Thulium Fiber Laser Lithotripsy Research Articles

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

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. 272-µm core-diameter laser fibers (Boston Scientific©) were connected to a 50Watts 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 (0.5/0.8/1J), 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. 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. 1J 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. 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.

Exploring optimal settings for safe and effective thulium fibre laser lithotripsy in a kidney model.

To explore the optimal laser settings and treatment strategies for thulium fibre laser (TFL) lithotripsy, namely, those with the highest treatment efficiency, lowest thermal injury risk, and shortest procedure time. An in vitro kidney model was used to assess the efficacy of TFL lithotripsy in the upper calyx. Stone ablation experiments were performed on BegoStone phantoms at different combinations of pulse energy (EP ) and frequency (F) to determine the optimal settings. Temperature changes and thermal injury risks were monitored using embedded thermocouples. Experiments were also performed on calcium oxalate monohydrate (COM) stones to validate the optimal settings. High EP /low F settings demonstrated superior treatment efficiency compared to low EP /high F settings using the same power. Specifically, 0.8 J/12 Hz was the optimal setting, resulting in a twofold increase in treatment efficiency, a 39% reduction in energy expenditure per unit of ablated stone mass, a 35% reduction in residual fragments, and a 36% reduction in total procedure time compared to the 0.2 J/50 Hz setting for COM stones. Thermal injury risk assessment indicated that 10 W power settings with high EP /low F combinations remained below the threshold for tissue injury, while higher power settings (>10 W) consistently exceeded the safety threshold. Our findings suggest that high EP /low F settings, such as 0.8 J/12 Hz, are optimal for TFL lithotripsy in the treatment of COM stones. These settings demonstrated significantly improved treatment efficiency with reduced residual fragments compared to conventional settings while keeping the thermal dose below the injury threshold. This study highlights the importance of using the high EP /low F combination with low power settings, which maximizes treatment efficiency and minimizes potential thermal injury. Further studies are warranted to determine the optimal settings for TFL for treating kidney stones with different compositions.

Super pulsed thulium fiber laser outcomes in retrograde intrarenal surgery for ureteral and renal stones: a systematic review and meta-analysis

BackgroundLaser lithotripsy using a thulium fiber laser (TFL) has become an effective treatment option for small renal stones with low complication rates. TFL has a higher absorption coefficient, smaller fibers, and better pulse rate capability.MethodsWe conducted a systematic review and meta-analysis to evaluate the published evidence regarding TFL's lithotripsy performance in retrograde intrarenal surgery (RIRS), for which we primarily assessed the outcomes of stone-free rate, operation time, and complications. We searched different databases from inception to April 2023. We assessed the methodological quality and risk of bias using the Cochrane Risk of Bias tool for randomized trials and the ROBINS-I tool for non-randomized studies. We used a random-effects model for meta-analysis and assessed heterogeneity using the I2 statistic.ResultsTwelve published studies evaluated the efficacy of RIRS using a TFL for treating renal and ureteral stones. The meta-analysis revealed a predicted stone-free rate of 89.37% (95% CI: 83.93% to 93.12%), indicating that, on average, approximately 89.37% of patients achieved a stone-free state after treatment. The substantial heterogeneity among the studies was evident, as shown by a Q-value of 33.1174 and a p-value of 0.0003. The I2 value of 69.80% (95% CI: 25.91% to 92.02%) highlighted the proportion of variability attributed to genuine heterogeneity across the studies. Moreover, the H2 value 3.31 (95% CI: 1.35 to 12.53) indicated significant heterogeneity beyond random chance. The estimated overall effect size (logit-transformed) of 2.1289 was highly statistically significant (z = 8.7648, p < 0.0001) with a confidence interval of 1.6528 to 2.6049. The reported complications varied across studies, encompassing Clavien grade I–II complications in most cases, with a subset experiencing more severe Clavien grade III–V complications. Additionally, other studies noted a range of complications, such as haematuria, fever, transient creatinine elevation, and postoperative issues like bleeding, pain, and sepsis.ConclusionThis meta-analysis suggests that RIRS using TFL is an effective and safe treatment option for renal and ureteral stones, with high stone-free and low complication rates. The included studies exhibited a low risk of bias and were of high quality. However, more extensive randomized controlled trials with extended follow-up periods are needed to investigate this technique's efficacy and safety.

Comparison Between Holmium:YAG Laser With MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery for Kidney Stones in Adults: A Propensity Score-Matched Analysis From the FLEXible Ureteroscopy Outcomes Registry. Reply.

Comparison Between Holmium:YAG Laser With MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery for Kidney Stones in Adults: A Propensity Score-Matched Analysis From the FLEXible Ureteroscopy Outcomes Registry. Reply.

[Comparison of the efficacy of thulium fiber laser and holmium laser lithotripsy in the treatment of upper urinary tract stones].

Objective: To compare the efficacy of thulium fiber laser (TFL) and holmium laser (HL) in the treatment of upper urinary tract stones. Methods: A total of 76 patients diagnosed with upper urinary tract stones by radiographic examination and who required ureteroscopy lithotripsy or retrograde intrarenal stone surgery were prospectively enrolled from the Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine between January 2022 and June 2022. Patients were divided into TFL group (n=38) and HL group (n=38) in a 1∶1 ratio according to the randomization schedule. The perioperative outcomes and stone-free rate of two groups were recorded and compared. Results: Finally, the clinical data of 71 patients were completely collected, including 55 males and 16 females, with a mean age of (45.7±14.1) years old. There were 36 patients in TFL group and 35 patients in HL group, and there was no significant difference in age, body mass index, gender, Charlson comorbidity index, stone site, stone location, stone size and stone density between two groups (all P>0.05). All the surgeries were successfully performed with no intraoperative complications. There were no significant differences between the two groups in terms of operation time, stone displacement during lithotripsy, visual field clarity, changes in hemoglobin, leukocyte, and C-reactive protein, and length of postoperative hospital stay (all P>0.05), but the laser action time[M (Q1,Q3)] in the TFL group was 30.0 (20.0, 48.8)s, which was significantly shorter than that in the HL group [90.0 (50.0, 120.0)s, P<0.001]. The stone-free rates of TFL group and HL group were 97.2% (35/36) and 88.6% (31/35), and there was no significant difference (P=0.337). The postoperative complication incidences of TFL group and HL group were 36.1% (13/36)and 22.9% (8/35), respectively, and the difference was not significant either (P=0.221). For ureter stones, the laser action time in TFL group was 22.5 (20.0, 43.8)s, which was significantly shorter than that in HL group [80.0 (50.0, 120.0)s, P<0.001]. For stones with maximum diameter≤10 mm, the laser action time in TFL group was 20.0 (10.0, 25.0)s, which was significantly shorter than that in HL group [50.0 (40.0, 80.0)s, P<0.001]. For stones with maximum diameter>10 mm, the laser action time in TFL group was 60.0(42.5, 180.0)s, which was significantly shorter than that in HL group [180.0(120.0, 210.0)s, P=0.035]. For stones with density≤1 000 CT, the laser action time in TFL group was 30.0 (20.0, 45.0)s, which was significantly shorter than that in HL group [95.0 (47.5, 120.0), P=0.001]. For stones with density>1 000 CT, the laser action time in TFL group was 30.0 (20.0, 90.0)s, which was significantly shorter than that in HL group [80.0 (55.0, 180.0)s, P=0.033]. Conclusion: TFL lithotripsy is an effective and safe surgical procedure for the treatment of upper urinary tract stones, with similar clinical efficacy but shorter laser action time compared to HL lithotripsy.

[Efficacy and safety of superpulse thulium laser lithotripsy in the intracavitary treatment of urinary calculi].

Objective: To evaluate the efficacy and safety of superpulse thulium laser lithotripsy in the intracavitary treatment of urinary calculi. Methods: From May 2021 to July 2022, patients diagnosed with urinary calculi were screened in four medical centers. Those who met the criteria were treated with superpulse thulium fiber laser under endoscope. The patients' perioperative conditions were recorded. The main effective index was stone-free rate (SFR) 4 weeks after operation, the main safety index was the failure rate of the experimental instruments during operation, and the secondary safety index was the incidence rate of perioperative complications. Results: A total of 76 eligible patients completed superpulse thulium fiber laser lithotripsy, with an average age of (52.0±11.1) years, 54 males and 22 females. There were 31 renal stones, 43 ureteral stones and 2 bladder stones. Percutaneous nephrolithotomy was performed in 17 patients. Ureteroscopy lithotripsy/flexible ureteroscopy lithotripsy was performed in 57 patients and transurethral bladder lithotripsy was in 2 patients. The lithotripsy time of all patients was (50.9±31.4) minutes. There was no failure of experimental instruments during the operation. Six patients refused follow-up examination after operation. The incidence of postoperative adverse events was 61.8% (47/76). One patient needed hospitalization due to inguinal hernia after operation, and the rest were classified as Clavien-dindo grade 1-2. The SFR was 94.3% (66/70) at 4 weeks after operation. Conclusion: It is effective and safe to use superpulse thulium fiber laser in the treatment of urinary calculi.

Incidence of Ureteric strictures Following Ureteroscopic Laser Lithotripsy: Holmium:YAG Versus Thulium Fiber Laser.

We aimed to compare the incidence of ureteric strictures between holmium:yttrium aluminum garnet and thulium fiber laser following ureteroscopic laser lithotripsy. In the present era of miniaturization of endourologic armamentarium and better optics, how safe are lasers to fire inside ureter? It is a prospective comparative study over a period of 2 years that included patients who underwent ureteroscopic laser lithotripsy for ureteric stones. Patients were randomly divided into 2 groups: group A underwent holmium:yttrium aluminum garnet laser lithotripsy and group B underwent thulium fiber laser lithotripsy. A total of 478 patients were analyzed after excluding patients not willing to participate and patients lost to follow-up. Two hundred forty patients underwent holmium:yttrium aluminum garnet laser lithotripsy (group A) and 238 patients underwent thulium fiber laser lithotripsy (group B). The demographic data of 2 groups were comparable. The mean age of patients in group A and group B was 36.5 ± 12.52 years and 38.62 ± 10.71 years, respectively. The mean operative time in group A and group B was 47 ± 15 and 36 ± 13 minutes, respectively, while the mean laser time in group A and group B was 13.5 ± 45 minutes and 9.25 ± 3.2 minutes, respectively. Four (1.67%) patients in group A and 11 (4.62%) patients in group B developed ureteric strictures during follow-up, and the difference was statistically significant (P <.001). The mean length of stricture was 2.67 ± 1.27 cm in group A and 4.42 ± 2.2 cm in group B, and the difference was statistically significant. Thulium fiber laser, projected as safe laser previously, has a higher incidence of ureteric strictures compared to holmium:yttrium aluminum garnet laser when used for ureteroscopic laser lithotripsy.

Comparison Between Holmium:YAG Laser with MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery for Kidney Stones in Adults: A Propensity Score-matched Analysis From the FLEXible Ureteroscopy Outcomes Registry.

We evaluated stone-free rate and complications after flexible ureteroscopy for renal stones, comparing thulium fiber laser and holmium:YAG laser with MOSES technology. Data from adults who underwent flexible ureteroscopy in 20 centers worldwide were retrospectively reviewed (January 2018-August 2021). Patients with ureteral stones, concomitant bilateral procedures, and combined procedures were excluded. One-to-one propensity score matching for age, gender, and stone characteristics was performed. Stone-free rate was defined as absence of fragments >2 mm on imaging within 3 months after surgery. Multivariable logistic regression analysis was performed to evaluate independent predictors of being stone-free. Of 2,075 included patients, holmium:YAG laser with MOSES technology was used in 508 patients and thulium fiber laser in 1,567 patients. After matching, 284 patients from each group with comparable baseline characteristics were included. Pure dusting was applied in 6.0% of cases in holmium:YAG laser with MOSES technology compared with 26% in thulium fiber laser. There was a higher rate of basket extraction in holmium:YAG laser with MOSES technology (89% vs 43%, P < .001). Total operation time and lasing time were similar. Nine patients had sepsis in thulium fiber laser vs none in holmium:YAG laser with MOSES technology (P = .007). Higher stone-free rate was achieved in thulium fiber laser (85% vs 56%, P < .001). At multivariable analysis, the use of thulium fiber laser and ureteral access sheath ≥8F had significantly higher odds of being stone-free. Lasing time, multiple stones, stone diameter, and use of disposable scopes showed significantly lower odds of being stone-free. This real-world study favors the use of thulium fiber laser over holmium:YAG laser with MOSES technology in flexible ureteroscopy for renal stones by way of its higher single-stage stone-free rate.

LBA01-16 COMPARATIVE ANALYSES AND ABLATION EFFICACY OF THULIUM FIBER LASER BY STONE COMPOSITION

You have accessJournal of UrologyCME1 Apr 2023LBA01-16 COMPARATIVE ANALYSES AND ABLATION EFFICACY OF THULIUM FIBER LASER BY STONE COMPOSITION Jeffrey Johnson, Miyad Movassaghi, David Han, Srinath-Reddi Pingle, Justin Lee, Prakash Gorroochurn, James Williams, Michael Schulster, and Ojas Shah Jeffrey JohnsonJeffrey Johnson More articles by this author , Miyad MovassaghiMiyad Movassaghi More articles by this author , David HanDavid Han More articles by this author , Srinath-Reddi PingleSrinath-Reddi Pingle More articles by this author , Justin LeeJustin Lee More articles by this author , Prakash GorroochurnPrakash Gorroochurn More articles by this author , James WilliamsJames Williams More articles by this author , Michael SchulsterMichael Schulster More articles by this author , and Ojas ShahOjas Shah More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003360.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is limited data on the ablation settings and photothermal effects of thulium fiber laser (TFL) lithotripsy across various stone compositions. We aim to identify settings by stone type that optimize efficiency and avoid undesirable effects (i.e. charring) during TFL lithotripsy. METHODS: Specimens of calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, struvite, cystine, carbonate apatite and brushite stones were ablated to ≤1mm residual fragments using 13 settings with the Coloplast© TFL Drive. Pre-ablation mass, post-ablation mass, ablation time and total energy were recorded. Samples were analyzed using FTIR spectroscopy and electron microscopy. RESULTS: Pulse duration impacted ablation effectiveness greatly with 75% of inadequate ablations occurring in medium or long pulse settings. Calcium oxalate dihydrate, cystine, and struvite ablated most efficiently with 0.2J×100Hz, short pulse. Calcium oxalate monohydrate ablated most efficiently with 0.4J×40Hz, short pulse. The average percent of mass lost during ablation was 57%; cystine averaged the highest at 71%. Charring was seen in 40% of stones, mostly in uric acid, cystine, and brushite stones. Electron microscopy of char demonstrated a porous melting effect. FTIR spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate. CONCLUSIONS: Our trial is the first in vitro trial on stone ablation efficacy by stone composition. Across all settings and stone types 0.05J×1000Hz was the most effective ablation setting, however this is above our clinically recommended power of <=20 W. When operating in the kidney and using clinically acceptable TFL settings to minimize the risk of thermal injury, we recommend starting with short pulse 0.2J×100Hz and 0.4J×40Hz to cover most stone types, and adjusting the settings based on visual ablation effects intraoperatively and the clinical scenario (e.g. limited irrigation flow, narrow infundibulum). Further investigation is needed to continue to optimize TFL stone treatment settings. Source of Funding: Coloplast © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1183 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Johnson More articles by this author Miyad Movassaghi More articles by this author David Han More articles by this author Srinath-Reddi Pingle More articles by this author Justin Lee More articles by this author Prakash Gorroochurn More articles by this author James Williams More articles by this author Michael Schulster More articles by this author Ojas Shah More articles by this author Expand All Advertisement PDF downloadLoading ...

Prospective Comparison of Thulium and Holmium Laser Lithotripsy for the Treatment of Upper Urinary Tract Lithiasis

BackgroundLithotripsy with holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the current gold standard for treating stones of the upper urinary tract (UUT). The recently introduced thulium fiber laser (TFL) has the potential to be more efficient and as safe as Ho:YAG. ObjectiveTo compare the performance and complications between Ho:YAG and TFL for UUT lithotripsy. Design, setting, and participantsThis was a prospective single-center study of 182 patients treated between February 2021 and February 2022. In a consecutive approach, laser lithotripsy was performed via ureteroscopy with Ho:YAG for 5 mo, and then with TFL for 5 mo. Outcome measurements and statistical analysisOur primary outcome was stone-free (SF) status at 3 mo after ureteroscopy with Ho:YAG versus TFL lithotripsy. Secondary outcomes were complication rates and results regarding the cumulative stone size. Patients were followed at 3 mo with abdominal imaging (ultrasound or computed tomography). Results and limitationsThe study cohort comprised 76 patients treated with Ho:YAG laser and 100 patients treated with TFL. Cumulative stone size was significantly higher in the TFL than in the Ho:YAG group (20.4 vs 14.8 mm; p = 0.01). SF status was similar in both groups (68.4% vs 72%; p = 0.06). Complication rates were comparable. In subgroup analysis, the SF rate was significantly higher (81.6% vs 62.5%; p = 0.04) and the operative time was shorter for stones measuring 1–2 cm, whereas the results were similar for stones <1 cm and >2 cm. The lack of randomization and single-center design are the main limitations of the study. ConclusionsTFL and Ho:YAG lithotripsy are comparable in terms of the SF rate and safety for the treatment of UUT lithiasis. According to our study, for a cumulative stone size of 1–2 cm, TFL is more effective than Ho:YAG. Patient summaryWe compared the efficiency and safety of two laser types for the treatment of stones in the upper urinary tract. We found that stone-free status at 3 months did not significantly differ between the holmium and thulium lasers.

Laser Efficiency and Laser Safety: Holmium YAG vs. Thulium Fiber Laser.

(1) Objective: To support the efficacy and safety of a range of thulium fiber laser (TFL) pre-set parameters for laser lithotripsy: the efficiency is compared against the Holmium:YAG (Ho:YAG) laser in the hands of juniors and experienced urologists using an in vitro ureteral model; the ureteral damage of both lasers is evaluated in an in vivo porcine model. (2) Materials and Methods: Ho:YAG laser technology and TFL technology, with a 200 µm core-diameter laser fibers in an in vitro saline ureteral model were used. Each participant performed 12 laser sessions. Each session included a 3-min lasering of stone phantoms (Begostone) with each laser technology in six different pre-settings retained from the Coloplast TFL Drive user interface pre-settings, for stone dusting: 0.5 J/10 Hz, 0.5 J/20 Hz, 0.7 J/10 Hz, 0.7 J/20 Hz, 1 J/12 Hz and 1 J/20 Hz. Both lasers were also used in three in vivo porcine models, lasering up to 20 W and 12 W in the renal pelvis and the ureter, respectively. Temperature was continuously recorded. After 3 weeks, a second look was done to verify the integrity of the ureters and kidney and an anatomopathological analysis was performed. (3) Results: Regarding laser lithotripsy efficiency, after 3 min of continuous lasering, the overall ablation rate (AR) percentage was 27% greater with the TFL technology (p < 0.0001). The energy per ablated mass [J/mg] was 24% lower when using the TFL (p < 0.0001). While junior urologists performed worse than seniors in all tests, they performed better when using the TFL than Ho:YAG technology (36% more AR and 36% fewer J/mg). In the in vivo porcine model, no urothelial damage was observed for both laser technologies, neither endoscopically during lasering, three weeks later, nor in the pathological test. (4) Conclusions: By using Coloplast TFL Drive GUI pre-set, TFL lithotripsy efficiency is higher than Ho:YAG laser, even in unexperienced hands. Concerning urothelial damage, both laser technologies with low power present no lesions.

Thermal Injury and Laser Efficiency with Holmium YAG and Thulium Fiber Laser-An In Vitro Study.

Objective: To evaluate using an inanimate model the thermal injury and laser efficiency on high frequency, high energy, and its combination in hands of junior and experienced urologists during holmium YAG (Ho:YAG) and Thulium fiber laser (TFL) lithotripsy. Methods: A Cyber: Ho 150 WTM and Fiber Dust TFL (Quanta System) with 200 μm core-diameter laser fibers (LF) were used in a saline in vitro ureteral model. Each participant (five junior and five experienced urologists) performed 32 sessions of 5-minute lasering (125 mm3 phantom BegoStones™), comparing four modes (3 J/5 Hz [1.5 W], 0.3 J/20 Hz [6 W], 1.2 J/5 Hz [6 W], and 1.2 J/20 Hz [24 W]). Transparent tip and cleaved LF, and digital and fiberoptic ureteroscopes were also compared. Ureteral damage was classified in a scale (0-5) according to the burns and holes seen in the ureteral model's surface. Results: High-power (HP) setting (24 W) was associated with higher delivered energy and higher ablation rates (ARs) in both lasers (p < 0.001). For the same power setting (6 W), there was no difference in delivered energy or stone ARs. Regardless the settings, a higher AR was observed with TFL than with Ho:YAG (0.5Δ mg/s ± 0.33 vs 0.39 Δmg/s ± 0.31, p = 0.002) laser. Higher mean AR was found with cleaved tip vs transparent tip (p = 0.03) in TFL. For both lasers, higher ureteral damage was observed in the 24 W group (p = 0.006) and in the junior urologists (p = 0.03). Between 6 W groups, different types of lesions were found and junior urologist have more lesions when high frequency was used, for both Ho:YAG (p = 0.05) and TFL (p = 0.04). Conclusion: More stone ARs and reduced operative time are observed in HP settings; however, more ureteral thermic-related damage is produced. When comparing the same power, higher energy or frequency does not modify the AR. Nonetheless, more ureteral thermic-related thermal damage is observed in high-frequency settings in unexperienced hands.

Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings.

PurposeProlonged ureteroscopy (URS) is associated with complications including ureteral perforation, stricture, and urosepsis. As laser lithotripsy is one of the most common urologic procedures, small cost savings per case can have a large financial impact. This retrospective study was designed to determine if Thulium fiber laser (TFL) lithotripsy decreases operative time and costs compared to standard Holmium:YAG (Ho:YAG) lithotripsy without pulse modulation.MethodsA retrospective review of URS with laser lithotripsy was conducted for 152 cases performed from August 2020 to January 2021. Variables including cumulative stone size, location, chemical composition, prior ureteral stenting, and ureteral access sheath use were recorded for each case. A cost benefit analysis was performed to show projected cost savings due to potentially decreased operative times.ResultsCompared to Ho:YAG, use of TFL resulted in an average decrease of 12.9 min per case (p = .021, 95% CI [2.03–23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15 mm, the difference was 14.0 min (p = .007, CI [3.95–23.95]). For cases less than 10 mm, the mean difference was 17.3 min in favor of TFL (p = .002, 95% CI [6.89–27.62]). This ~ 13 min reduction in operative time resulted in saving $440/case in direct operating room costs giving our institution a range of $294,000 to $381,900 savings per year.ConclusionsTFL has a significantly shorter operative time and decreased cost when compared to the standard Ho:YAG for equivalent kidney stone and patient characteristics. Longer term follow up is needed to see if recurrence rates are affected.

V03-09 THULIUM FIBER LASER: A UNIVERSAL DEVICE IN UROLOGY. FROM BENCH TO BEDSIDE

You have accessJournal of UrologyCME1 May 2022V03-09 THULIUM FIBER LASER: A UNIVERSAL DEVICE IN UROLOGY. FROM BENCH TO BEDSIDE Dmitry Enikeev, Mark Taratkin, Camilla Azilgareeva, Anastasia Shpikina, Leonid Rapoport, Roman Sukhanov, and Petr Glybochko Dmitry EnikeevDmitry Enikeev More articles by this author , Mark TaratkinMark Taratkin More articles by this author , Camilla AzilgareevaCamilla Azilgareeva More articles by this author , Anastasia ShpikinaAnastasia Shpikina More articles by this author , Leonid RapoportLeonid Rapoport More articles by this author , Roman SukhanovRoman Sukhanov More articles by this author , and Petr GlybochkoPetr Glybochko More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002539.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A new thulium fiber laser (TFL) has been recently developed as a novel surgical tool with multiple applications in urology. The latest modification of the device incorporates two modes for surgery – quasi-continuous (QCW, for soft tissue surgery) and SuperPulsed (SP, for lithotripsy). Evaluation of the utility of the novel device began with in-vitro comparison of TFL with conventional Ho:YAG. After clinical approval, device efficacy was assessed for soft tissues (BPH, NMIBC) and stones. METHODS: This prospective clinical trial started following local IRB approval. For TFL enucleation of the prostate (ThuFLEP), TFL (NTO IRE-Polus, Russia) in QCW mode with 600-μm laser fiber and 26 Ch resectoscope (Karl Storz, Germany) with continuous irrigation (0.9% saline) was used. TFL en bloc resection of bladder tumor (TFL-ERBT) was performed using the following settings: QCW; 1.0 J; 10 W. Lithotripsy was performed with TFL using 200-, 400- and 600-μm fibers in SP mode. Stone-free rate (SFR) was assessed with low-dose computed tomography 3 months after. RESULTS: ThuFLEP was performed in 1392 patients, TFL-ERBT in 118 cases, and TFL lithotripsy (PCNL, RIRS, URS, bladder) was performed in 321 patients. In the ThuFLEP group median prostate volume was 80 (IQR 60; 105) cc. Qmax and IPSS before surgery were 9.6±2.6 and 22.9±1.8, respectively. Mean surgery duration was 70.5±31.0 min, whereas the mass of resected tissue was 69.8±34.7 g. Mean catheterization time was 1.7±0.8 days; mean hospital stay was 3.7±1.0 days. PVR, Qmax, IPSS and QOL all significantly improved at 3 months after surgery (p <0.001). TFL-ERBT was performed in 118 patients with detrusor rate of 91.6%. RFS at 6 months was 91.5%. Of 321 patients with urinary calculi treated with TFL, 153 had kidney stones (median stone volume – 279.6 (IQR, 139.4–615.8) mm3, mean density – 1020±382 HU), 149 had ureter stones (median stone volume - 179 (IQR, 94–357) mm3, mean density – 985±360 HU) and 19 had bladder stones (mean size 22.2 mm, mean density – 1050 HU). Stone-free rate was 92%. CONCLUSIONS: TFL shows high efficiency and acceptable safety profile in the treatment of urinary stones, NMIBC and BPH. The combination of SuperPulsed and quasi-continuous modes within a single device allowed for developing a universal tool for urologic surgery. However, further studies are necessary to assess the comparative efficacy of this surgical modality with standard options offered by guidelines. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e204 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Enikeev More articles by this author Mark Taratkin More articles by this author Camilla Azilgareeva More articles by this author Anastasia Shpikina More articles by this author Leonid Rapoport More articles by this author Roman Sukhanov More articles by this author Petr Glybochko More articles by this author Expand All Advertisement PDF DownloadLoading ...

Thulium Fiber Laser Lithotripsy in COVID Positive Patients

Background: Thulium fiber laser technology has been shown to provide more power through a small fiber to enable faster stone fragmentation. In the Covid era, positive patients were postponed for a few weeks before any surgery to ensure their safety. However, with complete ureteric obstruction with large stones, delayed ureteroscopy and stone fragmentation could potentially compromise renal function. We aim to evaluate the Thulium Fiber Laser outcome as an alternative to holmium YAG laser as intracorporeal lithotripter in Covid-19 positive patients. Methods: From March-July 2020, during the peak of the corona outbreak, 11 COVID-19 positive patients were admitted through the emergency department with obstructing ureteric stones underwent urgent JJ stent insertion 2 weeks later from the initial surgery a definitive treatment offered. Results: The average age was 36+-11.7 years, all-male, all fit and healthy despite their Covid-19 status. The average stone size was 11+-3.1 mm with a volume of 395.8+-280 mm3 . The Hounsfield unit measurement was 1033.3+-57.7. Seven underwent short general anesthesia and 4 had spinal anesthesia. The average laser duration was of 593.9+-357.5 seconds, and the average stone ablation speed was 0.66+-0.19 mm3 /Sec. The overall stone- free rate was 90.9%. All 11 patients were discharged safely on the same day with only 1 patient readmitted with steinstrasse and underwent urgent ureteroscopy. None of our patients developed late complications. Conclusion: Using the Thulium laser technology allows for a quick and safe alternative to Holmium for fragmenting ureteric stones with a high stone-free rate.

PD54-08 HOLMIUM:YAG (HO:YAG) VERSUS THULIUM FIBER LASER (TFL) FOR TREATMENT OF UPPER URINARY TRACT CALCULI IN DUSTING MODE: A CLINICAL COMPARISON OF EFFICIENCY, EFFICACY AND COSTS EFFECTIVENESS

You have accessJournal of UrologyStone Disease: Surgical Therapy IV (PD54)1 Sep 2021PD54-08 HOLMIUM:YAG (HO:YAG) VERSUS THULIUM FIBER LASER (TFL) FOR TREATMENT OF UPPER URINARY TRACT CALCULI IN DUSTING MODE: A CLINICAL COMPARISON OF EFFICIENCY, EFFICACY AND COSTS EFFECTIVENESS Ahmed Ghazi, Mahmoud Khalil, Changyong Feng, Scott Quarrier, and Rajat Jain Ahmed GhaziAhmed Ghazi More articles by this author , Mahmoud KhalilMahmoud Khalil More articles by this author , Changyong FengChangyong Feng More articles by this author , Scott QuarrierScott Quarrier More articles by this author , and Rajat JainRajat Jain More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002081.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Preliminary studies have demonstrated the superiority of TFL compared to Ho:YAG for dusting of urinary calculi. These are mainly based on laboratory studies with emerging clinical reports limited to optimizing TFL dusting settings. We aim to compare the efficiency, effectiveness and costs effectiveness of high power Ho:YAG (100W Empower, Olympus) to TFL (Soltive PLS, Olympus) lasers operated at a fixed dusting protocol. METHODS: A prospective study of 62 patients (31 per group) with 10–30 mm renal calculi was completed. Fixed dusting settings (0.4J X 60Hz) during retrograde intrarenal surgery (RIRS) lithotripsy was used for both lasers. Laser on time (LOT), Ablation efficacy (J/mm3) and Ablation speed (mm3/second) were calculated. Retropulsion, visibility, and bleeding during RIRS were graded by 3 urologists using 5-point Likert scales. Stone-free rate (SFR) was assessed at 1 month with non-contrast CT. Projected cost savings were calculated utilizing the formula [average LOT difference x $100/minute billed to insurance for RIRS minus $178 differential between list price of the 200m TFL ball tip and regular Ho:YAG fiber plus price differential for upgrade to PLS Soltive ($18800/1000) amortized over 1000 procedures=$18.8]. RESULTS: Mean age, BMI, stone number, density, ellipsoid stone volume and STONE score was not significantly different among both groups (Table 1). TFL lithotripsy had significantly shorter LOTs (380.6 vs 533.6 seconds, p=0.015) and higher SFRs (68% vs 34.8%, p=0.03). Both ablation efficacy (21.2 vs 12.5 J/mm3, p=0.02) and speed (4.1 vs 1.2 mm3/second, p=0.003) were significantly higher with TFL. TFL was 2.6 min faster for all stones (3.4 min for stones <15mm vs 1.7min for stones >15mm) with an overall projected $69.2 saving per case [$266- ($178+ $18.8) (Table 1). TFL was superior in terms of retropulsion (1.6 vs 2.8), visibility (1.8 vs 3.3) and bleeding (1.1 vs 1.9) gradings. CONCLUSIONS: This clinical study demonstrates TFL as a more effective, efficient and cost effective laser during RIRS lithotripsy when operated in dusting mode, producing higher stone ablation rates and speed with improved stone free rates than Ho:YAG laser. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e925-e926 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ghazi More articles by this author Mahmoud Khalil More articles by this author Changyong Feng More articles by this author Scott Quarrier More articles by this author Rajat Jain More articles by this author Expand All Advertisement Loading ...

MP06-13 COMPARISON OF LASER OPERATOR DUTY CYCLES (ODC) DURING HIGH POWER HOLMIUM:YAG (HO:YAG) VERSUS THULIUM FIBER LASER (TFL) LITHOTRIPSY

You have accessJournal of UrologyStone Disease: Surgical Therapy I (MP06)1 Sep 2021MP06-13 COMPARISON OF LASER OPERATOR DUTY CYCLES (ODC) DURING HIGH POWER HOLMIUM:YAG (HO:YAG) VERSUS THULIUM FIBER LASER (TFL) LITHOTRIPSY Ahmed Ghazi, Mahmoud Khalil, Rajat Jain, and Scott Quarrier Ahmed GhaziAhmed Ghazi More articles by this author , Mahmoud KhalilMahmoud Khalil More articles by this author , Rajat JainRajat Jain More articles by this author , and Scott QuarrierScott Quarrier More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001973.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: ODC is a measure to compare efficiency of laser activation during ureteroscopy, ranging between 32% to 63% for Ho:YAG lithotripsy. Laser ODC is defined as LOT (overall time the laser pedal is depressed) divided by Lithotripsy Time (LT; first to last pedal activation including pauses). In vitro studies with TFL lithotripsy suggest decreased retropulsion and improved visualization compared to the Ho:YAG laser. These factors may directly impact LOT and pauses thus ODC. The objective of this study was to quantify if differences in retropulsion, visualization and efficiency between Ho:YAG (100W Empower, Olympus) and TFL (Soltive PLS, Olympus) lasers during ureteroscopic lithotripsy procedures. METHODS: A prospective study enrolled 62 patients (31 per group) with 10–30 mm renal calculi undergoing ureteroscopy with fixed dusting settings (0.4J X 60Hz) for both lasers by 3 endourology faculty. LOT and lithotripsy times were collected from laser logs of each case. LOT was verified by the formula (LOT= total energy delivered [J])/(energy [J] x frequency [Hz]) for any discrepancy. Retropulsion, visibility, and bleeding during lithotripsy were graded for all cases by the three urologists using 5-point Likert scales. ODC was calculated using the formula (LOT/LT). Correlation coefficients were calculated to define relationships between stone and lithotripsy characteristics. RESULTS: Mean age, BMI, stone number, density, ellipsoid stone volume and STONE score were not significantly different between the groups (Table 1). TFL was graded more favorably in retropulsion (1.6 vs 2.8), visibility (1.8 vs 3.3) and bleeding (1.1 vs 1.9) gradings. TFL lithotripsy also had significantly shorter LOTs (380.6 vs 533.6 seconds, p=0.015) and superior ODC efficiency (49.1% vs 34.2%, p=0.0001). (Table 1). An inverse correlation was found between ODC and stone density, volume and STONE score as well as retropulsion, visualization and bleeding grading. CONCLUSIONS: These findings suggest that TFL may be more efficient than Ho:YAG in the treatment of medium to large stones when operated in dusting mode. The longer pedal activation times during TFL especially at higher settings may necessitate future studies on their thermal implications. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e94-e95 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ghazi More articles by this author Mahmoud Khalil More articles by this author Rajat Jain More articles by this author Scott Quarrier More articles by this author Expand All Advertisement Loading ...

PD54-07 THULIUM FIBER LASER RESULTS IN SHORTER OPERATING TIMES DURING URETEROSCOPY AND LASER LITHOTRIPSY

You have accessJournal of UrologyStone Disease: Surgical Therapy IV (PD54)1 Sep 2021PD54-07 THULIUM FIBER LASER RESULTS IN SHORTER OPERATING TIMES DURING URETEROSCOPY AND LASER LITHOTRIPSY James R. Ryan, Mitchell H. Nguyen, Joshua A. Linscott, Samuel W. Nowicki, Brian M. Jumper, and Johann P. Ingimarsson James R. RyanJames R. Ryan More articles by this author , Mitchell H. NguyenMitchell H. Nguyen More articles by this author , Joshua A. LinscottJoshua A. Linscott More articles by this author , Samuel W. NowickiSamuel W. Nowicki More articles by this author , Brian M. JumperBrian M. Jumper More articles by this author , and Johann P. IngimarssonJohann P. Ingimarsson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002081.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroscopy (URS) procedure duration has been associated with complications such as ureteral perforation and urosepsis, as well as higher costs. A new FDA approved lithotripter, the thulium fiber laser (TFL), was made commercially available in June of 2020 and was acquired by our institution. This retrospective study was designed to determine if TFL lithotripsy decreased operative time when compared to standard Holmium:YAG (Hol:YAG) lithotripsy without pulse modulation. METHODS: A retrospective review of URS with laser lithotripsy at a tertiary stone center was conducted for cases performed 2 months before and 2 months after conversion to TFL lasers for URS. 152 procedures were identified. Cases that involved bilateral procedures, aberrant anatomy, had no recorded kidney stone composition, and those that were aborted due to complications or tight ureters were excluded from analysis. 102 cases met inclusion criteria, 51 in each arm. Operative time was measured from scope in to scope out. Variables including stone size, location, chemical composition, prior ureteral stenting and ureteral access sheath use were recorded. In cases with 2 or more stones, the cumulative stone diameter was measured from pre-op CT imaging and reported as the summation of diameters from all treated stones. RESULTS: Baseline characteristics of the patients and stones treated did not differ significantly between laser groups (table 1). Compared to Hol:YAG, use of TFL resulted in an average decrease of 12.94 minutes per case (p=.021, 95% CI [2.03-23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15mm, the difference was 13.95 minutes (p=.007, CI [3.95-23.95]). For cases less than 10mm, the mean difference was 17.27 minutes in favor of TFL (p=.002, 95% CI [6.89-27.62]). Stone free states confirmed by retroperitoneal ultrasound were similar between groups but could not be reliably estimated due to low (36%) compliance with post op imaging in the COVID era. CONCLUSIONS: TFL is a substantially faster means of laser lithotripsy than Hol:YAG with average case time reduced by 20% overall (13 min). As the number of URS laser lithotripsy procedures being performed in the United States continues to increase, reducing procedure times has the potential to improve patient outcomes and decrease costs. Longer term follow up is needed to see if recurrence rates are affected. Source of Funding: The authors received no specific funding for this work © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e925-e925 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information James R. Ryan More articles by this author Mitchell H. Nguyen More articles by this author Joshua A. Linscott More articles by this author Samuel W. Nowicki More articles by this author Brian M. Jumper More articles by this author Johann P. Ingimarsson More articles by this author Expand All Advertisement Loading ...

A Systematic Review of Thulium Fiber Laser: Applications and Advantages of Laser Technology in the Field of Urology.

Laser technology is widely used in urological surgery, from lithotripsy, prostate surgery to en-bloc resection of tumours. While Holmium:YAG has been widely employed over the last two decades, in recent years, there has been a surge of interest in Thulium Fiber Laser (TFL), which offers theoretical advantages of better water absorption and lower stone ablation thresholds. A systematic review was conducted to assess the evidence from clinical research on TFL’s application for lithotripsy and prostate surgery. It identified 357 articles and 8 (1506 patients) were selected, of which 4 clinical studies each investigated TFL enucleation of prostate (ThuFLEP) and TFL lithotripsy. For flexible ureteroscopic lithotripsy (FURSL), stone ablation settings ranged from 0.1–4 J, and 7–300 Hz, mean operative time ranged from 23.4–39.8 minutes and lasing time ranged from 1.2–10 minutes. For stone dusting in percutaneous nephrolithotomy (PCNL), settings of 0.2 J and 125–200 Hz were found to be optimal. For ThuFLEP, all studies showed a significant improvement in IPSS (International Prostate Symptom Score), urinary flow rate (Qmax), quality of life measures, and post-void residual volume, with mean operative time ranging from 67–104.5 minutes. Our review shows that there is limited evidence on the use and clinical outcomes of TFL. ThuFLEP might suggest equivalence to the widely used HoLEP in the available evidence so far. TFL lithotripsy shows promising results but further prospective, randomized trials are required to properly assess its usability, clinical effectiveness and standardisation of the settings for successful adoption of the technology.

Simulations and testing of the mechanical properties of small core optical fibers for ureteroscopy

Thulium fiber laser (TFL) lithotripsy has recently been introduced for clinical use. Previous TFL laboratory studies demonstrated high-power delivery through small (50- to 150-μm core) optical fibers. This preliminary study simulates forces on fibers during insertion into a flexible ureteroscope and determines mechanical feasibility of small fibers for a clinical setting. Simulations were conducted with commercially available fiber (core/cladding) sizes of 50/70, 72/108, 100/140, 150/165, 150/180, and 200 / 240 μm. Solidworks software integrating Euler’s buckling equation was used to calculate fiber buckling thresholds as a function of typical manual forces (0.15 to 2.0 N) applied near the proximal end of a ureteroscope. Forces on fibers were modeled assuming support from saline flow and resistance by the working channel wall. Simulation results were categorized based on force values previously reported in the literature, with smaller forces (<0.4 to 0.8 N) buckling fibers, mid-range forces (0.8 to 1.6 N) optimal for fiber manipulation, and higher forces (>1.6 to 2.0 N) at risk of damaging the ureteroscope working channel. Fiber sizes were simulated with two different types of holdings on each end to find a range of possible values that most closely simulate clinical behavior. Simulation results were confirmed using a force meter and a benchtop experimental setup. Numerical simulations predicted that optical fibers for TFL lithotripsy should be equal to or larger than 150 / 190 μm (core/cladding), for effective manual manipulation within flexible ureteroscopes.