Consultation on kidney stones, Copenhagen 2019: aspects of intracorporeal lithotripsy in flexible ureterorenoscopy

Søren Kissow Lildal,Helene Jung,Guido Kamphuis,Peter Kronenberg,Ylva Eriksson,Palle Jörn Sloth Osther,Marianne Brehmer,Khurshid R Ghani,Ben Turney,Olivier Traxer,Kim Hovgaard Andreassen,Joyce Baard,Øyvind Ulvik,Matthew Bultitude

doi:10.1007/s00345-020-03481-9

Abstract

PurposeTo summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety.MethodsA scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark.Results and conclusionsLasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

Highlights

Flexible ureterorenoscopy has evolved as one of the major modalities for upper urinary tract stone management
In another in vitro model, Aldoukhi et al found that the popcorn te chnique was more effective when the laser fibre was positioned in contact with the stone as compared to at a distance of 2 mm from the stone, and when performed in a small (11 mm) rather than a larger calyceal model [25]
Lasers have revolutionized the scenario of intracorporeal lithotripsy during Flexible ureterorenoscopy (fURS)

Summary

Introduction

Flexible ureterorenoscopy (fURS) has evolved as one of the major modalities for upper urinary tract stone management. This development is largely the result of continuing advancements in laser technology for intracorporeal lithotripsy, which is the focus of this review. Most daily clinical practices in the field of kidney stones, including lithotripsy techniques, are not supported by randomized trials and metaanalyses This is not due to low research activity in this area, but rather to difficulties in designing meaningful trials that reflect daily clinical practice, because stone disease is so diverse. In this context, it is important for practising experts to share their knowledge on clinical applications. The concept of the meeting “Consultation on Kidney Stones”, on which this review is based, was to create a forum for transfer and development of clinical expertise

Methods

Study design

Conclusions

Findings

Compliance with ethical standards