vs 38.56 ± 2.70°C, p < 0.0001). In addition, the UCA-URSL group showed higher absolute SFR (immediately, 89.81% vs 53.21%, p < 0.0001; 3 months, 99.07% vs 72.48%, p < 0.0001), and reduced operation time (22.74 ± 7.08 minutes vs 26.40 ± 6.72 minutes, p = 0.0001), postoperative fever rate (1.85% vs 15.60%, p = 0.0003), and ureteral stricture rate (0% vs 3.67%, p = 0.04). Conclusions: In treating ureteral calculi, UCA lithotripsy shows better safety than traditional URSL. Catheter-assisted URSL can be used to improve traditional URSL.

Evaluating safe irrigation rates for Tm fiber laser lithotripsy to prevent thermal injury: an in vitro and numerical simulation

PURPOSE

To evaluate temperature changes and thermal injury during thulium fiber laser (TFL) lithotripsy in the urinary tract and identify the safe irrigation rate, providing a reference for optimal parameter settings in clinical practice.

METHODS

An in vitro thermal injury experiment was conducted using a home-made TFL operating at 40 W. The experiment utilized a glass tube simulating the urinary tract. A peristaltic pump circulated 25 °C saline at irrigation rates ranging from 10 to 40 mL/min. Real-time temperature measurements were recorded using thermocouples, and thermal injury was assessed by calculating the thermal dose threshold. Additionally, a validated numerical simulation model was developed to analyze temperature distributions and predict safe irrigation rates at 20 and 30 W.

RESULTS

In the in vitro experiment, at 40 W, severe thermal injury occurred in the urinary tract when the irrigation rate was below 30 mL/min, particularly in the ureter and renal calyx. The numerical simulation model demonstrated a high degree of consistency with the experimental results. According to the simulation, at 30 W, thermal injury occurred in the renal calyx when the irrigation rate was below 20 mL/min. At 20 W, thermal injury was observed in the renal calyx when the irrigation rate was below 10 mL/min.

CONCLUSIONS

The increase in temperature and the extent of thermal injury were strongly dependent on laser power and irrigation rate, with a lesser dependence on anatomical location. The accuracy of the numerical simulation was validated through experiments, demonstrating its capability to reliably predict temperature variations and thermal injury under different laser power settings and irrigation rates.

Ureteral Tissue Temperature During Ureteroscopy With Ho:YAG Laser Activation in an In Vivo Porcine Model

OBJECTIVE

To measure temperature of the outer ureteral wall and calculate thermal dose with different irrigation and laser power settings during ureteroscopy in a porcine in vivo model.

METHODS

The ureters of two porcine subjects were exposed through laparotomy incisions. A length of PFA tubing, with equally spaced windows, was inserted into the ureter through a ureterotomy. An array of thermocouples was positioned on the outside of the ureter, colocated with the windows. A LithoVue Elite (Boston Scientific) ureteroscope with a wire thermocouple attached was inserted into the tube adjacent to the ureteral windows. Trials of 60 seconds laser activation were performed at different power and irrigation rates. Thermal dose was calculated at each thermocouple with the threshold of thermal injury considered to be 120 equivalent minutes.

RESULTS

All trials conducted with 8 mL/min irrigation: 20 W laser power produced elevated ureteral temperatures. Thermal doses exceeded the thermal injury threshold along a 3 cm length of ureter in some cases. 67% of trials using 15 mL/min irrigation: 30 W laser power also produced suprathreshold thermal doses within ureteral tissue. Employing a 50% operator duty cycle at these same settings decreased thermal dose below threshold. Thermal dose did not reach the threshold of thermal injury in any trials with 40 mL/min irrigation.

CONCLUSION

Ureteroscopy in a porcine model with commonly used irrigation rates and laser settings can elevate ureteral temperatures and produce thermal doses above the threshold of thermal injury.

Warm irrigation fluid effect on Thulium fiber laser (TFL) ablation of uroliths

Prior laser studies have demonstrated that as the temperature of a medium increases, the amount of energy delivered to the target increases. We sought to investigate the role of irrigation fluid temperature on Thulium fiber laser (TFL) urolith ablation. 360 calculi were divided in vitro according to chemical composition: calcium oxalate monohydrate (COM), cystine (CYS), struvite (STR), calcium phosphate (CAP), uric acid (UA), and calcium oxalate dihydrate (COD). A 200 μm TFL was placed directly on each stone, while immersed in 0.9% NaCl at four different temperatures (25 C, 37 C, 44 C, 60 C) and a single laser pulse administered at distinct energy settings (0.1 J, 0.5 J, 1.5 J). Optical coherence tomography assessed the resulting ablation cone volume. Mean stone volume and porosity were evaluated through ANOVA and Tukey post-hoc analysis. A multivariate generalized model for each composition accounted for the impact of fluid temperature and laser energy on stone ablation. Warmer fluid temperatures yielded greater ablation cone volumes for most energy settings, excluding UA stones. When accounting for chemical composition, higher tensile strength stones (COM, CYS) benefited most from warmer fluid in comparison to frangible stones (CAP, STR). The effects of increasing fluid temperature are modest relative to laser pulse energy as a large temperature increase (i.e. 7ºC) is equivalent to a minor energy increase (i.e. 0.1 J). For non-UA stones, TFL ablation efficiency increases with warmer irrigation fluid. The effect, albeit modest compared to laser pulse energy, was most notable for COM and CYS stones.

Evaluating temperature dynamics: a single-center prospective randomized pilot study of holmium versus thulium laser fiber for renal stones

BACKGROUND

We aimed to evaluate and compare the rise in the temperature for the safety of the kidney parenchyma on firing the Holmium: Yttrium Aluminium Garnet laser and the Thulium Fiber Laser during laser lithotripsy in humans.

METHOD

We included 30 pre-stented patients with renal calculi undergoing Retrograde intra-renal surgery. They were randomized into two groups - 15 patients underwent holmium laser lithotripsy and 15 patients underwent TFL laser lithotripsy. We used Philips paediatric esophageal probe to measure rise in temperature on firing holmium or TFL laser with irrigation at 10 ml/min and pressure at 100 mmHg. Different laser settings were used.

RESULT

The mean size of the calculi was 0.8 mm. The rise in temperature with holmium and TFL lasers depended on the firing time and irrigation flow, keeping power constant. On continuous firing for 10s, 20s, and 30s, the average rise in temperature went up to 28.67 °C, 29.70 °C, and 37.17 °C with holmium and with TFL it was 28.77 °C, 29.83 °C, and 37.62 °C, respectively. The difference in rise in temperature between two groups was statistically insignificant with p-values > 0.05. The maximum temperature reached with TFL was 39.4 °C with a 30s lasing time, and that with Ho: YAG was 38.9 °C.

CONCLUSIONS

The rise in temperature was almost equivalent with holmium and TFL. Hence, both Ho: YAG and TFL can be safely used in laser lithotripsy. Adequate irrigation is a must during the surgery. The continuous lasing time should be strictly restricted to less than 20s.

Comparison of Temperature Changes Between Holmium-YAG Laser and Thulium Fiber Laser in an In Vitro Setting

Objective

We aimed to evaluate and compare the rise in the temperature for the safety of the ureter and kidney parenchyma when firing the holmium laser and the thulium fiber laser (TFL).

Methods

We performed a laboratory experiment to measure the rise in temperature upon firing holmium laser and a TFL in a 10 cm3 transparent test tube in an outdoor environment and then in a container with normal saline.

Results

In a 10 cc test tube with static water at 25°C, the rise in temperature with holmium and TFL depends on the firing time, keeping power constant. On continuous firing for 10, 20, and 30 seconds, the temperature rose to 35.1, 42.7, and 53.2°C with holmium. The temperature went up to 38.3, 46.8, and 55.4°C when TFL was used. The power was kept at 10 W for both types of lasers. The temperature rise was relatively low when the test tube was immersed in a water container. It was even lower with irrigation.

Conclusion

The rise in the temperature reaches to hazardous level in static water with a firing time of 30 seconds, which is almost equivalent to holmium and TFL. Thus, while using lasers in RIRS and ureteroscopy, the firing time should not exceed 20 seconds and adequate irrigation is required to prevent damage to the tissues. Also, the rise in temperature was almost equivalent to holmium and TFL; hence, TFL can be safely used in laser lithotripsy in any part of the genitourinary (GU) system.

Factors affecting the thermal effects of lasers in lithotripsy: A literature review

Objective

The use of lasers has been an important part of urology in the treatment of stone and prostate disease. The thermal effects of lasers in lithotripsy have been a subject of debate over the years. The objective of this review was to assess the current state of knowledge available on the thermal effects of lasers in lithotripsy, as well as explore any new areas where studies are needed.

Methods

In August 2022, a keyword search on Google Scholar, PubMed, and Scopus for all papers containing the phrases "thermal effects" AND "laser" AND "lithotripsy" AND "urology" was done followed by citation jumping to other studies pertaining to the topic and 35 relevant papers were included in our study. The data from relevant papers were segregated into five groups according to the factor studied and type of study, and tables were created for a comparison of data.

Results

Temperature above the threshold of 43 °C was reached only when the power was >40 W and when there was adequate irrigation (at least 15-30 mL/min). Shorter lasing time divided by lithotripsy time or operator duty cycles less than 70% also resulted in a smaller temperature rise.

Conclusion

At least eight factors modify the thermal effects of lasers, and most importantly, the use of chilled irrigation at higher perfusion rates, lower power settings of <40 W, and with a shorter operator duty cycle will help to prevent thermal injuries from occurring. Stones impacted in the ureter or pelvi-ureteric junction further increase the probability of thermal injuries during laser firing.

Rise in intraluminal temperature during ureteroscopy: Is this a concern?

The global increase in urolithiasis prevalence has led to a shift towards minimally invasive procedures, such as retrograde intrarenal surgery, supported by advancements in laser technologies for lithotripsy. Pulsed lasers, particularly the holmium YAG and the newer thulium fiber laser, have significantly transformed the management of upper urinary tract stones. However, the use of high-power lasers in these procedures introduces risks of heat-related injury. Laser lithotripsy works through photothermal and photomechanical effects to fragment stones, but up to 96% of the laser energy is converted into heat, increasing the risk of thermal damage to the surrounding urothelial mucosa. Studies show that even at low-power settings, intrarenal temperatures can exceed the threshold for cellular injury, particularly in confined spaces like the ureter. This narrative review explores strategies to mitigate thermal injury, including optimizing laser settings, improving irrigation flow rates, and incorporating novel methods such as cold irrigation, controlling outflow resistance, and using suction. Understanding these approaches is crucial to enhancing patient safety during high-power laser lithotripsy procedures.

High-power versus low-power laser settings during endoscopic stone disease management: a systematic review from the EAU endourology section

PURPOSE

Optimal laser settings during endoscopic stone disease management still represents a debatable issue. The aim of this systematic review is to summarize all existing evidence regarding the comparison of high-power (HP) versus low-power (LP) laser settings during different endoscopic lithotripsy procedures.

METHODS

PubMed, Scopus and Cochrane databases were systematically screened, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. All endoscopic laser lithotripsy surgical approaches were included, including ureteroscopy (URS), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL) and transurethral lithotripsy for bladder stones. Pediatric patients were also included.

RESULTS

In total, 10 studies met the inclusion criteria and were included in final qualitative synthesis. In most studies total operative time (OT) was shorter for the HP group. Mean fragmentation time was homogenously significantly shorter in the HP group. Stone-free rates (SFR) ranged from 59.0% to 100% for the LP group and from 78.9% to 100% for the HP group. Total complication rates were higher for the LP group in six studies, equivalent between the two groups in one study and higher in the HP group in one study.

CONCLUSION

HP laser lithotripsy is a safe and efficient approach for URS, RIRS, PCNL and cystolithotripsy. HP laser settings were associated with significantly shorter total operative time, while some studies reported also better SFR in the HP groups. The implementation of more Randomized Controlled Trials comparing HP and LP laser lithotripsy in different stone settings is of outmost importance, so that better conclusions can be drawn.

Assessment of Holmium:YAG, Pulsed-Thulium:YAG and Thulium Fiber Lasers for Urinary Stone Ablation. In Vitro Study

Objective: To evaluate the ablation speed (AS), laser efficiency and direct thermal lesions during urinary stone lithotripsy with the current available laser technologies: Holmium:YAG (Ho:YAG), pulsed-Thulium:YAG (p-Tm:YAG) and thulium fiber laser (TFL) in vitro using different laser settings. Materials and Methods: Ho:YAG, p-Tm:YAG, and TFL laser system were used in an in vitro ureteral model with a volume of 125 mm3 Begostone. The following parameters were tested across all laser devices: 0.6J/10 Hz (6 W), 0.6 J/20 Hz (12 W), 1.5 J/10 Hz (15 W), and 1.5 J/20 Hz (30 W), employing short pulse width for all lasers and long pulse width for Ho:YAG and p-Tm:YAG. Ten participants conducted the experimental setup during 3-minutes laser on time, combining the laser technology, settings, and pulse widths, with a total of 20 different combinations. The efficiency, AS and ureteral damage resulting from each intervention were analyzed. Results: p-Tm:YAG and TFL demonstrated significantly higher efficiency compared with Ho:YAG (0.049 ± 0.02 Δgr/KJ and 0.042 ± 0.01 Δgr/KJ vs 0.029 ± 0.01 Δgr/KJ; p < 0.05). In all laser sources, as the power increases, the AS also increases (p < 0.05). Furthermore, only at high-energy settings (1.5 J) higher frequency led to increase AS (p < 0.05). Both, p-Tm:YAG and TFL exhibited higher AS compared to Ho:YAG (0.64 ± 0.33 Δgr/s and 0.62 ± 0.31 Δgr/s vs 0.44 ± 0.22 Δgr/s; p < 0.05). Regarding ureteral injuries, as the power increases, there is a higher chance of ureteral damage (p = 0.031). No differences were observed between laser technologies (p = 0.828). Conclusions: Both, p-Tm:YAG and TFL exhibited superior performances during laser lithotripsy compared with Ho:YAG, as they demonstrated higher efficiency and ablation speed. Thermal damage did not appear to be associated with specific laser equipment, but higher grades of lesions are described by increasing power.

Ablation efficiency and laser safety of a novel superpulsed thulium fiber laser: a in vitro study

PURPOSE

To assess the ablation efficiency of the Superpulsed Thulium Fiber Laser (SP-TFL) and investigate the thermal effects of SP-TFL.

METHODS

A SP-TFLwas employed to evaluate ablation efficiency. Fresh ex-vivo pig kidneys and ureters were utilized to evaluate the renal pelvis and ureter temperature changes, different irrigation rates(0, 15, 38mL/min) and a long pulse width were used.

RESULTS

The research indicated that as laser output power increased, ablation rates significantly increased. Ablation rates(mg/min) were higher and the energy per ablated mass(J/mg) was lower at lower frequencies(10-50 Hz). Under the same frequency and single pulse energy, super short and short pulse widths demonstrated higher ablation rates at higher frequencies (exceeding 100 Hz). The temperature of the renal pelvis and ureter decreased with increasing irrigation rates. In the renal pelvis, without irrigation, the temperature quickly reached the critical threshold of 43℃. The irrigation rate was 15 ml/min and power was no more than 18 W, the renal pelvis temperature did not reach 43℃. When the irrigation rate were 38 ml/min, the temperature did not risen to 43℃. In the ureter, without irrigation, the temperature also quickly reached 43℃. The temperature reached 43℃ when the power exceeded to12W with an irrigation rate of 15 ml/min. With an irrigation rate of 38 ml/min, the temperature reached 43℃ at a laser power of 30 W.

CONCLUSIONS

The SP-TFL demonstrated promising ablation effectiveness especially for lower frequencies and super short and short pulse widths model. Proper irrigation rates, single pulse energy, frequency and pulse width are crucial during lithotripsy.

Steady-state versus burst lasing techniques for thulium fiber laser

OBJECTIVE

To evaluate the stone ablation rate and direct thermal damage from thulium fiber laser (TFL) lithotripsy using continuous (C) and burst (B) lasing techniques on an in vitro ureteral model.

METHODS

The TFL Drive (Coloplast, Humlebaek, Denmark) was used in an in vitro saline-submerged ureteral model. Ten participants, including five junior and five experienced urologists, conducted the experimental setup with 7 different settings comparing two lasing techniques: steady-state lasing (0.5 J/10 Hz = 5W for 300 s and 0.5 J/20 Hz = 10W for 150 s) and burst, intermittent 5 s on/off lasing (0.5 J/20 Hz, 0.5 J/30 Hz, 0.5 J/60 Hz, 0.1 J/200 Hz, and 0.05 J/400 Hz) with a target cumulative energy of 1500 J using cubic 125 mm3 phantom BegoStonesTM. Ureteral damage was graded 1-3 based on the severity of burns and holes observed on the surface of the ureteral model.

RESULTS

The were no significant differences in stone ablation mass neither between C and B lasing techniques, nor between expertise levels. At C lasing technique had only mild ureteral lesions with no significant differences between expertise levels (p: 0.97) or laser settings (p: 0.71). At B lasing technique, different types of thermal lesions were found with no expertise (p: 0.11) or setting (p: 0.83) differences. However, B laser setting had higher grade direct thermal lesions than C (p: 0.048).

CONCLUSION

Regarding efficacy, C and B lasing techniques achieve comparable stone ablation rates. Safety-wise, B lasing mode showed higher grade of direct thermal lesions. These results should be further investigated to verify which of the lasing mode is the safest in vivo. Until then and unless proven otherwise, a C mode with low frequency should be recommended to avoid ureteral wall lesions.

An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis

PURPOSE

Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis.

METHODS

Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%.

RESULTS

The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments.

CONCLUSIONS

This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

Turning up the HEAT Surgical simulation of the Moses 2.0 laser in an anatomic model

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.

Monitoring Intrarenal temperature changes during Ho: YAG laser lithotripsy in patients undergoing retrograde intrarenal surgery: a novel pilot study

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.

Arterial pseudoaneurysm: a rare complication following laser lithotripsy-case series and literature review

OBJECTIVE

To perform a comprehensive narrative review that will examine the risk factors and treatment outcomes of arterial pseudoaneurysm following laser flexible ureteroscopy (F-URS).

METHODS

A retrospective case series and a review of literature was performed. Clinical records from three patients treated for postoperative arterial pseudoaneurysm from January of 2021 to November 2023 were identified. A comprehensive literature review was also performed. The MEDLINE and Scopus databases were searched. The analysis was made by a narrative synthesis.

RESULTS

Three cases of postoperative arterial pseudoaneurysm were included, one from our center, one from Dubai, UAE, and one from Barcelona. The literature review identified six case reports, two after endocorporeal laser lithotripsy with thulium fiber laser (TFL) and four with Ho:YAG laser. All cases, from our series and literature review, presented with macroscopic hematuria and used high-power laser settings. All cases were treated by selective embolization.

CONCLUSION

Ho:YAG or TFL lasers are both capable of causing arterial pseudoaneurysms following F-URS if high-power settings are used. Selective artery embolization continues to be the treatment of choice with good outcomes.

Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis

PURPOSE

We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors.

METHODS

We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design).

RESULTS

A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively.

CONCLUSIONS

The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

Temperature Measurements During Flexible Ureteroscopic Laser Lithotripsy: A Prospective Clinical Trial

Objective: The primary aim of the study was to explore intrarenal temperatures (IRTs) during flexible ureteroscopic laser lithotripsy (FURSL). The secondary aim was to investigate the correlation between temperatures and renal pelvis anteroposterior diameter (APD). Materials and Methods: From February 2023 to June 2023, 10 patients with an indwelling nephrostomy tube (NT) undergoing FURSL were enrolled in the study. Sheathless FURSL was performed using gravitational irrigation (23°C) at 60 cm. A sterile K-type thermocouple was inserted through the NT. Temperatures were recorded for 120 seconds with continuous laser activation and for another 60 seconds after deactivation. Thulium fiber laser delivered energy using a 150 μm fiber and incremental power settings of 5, 10, 20, and 30 W. The laser was deactivated whenever the IRT reached 43°C. Results: IRT correlated directly to power settings. Each time the power settings were increased, the temperature rose significantly. The increase in average peak temperature was 2.6°C between 5 and 10 W (p < 0.001), 3.4°C between 10 and 20 W (p < 0.001), and 2.5°C between 20 and 30 W (p < 0.001). Temperatures reached 43°C in three patients applying 20 W and in eight patients applying 30 W. The shortest activation-time until threshold was 12 and 28 seconds with 30 and 20 W settings, respectively. When reaching 43°C, temperatures remained above this threshold for an additional 29 seconds on average. There was a significant correlation between IRT and renal APD. For example, when 10 W was applied in the setting of APD ≤20 mm, the recorded temperature was on average 2.3°C higher compared with APD >20 mm, with the same power settings applied, p < 0.001. Conclusion: During FURSL, IRT correlates directly with power settings and is inversely correlated with renal pelvic APD. Using a sheathless approach, power settings ≥20 W should arguably be avoided, especially in the context of a nondilated renal pelvis. ClinicalTrials: The study was registered on ClinicalTrials.gov (NCT05677425).

Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions?

Objective

This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery.

Methods

A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above.

Results

The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples.

Conclusion

This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.

Assessing renal tissue temperature changes and perfusion effects during laser activation in an in vivo porcine model

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.

WATTS happening? Evaluation of thermal dose during holmium laser lithotripsy in a high-fidelity anatomic model

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.

Evaluation of a novel circulation system for ureteroscopic laser lithotripsy in vitro

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.

High-power Holmium:Yag lithotripsy in bladder urolithiasis: Is it safe and effective? A combined clinical and experimental study

Objective

To evaluate the efficacy and safety of Holmium: Yttrium-Aluminum-Garnet (Ho:YAG) laser in bladder lithotripsy using high-power settings > 100 W.

Materials and Methods

A combined experimental and clinical study was conducted. The Quanta Cyber: Ho 150 with a 550 μm Quanta optical fiber was utilized in all set-ups. Ablation rates for soft and hard artificial stones were tested in vitro using 100 W and 20 W power settings. In the experiment, a porcine bladder was used. The optical fiber was inserted through a rigid cystoscope, whilst a K-type thermocouple was inserted in the bladder dome. The tested high-power settings were 152 W, 120 W and 105 W. In every trial, the lasing time was over 60 s. In the clinical study, 35 patients underwent transurethral high-power bladder lithotripsy. Laser settings were set between 100 W and 150 W.

Results

Stone mass (stone weight) was significantly lower after stone ablation independently of the stone type or the laser settings. Significantly higher mass decrease and ablation rate were detected in high-power compared to low-power settings. In the experiment, the highest temperature recorded was 32°C at 152 W. At 120 W and 105 W, the peak temperatures didn't reach 30°C. In the clinical study, a stone-free rate of 100% and a mean operative time of 43 ± 18 min were reported. All patients stayed in the hospital for one day except for one who presented minor hematuria. Additional complications did not occur.

Conclusion

Ho:YAG laser lithotripsy > 100 W is an effective, fast and safe modality for the treatment of bladder calculi.

Laser safety, warnings, and limits in retrograde intrarenal surgery

OBJECTIVE

To analyze the current information about laser safety in retrograde intrarenal surgery (RIRS), focusing on the two main laser technologies that we use in urology, the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, and the thulium fiber laser (TFL).

METHODS

Narrative overview of the most relevant articles published in MEDLINE and Scopus databases about this subject.

RESULTS

TFL and Ho:YAG laser at similar settings (0.2 J/40 Hz) have similar volume-averaged temperature increase and the average heating rate increase proportionally to laser power, especially when high frequencies are used. Recent preclinical data, comparing both laser technologies at different laser settings, agreed that when the delivered energy increases in expenses of higher frequencies, the thermal damage increases too. Higher frequencies, despite of the rise of temperature in the irrigation medium, can cause accidental thermal lasering lesions.

CONCLUSION

The use of low frequency settings and a proper irrigation is critical to avoid thermal injury in endoscopic laser lithotripsy. In addition, the use of laser safety eyeglasses is recommended in Ho:YAG and TFL ELL.

How to measure intra-renal pressure during flexible URS: Historical background, technological innovations and future perspectives

INTRODUCTION

High intrarenal pressure (IRP) is a potential risk factor for infectious complications related to URS. Methods to lower IRP have been described. However, it is still not possible to assess live IRP values during URS. The objective of this study was to perform a systematic review of the literature regarding endoscopic methods to measure IRP during URS.

METHODS

A systematic search and review of Medline, PubMed and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) checklist and a narrative synthesis of the study results was performed.

RESULTS

A total of 19 articles were included in the review. Four non invasive (i.e. endoscopic) methods to measure IRP were reported: ureteral catheter, sensor wire, pressure sensor proximal to an irrigation system and a novel ureteral access sheath that integrates suction, irrigation, and IRP measurement.

CONCLUSIONS

We provide here a comprehensive overview of the reported clinical measuring systems of IRP during URS. The ideal system has not been developed yet, but urologists will be able to measure IRP during their daily practice soon. The implications of having this type of data during surgery remains unknown. Systems that could integrate irrigation, suction, IRP and temperature seems to be ideal.

The heat is on: the impact of excessive temperature increments on complications of laser treatment for ureteral and renal stones

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.

Thermal Safety Boundaries for Laser Power and Irrigation Rate During Ureteroscopy: In Vivo Porcine Assessment With a Ho:YAG Laser

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.

Temperature changes of renal calyx during high-power flexible ureteroscopic Moses holmium laser lithotripsy: a case analysis study

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.

Temperature change during laser upper-tract endourological procedures: current evidence and future perspective

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.

Dynamic Changes in Fluid Temperatures during Laser Irradiation Using Various Laser Modes: A Thermography-Based In Vitro Phantom Study

The differences in dynamic thermal changes during laser lithotripsy between various laser pulse modes are unclear. We used thermography to evaluate the temporal changes in high-temperature areas during laser activation in order to compare different laser pulse modes. An unroofed artificial kidney model was used for the experiments. The laser fired for 60 s with a laser setting of 0.4 J/60 Hz in the following four different laser pulse modes without saline irrigation: short pulse mode (SPM), long pulse mode (LPM), virtual basket mode (VBM) and Moses mode (MM). Using the first 30 s of moving images, we compared the ratio of a high-temperature area of >43 °C to the total area every 5 seconds. The dynamic changes in fluid temperatures were shown to be different between the laser pulse modes. The extent of the high-temperature areas during the laser activation was large in the LPM and MM compared with the SPM and VBM. While the high-temperature areas expanded in an anterior direction in the early laser irradiation period using the LPM, they spread in a posterior direction in the early laser activation period using the MM. Although only the temperature profile in one specific plane was investigated, these results are considered useful for preventing thermal injuries during retrograde intrarenal surgeries.

Assessing critical temperature dose areas in the kidney by magnetic resonance imaging thermometry in an ex vivo Holmium:YAG laser lithotripsy model

PURPOSE

We aimed to assess critical temperature areas in the kidney parenchyma using magnetic resonance thermometry (MRT) in an ex vivo Holmium:YAG laser lithotripsy model.

METHODS

Thermal effects of Ho:YAG laser irradiation of 14 W and 30 W were investigated in the calyx and renal pelvis of an ex vivo kidney with different laser application times (t_L) followed by a delay time (t_D) of t_L/t_D = 5/5 s, 5/10 s, 10/5 s, 10/10 s, and 20/0 s, with irrigation rates of 10, 30, 50, 70, and 100 ml/min. Using MRT, the size of the area was determined in which the thermal dose as measured by the Cumulative Equivalent Minutes (CEM₄₃) method exceeded a value of 120 min.

RESULTS

In the calyx, CEM₄₃ never exceeded 120 min for flow rates ≥ 70 ml/min at 14 W, and longer t_L (10 s vs. 5 s) lead to exponentially lower thermal affection of tissue (3.6 vs. 21.9 mm²). Similarly at 30 W and ≥ 70 ml/min CEM₄₃ was below 120 min. Interestingly, at irrigation rates of 10 ml/min, t_L = 10 s and t_D = 10 s CEM₄₃ were observed > 120 min in an area of 84.4 mm² and 49.1 mm² at t_D = 5 s. Here, t_L = 5 s revealed relevant thermal affection of 29.1 mm² at 10 ml/min.

CONCLUSION

We demonstrate that critical temperature dose areas in the kidney parenchyma were associated with high laser power and application times, a low irrigation rate, and anatomical volume of the targeted calyx.

Image Distortion During Flexible Ureteroscopy: A Laboratory Model Comparing Super Pulsed Thulium Fiber Laser vs High-Power Ho:YAG Laser

Purpose: Digital ureteroscopes employ "chip-on-the-tip" technology that allows for significant improvement in image resolution. However, image distortion often occurs during laser lithotripsy owing to acoustic wave production. We sought to compare image distortion using different laser power settings and distances from the laser fiber tip to the scope for the Super Pulsed Thulium Fiber (SPTF) laser and high-power Holmium:YAG (Ho:YAG) laser. Materials and Methods: Ureteroscopy was simulated using a silicon kidney-ureter-bladder model fitted with a 12F/14F access sheath and the Lithovue™ (Boston Scientific), disposable digital flexible ureteroscope. At defined laser parameters (10, 20, 30 and 40 W, short pulse), a 200-μm laser fiber was slowly retracted toward the tip of the ureteroscope during laser activation. Image distortion was identified, and distance from the laser tip to the scope tip was determined. Data from the two lasers were compared utilizing t-tests. Results: After controlling for frequency, power, and laser mode, utilizing 1.0 J of energy was significantly associated with less feedback than 0.5 J (-0.091 mm, p ≤ 0.05). Increased power was associated with larger feedback distance (0.016 mm, p ≤ 0.05); however, increase in frequency did not have a significant effect (-0.001 mm, p = 0.39). The SPFT laser had significantly less feedback when compared with all Holmium laser modes. Conclusions: Increased total power results in image distortion occurring at greater distances from the tip of the ureteroscope during laser activation. Image distortion occurs further from the ureteroscope with Ho:YAG laser than with SPTF fibers at the same laser settings. In clinical practice, the tip of the laser fiber should be kept further away from the tip of the scope during ureteroscopy as the power increases as well as when utilizing the Ho:YAG system compared with the SPTF laser platform. The SPTF laser may have a better safety profile in terms of potential scope damage.

Thermal Injury and Laser Efficiency with Holmium YAG and Thulium Fiber Laser-An In Vitro Study

Objective: To evaluate using an inanimate model the thermal injury and laser efficiency on high frequency, high energy, and its combination in hands of junior and experienced urologists during holmium YAG (Ho:YAG) and Thulium fiber laser (TFL) lithotripsy. Methods: A Cyber: Ho 150 WTM and Fiber Dust TFL (Quanta System) with 200 μm core-diameter laser fibers (LF) were used in a saline in vitro ureteral model. Each participant (five junior and five experienced urologists) performed 32 sessions of 5-minute lasering (125 mm³ phantom BegoStones™), comparing four modes (3 J/5 Hz [1.5 W], 0.3 J/20 Hz [6 W], 1.2 J/5 Hz [6 W], and 1.2 J/20 Hz [24 W]). Transparent tip and cleaved LF, and digital and fiberoptic ureteroscopes were also compared. Ureteral damage was classified in a scale (0-5) according to the burns and holes seen in the ureteral model's surface. Results: High-power (HP) setting (24 W) was associated with higher delivered energy and higher ablation rates (ARs) in both lasers (p < 0.001). For the same power setting (6 W), there was no difference in delivered energy or stone ARs. Regardless the settings, a higher AR was observed with TFL than with Ho:YAG (0.5Δ mg/s ± 0.33 vs 0.39 Δmg/s ± 0.31, p = 0.002) laser. Higher mean AR was found with cleaved tip vs transparent tip (p = 0.03) in TFL. For both lasers, higher ureteral damage was observed in the 24 W group (p = 0.006) and in the junior urologists (p = 0.03). Between 6 W groups, different types of lesions were found and junior urologist have more lesions when high frequency was used, for both Ho:YAG (p = 0.05) and TFL (p = 0.04). Conclusion: More stone ARs and reduced operative time are observed in HP settings; however, more ureteral thermic-related damage is produced. When comparing the same power, higher energy or frequency does not modify the AR. Nonetheless, more ureteral thermic-related thermal damage is observed in high-frequency settings in unexperienced hands.

Characterization of Fluid Dynamics and Temperature Profiles During Ureteroscopy with Laser Activation in a Model Ureter

Introduction: Ureteral thermal injury has been reported in patients following ureteroscopy with laser lithotripsy due to overheating of fluid within the ureter. Proper understanding of this risk necessitates knowing the volume of fluid available to absorb laser energy. This can be approximated as the volume of fluid that mixes during laser activation, since energy transfer through fluid is dominated by convection. Objectives of this study were to determine the volume of fluid that mixes during laser activation at different irrigation rates and to characterize the temporal/spatial temperature distribution in a model ureter. Methods: The model ureter consisted of a plastic tube-160 mm length and 5.3 mm inner diameter. Irrigation was first applied with clear, then dyed, deionized water at rates from 8 to 40 mL/min. The laser was activated at 20 W (0.5 J/40 Hz). The distances the dyed fluid propagated were measured and volumes calculated. Temperatures were recorded from six thermocouples-five embedded within the tube and one affixed to the ureteroscope. Thermal dose was calculated using the Dewey and Sapareto methodology. Results: The volume of total fluid mixing in the model ureter was ≤1.26 ± 0.10 cm³, consistent with a sharp temperature increase after laser activation from -5 to 25 mm from the ureteroscope tip. With irrigation rates ≤12 mL/min, calculated thermal dose within the model ureter exceeded the threshold of tissue injury and extended greater distances along the ureter with lower irrigation rates. Conclusion: The volume of total fluid mixing within the model ureter was found to be small thus conferring a greater risk of ureteral thermal injury. A thermocouple positioned near the tip of the ureteroscope reasonably approximates temperature in front of the ureteroscope. Until temperature sensors are incorporated into ureteroscopic systems, laser power settings should be carefully selected to minimize risk of ureteral thermal injury.

Laser Heating of Fluid With and Without Stone Ablation: In Vitro Assessment

Introduction: Laser lithotripsy can cause excessive heating of fluid within the collecting system and lead to tissue damage. To better understand this effect, it is important to determine the percentage of applied laser energy that is converted to heat and the percentage used for stone ablation. Our objective was to calculate the percentage of laser energy used for stone ablation based on the difference in fluid temperature measured in an in vitro model when the laser was activated without and with stone ablation. Methods: Flat BegoStone disks (15:5) were submerged in 10 mL of deionized water at the bottom of a vacuum evacuated double-walled glass Dewar. A Moses 200 D/F/L laser fiber was positioned above the surface of the stone at a distance of 3.5 mm for control (no stone ablation) or 0.5 mm for experimental (ablation) trials. The laser was activated and scanned at 3 mm/second across the stone in a preprogrammed pattern for 30 seconds at 2.5 W (0.5 J × 5 Hz) for both short-pulse (SP) and Moses distance (MD) modes. Temperature of the fluid was recorded using two thermocouples once per second. Results: Control trials produced no stone ablation, while experimental trials produced a staccato groove in the stone surface, simulating efficient lithotripsy. The mean temperature increase for SP was 1.08°C ± 0.04°C for control trials and 0.98°C ± 0.03°C for experimental trials, yielding a mean temperature difference of 0.10°C ± 0.06°C (p = 0.0005). With MD, the mean temperature increase for control trials was 1.03°C ± 0.01°C and for experimental trials 0.99°C ± 0.06°C, yielding a smaller mean temperature difference of 0.04°C ± 0.06°C (p = 0.09). Conclusions: Even under conditions of energy-efficient stone ablation, the majority of applied laser energy (91%-96%) was converted to heat.

Factors affecting the irrigation fluid temperature during laser lithotripsy: in vitro experimental study

OBJECTIVE

To investigate the effect of the diameter of laser fiber, pelvis volume, presence and type of the stone on irrigation fluid temperature rise.

MATERIAL AND METHODS

A 20ml syringe, 12/14 ureteral access sheath(UAS), a dual-lumen catheter and a thermocouple were used.  The 12/14Fr UAS(Cook Ireland Ltd., Limerick, Ireland) and the Thermocouple(SE001, Pico Technologies, Cambridgeshire, UK) were inserted in the syringe. The syringe was closed allowing outflow from the UAS with rate at 10ml/min. The Quanta Ho 150W(Quanta System, Samarate, Italy) laser was used and fired with 10W(2Jx5Hz), 20W(2 × 10 Hz), 40W(2 × 20 Hz), 60W(2 × 30 Hz). These power settings were tested in different conditions: fibers(200µm, 365µm and 550µm), volumes(5ml, 10ml and 20ml) and artificial stones(soft, hard). The laser was activated for 30 seconds and reactivation was performed when the temperature reached below 26 ⁰C.

RESULTS

For all trials 60W of energy resulted in higher temperature rise. No differences were observed when different fibers were used. The highest temperatures (up to 80 ⁰C) for 60W were reported in 5ml syringe and the lowest (<45 ⁰C) with 20ml.  The maximal temperature of >59°C was recorded for the power of 60W(1Jx60Hz). The temperature exceeded 43 ⁰C when power settings >40W were applied.

CONCLUSION

Increasing the overall power, increases the irrigation fluid temperature significantly. The smaller the volume of the pelvis, the greater the temperature elevation. The fiber size did not affect the temperature increase pattern. The presence of artificial stones was associated with the absorption of energy emitted by the laser.

Glossary of pre-settings given by laser companies: no consensus!

INTRODUCTION

Since the construction of the first laser, many companies around the world have contributed to the development of new lasers technologies. To be user-friendly, some companies have developed a pre-setting mode in their laser devices. We aimed to review and compare all laser companies' pre-settings (PS) already established in the market.

MATERIALS AND METHODS

An online search of holmium:YAG (Ho:YAG) and thulium fiber laser (TFL) devices was carried out. Manual and PS mode, pulse width and pulse modulation technology data were collected. The PS parameters were collected directly from the brochure devices or by asking the companies consulting agents.

RESULTS

Thirty-nine laser devices were analyzed (33 Ho:YAG and 6 TFL). The power range varies from 15 to 152 W and 35 W to 60 W for Ho:YAG and TFL, respectively. PS are present in 66% of Ho:YAG lasers and the 33% of TFL. Long-pulse modes can be modified in 12 Ho:YAG and 1 TFL lasers. The median (IQR) PS for dusting stones with Ho:YAG laser is 0.4 J (0.2-1), 21.5 Hz (5-120), and 10 W (1.5-28) for energy, frequency and power, respectively; for Ho:YAG fragmentation is 0.8 J (0.3-5), 10 (3-15) Hz and 5 (1.5-50) W for energy, frequency, and power, respectively; and for popcorn is 0.8 J (0.4-1.2), 10 Hz (6-15) and 5 W (4-18) for energy, frequency, and power, respectively. Dusting and fragmentation mode of Rocamed MH01 and EMS LaserClast 35 are programmed according to the stone type. Most of these settings do not depend on the size of the fiber being used nor the location and type of stone. For TFL, the pre-sets are divided in bladder stone, dusting, fine dusting, fragmentation, and ureteral stone.

CONCLUSION

There is a huge variability regarding pre-sets offered by companies because there is no consensus. Pre-sets should provide a range to work efficacy and safety.

Moses and Moses 2.0 for Laser Lithotripsy: Expectations vs. Reality

Moses technology was born with the aim of controlling the Moses effect present in every single Ho:YAG laser lithotripsy. The capacity to divide the energy pulse into two sub-pulses gained popularity due to the fact that most of the energy would be delivered in the second pulse. However, is this pulse modulation technique really better for endocorporeal laser lithoripsy? A review of the literature was performed and all relevant clinical trials of Moses 1.0 and 2.0, as well as the lab studies of Moses 2.0 carried out up to June 2022 were selected. The search came back with 11 clinical experiences (10 full-text clinical trials and one peer-reviewed abstract) with Moses 1.0 and Moses 2.0, and three laboratory studies (peer-reviewed abstracts) with Moses 2.0 only. The clinical experiences confirmed that the MT (1.0) has a shorter lasing time but lower laser efficacy, because it consumes more J/mm³ when compared with the LP Ho:YAG laser (35 W). This gain in lasing time did not provide enough savings for the medical center. Additionally, in most comparative studies of MT (1.0) vs. the regular mode of the HP Ho:YAG laser, the MT did not have a significant different lasing time, operative time or stone-free rate. Clinical trials with Moses 2.0 are lacking. From what has been published until now, the use of higher frequencies (up to 120 Hz) consumes more total energy and J/mm³ than Moses 1.0 for similar stone-free rates. Given the current evidence that we have, there are no high-quality studies that support the use of HP Ho:YAG lasers with MT over other lasers, such as LP Ho:YAG lasers or TFL lasers.

Determination of Irrigation Flowrate During Flexible Ureteroscopy: Methods for Calculation Using Renal Pelvis Pressure

BACKGROUND

Proper control of irrigation flowrate during ureteroscopy is important to manage thermal and pressure risks. This task is challenging because flowrate is not directly measured by commercially available ureteroscopic or fluid management systems. However, flowrate can be calculated using a hydrodynamic relationship based on measurable values during ureteroscopy. Objectives of this in vitro study were to 1) calculate inflow resistance for different working channel conditions and then using these values 2) calculate irrigation flowrate and determine its accuracy across a range of renal pelvis pressures.

MATERIALS AND METHODS

A 16 Liter container was filled with deionized water and connected by irrigation tubing to a 9.6Fr single-use ureteroscope. Inflow resistance was determined by plotting flowrate (mass of fluid collected from ureteroscope tip in 60 seconds) versus irrigation pressure (range 0-200 cmH2O). Next, the tip of the ureteroscope was inserted into the renal pelvis of a silicone kidney-ureter model and renal pelvis pressure was measured. In conjunction with the previously determined inflow resistance and known irrigation pressure values, flowrate was calculated and compared to experimentally measured values. All trials were performed in triplicate for working channel conditions: empty, 200µm laser fiber, 365µm laser fiber, and 1.9Fr stone basket.

RESULTS

Flowrate was linearly dependent on irrigation pressure for each working channel condition. Inflow resistance was determined to be 5.0 cmH2O/(ml/min) with the 200µm laser fiber in the working channel and calculated flowrates were within 1 ml/min of measured flowrates. Similar results were seen with a 365µm laser fiber, and 1.9Fr basket.

CONCLUSIONS

Utilizing renal pelvis pressure measurements, flowrate was accurately calculated across a range of working channel conditions and irrigation pressures. Incorporation of this methodology into future ureteroscopic systems that measure intrarenal pressure, could provide a real-time readout of flowrate for the urologist and thereby enhance safety and efficiency of laser lithotripsy.

Temperature profiles during ureteroscopy with thulium fiber laser and holmium:YAG laser: Findings from a pre-clinical study

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.

Initial clinical experience with the thulium fiber laser from Quanta System: First 50 reported cases

OBJECTIVE

To evaluate the new thulium fiber laser (TFL) from Quanta System (Fiber Dust™) in terms of efficiency, safety, and laser settings in laser lithotripsy during retrograde intrarenal surgery (RIRS).

METHODS

A prospective study of the first 50 patients with ureteral and renal stones who underwent RIRS using the new Fiber Dust (TFL from Quanta System, Italy) was performed in a single center. 200 µm and 150 µm laser fibers were used. Stone size, stone density, laser-on time (LOT) and laser settings were recorded. We also assessed the ablation speed (mm³/s), Joules/mm³ and laser power (W) values for each procedure.

RESULTS

A total of 50 patients were analyzed. The median (IQR) age was 54.5 (43-65) years old. Median (IQR) stone volume was 347 (147-1800) mm³ and 1125 (294-4000) mm³ for ureteral and renal stones, respectively. Median (IQR) stone density was 900 (400-1500) HU for ureteral stones and 950 (725-1125) HU for renal stones. Median (IQR) pulse energy was 0.6 (0.5-1) J and 0.6 (0.5-0.9) J for ureteral and renal stones, respectively. Median (IQR) frequency for ureteral stones was 10 (10-20) Hz and for renal stones, 15 (10-20) Hz. All procedures used short pulse. There were no statistically significant differences in pulse energy, frequency, laser power or LOT in both groups. The median (IQR) J/mm³ was 8.7 (4.8-65.2) for ureteral stones vs 14.3 (7.8-24.7) for renal stones. The median (IQR) ablation rate was 0.3 (0.2-1.3) mm³/s for ureteral stones vs 0.7 (0.4-1.2) mm³/s for renal stones. Neither of those results reached the significance threshold. Overall complication rate was low in both groups, and none was related to TFL.

CONCLUSION

According to our results, the new TFL laser is safe and effective for lithotripsy during RIRS, using low pulse energy and low pulse frequency.

Thulium fiber laser's dust for stone composition analysis: Is it enough?

Introduction: We aimed to evaluate if the biochemical composition of urinary stones can be determined by analyzing the stone dust only, and whether a photo taken during the surgery could be useful for completing the morpho-constitutional analysis. Materials and methods: 20 patients went through a retrograde intrarenal surgery (RIRS) for renal stone treatment with TFL (Fiber Dust, Quanta, 2020) using 150 µm silica core laser fibers. After laser lithotripsy, residual fragments (RF) were removed with a basket (ZeroTip, Boston Scientific) and spontaneously floating stones particles were considered stone dust and were aspirated through the working channel. Pairs of RF and stone dust were labelled and sent to analysis by scanning electron microscopy and Fourier transform infrared spectroscopy (FTIR). Photos of the stone (surface and section) were taken from videos recorded during the surgery. Results: A total of 20 patients were included in the study. Mean age was 49,8 years old with metabolic and genetic disorders. Mean stone volume was 750 mm3 for ureteral stones and 2334 mm3 for renal stones. Mean stone density was 1187 HU. Positive urine culture was found in 25% patients. In 2/20 (10%) the biochemistry differed only in the relative proportions of each constituent, whilst 5/20 (25%) only one component was missing. Laser crystalline conversion was found in 3/20 (15%). Whewellite and weddellite layers were found in photos thus adding missing information from dust stone analysis. Conclusion: Analyzing aspirated dust through the ureteroscope's working channel by physical techniques, we can understand the lithogenic process of the urinary stone, without needing to analyze the stone fragment. Morphological analysis, given by a proper stone picture, adds missing information in specific cases.

What is the impact of pulse modulation technology, laser settings and intraoperative irrigation conditions on the irrigation fluid temperature during flexible ureteroscopy? An in vivo experiment using artificial stones

PURPOSE

To investigate the effect of different combinations of laser power settings and irrigation conditions using the pulse modulation technology of Quanta™ on irrigation fluid temperature (IFT) during FURS (flexible ureteroscopy) on an in-vivo porcine model with artificial stones.

MATERIALS AND METHODS

A female pig was used. Following the insertion of artificial stones (Begostone™, BEGO USA, Lincoln, RI), a K-type thermocouple was fixed to the created percutaneous access tract. Real-time recordings of IFT during FURS were performed without UAS (ureteral access sheath), with 10/12 UAS, 12/14 UAS and 14/16 UAS. Stone fragmentation was achieved using Quanta Litho Cyber Ho 150 W™ (Samarate, Italy). The IFT was recorded for 30 s, during laser activation, with power settings of 20, 40, 60, 75 and 100 W under both manual pump and gravity irrigation.

RESULTS

The IFT rise above 54 °C was recorded above a power of 40 W when gravity irrigation was used. The use of UAS prolonged the time for IFT to reach high values, although high power settings increase IFT within seconds from the laser activation. Under pump irrigation, only the 100 W power setting without the use of UAS resulted in dangerous IFT after approximately 10 s.

CONCLUSION

The high-power Ho:YAG laser can cause a damaging thermal effect to the kidney exceeding the threshold of 54 °C, under gravity irrigation. Lower power settings (up to 40 W) can be used with safety. According to our experiment, when using high power settings, the use of UAS and manual pump irrigation, is the safest combination regarding renal thermal damage.

A Practical Guide for Intra-Renal Temperature and Pressure Management during Rirs: What Is the Evidence Telling Us

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.

Comparison of low power and high power holmium YAG laser settings in flexible ureteroscopy

PURPOSE

To compare the efficacy of conventional low power and high power holmium: yttrium aluminum-garnet (Ho: YAG) laser lithotripsy settings during retrograde intrarenal surgery (RIRS).  METHODS: The prospective study was conducted in patients undergoing RIRS for renal stones less than 2 cm diameter. Pulsed Ho:YAG laser (Lumenis^® Pulse TM P120 H) was used for laser lithotripsy and the patients were randomized into low power (LP) and high power (HP) laser lithotripsy settings groups. The lasing duration, total laser energy used (Joules), laser energy used to ablate 1 mm³ of stone (Joules/mm³), operative duration, stone ablation speed (mm³/s) and stone free rate were compared.

RESULTS

A total of 120 underwent RIRS with 63 and 57 patients in LP and HP group, respectively. Median stone volume and stone density were comparable between the groups. The total energy used and laser energy used to ablate 1mm³ of stone (Joules/mm³) were significantly higher in the HP group than in LP group (27.9 (16.4-46.2) J/ mm³ vs 9.7 (5.3-17.7) J/ mm³) (p < 0.01). Median (IQR) ablation speed were 0.8 (0.5-1.3) mm³/s and 0.6 (0.4-1) mm³/s in the LP and HP groups, respectively. The median lasing time, operative time and stone free rate were similar in both the groups.

CONCLUSION

The total energy used and J/mm³ were lower in the LP group than in HP group with similar lasing duration, operative duration, ablation speed and stone free rate for renal stones less than 2 cm.