FIRE Stones: impact of forced diuresis on the residual fragment rate after flexible ureteroscopy for destruction of kidney stones with laser-protocol for a randomized controlled two-parallel group multicenter trial with blinding evaluation.

BACKGROUND: Lithiasis is a common and recurrent disease. Flexible ureteroscopy (fURS) is the cornerstone of laser treatment of kidney stones. Kidney stones destruction requires its laser pulverization into small fragments in order to remove them through the ureter or improve their spontaneous expulsion along the urinary tract. However, most of the time, all the micro-fragments and dust created cannot be extracted using our surgical tools and may stay intra-renally at the end of the procedure. Adjuvant treatments (such as forced diuresis, inversion or mechanical pressure) were previously described to improve the expulsion of stone fragments after extra-corporeal shock wave lithotripsy. Nevertheless, the impact of adjuvant treatment after fURS remains unclear and mainly theoretical. OBJECTIVE: The primary objective is to show that the injection of 40 mg of furosemide in slow intravenous during 10 min, after the procedure, increases the stone-free rate 3 months after a fURS for destruction of kidney stones with laser. METHODS/DESIGN: The study will be a two-parallel group randomized, controlled, multicentric trial with a blinding evaluation. Nine French departments of urology will participate. Patients will be randomized in 2 groups: the experimental group (injection of 40 mg of furosemide at the end of the surgery) and a control one (usual care). Patients will be followed up for 3 months (± 2 weeks) after the surgery. Then, we will perform a low dose abdomino-pelvic CT scan. The primary outcome is the stone-free rate at 3 months. A centralized review of the images will be performed by two specialized radiologists, in a blind and crossed way to allow a homogenization of the results. The secondary outcomes will include the rate of early post-operative urinary tract infection (UTI), the evaluation of post-operative pain, and the safety of the use of furosemide in patients treated by fURS for renal stone laser destruction. As secondary objectives, it is also planned to look at the effect of the prescription of an alpha-blocker as usual treatment on stone-free rate and to assess the agreement between the imaging analysis of the urologist and the specialized radiologist. DISCUSSION: Lithiasis is a public health problem. It affects about 10% of the general population. This prevalence is increasing (multiplied by 3 in 40 years), partly due to changes in the population's eating habits over the years. The lithiasis patient is a patient with a chronic disease requiring annual follow-up and who may suffer from multiple recurrences, with a recurrence rate at 5 years of 50%. Recurrences are partly due to residual fragments left in the kidneys at the end of the operation. Other risk factors for recurrence include dietary hygiene and the presence of an associated metabolic disease. The metabolic blood and urine tests recommended by the Association Française d'Urologie (AFU) can be used to manage these last two problems. As far as residual fragments are concerned, their presence leads to an early recurrence of stones because they form the bed for a new aggregation of crystals in the kidneys. Being able to reduce the rate of residual fragments in patients with the use of furosemide at the end of the intervention therefore seems essential in the management of recurrences in our patients. This will also improve our patients' quality of life. Indeed, lithiasis disease leads to chronic pain associated with acute pain that motivates consultations to the emergency for specialized management. This study is the first to evaluate the impact of forced diuresis with the use of furosemide on the stone-free rate after a fURS for destruction of kidney stone with laser. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05916963 , first received: 22 June 2023. EU Clinical Trials Register EudraCT Number: 2022-502890-40-00.

Comparison of conventional (basketing + dusting) and Moses (pop-dusting) holmium lasers during flexible ureteroscopy in the treatment of renal stones between 2 and 3 cm: a randomized clinical trial.

To investigate the feasibility of conventional (basketing + dusting) and Moses (pop-dusting) holmium lasers during flexible ureteroscopy (FURS) in the treatment of 2-3 cm renal calculi and to compare the efficiency and safety of the two methods, a total of 230 patients with 2-3 cm kidney stones who underwent FURS were randomly divided into the conventional group and the Moses group. The mode of lithotripsy in the conventional group was fragmentation and dusting. The mode of lithotripsy in the Moses group was dusting and pop-dusting. Clinical and perioperative variables and complications were compared between the two cohorts. Multivariate analyses of factors contributing to the stone-free rate (SFR) and operation time were performed. No statistically significant differences were found in the demographics, renal stone-related data, SFR, or complications between the cohorts. The laser energy was higher in the Moses cohort than in the conventional cohort (119.3 ± 15.2 vs. 92.8 ± 15.1 kJ; P < 0.001), and the operation time was shorter in the Moses cohort than in the conventional cohort (99.5 ± 18.9 vs. 105.3 ± 13.7 min; P = 0.009). When there was isolated stone, the operation time was shorter in the Moses cohort than in the conventional cohort (99.6 ± 17.5 vs. 111.4 ± 10.7 min; P < 0.001), while there was no significant difference between the two cohorts when there were multiple stones (99.5 ± 20 vs. 101.2 ± 14 min; P = 0.415). Multivariate analyses found that an increase in stone volume can decrease the SFR and prolong the operation time, and use of a Moses laser can shorten the operation time. Both holmium laser modes during FURS can effectively treat 2-3 cm renal calculi. The Moses mode is recommended as the first choice for the treatment of isolated 2-3 cm renal stones. When treating multiple stones, the efficiency of these two laser modalities is the same. TRIAL REGISTRATION: ChiCTR2200056091.

PERCUTANEOUS CHOLANGIOSCOPY AND LASER BILIARY LITHOTRIPSY FOR BILIARY INTRAHEPATIC STONES MANAGEMENT: CASE REPORT.

Intrahepatic biliary stone disease is a difficult condition to treat, due to anatomical complexity of biliary tract, association with colestasis, and high recurrence rates, with potential short- and long-term complications, such as cholangitis and secondary biliary cirrhosis. Removal of biliary stones via intraductal access can be achieved endoscopically or percutaneously, with preference for cholangioscopy-guided laser lithotripsy in complex cases. The surgical approach, despite its prolonged results, is a more invasive and risky procedure. The authors present a case of cholangioscopy with percutaneous laser biliary lithotripsy as an option for the treatment of intrahepatic biliary stone disease associated with biliary stricture following biliodigestive anastomosis due to bile duct injury following cholecystectomy, a safe and effective alternative with low morbidity and satisfactory outcomes in follow-up.

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.

Application Analysis of Low-Pressure Perfusion Combined with Occluder in Holmium Laser Lithotripsy for Patients with Middle and Upper Ureteral Calculi.

BACKGROUND: Ureteroscopic holmium laser lithotripsy has become one of the main methods of treating ureteral calculi. However, in the treatment of middle and upper ureteral calculi, ureteroscopy is difficult to operate owing to the high location of calculi. Thus, how to improve the treatment effect and reduce the stone migration has become the focus in clinical settings. On this basis, we evaluated the application effect of low-pressure perfusion combined with occluder in holmium laser lithotripsy for patients with middle and upper ureteral calculi. METHODS: This retrospective study selected 107 patients with middle and upper ureteral calculi who underwent low-pressure perfusion combined with ureteroscopic holmium laser lithotripsy from January 2021 to December 2022. We excluded 7 patients who did not meet the criteria, and ultimately included 100 patients. According to whether the occluder was used during the surgery, 100 patients were divided into groups A (n = 52, occluder) and B (n = 48, without occluder). The stone-migration rate during surgery, stone-clearance rate at 3 months after surgery, perioperative indicators, postoperative complication rate, and postoperative quality of life between the two groups were compared. RESULTS: The stone-migration rate in group A was significantly lower than that in group B, with statistically significant difference (p < 0.05). Both groups had no significant difference in stone-clearance rate at 3 months after surgery (p > 0.05). Group A had a significantly lower index of EuroQol (EQ) Five Dimensions Questionnaire and significantly higher score of EQ-Visual Analogue Scale than group B (all p < 0.001). CONCLUSIONS: Compared with the simple application of low-pressure perfusion, the combined application of low-pressure perfusion and occluder in ureteroscopic holmium laser lithotripsy can effectively reduce the stone migration and improve the postoperative quality of life.

The Effect of High- and Low-power Holmium Laser Settings for Transurethral Lithotripsy in the Management of Adults with Ureteral Stone.

Since there is insufficient evidence to determine the best treatment of transurethral laser lithotripsy (TLL) in ureteral stones, this study compared the effectiveness and safety of TLL using high-power (HP) (100 W) and low-power (LP) (20 W) laser settings. All patients with maximally sized ureteral stones who were planned for transurethral holmium laser lithotripsy were enrolled in this open study. One of the two laser setting groups-LP or HP-was allocated to each alternate patient. Using IBM SPSS Statistics 24, the treatment groups were compared for operating time, intraoperative and postoperative problems (up to 1 year), and rates of stone-free recovery. Welch tests were employed to compare continuous data, whereas Fisher's exact or Chi-square tests were used to assess categorical variables. At P < 0.05, statistical significance was established. A total of 207 individuals were included and preoperative data were comparable between the two groups. The HP group had a considerably greater ablation rate and a significantly shorter procedure duration (42.61 ± 11.74 min) than the LP group (78.56 ± 25.91 min) ( P = 0.025). The Overactive Bladder Symptom Score and International Prostate Symptom Score were considerably higher in the HP group than in the LP group. Treatment effectiveness was considerably impacted by the location of the ureteral stone, according to univariate and multivariate logistic regression models. A HP laser setting of up to 100 W greatly shortens the duration of the process for treating ureteral stones without raising the risk of problems.

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.

Extracorporeal shock wave lithotripsy versus laser lithotripsy in the treatment of post-SWL steinstrasse: a randomized comparative study.

OBJECTIVE: To compare the efficacy of Holmium laser lithotripsy with that of extracorporeal shock lithotripsy (SWL) for post-SWL ureteral steinstrasse. MATERIALS AND METHODS: From January 2022 to July 2023, 36 patients with post-SWL ureteral steinstrasse were randomly divided into laser lithotripsy and SWL groups. Patients with pain, moderate to marked hydronephrosis, large leading stone fragments, and showing no spontaneous resolution within 3-4 weeks after medical expulsive therapy were included. Patients with sepsis were excluded. The success rate was the primary outcome. We compared the perioperative data between the groups. RESULTS: The success rate was higher in the ureteroscopy group than in the SWL group (p = 0.034). SWL was a significantly longer operation, and the fluoroscopy time was significantly longer in the SWL group than in the URS group (p = 0.027). Auxiliary procedures were more frequently performed in the SWL group than in the URS group (p = 0.02). JJ stents were inserted in 100% of patients in the URS group. Three patients (16.7%) underwent conversion to laser ureteroscopy after the second SWL session failed. No significant difference in the incidence of postoperative complications was observed between the groups, but the incidence of postoperative LUT was high in the ureteroscopy group. The mean hospital stay was 30 h in the ureteroscopy group. SWL was performed without the need for hospital admission. CONCLUSION: Ureteroscopic laser lithotripsy for steinstrasse was safe and effective, with a higher success rate, shorter fluoroscopy time, and shorter recovery period than SWL.

Utility of the modified 5-item frailty index as a predictor of postoperative febrile urinary tract infection in patients who underwent ureteroscopy with laser lithotripsy.

PURPOSE: This study aimed to assess the effect of the modified 5-item frailty index on perioperative complications and surgical outcomes in patients who underwent ureteroscopy with laser lithotripsy for upper urinary tract stones. METHODS: Patients who underwent ureteroscopy with laser lithotripsy for upper urinary tract stones between 2019 and 2022 were reviewed retrospectively. Assessment was performed using the modified 5-item frailty index based on medical history (hypertension, diabetes, heart failure, chronic obstructive pulmonary disease) and functional status. Patients were categorized into the high (≥ 2) and low (≤ 1) modified 5-item frailty index groups based on the frailty score. We compared the perioperative complications and surgical outcomes between the two groups. RESULTS: Seventy-one (15.8%) and 393 (84.1%) of the 467 patients were classified into the high and low modified 5-item frailty index groups, respectively. The high modified 5-item frailty index group exhibited a significant association with increased febrile urinary tract infections compared to the low modified 5-item frailty index group [≥ 37.8 °C: 15 (20.3%) vs 13 (3.3%), p < 0.001; ≥ 38 °C: 9 (12.2%) vs 7 (1.8%), p < 0.001]. Surgical outcomes, including operative time and stone-free rate, did not differ significantly between the two groups. CONCLUSION: The modified 5-item frailty index is valuable for predicting postoperative complications, particularly febrile urinary tract infections, after ureteroscopy with laser lithotripsy for upper urinary tract stones. This index allows for practical preoperative risk assessment in patients who underwent ureteroscopy with laser lithotripsy.

What is the definition of stone dust and how does it compare with clinically insignificant residual fragments? A comprehensive review.

PURPOSE: During endoscopic stone surgery, Holmium:YAG (Ho:YAG) and Thulium Fiber Laser (TFL) technologies allow to pulverize urinary stones into fine particles, ie DUST. Yet, currently there is no consensus on the exact definition of DUST. This review aimed to define stone DUST and Clinically Insignificant Residual Fragments (CIRF). METHODS: Embase, MEDLINE (PubMed) and Cochrane databases were searched for both in vitro and in vivo articles relating to DUST and CIRF definitions, in November 2023, using keyword combinations: "dust", "stones", "urinary calculi", "urolithiasis", "residual fragments", "dusting", "fragments", "lasers" and "clinical insignificant residual fragments". RESULTS: DUST relates to the fine pulverization of urinary stones, defined in vitro as particles spontaneously floating with a sedimentation duration ≥ 2 sec and suited for aspiration through a 3.6Fr-working channel (WC) of a flexible ureteroscope (FURS). Generally, an upper size limit of 250 µm seems to agree with the definition of DUST. Ho:YAG with and without "Moses Technology", TFL and the recent pulsed-Thulium:YAG (pTm:YAG) can produce DUST, but no perioperative technology can currently measure DUST size. The TFL and pTm:YAG achieve better dusting compared to Ho:YAG. CIRF relates to residual fragments (RF) that are not associated with imminent stone-related events: loin pain, acute renal colic, medical or interventional retreatment. CIRF size definition has decreased from older studies based on Shock Wave Lithotripsy (SWL) (≤ 4 mm) to more recent studies based on FURS (≤ 2 mm) and Percutaneous Nephrolithotomy(PCNL) (≤ 4 mm). RF ≤ 2 mm are associated with lower stone recurrence, regrowth and clinical events rates. While CIRF should be evaluated postoperatively using Non-Contrast Computed Tomography(NCCT), there is no consensus on the best diagnostic modality to assess the presence and quantity of DUST. CONCLUSION: DUST and CIRF refer to independent entities. DUST is defined in vitro by a stone particle size criteria of 250 µm, translating clinically as particles able to be fully aspirated through a 3.6Fr-WC without blockage. CIRF relates to ≤ 2 RF on postoperative NCCT.

Optimal parameter settings of thulium fiber laser for ureteral stone lithotripsy: a comparative study in two different testing environments.

This study aims to identify optimal parameters for using Thulium fiber lasers (TFL) in ureteral stone lithotripsy to ensure laser safety and maximize efficacy. Our goal is to improve the outcomes of single-use semi-rigid ureteroscopy for treating stones located in the proximal ureter. A clinically relevant thermal testing device was designed to investigate heating effects during TFL stone fragmentation. The device was utilized to identify safe power thresholds for TFL at various irrigation rates. Three other devices were used to assess varying pulse energy effects on stone fragmentation efficiency, dusting, retropulsion, and depth of tissue vaporization. Comparative experiments in fresh porcine renal units were performed to validate the efficacy and safety of optimal TFL parameters for semi-rigid ureteroscopy in proximal ureteral stone procedures. Our study found that the improved device generated a higher thermal effect. Furthermore, the safe power threshold for laser lithotripsy increased as the irrigation rate was raised. At an irrigation rate of 40 ml/min, it is safe to use an average power of less than 30 watts. Although increasing pulse energy has a progressively lower effect on fragmentation and dust removal efficiency, it did lead to a linear increase in stone displacement and tissue vaporization depth. Thermal testing showed 20 W (53.87 ± 2.67 °C) indicating potential urothelial damage. In our study of laser lithotripsy for proximal ureteral stones, the group treated with 0.3 J pulses had several advantages compared to the 0.8 J group: Fewer large fragments (> 4 mm): 0 vs. 1.67 fragments (1-2.25), p = 0.002, a lower number of collateral tissue injuries: 0.50 (0-1.25) vs. 2.67 (2-4), p = 0.011, and lower stone retropulsion grading: 0.83 (0.75-1) vs. 1.67 (1-2), p = 0.046. There was no significant difference in operating time between the groups (443.33 ± 78.30 s vs. 463.17 ± 75.15 s, p = 0.664). These findings suggest that TFL irradiation generates a greater thermal effect compared to non-irradiated stones. Furthermore, the thermal effect during laser lithotripsy is influenced by both power and irrigation flow rate. Our study suggests that using a power below 15 W with an irrigation flow rate of 20 ml/min is safe. Moreover, a pulse energy of 0.3 J appears to be optimal for achieving the best overall stone fragmentation effect.

Effects of Thermal Insulation on Recovery and Comfort of Patients Undergoing Holmium Laser Lithotripsy.

BACKGROUND Patients with urolithiasis often undergo transurethral ureteroscopic holmium laser lithotripsy, a procedure that can be affected by perioperative thermal management. This study examines the impact of compound thermal insulation management on patient recovery and comfort during transurethral ureteroscopic holmium laser lithotripsy. MATERIAL AND METHODS In this study, 551 patients who underwent transurethral ureteroscopic holmium laser lithotripsy from April 2019 to December 2022 were randomly assigned to either an observation group (n=276) or control group (n=275). Both groups received routine surgical care, with the observation group additionally receiving compound thermal insulation management. We recorded and compared perioperative body temperature changes, anesthetic resuscitation indicators (bispectral index recovery time, extubation time, fully awake time, Postanesthesia Care Unit retention time), comfort level (General Comfort Questionnaire), and quality of life (Nottingham Health Profile). We also compared the incidence of complications. RESULTS There was no significant difference in body temperature between groups at the start surgery. However, the observation group showed significantly higher temperatures during and at the end of surgery. Anesthetic resuscitation indicators were significantly better in the observation group. Both groups showed improved comfort and quality of life after surgery, with more significant improvements in the observation group. The observation group also had a lower incidence of complications, such as hypothermia and rigor. CONCLUSIONS Compound thermal insulation management during transurethral ureteroscopic holmium laser lithotripsy improved perioperative temperature maintenance, accelerated postoperative recovery, reduced complication rates, and enhanced patient comfort and quality of life.

Japanese survey of perioperative complications and ureteral stricture after ureteroscopy with laser lithotripsy for upper urinary tract stones in multicenter collaborative study.

OBJECTIVES: This study aimed to investigate perioperative complications and the details of postoperative ureteral stricture after ureteroscopy with laser lithotripsy (URS-L) for upper urinary tract stones in Japan. METHODS: Patient data on intra- and postoperative complications after ureteroscopy using URS-L were retrospectively collected from multiple centers in Japan between April 2017 and March 2020 with the cooperation of the Japanese Society of Endourology and Robotics. Data included the number of patients undergoing URS-L, number and type of intra- and postoperative complications, and detailed characteristics of postoperative ureteral stricture. RESULTS: In total, 14 125 patients underwent URS-L over 3 years at 82 institutions. Annual URS-L numbers gradually increased from 4419 in 2017, to 4760 in 2018, and 4946 in 2019. The total complication rate was 10.5%, which was divided into intra-operative complications in 1.40% and postoperative complications in 9.18%. The annual incidences of intra- and postoperative complications were not significantly different from year to year (p = 0.314 and p = 0.112). Ureteral perforation, ureteral avulsion, and the intra-operative conversion rate were 1.35%, 0.03%, and 0.02%, respectively. Fever >38°C, septic shock, blood transfusion, and postoperative mortality were 7.44%, 0.81%, 0.07%, and 0.04%, respectively. Ureteral stricture occurred in 0.8% of cases. The median length of stricture site was 10.0 mm and the success rate of stricture treatment was 54.6%. CONCLUSION: Although URS-L utilization has increased in Japan, the annual complication rate has remained steady. Although URS-L is a useful and less invasive procedure, devastating complications can still occur.

[Thulium or holmium laser or both: where will the journey take us?] / Thulium oder Holmium-Laser oder beides: wo geht die Reise hin?

The Holmium:YAG laser has been the gold standard for laser lithotripsy over the past three decades and, since the late 1990s, also for prostate enucleation. Pulsed thulium fibre lasers (TFL) demonstrated their efficacy in in-vitro experiments and were introduced to the market a few years ago. Initial clinical results for TFL in lithotripsy and enucleation are very promising. In addition to TFL, a pulsed Thulium:YAG solid-state laser has been introduced, but clinical data for this laser are currently limited. This article aims to review the key technological differences between Ho:YAG lasers and pulsed thulium lasers and compare/discuss the initial clinical results for stone lithotripsy and laser enucleation.In-vitro studies have demonstrated the technical superiority of TFL compared with Ho:YAG lasers. However, as TFL is still a new technology, only limited studies are available to date, and optimal settings for lithotripsy have not been established. For enucleation, the differences of TFL compared with a high-power Ho:YAG laser seem to be clinically irrelevant. Initial studies on pulsed Tm:YAG lasers show good results, but there continues to be a lack of comparative studies.Based on the current literature, pulsed thulium lasers have the potential of being an alternative to Ho:YAG lasers. However, further studies are necessary to determine the optimal laser technology for enucleation and lithotripsy of urinary stones, considering all parameters, including efficacy, safety, and cost.