Comparison of holmium:yttrium-aluminium-garnet (YAG), thulium fiber laser, and pulsed thulium:YAG lasers on soft tissue: an ex vivo study.

OBJECTIVES: To assess laser-tissue interactions through ablation, coagulation, and carbonisation characteristics in a non-perfused porcine kidney model between three pulsed lasers: holmium (Ho): yttrium-aluminium-garnet (YAG), thulium fiber laser (TFL), and pulsed thulium (p-Tm):YAG. MATERIALS AND METHODS: A 150-W Ho:YAG, a 60-W TFL, and a 100-W p-Tm:YAG lasers were compared. The laser settings that can be set identically between the three lasers and be clinically relevant for prostate laser enucleation were identified and used on fresh, unfrozen porcine kidneys. Laser incisions were performed using stripped laser fibers of 365 and 550 µm, set at distances of 0 and 1 mm from the tissue surface at a constant speed of 2 mm/s. Histological analysis evaluated shape, depth, width of the incision, axial coagulation depth, and presence of carbonisation. RESULTS: Incision depths, widths, and coagulation zones were greater with Ho:YAG and p-Tm:YAG lasers than TFL. Although no carbonisation was found with the Ho:YAG and p-Tm:YAG lasers, it was common with TFL, especially at high frequencies. The shapes of the incisions and coagulation zones were more regular and homogeneous with the p-Tm:YAG laser and TFL than with Ho:YAG laser. Regardless of the laser used, short pulse durations resulted in deeper incisions than long pulse durations. Concerning the distance, we found that to be effective, TFL had to be used in contact with the tissue. Finally, 365-µm fibers resulted in deeper incisions, while 550-µm fibers led to wider incisions and larger coagulation zones. CONCLUSION: Histological analysis revealed greater tissue penetration with the p-Tm:YAG laser compared to the TFL, while remaining less than with Ho:YAG. Its coagulation properties seem interesting insofar as it provides homogeneous coagulation without carbonisation, while incisions remained uniform without tissue laceration. Thus, the p-Tm:YAG laser appears to be an effective alternative to Ho:YAG and TFL lasers in prostate surgery.

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.

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.

How much energy do we need to ablate 1 cubic millimeter of stone during Thulium Fiber Laser lithotripsy? An in vitro study.

INTRODUCTION: Both Holmium:yttrium-aluminium-garnet (Ho:YAG) laser and Thulium Fiber Laser (TFL) can effectively treat all urinary stone types. This in vitro study evaluated the ablation volume per pulse (AVP) and required energy needed to ablate 1mm3 (RE, J/mm3) of various stone types at different laser settings with TFL. METHODS: 272-µm core-diameter laser fibers (Boston Scientific©) were connected to a 50 Watts TFL generator (IPG®). An experimental setup immerged human stones of calcium oxalate monohydrate (COM), uric acid (UA), and cystine (CYS) with a single pulse lasing emission (0.5/0.8/1 J), in contact mode. Stones were dried out before three-dimensional scanning to measure AVP and deduce from the pulse energy (PE) and AVP the RE. A direct comparison with known Ho:YAG's AVP and RE was then carried out. RESULTS: AVP for COM stones was significantly greater than those for CYS stones and similar to UA stones (p = 0.02 and p = 0.06, respectively). If AVP increased with PE against COM and UA stones, AVP decreased against CYS stones. 1 J PE resulted in a threefold lower RE compared with other PE for COM stones. On the contrary, RE for CYS increased with PE, whereas PE did not had influence on RE for UA. TFL was associated with greater AVP for COM, but lower for UA and CYS stones compared to Ho:YAG laser. CONCLUSION: This in vitro study firstly describes the ablation volume per pulse and required energy to treat a cubic millimeter of three frequent human stone types, and suggest TFL could not be suited for cystine. Therefore, stone composition could be considered when choosing the laser source for lithotripsy.

Illumination matters part IV: blackout and whiteout in flexible ureteroscopy - first report on a phenomenon observed by PEARLS.

PURPOSE: To date, no study has evaluated effects of varying brightness settings on image quality from flexible ureteroscopes submerged in saline. The aim was to evaluate blackout and whiteout occurrences in an in-vitro kidney calyx model. MATERIAL AND METHODS: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU WiScope using a 3D-printed enclosed pink in-vitro kidney calyx model submerged in saline. Endoscopic images were captured with ureteroscope tip placed at 5 mm,10 mm and 20 mm distances. The complete range of brightness settings and video capture modes were evaluated for each scope. Distribution of brightness on a grayscale histogram of images was analyzed (scale range 0 to 255). Blackout and whiteout were defined as median histogram ranges from 0 to 35 and 220 to 255, respectively (monitor image too dark or too bright for the human eye, respectively). RESULTS: Blackout occurred with the P7, Pusen 7.5F, 9.2F and WiScope at all distances, and V3 at 20 mm - with lowest brightness settings. Whiteout occurred with Flex-X2s, V3 and P7 at 5 mm and 10 mm, as well as with V3 and P7 at 20 mm - mostly with highest brightness settings. The Flex-Xc had neither blackout nor whiteout at all settings and distances. CONCLUSION: Blackout or whiteout of images is an undesirable property that was found for several scopes, possibly impacting diagnostic and therapeutic purposes during ureteroscopy. These observations form a guide to impact a urologist's choice of instruments and settings.

Illumination matters Part II: advanced comparative analysis of flexible ureteroscopes in a kidney model by PEARLS.

PURPOSE: The aim of the study was to evaluate illumination properties in an in-vitro kidney calyx model in saline. DESIGN AND METHODS: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU WiScope using a 3D-printed closed pink kidney calyx model, submerged in saline. A spectrometer was used for illuminance and color temperature measurements at different openings located at center (direct light), 45° (direct and indirect light) and 90°(indirect light) to the axis of the scope. RESULTS: Maximum illuminance was at the center opening for all scopes (range: 284 to 12,058 lx at 50% brightness and 454 to 11,871 lx at 100% brightness settings). The scope with the highest center illuminance (Flex-Xc) was 26 times superior to the scope with the lowest illuminance (Pusen 7.5Fr) at 100% brightness setting. For each scope, there was a peripheral illuminance drop ranging from - 43 to - 92% at 50% brightness and - 43% to - 88% at 100% brightness settings, respectively (all p < 0.01). Highest drop was for the P7 and the Pusen 9.2F. All scopes had illuminance skew, except the V3. All scopes had a warm color temperature. CONCLUSION: Illumination properties vary between ureteroscopes in an enclosed cavity in saline, and differs at center vs 45° and 90° positions within scopes. Peripheral illuminance drop can be as high as - 92%, which is undesirable. This may affect the choice of ureteroscope and light brightness settings used in surgery by urologists.

Illumination matters part I: comparative analysis of light sources and illumination in flexible ureteroscopy-fundamental findings from a PEARLS analysis.

PURPOSE: Illumination characteristics of flexible ureteroscopes have been evaluated in air, but not in saline, the native operative medium for endourology. The aim was to evaluate light properties of contemporary ureteroscopes in air versus saline, light distribution analysis, and color temperature. METHODS: We evaluated the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, and OTU WiScope using a 3D printed black target board in-vitro model submerged in saline. A spectrometer was used for lux and color temperature measurements at different opening locations. RESULTS: Illuminance was higher in saline compared to air (5679 vs. 5205 lx with Flex-Xc, p = 0.02). Illuminance in saline differed between ureteroscopes (ANOVA p < 0.001), with highest for the Flex-Xc at 100% brightness setting (5679 lx), followed by Pusen 9.2F (5280 lx), Flex-X2s (4613 lx), P7 (4371 lx), V3 (2374 lx), WiScope (582 lx) and finally Pusen 7.5F (255 lx). The same ranking was found at 50% brightness setting, with the highest ureteroscope illuminance value 34 times that of the scope with lowest illuminance. Most scopes had maximum illuminance off center, with skewness. Three scopes had two light sources, with one light source for all other scopes. Inter-scope comparisons revealed significant differences of color temperature (ANOVA p < 0.001). CONCLUSION: The study demonstrates the presence of inhomogeneous light spread as well as large differences in illumination properties of ureteroscopes, possibly impacting on the performance of individual scopes in vivo. Additionally, the study suggests that future studies on illumination characteristics of flexible ureteroscopes should ideally be done in saline, and no longer in air.

Ureteroscopic management in cystinuric patients: long-term results from a tertiary care referral center.

OBJECTIVE: To evaluate long-term surgical and functional outcomes of cystinuric patients exclusively treated with Ureteroscopy (URS). METHODS: Data from patients treated for cystine stones at a single academic center were retrospectively analyzed. The management protocol consisted of (i) treating symptomatic or > 7 mm stones, (ii) multi-staged URS for voluminous stones, (iii) referring patients to a dedicated nephrological clinic. The eGFR was calculated according to the MDRD formula. CKD category was assessed according to the NKF classification. Relevant CKD was defined as CKD category ≥ 3a. Descriptive statistics were used to analyze the cohort data. RESULTS: Data from 46 cystinuric patients treated with 332 URS were available. Median age at diagnosis and at first URS in our center were 18 and 32 years, respectively. Median follow-up was 101 months. Median number of URS and recurrences per patient were 6 and 2, respectively. The median interval between the first and the last available creatinine level was 64 months. Median first and last eGFR were 72 and 74 mL/min, respectively. Overall, 83% of patients had stable or improved renal function within the study period. Ureteral stricture occurred in 3 (6.5%) patients. CONCLUSIONS: Cystinuria requires intensive endoscopic management. Most patients treated with URS have stable or improved renal function within a long-term follow-up. CKD is a not neglectable event that potentially occurs at an early stage of life. Current findings should be considered for the surgical management of cystinuric patients.

Illumination matters Part III: Impact of light obstruction on illuminance from flexible ureteroscopes - a comparative PEARLS analysis.

PURPOSE: Artifacts from poor ureteroscopes' light design with shadowing and dark areas in the field of view have been reported. The aim was to quantify effects of light obstruction in a kidney calyx model. METHODS: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU Wiscope using an enclosed 3D-printed pink in vitro kidney calyx model submerged in saline, where the field of light was intentionally partially obstructed alternatively at 12, 3, 6, and 9 o'clock. A color spectrometer was used for illuminance measurements at a 45° opening position in the background of the model. RESULTS: Overall and mean background illuminance for each obstructive situation were significantly different between scopes for both 50% and 100% brightness settings (ANOVA p < 0.001). At 50% brightness setting, almost all scopes had their highest and lowest background illuminance with the 6 o'clock and 3 o'clock obstructive situation, respectively. At 100% brightness setting, these became 6 o'clock and 12 o'clock obstructive situations. Considering each obstructive situation individually, the Flex-Xc was consistently the scope with highest background illuminance and the Pusen 7.5F the lowest. Background illuminance for each obstructive situation varied significantly for each scope individually, with the greatest range of variability for Pusen 7.5F and V3. CONCLUSIONS: Illuminance performance of ureteroscopes within an obstructed calyx model differ significantly for various obstructive situations. Urologists should be aware of this to help guide their choice of ureteroscope.

Is "Kidney Stone Calculator" efficient in predicting ureteroscopic lithotripsy duration? A holmium:YAG and thulium fiber lasers comparative analysis.

PURPOSE: This study aimed to evaluate the ability of Kidney Stone Calculator (KSC), a flexible ureteroscopy surgical planning software, to predict the lithotripsy duration with both holmium:YAG (Ho:YAG) and thulium fiber laser (TFL). METHODS: A multicenter prospective study was conducted from January 2020 to April 2023. Patients with kidney or ureteral stones confirmed at non-contrast computed tomography and treated by flexible ureteroscopy with laser lithotripsy were enrolled. "Kidney Stone Calculator" provided stone volume and subsequent lithotripsy duration estimation using three-dimensional segmentation of the stone on computed tomography and the graphical user interface for laser settings. The primary endpoint was the quantitative and qualitative comparison between estimated and effective lithotripsy durations. Secondary endpoints included subgroup analysis (Ho:YAG-TFL) of differences between estimated and effective lithotripsy durations and intraoperative outcomes. Multivariate analysis assessed the association between pre- and intraoperative variables and these differences according to laser source. RESULTS: 89 patients were included in this study, 43 and 46 in Ho:YAG and TFL groups, respectively. No significant difference was found between estimated and effective lithotripsy durations (27.37 vs 28.36 min, p = 0.43) with a significant correlation (r = + 0.89, p < 0.001). Among groups, this difference did not differ (p = 0.68 and 0.07, respectively), with a higher correlation between estimated and effective lithotripsy durations for TFL compared to Ho:YAG (r = + 0.95, p < 0.001 vs r = + 0.81, p < 0.001, respectively). At multivariate analysis, the difference was correlated with preoperative (volume > 2000 mm3 (Ho:YAG), 500-750 mm3 SV and calyceal diverticulum (TFL)), operative (fragmentation setting (p > 0.001), and basket utilization (p = 0.05) (Ho:YAG)) variables. CONCLUSION: KSC is a reliable tool for predicting the lithotripsy duration estimation during flexible ureteroscopy for both Ho:YAG and TFL. However, some variables not including laser source may lead to underestimating this estimation.

Temperature profile during endourological laser activation: introducing the thermal safety distance concept.

PURPOSE: To examine temporal-spatial distribution of heat generated upon laser activation in a bench model of renal calyx. To establish reference values for a safety distance between the laser fiber and healthy tissue during laser lithotripsy. METHODS: We developed an in-vitro experimental setup employing a glass pipette and laser activation under various intra-operative parameters, such as power and presence of irrigation. A thermal camera was used to monitor both temporal and spatial temperature changes during uninterrupted 60-second laser activation. We computed the thermal dose according to Sapareto and Dewey's formula at different distances from the laser fiber tip, in order to determine a safety distance. RESULTS: A positive correlation was observed between average power and the highest recorded temperature (Spearman's coefficient 0.94, p < 0.001). Irrigation was found to reduce the highest recorded temperature, with a maximum average reduction of 9.4 °C at 40 W (p = 0.002). A positive correlation existed between average power and safety distance values (Spearman's coefficient 0.86, p = 0.001). A thermal dose indicative of tissue damage was observed at 20 W without irrigation (safety distance 0.93±0.11 mm). While at 40 W, irrigation led to slight reduction in mean safety distance (4.47±0.85 vs. 5.22±0.09 mm, p = 0.08). CONCLUSIONS: Laser settings with an average power greater than 10 W deliver a thermal dose indicative of tissue damage, which increases with higher average power values. According to safety distance values from this study, a maximum of 10 W should be used in the ureter, and a maximum of 20 W should be used in kidney in presence of irrigation.

Flexible ureteroscopy for lower pole calculus: is it still a challenge?

PURPOSE: Flexible ureteroscopy (fURS) is steadily gaining popularity in the management of renal calculi, including those located in the lower pole (LP). Due to difficulty in accessing to the LP of kidney in minority of cases with fURS and reports of lower stone-free rate (SFR), it is still considered as a challenge in selected cases. The purpose of the review was to analyze the various aspects of fURS for LP stones. METHODS: An extensive review of the recent literature was done including different factors such as anatomy, preoperative stenting, stone size, flexible scopes, types of lasers, laser fibers, suction, relocation, stone-free rates, and complications. RESULTS: The significance of various lower pole anatomical measurements remain a subject of debate and requires standardization. Recent improvements in fURS such as single-use digital scopes with better vision and flexibility, high power laser, thulium fiber laser, smaller laser fiber, and accessories have significantly contributed to make flexible ureteroscopy  more effective and safer in the management of LP stone. The utilization of thulium fiber lasers in conjunction with various suction devices is being recognized and can significantly improve SFR. CONCLUSIONS: With the significant advancement of various aspects of fURS, this treatment modality has shown remarkable efficacy and gaining widespread acceptance in management of LP kidney stones. These developments have made the fURS of LP stones less challenging.

Initial experience with the graphical user interface for laser parameters setting of a new thulium fibre laser source device for urinary pathologies treatment.

BACKGROUND AND OBJECTIVE: We aimed to evaluate the concordance between the pre-settings ranges of thulium fibre laser (TFL) (Coloplast TFL Drive, Denmark) with easy-to-use graphical user interface and the laser settings used by a high-volume endo-urologist during surgical procedures. MATERIALS AND METHODS: In October 2022, we prospectively collected data of 67 patients who underwent TFL Drive (Coloplast, Denmark) for the management of urinary stones. Urothelial tumour (upper tract urinary cancer (UTUC) and bladder) 200 and 150 µm laser fibres were used for procedures. Stones characteristics (size and density) tumours and stenosis localizations, laser-on time (LOT), and laser settings were recorded. We also assessed the ablation speed (mm3/s), laser power (W), and Joules/mm3 values for each lithotripsy. RESULTS: A total 67 patients took part in the study. Median age was 52 (15-81) years. 55 (82%), 8 (12%), and 4 (6%) patients presented urinary stones, urothelial tumour, and stenosis, respectively. Median stone volume was 438 (36-6027) mm3 and median density was 988 (376-2000) HU. Median pulse energy was 0.6 (0.3-1.2), 0.8 (0.5-1) and 1 J for urinary stones, urothelial tumour and stenosis respectably. Endoscopically stone-free rate was 89%. Graphical user interface and surgeon accordance with the safety range were observed in 93.2%, 100% and 100% for urinary stones, UTUC and stenosis, respectively. CONCLUSION: During endoscopic procedures for urinary stones treatment, it is frequently needed to change laser parameters. These new TFL and GUI technology parameters remained in the pre-set security range in 94.1% of procedures.

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.

Initial clinical experience with the pulsed solid-state thulium YAG laser from Dornier during RIRS: first 25 cases.

INTRODUCTION: Holmium:yttrium-aluminium-garnet (Ho:YAG) and thulium fiber (TFL) lasers are currently the two laser sources recommended for endocorporeal laser lithotripsy (ELL). Recently, the pulsed-thulium:YAG (Tm:YAG) laser was also proposed for ELL, as an answer to both Ho:YAG and TFL limitations. We aimed to evaluate the efficiency, safety, and laser settings of Tm:YAG laser in ELL during retrograde intrarenal surgery (RIRS). METHODS: A prospective study of the first 25 patients with ureteral and renal stones who underwent RIRS using the Thulio (pulsed-Tm:YAG, Dornier©, Germany) was performed in a single center. 272 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. Postoperative results, such as stone-free rate (SFR) and zero fragments rate (ZFR) were also recorded. RESULTS: A total of 25 patients were analyzed (Table 1). The median (IQR) age was 55 (44-72) years old. Median (IQR) stone volume was 2849 (916-9153)mm3. Median (IQR) stone density was 1000 (600-1174)HU. Median (IQR) pulse energy, pulse rate and total power were 0.6 (0.6-0,8)J, 15(15-20)Hz and 12(9-16)W, respectively. All procedures used "Captive Fragmenting" pulse modulation (Table 2). The median (IQR) J/mm3 was 14,8 (6-21). The median (IQR) ablation rate was 0,75 (0,46-2)mm3/s. One postoperative complications occurred (streinstrasse). SFR and ZFR were 95% and 55%, respectively. CONCLUSION: The pulsed-Tm:YAG laser is a safe and effective laser source for lithotripsy during RIRS, using low pulse energy and low pulse frequency.

Thulium:YAG laser: a good compromise between holmium:YAG and thulium fiber laser for endoscopic lithotripsy? A narrative review.

PURPOSE: To provide a technological description of the new pulsed solid-state Thulium:YAG laser (Tm:YAG). In addition, current available literature on Tm:YAG lithotripsy is also reviewed. MATERIALS AND METHODS: Medline, Scopus, Embase, and Web of Science databases were used to search for Tm:YAG operating mode articles. RESULTS: Tm:YAG technology works with a laser cavity with thulium-doped YAG crystal, pumped by laser diodes. Laser beam operates at 2013 nm, with an adjustable peak power (≥ 1000 W) and the minimal fiber laser diameter is of 200 µm. It has an intermediate water absorption coefficient and peak power-pulse duration. Various pulse modulations are proposed, aiming to minimize stone retropulsion. Multiple comparative in vitro studies suggest that Tm:YAG's ability to fragment stones is similar to the one of the Ho:YAG laser; on the contrary, its ability to dust all stone types is similar to the one of the TFL, with a low retropulsion. A single in vivo study assessed Tm:YAG lithotripsy feasibility. CONCLUSIONS: The new pulsed solid-state thulium:YAG laser could represent a safe and effective compromise between Ho:YAG laser and TFL for endoscopic lithotripsy, either in retrograde intra-renal surgeries or in percutaneous nephrolithotomy.

Pulsed thulium:YAG laser-ready to dust all urinary stone composition types? Results from a PEARLS analysis.

PURPOSE: To evaluate whether stone dust can be obtained from all prevailing stone composition types using the novel pulsed thulium:YAG (p-Tm:YAG), including analysis of stone particle size after lithotripsy. METHODS: Human urinary stones of 7 different compositions were subjected to in vitro lithotripsy using a p-Tm:YAG laser with 270 µm silica core fibers (Thulio®, Dornier MedTech GmbH®, Wessling, Germany). A cumulative energy of 1000 J was applied to each stone using one of three laser settings: 0.1 J × 100 Hz, 0.4 J × 25 Hz and 2.0 J × 5 Hz (average power 10 W). After lithotripsy, larger remnant fragments were separated from stone dust using a previously described method depending on the floating ability of dust particles. Fragments and dust samples were then passed through laboratory sieves to evaluate stone particle count according to a semiquantitative analysis relying on a previous definition of stone dust (i.e., stone particles ≤ 250 µm). RESULTS: The p-Tm:YAG laser was able to produce stone dust from lithotripsy up to measured smallest mesh size of 63 µm in all seven stone composition types. Notably, all dust samples from all seven stone types and with all three laser settings had high counts of particles in the size range agreeing with the definition stone dust, i.e., ≤ 250 µm. CONCLUSION: This is the first study in the literature proving the p-Tm:YAG laser capable of dusting all prevailing human urinary stone compositions, with production of dust particles ≤ 250 µm. These findings are pivotal for the broader future implementation of the p-Tm:YAG in clinical routine.

Pulsed Thulium:YAG laser - What is the lithotripsy ablation efficiency for stone dust from human urinary stones? Results from an in vitro PEARLS study.

BACKGROUND: The novel pulsed thulium:yttrium-aluminum-garnet (p-Tm:YAG) laser was recently introduced. Current studies present promising p-Tm:YAG ablation efficiency, although all are based on non-human stone models or with unknown stone composition. The present study aimed to evaluate p-Tm:YAG ablation efficiency for stone dust from human urinary stones of known compositions. METHODS: Calcium oxalate monohydrate (COM) and uric acid (UA) stones were subjected to lithotripsy in vitro using a p-Tm:YAG laser generator (Thulio®, Dornier MedTech GmbH, Germany). 200 J was applied at 0.1 J × 100 Hz, 0.4 J × 25 Hz or 2.0 J × 5 Hz (average 10W). Ablated stone dust mass was calculated from weight difference between pre-lithotripsy stone and post-lithotripsy fragments > 250 µm. Estimated ablated volume was calculated using prior known stone densities (COM: 2.04 mg/mm3, UA: 1.55 mg/mm3). RESULTS: Mean ablation mass efficiency was 0.04, 0.06, 0.07 mg/J (COM) and 0.04, 0.05, 0.06 mg/J (UA) for each laser setting, respectively. This translated to 0.021, 0.029, 0.034 mm3/J (COM) and 0.026, 0.030, 0.039 mm3/J (UA). Mean energy consumption was 26, 18, 17 J/mg (COM) and 32, 23, 17 J/mg (UA). This translated to 53, 37, 34 J/mm3 (COM) and 50, 36, 26 J/mm3 (UA). There were no statistically significant differences for laser settings or stone types (all p > 0.05). CONCLUSION: To our knowledge, this is the first study showing ablation efficiency of the p-Tm:YAG laser for stone dust from human urinary stones of known compositions. The p-Tm:YAG seems to ablate COM and UA equally well, with no statistically significant differences between differing laser settings.

Retrograde intra renal surgery and safety: pressure and temperature. A systematic review.

PURPOSE OF REVIEW: Retrograde intra renal surgery (RIRS) with laser lithotripsy represents the gold-standard to treat renal stones up to 20 mm. Controlling intraoperative parameters such as intrarenal pressure (IRP) and temperature (IRT) is mandatory to avoid complications. This article reviews advances in IRP and IRT over the last 2 years. RECENT FINDINGS: We conducted a PubMed/Embase search and reviewed publications that include temperature and pressure during RIRS. Thirty-four articles have been published which met the inclusion criteria. Regarding IRP, a consensus has emerged to control IRP during RIRS, in order to avoid (barotraumatic and septic) complications. Several monitoring devices are under evaluation but none of them are clinically approved for RIRS. Ureteral access sheath, low irrigation pressure and occupied working channel help to maintain a low IRP. Robotic systems and suction devices would improve IRP intraoperative management and monitoring. IRT determinants are the irrigation flow and laser settings. Low power settings(<20 W) with minimal irrigation flow (5-10 ml/min) are sufficient to maintain low IRT and allows continuous laser activation. SUMMARY: Recent evidence suggests that IRP and IRT are closely related. IRP depends on inflow and outflow rates. Continuous monitoring would help to avoid surgical and infectious complications. IRT depends on the laser settings and the irrigation flow.

Comparison of the ablation rates, fissures and fragments produced with 150 µm and 272 µm laser fibers with superpulsed thulium fiber laser: an in vitro study.

INTRODUCTION: Holmium:YAG(Ho:YAG) is currently the standard for lithotripsy. Superpulsed Thulium Fiber Laser(TFL) has been evaluated as an alternative for lithotripsy, using laser fibers with core-diameters(CDF) down to 50 µm and additional available settings suitable for "dusting" technique. This in-vitro study compared ablation rates, fissures and fragments' size with 150µmCDF or 272µmCDF with different laser settings using TFL and Ho:YAG. METHODS: 150CDF and 272CDF were compared using three settings for TFL "fine dusting"(FD:0.15 J/100 Hz); "dusting"(D:0.5 J/30 Hz); "fragmentation"(Fr:1 J/15 Hz) and Ho:YAG(D and Fr). An experimental setup consisting of immerged 10 mm cubes of artificial hard(H) or soft(S) stone phantoms was used with a 20 s' lasing time and a spiral trajectory, in contact mode. Fragments (acquired through sieves) and stones were observed under optical microscopy before three-dimensional scanning to measure fragments and fissures(DOF) mean diameters and ablation volumes. RESULTS: Ablation volumes in with 150CDF-TFL and 272CDF-TFL were higher than those for 272CDF-Ho:YAG in both "dusting" (twofold and threefold) and "fragmentation"(1,5-fold and twofold). "Fine dusting" ablation rates with 150CDF-TFL and 272CDF-TFL were respectively at least 1,5-fold and twofold higher than those for 272CDF-Ho:YAG in "dusting". 150CDF produced significantly smaller DOF than 272CDF in all settings against S and H except in fragmentation. 150CDF produced lower fragments' diameter than 272CDF in all settings except dusting. CONCLUSION: These preliminary studies demonstrate that at equal settings and CDF, TFL ablation rates are at least two-fold higher than those with Ho:YAG. 150CDF produces smaller fissures and fragments (that meets the definition of "dusting" lithotripsy) than 272CDF and higher ablation volumes than Ho:YAG.