Interprostatic bridge as complication of transurethral resection of prostate: case reports.

Interprostatic bridge formation may occur as a complication of transurethral resection. Two patients with this complication presented with symptoms of prostatism that were relieved by laser resection of the aberrant tissue.

Lasers in urology.

Ever since Mulvany first described use of Ruby laser for lithotripsy, urologists have been exploiting every possible application of this technology. Laser lithotripsy in the 1980s and now laser prostatectomy in the 1990s have dominated laser usage in urology. Applications of lasers for superficial lesions (e.g., condylomata acuminata and carcinoma of penis) have found an established role. Interests in laser welding, photodynamic therapy and fluorescence continues to grow and evolve. The laser industry at the same time is striving to provide more efficient lasers. High power lasers (Holmium:YAG, KTP:YAG) and laser machines combining double wavelengths (Nd:YAG and KTP, Ho: YAG and Nd:YAG) are commercially available. Diode lasers with their portability and reliability qualities can now provide high output powers in various wavelengths. Here, we have reviewed different lasers, laser tissue interaction and clinical laser applications relevent to urology.

Comparative study of different laser systems.

OBJECTIVE: To review lasers, laser physics, laser-tissue interaction, delivery systems, and their clinical applications relevant to gynecology. SETTINGS: Gynecological Service at Massachusetts General Hospital (MGH) and MGH Laser Center. INTERVENTIONS: None. DESIGN: Laser literature review and personal experiences of the authors were used to prepare this manuscript. CONCLUSIONS: Lasers have been used in gynecologic practice for cutting and coagulating purposes. Photodynamic therapy has been used clinically for malignant conditions and is being investigated for dysplastic lesions of the lower genital tract and for endometrial ablation. Laser welding has potential, but further work is required in this field before it finds a clinical application. The main lasers used in gynecology are CO2, neodymium-yttrium aluminum garnet (Nd:YAG), and potassium tatanyl-phosphate-doubled Nd:YAG. Pulsed Ho:YAG laser looks promising, as does diode lasers. Holmium-yttrium aluminum garnet and diode lasers will be soon available commercially. Improvements in delivery systems have increased user friendliness, and more developments in this area are anticipated, for example, a fiber-optic delivery system for CO2 lasers. We believe that enhanced understanding of laser technology will provide unique applications for development in gynecology.

The laser-assisted scalpel: initial clinical evaluation of its use in gynecologic endoscopy.

The laser-assisted scalpel is a new disposable laparoscopic instrument that improves the precision and control of fiberoptic laser energy delivery and provides a means of tactile probing and blunt tissue dissection. The instrument simplifies laparoscopic technique by providing the surgeon with the ability to place tissue under tension when firing the laser, thus minimizing the need to exchange instruments. We describe the use and our impressions of the laser-assisted scalpel for six common human laparoscopic gynecologic procedures performed in 68 patients.

Clinical experience with high power (140 mj.), large fiber (320 micron) pulsed dye laser lithotripsy.

The pulsed dye laser, at 504 nm. wavelength with a pulse duration of 1 microsecond, was used at 140 mj. per pulse via a 320 mu. (core) fiber for fragmentation of 72 ureteral calculi. The fragmentation efficiency and clinical results using the 140 mj./320 mu. fiber were compared to previous experience using the 60 mj./200 mu. (core) fiber. Fragmentation efficiency was significantly improved requiring many fewer laser pulses to fragment calculi of similar size and composition, and decreasing the need for auxiliary methods to complete stone fragmentation. The higher energy and larger fiber allowed for more efficient ureteroscopic ureteral stone fragmentation without compromising tissue safety.

Conversion of the electrohydraulic electrode to an electromechanical stone impactor: basic studies and a case report.

A 3.3F electrohydraulic electrode (Wolf 2137.23) has been confined within a spring with a metal end cap, irrigated with water and covered with a 0.003-inch metal sheath (outside diameter 5F). The electrohydraulic lithotripsy discharge (Wolf Generator 2137.50) at E1 causes the metal cap to extend 3 mm. at 1,500 cm. per second and creates an impact pressure of 600 to 800 bar. Stone fragmentation efficiency of the electromechanical impactor was equivalent to unshielded electrohydraulic lithotripsy (gallstone 2.83 mg. per pulse, struvite/apatite 1.41 mg. per pulse, cystine 0.41 mg. per pulse, uric acid 1.48 mg. per pulse and 100% calcium oxalate monohydrate 0.10 mg. per pulse). Studies of the discharge of the electromechanical impactor within the pig ureter showed that minimal ureteral submucosal edema and hemorrhage occurred at 300 shocks discharged at a single point, and disruption of the mucosa and partial injury to the muscle layer occurred after 600 shocks given at the site of a pinched pig ureter. Pushing the electromechanical impactor perpendicular to the wall of the pig bladder will create a mechanical perforation within 35 shocks (electrohydraulic lithotripsy within 2 shocks). One patient had excellent fragmentation of a lower ureteral mixed monohydrate and dihydrate stone under direct vision performed with the electromechanical impactor passed via a 9.5F ureteroscope. There was no evidence of mucosal injury with 500 shocks. The electromechanical impactor has been developed to provide a safe and inexpensive method of ureteral stone fragmentation or disimpaction. These studies were performed to establish limits of safety that may allow use of the electromechanical impactor for stone fragmentation in the ureter without the need for ureteroscopy.

New laser delivery device for laparoscopic procedures.

A new device to facilitate laser delivery and improve mechanical advantage during surgical procedures is described. In the device, a quartz fiber is used to transmit laser energy to a forked metal tip. The utility of the device was assessed in five pigs. In three pigs a laparoscopic cholecystectomy was performed and in two pigs a laparoscopic lymph node dissection was performed. Advantages of the device included reduced smoke, clearer dissection planes, tactile feedback, and excellent mechanical advantage when used for blunt dissection. The device was qualitatively superior to both sculpted tip quartz fibers and electrocautery.

Effects of shielded or unshielded laser and electrohydraulic lithotripsy on rabbit bladder.

The pulsed dye laser and electrohydraulic lithotriptor (EHL) are both effective devices for fragmenting urinary and biliary calculi. Both fragment stones by producing a plasma-mediated shockwave. Recently, a plasma shield consisting of a hollow spring and a metal end cap has been described for use with the laser and EHL devices in an attempt to minimize tissue damage without adversely affecting stone fragmentation rates. The tissue effects produced by a pulsed dye laser and an EHL device with and without plasma shields were examined and compared using rabbit urinary bladders. If blood was present, the unshielded laser perforated the bladder wall in two pulses. However, in the absence of blood, over 100 pulses were needed for the laser to perforate the bladder. A mean of six pulses were required to perforate the bladder wall with a shielded laser. The unshielded EHL perforated the bladder wall in two pulses, whereas, the shielded EHL required a mean of 35 pulses. Microscopically, areas of exposure revealed hemorrhage and tissue ablation. We conclude that all devices examined can produce significant tissue damage when discharged directly onto bladder epithelium.

Plasma shield lasertripsy: in vitro studies.

A technique for safer and more effective pulsed laser lithotripsy of urinary and biliary calculi was investigated in vitro. The technique involves enclosing the distal end of the laser delivery fiber in a "plasma shield." The plasma shield is a specially designed metal cap that serves to transfer the laser-induced mechanical impulse to the calculus while shielding surrounding tissue from direct laser exposure and thermal radiation. The metal cap also offers the advantage of effectively blunting the sharp fiber tip and improving its visualization under fluoroscopy. Plasma shield lithotripsy using a 200 micron quartz fiber inserted into a section of a modified 0.034 in. diameter stainless steel guide wire was tested in vitro on a variety of calculi and compared with results obtained using a 200 micron laser fiber applied directly. Calculi tested included cystine, struvite and calcium oxalate dihydrate urinary stones and pigmented cholesterol gallstones. The laser source was a flashlamp-pumped dye laser producing pulses of 1.2 microsecond duration and operated at a wavelength of 504 nm and pulse repetition frequency of 5 Hz. The results show that plasma shield lasertripsy is as effective as direct lasertripsy for fragmenting gallstones, struvite and calcium oxalate dihydrate calculi, is potentially safer, and can fragment cystine calculi which the pulsed dye laser applied directly cannot.

Cystine calculi--rough and smooth: a new clinical distinction.

Four stones each from 2 populations of cystine calculi, 1 with a rough external surface (cystine-R) and the other smooth (cystine-S), were studied for their crystal structure with stereoscopic and scanning electron microscopy. Two stones each of cystine-R and cystine-S, calcium oxalate monohydrate, calcium oxalate dihydrate, struvite plus apatite and brushite were fragmented with extracorporeal shock wave lithotripsy and the fragmentability was compared. Fragments resulting from cystine-R and cystine-S extracorporeal shock wave lithotripsy were examined under the stereoscope to assess the plane of cleavage or fracture. Results show that cystine-R stones are comprised of well formed blocks of hexagonal crystals, whereas cystine-S calculi have small, irregular and poorly formed interlacing crystals. The center of cystine-R stones was similar to that of the periphery but the center of cystine-S stones was formed of blocks of hexagons similar to but smaller than the cystine-R calculi. Fragmentation with extracorporeal shock wave lithotripsy revealed that cystine-S stones are the least fragile, calcium oxalate dihydrate and struvite plus apatite were the most fragile, and cystine-R, brushite and calcium oxalate monohydrate calculi were in the intermediate fragility range. The possibility of the patient having a cystine-R calculus should be considered during therapeutic procedures.

Acoustic and plasma guided lasertripsy (APGL) of urinary calculi.

The feasibility of using pulsed laser generated acoustic and plasma optical emission signals to monitor laser fragmentation of urinary stones was studied in vitro. A flashlamp pumped tunable dye laser operating at a wavelength of 504 nm. (coumarin green) was used as the laser source. Acoustic signals were recorded with a hydrophone which has a useful frequency response of up to 350 KHz. Plasma optical emissions were transmitted retrograde along the laser fiber and reflected through a beam splitter to an optical detection system consisting of a series of spectral filters (to transmit plasma radiation from 380 nm.-440 nm. and block any 504 nm. laser light) and a photomultiplier tube. Measurements of acoustic and plasma signals were taken from different urinary calculi, guidewires, catheters, blood, blood clots, bruised soft tissue and normal ureter. Signals were also obtained from stones placed in ureter of an ex vivo bovine urinary tract specimen. Results of monitoring both plasma and acoustic signals show that it is possible to determine, without direct vision, whether the laser is hitting stone, ureteral wall or lumen. Strong plasma and strong acoustic signals are produced by calculi; strong acoustic but no plasma signals suggest that the laser is hitting blood clot or bruised ureteral wall. Absent plasma and acoustic response indicate that the laser is discharging on normal ureter or in the lumen. These distinctions may allow clinical stone fragmentation without direct ureteroscopic vision.

Acoustic and plasma-guided laser angioplasty.

The feasibility of using acoustic and plasma-guided laser (APGL) for angioplasty was studied in vitro. A flashlamp-pumped tunable dye laser operating at a wavelength of 504 nm (coumarin green) was used as the laser source. Acoustic signals were recorded with a hydrophone, which has a useful frequency response of up to 350 kHz. Plasma optical emissions were transmitted retrograde along the laser fiber and reflected through a beam splitter to an optical detection system consisting of a series of spectral filters (to transmit plasma radiation from 380 nm to 440 nm and block any 504 nm laser light) and a photomultiplier tube. Measurements of the acoustic and the plasma optical signals were obtained from blood, atheromatous plaque, and normal arterial wall. Results of monitoring show that it is possible to know without direct vision whether the laser energy is being discharged in the lumen (blood), on the normal arterial wall, or on the atheromatous plaque. Blood produced strong acoustic signals but no plasma signals; plaque produced strong plasma and strong acoustic signals. Neither plasma nor significant acoustic signals were produced by the normal arterial wall. These distinctions may allow clinical laser ablation of plaque to be performed with fewer complications.

Effect of pulse duration on microsecond-domain laser lithotripsy.

The pulsed dye laser (wavelength 504 nm, pulse duration 1 microsecond) is widely used for fragmenting urinary and biliary calculi. In this study, the performance of this laser was compared with pulsed dye lasers producing pulse durations of 8 and 20 microseconds. Fragmentation thresholds and fragmentation rates were measured using a variety of urinary and biliary calculi. Effective fragmentation of urinary and biliary calculi was obtained with 1-microsecond and 8-microseconds pulse durations, but satisfactory fragmentation could not be achieved at 20 microseconds.