Moses 2.0 for High-Power Ureteroscopic Stone Dusting: Clinical Principles for Step-by-Step Video Technique

Optimizing the Appropriate Mode of the Pulse-modulated Holmium Laser in a Pop-dusting Benchtop Model

OBJECTIVE

To investigate the effectiveness of different holmium:yttrium-aluminum-garnet (Ho:YAG) laser modes for lithotripsy in the "dusting era" and identify the optimal laser mode for producing stone fragments measuring ≤0.5mm.

METHODS

We used plaster of Paris-made artificial stones crushed into 2-3 mm pieces, weighing 1 g in total. The primary endpoint was the mass of stone fragments ≤0.5mm produced by different laser modes. The secondary endpoints were size categories, fragment mass, and changes in irrigation fluid temperature. The Lumenis Pulse 120 H Ho:YAG laser, with a 200-μm fiber, was used in 3 modes (Moses contact [MC], Moses distance [MD], and long pulse [LP], all at 0.5 J × 80 Hz). Laser lithotripsy involved a 20-second exposure with a 10-second pause for 15 cycles, conducted 7 times per mode while measuring the maximum irrigation fluid temperatures for each cycle.

RESULTS

The MC mode demonstrated superior performance in producing fragments ≤0.5mm (P =.0034) compared with the MD mode. No notable differences were observed for other size categories. The MD and LP modes showed higher rates of mass loss in fluid (MD, P =.023; LP, P =.046) compared with the MC mode. In addition, the increase in irrigation fluid temperature was more pronounced in the MD and LP modes than in the MC mode (MD, P =.015; LP, P =.010).

CONCLUSION

In renal stone lithotripsy during the "dusting era," the MC mode is preferable for generating smaller stone fragments ≤0.5mm. These insights are valuable for optimizing stone fragmentation techniques.

Sheathless RIRS in the era of slim and single use flexible ureteroscopy (ssFURS): Prospective analysis of clinical outcome

INTRODUCATION

the purpose is to assess the feasibility of sheathless and time-limited retrograde intrarenal surgery (RIRS) using slim and single use flexible ureteroscopy (ssFURS) in view of the stone-free rate (SFR), complication rate and upfront ureteral stenting.

METHODS

A prospective, cross-sectional study of patients who underwent RIRS for kidney stones between December 2021 and December 2023 at our tertiary urology center was performed. Patient demographics, clinical presentations and stone characteristics were calculated. The SFR and complication rate were included.

RESULTS

Hundred and eighteen patients were included. The median age was 48 (35.7-60.0) years. Diabetes mellitus (DM) was present in 32 patients (27.1%). The median length of the kidney stones was 1.15 (range [0.4-3.0]), and the median width was 1 (range [0.05-3.7]). The pelvi-ureteric junction (PUJ) represented 75 (63.6%) patients. The lower pole stone (LP) consisted of 27 (22.9%) patients. Thirty-seven (31.4%) of the patients had multiple kidney stones. An overall complete SFR after the first session was observed for 94 (79.7%) patients. The second session of complete SFR was observed in 15 patients (12.7%). A median stone length of 1 (0.8-1.5) cm and a median stone width of 0.95 (0.7-1.3) cm were both significantly associated with a complete SFR after the first session (p < 0.001). A single kidney stone in 69 (73.4%) patients was significantly more strongly associated with a complete SFR after the first session than was multiple kidney stones in 25 (26.6%) patients (p = 0.027). Upfront stenting was performed in 74 patients (62.7%). The complete SFR after the first session was significantly greater in patients who underwent upfront stenting (65; 69.1%) than in those who underwent primary ssFURS (29; 30.9%, p = 0.004).

CONCLUSION

Sheathless and time-limited RIRS using ssFURS is a feasible and successful procedure with low complication rate.

Flexible ureteroscopic treatment of kidney stones: How do the new laser systems change our concepts?

Objective

Flexible ureteroscopy (fURS) has become a widely accepted and effective technique for treating kidney stones. With the development of new laser systems, the fURS approach has evolved significantly. This literature review aims to examine the current state of knowledge on fURS treatment of kidney stones, with a particular focus on the impact of the latest laser technologies on clinical outcomes and patient safety.

Methods

We conducted a search of the PubMed/PMC, Web of Science Core Collection, Scopus, Embase (Ovid), and Cochrane Databases for all randomized controlled trial articles on laser lithotripsy in September 2023 without time restriction.

Results

We found a total of 22 relevant pieces of literature. Holmium laser has been used for intracavitary laser lithotripsy for nearly 30 years and has become the golden standard for the treatment of urinary stones. However, the existing holmium laser cannot completely powder the stone, and the retropulsion of the stone after the laser emission and the thermal damage to the tissue have caused many problems for clinicians. The introduction of thulium fiber laser and Moses technology brings highly efficient dusting lithotripsy effect through laser innovation, limiting pulse energy and broadening pulse frequency.

Conclusion

While the holmium:yttrium-aluminum-garnet laser remains the primary choice for endoscopic laser lithotripsy, recent technological advancements hint at a potential new gold standard. Parameter range, retropulsion effect, laser fiber adaptability, and overall system performance demand comprehensive attention. The ablation efficacy of high-pulse-frequency devices relies on precise targeting, which may pose practical challenges.

Getting hot in here! Comparison of Holmium vs. thulium laser in an anatomic hydrogel kidney model

As laser technology has advanced, high-power lasers have become increasingly common. The Holmium: yttrium-aluminum-garnet (Ho:YAG) laser has long been accepted as the standard for laser lithotripsy. The thulium fiber laser (TFL) has recently been established as a viable option. The aim of this study is to evaluate thermal dose and temperature for the Ho:YAG laser to the TFL at four different laser settings while varying energy, frequency, operator duty cycle (ODC). Utilizing high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system (PCS) with a synthetic BegoStone implanted in the renal pelvis, laser lithotripsy was performed with the Ho:YAG laser or TFL. At a standard power (40W) and irrigation (17.9 ml/min), we evaluated four different laser settings with ODC variations with different time-on intervals. Temperature was measured at two separate locations. In general, the TFL yielded greater cumulative thermal doses than the Ho:YAG laser. Thermal dose and temperature were typically greater at the stone when compared away from the stone. Regarding the TFL, there was no general trend if fragmentation or dusting settings yielded greater thermal doses or temperatures. The TFL generated greater temperatures and thermal doses in general than the Ho:YAG laser with Moses technology. Temperatures and thermal doses were greater closer to the laser fiber tip. It is inconclusive as to whether fragmentation or dusting settings elicit greater thermal loads for the TFL. Energy, frequency, ODC, and laser-on time significantly impact thermal loads during ureteroscopic laser lithotripsy, independent of power.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

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.

New Generation Pulse Modulation in Holmium:YAG Lasers: A Systematic Review of the Literature and Meta-Analysis

(1) Background: New pulse modulation (PM) technologies in Holmium:YAG lasers are available for urinary stone treatment, but little is known about them. We aim to systematically evaluate the published evidence in terms of their lithotripsy performance. (2) Methods: A systematic electronic search was performed (MEDLINE, Scopus, and Cochrane databases). We included all relevant publications, including randomized controlled trials, non-randomized comparative and non-comparative studies, and in-vitro studies investigating Holmium:YAG lithotripsy performance employing any new PM. (3) Results: Initial search yielded 203 studies; 24 studies were included after selection: 15 in-vitro, 9 in-vivo. 10 In-vitro compared Moses with regular PM, 1 compared Quanta’s, 1 Dornier MedTech’s, 2 Moses with super Thulium Fiber Laser, and 1 compared Moses with Quanta PMs. Six out of seven comparative studies found a statistically significant difference in favor of new-generation PM technologies in terms of operative time and five out of six in fragmentation time; two studies evaluated retropulsion, both in favor of new-generation PM. There were no statistically significant differences regarding stone-free rate, lasing and operative time, and complications between Moses and regular PM when data were meta-analyzed. (4) Conclusions: Moses PM seems to have better lithotripsy performance than regular modes in in-vitro studies, but there are still some doubts about its in-vivo results. Little is known about the other PMs. Although some results favor Quanta PMs, further studies are needed.