Holmium with MOSES technology or Thulium Fiber Laser in Miniperc with suction - A new curiosity

Expanding urolithiasis treatment: comparison of super pulsed thulium laser and holmium:YAG laser for ureteral stone management

OBJECTIVES

The purpose of this review is to compare the effectiveness of SuperPulsed thulium fiber laser (SP TFL) and holmium:yttrium-aluminum-garnet (Ho:YAG) laser in lithotripsy, with the aim of evaluating the differences between the two in key indicators, such as lithotripsy efficiency and safety, and providing reference for clinical selection of better lithotripsy methods.

METHODS

By searching multiple authoritative medical databases (PubMed, Embase, and Web of Science databases) and including the results of relevant clinical studies and laboratory studies, the indexes involving SP TFL and Ho:YAG lasers in the included literature were analyzed.

RESULTS

We found a total of 24 relevant pieces of literature. The laser parameters, such as ablation efficiency, ablation speed, operative time, dust quality, retropulsion, visibility, temperature safety, and stone-free rate, were compared between laboratory studies and clinical outcomes. Preclinical studies have shown that SP TFL has a higher rate of stone ablation, a weaker retropulsion and a lower risk of fiber breakage. The results of clinical studies showed that the two methods were comparable in the ablation rate, laser time and operative time, stone-free rate and complication. SP TFL offered better endoscopic view quality and less retropulsion.

CONCLUSIONS

While the Ho:YAG laser remains the primary choice for endoscopic laser lithotripsy, the emergence of SP TFL offers a promising new option for the minimally invasive treatment of urinary calculi. Parameter range, retropulsion effect, laser fiber adaptability, and overall system performance demand comprehensive attention. SP TFL has a relatively short clinical application history, and further research is necessary to fully explore its long-term advantages, clinical significance, and possible limitations.

Efficacy and safety of thulium fiber laser versus holmium: yttrium-aluminum-garnet laser in lithotripsy for urolithiasis: a systematic review and meta-analysis

This meta-analysis compares the efficacy and safety of thulium fiber laser (TFL) with holmium: yttrium-aluminum-garnet (Ho: YAG) laser in lithotripsy for urolithiasis. A literature search was conducted across PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov to identify studies published up to July 2024. Studies evaluating clinical outcomes for urolithiasis treated with either Ho: YAG laser or TFL were included. The meta-analysis, using RevMan 5.4 software, focused on comparing the stone-free rate (SFR) between the two lasers. A total of 21 studies were included. TFL was associated with a significantly higher SFR (RR 1.09, 95% CI: 1.02 to 1.16; P = 0.01), shorter operation time (SMD - 1.24, 95% CI: -1.82 to -0.66; P < 0.001), shorter lasing time (SMD - 1.26, 95% CI: -1.98 to -0.54; P < 0.001), shorter hospital stay (SMD - 2.08, 95% CI: -4.15 to -0.02; P = 0.05), reduced stone basket usage (SMD 0.50, 95% CI: 0.33 to 0.76; P = 0.001), and a lower total number of intraoperative complications (RR 0.67, 95% CI: 0.47 to 0.96; P = 0.03). However, TFL was also associated with a higher risk of postoperative sepsis (RR 5.32, 95% CI: 1.71 to 16.56; P = 0.004). Subgroup analyses revealed that TFL achieved a higher SFR in several subgroups, including ureteral stones, non-MOSES technology, and follow-up periods of ≥ 3 months, among others. In conclusion, TFL lithotripsy shows superior efficiency and safety compared to the Ho: YAG laser, though the increased risk of postoperative sepsis warrants further investigation.

Holmium:yttrium-aluminium-garnet laser with MOSES technology is more efficient than thulium fibre laser in supine mini-percutaneous nephrolithotomy

OBJECTIVES

To address the paucity of literature comparing outcomes achieved with utilisation of the high-power holmium:yttrium-aluminium-garnet (Ho:YAG) laser with MOSES technology vs those achieved with the thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (PCNL).

METHODS

A retrospective review was performed of patients undergoing supine mini-PCNL between August 2021 and May 2023. Exclusion criteria were urinary diversion, simultaneous utilisation of >1 laser platform, use of any other form of fragmentation, and ureteric stones. The Ho:YAG platform (Lumenis Pulse P120H™ with MOSES technology, 120W; Boston Scientific®) and the TFL (Soltive SuperPulsed Thulium Fibre [SPTF], 60W; Olympus®) were compared. Data on stone-free rate (SFR) were determined by computed tomography performed on the first postoperative day and presented as absence of stone fragments, no fragments larger than 2 mm, or no fragments larger than 4 mm.

RESULTS

A total of 100 patients met the inclusion criteria, 51 mini-PCNLs with the Ho:YAG laser and 49 with the SPTF laser. No significant differences in demographics or stone characteristics were detected between the two groups. The Ho:YAG laser utilised less energy and time, resulting in higher ablation efficiency (P < 0.05) and less total operating time (P < 0.05). Overall, there was no difference in SFR in any category between the Ho:YAG group and the SPTF group (no fragments: relative risk [RR] 0.81, 95% confidence interval [CI] 0.59-1.12, P = 0.21; fragments <2 mm: RR 0.86, 95% CI 0.67-1.10, P = 0.23; fragments <4 mm: RR 0.96, 95% CI 0.80-1.15, P = 0.67).

CONCLUSIONS

Although we observed an equivalent postoperative SFR, this study supports a shorter operating time and greater intra-operative laser efficiency with the Ho:YAG laser over the SPTF laser in mini-PCNL.

Laser Ablation Efficiency, Laser Ablation Speed, and Laser Energy Consumption During Lithotripsy: What Are They and How Are They Defined? A Systematic Review and Proposal for a Standardized Terminology

CONTEXT

Laser performance for lithotripsy is currently reported using units of measurement such as J/mm3, mm3/J, mm3/s, s/mm3, and mm3/min. However, there are no current standardized definitions or terminology for these metrics. This may lead to confusion when assessing and comparing different laser systems.

OBJECTIVE

The primary objective was to summarize outcome values and corresponding terminology from studies on laser lithotripsy performance using stone volume in relation to time or energy. The secondary objective was to propose a standardized terminology for reporting laser performance metrics.

EVIDENCE ACQUISITION

A systematic review of the literature was conducted using the search string ("j*/mm3" OR "mm3/j*" OR "mm3/s*" OR "s*/mm3" OR "mm3/min*" OR "min*/mm3" AND "lithotripsy") on Scopus, Web of Science, Embase, and PubMed databases. Study selection, data extraction, and quality assessment were performed independently by two authors.

EVIDENCE SYNTHESIS

A total of 28 studies were included, covering holmium:yttrium-aluminum-garnet (Ho:YAG), MOSES, and thulium fiber laser (TFL) technologies. Laser energy consumption values reported for the studies ranged from 2.0 - 43.5 J/mm3in vitro and from 2.7 - 47.8 J/mm3in vivo, translating to laser ablation efficiency of 0.023 - 0.500 mm3/J and 0.021 - 0.370 mm3/J, respectively. Laser ablation speeds ranged from 0.3 - 8.5 mm3/s in vivo, translating to lasing time consumption of 0.12 - 3.33 s/mm3. Laser efficacy ranged from 4.35 - 51.7 mm3/min in vivo. There was high heterogeneity for the terminology used to describe laser performance for the same metrics.

CONCLUSIONS

The range of laser performance metric values relating stone volume to energy or time is wide, with corresponding differing terminology. We propose a standardized terminology for future studies on laser lithotripsy, including laser ablation efficiency (mm3/J), laser ablation speed (mm3/s), and laser energy consumption (J/mm3). Laser efficacy (mm3/min) is proposed as a broader term that is based on the total operative time, encompassing the whole technique using the laser.

PATIENT SUMMARY

We reviewed studies to identify the units and terms used for laser performance when treating urinary stones. The review revealed a wide range of differing units, outcomes, and terms. Therefore, we propose a standardized terminology for future studies on laser stone treatment.

Thulium Fiber Laser Versus Holmium:Yttrium Aluminum Garnet for Lithotripsy: A Systematic Review and Meta-analysis

CONTEXT

Thulium fiber laser (TFL) emerged as a competitor of holmium:yttrium aluminum garnet (Ho:YAG) laser for the treatment of urinary stones.

OBJECTIVE

To compare the efficacy between Ho:YAG and TFL for laser lithotripsy of renal and ureteral stones.

EVIDENCE ACQUISITION

A literature search was conducted using PubMed/Medline, Embase, and Web of Science databases to identify reports published until May 2023. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The primary outcome was to compare the stone-free rate (SFR) between Ho:YAG and TFL for laser lithotripsy.

EVIDENCE SYNTHESIS

Eleven studies met our inclusion criteria, and data from 1286 and 880 patients who underwent, respectively, Ho:YAG and TFL laser lithotripsy were reviewed. Most studies included ureteroscopy (URS) and retrograde intrarenal surgeries as procedures, two included percutaneous nephrolithotomy, and one included URS exclusively. Only two studies reported results in pediatric patients. TFL was associated with a higher SFR (odds ratio [OR] 1.84, 95% confidence interval [CI]: 1.06-3.20; p = 0.031) when no residual fragment is considered, but not when SFR refers to the presence of fragments <3 mm (OR 2.48, 95% CI: 0.98-6.29; p = 0.055) or when only Ho:YAG with MOSES is considered (p = 0.068). According to the stones' location, TFL was associated with higher SFRs than Ho:YAG for renal (OR 3.14, 95% CI: 1.69-5.86; p < 0.001) but not for ureteral (p = 0.8) stones. TFL was associated with a lower intraoperative complication rate (OR 0.34, 95% CI: 0.19-0.63; p < 0.001). No difference was found in major (p = 0.4) or overall (p = 0.4) complication rate, operative time (p = 0.051), and laser time (p = 0.9).

CONCLUSIONS

TFL is a promising laser for the treatment of urinary stones with some advantages over Ho:YAG. Further high-quality studies are needed to confirm these findings and optimize the surgical settings.

PATIENT SUMMARY

The use of thulium fiber laser rather than holmium:yttrium aluminum garnet permits to reach a higher stone-free rate in stones located in the kidney rather than in the ureter.

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.

Suction in Percutaneous Nephrolithotripsy: Evolution, Development, and Outcomes from Experimental and Clinical studies. Results from a Systematic Review

CONTEXT

Controversy exists regarding the therapeutic benefit of suction use during percutaneous nephrolithotripsy (PCNL).

OBJECTIVE

To review and highlight the options available in the use of suction for PCNL, and to discuss their strengths and limitations.

EVIDENCE ACQUISITION

A systematic literature search was performed using Scopus, EMBASE, and PubMed. Thirty four studies were included. There was one ex vivo study. Among clinical studies, 24 used a vacuum/suctioning sheath and nine a handpiece suction device/direct-in-scope suction. The suction technique was employed in standard, mini-PCNL, supermini-PCNL, and enhanced supermini‑PCNL techniques.

EVIDENCE SYNTHESIS

Handpiece suction devices demonstrated better safety and efficiency in treating large stones than nonsuction PCNL and in a much shorter time. Trilogy and ShockPulse-SE were equally effective, safe, and versatile for standard PCNL and mini-PCNL. The heavier handpiece makes Trilogy less ergonomically friendly. Laser suction handpiece devices can potentiate laser lithotripsy by allowing for better laser control with simultaneous suction of small fragments and dust. Integrated suction-based sheaths are available in reusable and disposable forms for mini-PCNL only. Mini-PCNL with suction reported superior outcomes for operative time and stone-free rate to mini-PCNL. This also helped minimize infectious complications by a combination of intrarenal pressure reduction and faster aspiration of irrigation fluid reducing the risk of sepsis, enhance intraoperative vision, and improve lithotripsy efficiency, which makes it a very attractive evolution for PCNL.

CONCLUSIONS

Suction devices in PCNL are reforming the way PCNL is being done. Adding suction to mini-PCNL reduces infectious complications and improves the stone-free rate. Our review shows that despite the limited evidence, suction techniques appear to improve PCNL outcomes.

PATIENT SUMMARY

In this review, we looked at the intra- and perioperative outcomes of percutaneous nephrolithotripsy (PCNL) with the addition of suction. With better stone fragmentation and fewer postoperative infections, this technology is very useful particularly for mini-PCNL.

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.

Which Laser System Is Optimal for Cystolithotripsy of Large Bladder Calculi?

Introduction and Objective: A variety of laser sources are available to treat bladder stones. The aim of this study was to compare time and cost efficiency of the thulium fiber laser (TFL) to four holmium lasers (HLs) with different powers or technologies, including MOSES™ during simulated cystolithotripsy. Materials and Methods: In a benchtop simulation of laser cystolithotripsy, 25 identical 4-cm BegoStones (calcium oxalate monohydrate consistency) were placed on a grid within a 3D-printed bladder model. Lasers were operated at maximal energy, using a 550 μm fiber. Lasers compared were as follows: 60 W TFL, 120 W HL with MOSES, and conventional 120, 100, and 30 W HLs. Five trials were performed for each laser with endpoints of laser time, total time, number of fiber strippings, and total energy. Cost-effectiveness was modeled using laser purchase price, fiber, and operating room (OR) time cost. ANOVA with Tukey's B post hoc was performed to compare outcomes. Spearman's test was used to assess correlation between laser power and procedure time. Results: The laser and total operating times were significantly different between the five systems (p < 0.001). The 120 W HL with MOSES was the fastest with 60.9 minutes of laser and 68.3 minutes of procedure times, while the 30 W HL was the slowest with 281.2 minutes of laser and 297.5 minutes of procedure times. The 60 W TFL was faster than the 30 W HL, but slower than the higher power HLs. Higher laser power was associated with shorter procedure time (Rs = -0.98; p = 0.002). When estimating cost per procedure, the MOSES HL was the cheapest, but had the highest purchase cost. The TFL was not cost-effective for large bladder stones compared with the 100 W HL. Conclusions: When treating large bladder stones, total laser power was highly correlated with laser and procedure times and the TFL was limited by its total power. The most cost-effective laser for use will depend on the case volume.

Navigating urolithiasis treatment: assessing the practicality and performance of thulium fiber laser, holmium YAG, and thulium YAG in real-world scenarios

BACKGROUND

The management of urolithiasis has undergone significant advancements with the introduction of pulsed lasers, particularly the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, which is currently considered the gold standard in endourology. However, the Ho:YAG laser has certain limitations, such as the inability to support small laser fibers (150 μm) and the requirement of a heavy water cooling system, making it challenging to transfer between operating rooms. These limitations have led to the emergence of new laser technologies, including the thulium fiber laser (TFL) and the thulium:yttrium-aluminum-garnet laser (Tm:YAG), as potential alternatives to the Ho:YAG laser.

METHODS

In this review, we aimed to evaluate the effectiveness and safety of TFL, Ho:YAG, and Tm:YAG lasers in real-life scenarios by comparing clinical trial data with laboratory findings. A literature review was conducted, and relevant in vitro studies and clinical trials until March 2023 were analyzed.

RESULTS

The findings indicate that TFL has demonstrated high ablation efficiency for stones of any composition, size, and location, superior the capabilities of Ho:YAG lasers. TFL has shown superior dusting and fragmentation abilities, lower retropulsion, and increased patient safety. The laser parameters, such as ablation efficiency, speed, operative time, dust quality, retropulsion, visibility, temperature safety, and stone-free rate, were compared between laboratory studies and clinical outcomes.

CONCLUSION

Although the number of studies on TFL is limited, the available evidence suggests that TFL represents a significant advancement in laser technology for lithotripsy. However, further research is needed to fully explore the implications and limitations of TFL and Tm:YAG lasers.

Thulium Fiber Laser vs Pulse-Modulated Holmium MOSES Laser in Flexible Ureteroscopy for the Management of Kidney Stones: A Single-Center Retrospective Analysis

Introduction and Objective: The study's primary objective was to compare the laser efficiency and clinical outcomes of two widely used systems, the holmium MOSES laser and the thulium fiber laser (TFL), in managing kidney stones. The secondary outcomes were to evaluate the impact of stone composition on laser efficacy. Methods: We conducted a retrospective review of patients who underwent flexible ureteroscopy (f-URS) for solitary renal calculi between December 2020 and August 2022 at our institution and had a 3-month postoperative CT scan. Patient demographics and stone parameters were recorded, including stone site, size, volume, and density. Intraoperative data were collected and analyzed, including total operative time, ureteroscopy time, lasing time, technique, total energy delivered, and stone composition. All patients underwent a CT scan at 3 months follow-up. We recorded the presence of residual stones and the percentage of stone volume reduction. Ablation efficiency was calculated by dividing the energy utilized (J) by the stone volume (mm3). The ablation speed was calculated by dividing the stone volume (mm3) by the lasing time (seconds). Patients with a stone size <4 mm were deemed stone-free. Results: The MOSES and TFL groups comprised 62 and 49 patients, respectively. There were no significant differences between groups for baseline patient demographics or stone characteristics. The two modalities had comparable total energy, laser time, efficacy, and ablation speeds. No differences were detected in stone-free rates or complications between both groups. When dealing with calcium phosphate stones, we observed that the lasing time was significantly shorter with MOSES than TFL (7.95 vs 10.85 minutes, respectively [p = 0.01]). Conclusions: MOSES and TFL laser systems had comparable efficacy for lithotripsy of renal calculi during f-URS; however, calcium phosphate stones had a longer lasing time with TFL. REB Number: 100210.

Thulium fibre laser vs holmium: yttrium-aluminium-garnet laser lithotripsy for urolithiasis: meta-analysis of clinical studies

OBJECTIVE

To compare and assess the clinical outcomes between thulium fibre laser (TFL) and holmium: yttrium-aluminium-garnet (Ho:YAG) laser endoscopic lithotripsy of urolithiasis through a meta-analysis of comparative clinical studies.

METHODS

A systematic literature search was performed in May 2022, grey literature search in July 2022. Comparative clinical studies were evaluated according to Cochrane recommendations. Assessed outcomes include the stone-free rate (SFR), complication rate, operative time (OT), laser utilisation time (LUT), ablation rate (stone volume/laser time), ablation efficiency (energy use/stone volume), total energy usage, degree of retropulsion, and hospital stay. Risk ratios (RRs) and standardised mean differences (SMDs) were extrapolated. Subgroup analyses, heterogeneity, publication bias, and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment were performed. International Prospective Register of Systematic Reviews (PROSPERO) registration: CRD42022300788.

RESULTS

A total of 15 studies with 1698 cases were included in this review. The outcome of SFR showed no significant between-group difference (RR 1.09, 95% confidence interval [CI] 0.99-1.20). However, subgroup analysis of TFL vs Ho:YAG with no pulse modulation showed a SFR favouring TFL (RR 1.11, 95% CI 1.01-1.23). The composite postoperative complication rate was comparable between the two intervention groups (RR 0.97, 95% CI 0.66-1.43). OT, LUT and ablation rate were significantly better for TFL than Ho:YAG (SMD -1.19, 95% CI -1.85 to -0.52; SMD -1.67, 95% CI -2.62 to -0.72; SMD 0.59, 95% CI 0.15-1.03; respectively). The degree of retropulsion was significantly lower for TFL than Ho:YAG without pulse modulation (SMD -1.23, 95% CI -1.74 to -0.71). Ablation efficiency, total energy usage, and hospital stay were all comparable. Based on GRADE criteria, the evidence certainty was determined to be very low.

CONCLUSION

Overall, there was no between-group difference for the SFR. However, compared to Ho:YAG with no pulse modulation, TFL rendered a better SFR. Shorter OT and LUT, a lesser degree of retropulsion, and a better ablation rate were noted in favour of the TFL. There was no overall between-group difference for composite postoperative complication rate, ablation efficiency, total energy usage, and hospital stay. Currently, the available clinical evidence was assessed to be of very low certainty.

Miniaturization in percutaneous nephrolithotomy: What is new?

Objective

To summarize recent advancements in mini-percutaneous nephrolithotomy (mini-PCNL) in surgical technique, stone removal strategy, lithotripsy, and surgical model from the current literature.

Methods

We conducted a narrative review of relevant English-language articles up to October 2022 using the PubMed and Web of Science databases. The following keywords were used in the search: "percutaneous nephrolithotomy", "minimally invasive percutaneous nephrolithotomy", "mini-PCNL", "mini-perc", "mPCNL", and "miniaturization".

Results

A series of new progress has been made in many aspects of mini-PCNL, such as further reduction of tract size-needle perc and further improvement of robotic-assisted PCNL-artificial intelligence-powered robotic devices.

Conclusion

Many studies and trials have been conducted to reduce morbidity and increase the safety and effectiveness of mini-PCNL. It is crucial to realize that miniaturization of PCNL requires not only a smaller percutaneous tract size, but also an adjustment strategically in renal access, stone removal, lithotripsy, and surgical model in general. More large-scale prospective research needs to be carried out to further validate and optimize the safety and effectiveness of mini-PCNL.