The laser of the future: reality and expectations about the new thulium fiber laser-a systematic review

The Holmium:yttrium-aluminum-garnet (Ho:YAG) laser has been the gold-standard for laser lithotripsy over the last 20 years. However, recent reports about a new prototype thulium fiber laser (TFL) lithotripter have revealed impressive levels of performance. We therefore decided to systematically review the reality and expectations for this new TFL technology. This review was registered in the PROSPERO registry (CRD42019128695). A PubMed search was performed for papers including specific terms relevant to this systematic review published between the years 2015 and 2019, including already accepted but not yet published papers. Additionally, the medical sections of ScienceDirect, Wiley, SpringerLink, Mary Ann Liebert publishers, and Google Scholar were also searched for peer-reviewed abstract presentations. All relevant studies and data identified in the bibliographic search were selected, categorized, and summarized. The authors adhered to PRISMA guidelines for this review. The TFL emits laser radiation at a wavelength of 1,940 nm, and has an optical penetration depth in water about four-times shorter than the Ho:YAG laser. This results in four-times lower stone ablation thresholds, as well as lower tissue ablation thresholds. As the TFL uses electronically-modulated laser diodes, it offers the most comprehensive and flexible range of laser parameters among laser lithotripters, with pulse frequencies up to 2,200 Hz, very low to very high pulse energies (0.005-6 J), short to very long-pulse durations (200 µs up to 12 ms), and a total power level up to 55 W. The stone ablation efficiency is up to four-times that of the Ho:YAG laser for similar laser parameters, with associated implications for speed and operating time. When using dusting settings, the TFL outperforms the Ho:YAG laser in dust quantity and quality, producing much finer particles. Retropulsion is also significantly reduced and sometimes even absent with the TFL. The TFL can use small laser fibers (as small as 50 µm core), with resulting advantages in irrigation, scope deflection, retropulsion reduction, and (in)direct effects on accessibility, visibility, efficiency, and surgical time, as well as offering future miniaturization possibilities. Similar to the Ho:YAG laser, the TFL can also be used for soft tissue applications such as prostate enucleation (ThuFLEP). The TFL machine itself is seven times smaller and eight times lighter than a high-power Ho:YAG laser system, and consumes nine times less energy. Maintenance is expected to be very low due to the durability of its components. The safety profile is also better in many aspects, i.e., for patients, instruments, and surgeons. The advantages of the TFL over the Ho:YAG laser are simply too extensive to be ignored. The TFL appears to be a real alternative to the Ho:YAG laser and become a true game-changer in laser lithotripsy. Due to its novelty, further studies are needed to broaden our understanding of the TFL, and comprehend the full implications and benefits of this new technology, as well its limitations.info:eu-repo/semantics/publishedVersio

In vitro fragmentation efficiency of holmium: yttrium-aluminum-garnet (YAG) laser lithotripsy--a comprehensive study encompassing different frequencies, pulse energies, total power levels and laser fibre diameters

OBJECTIVE: To assess the fragmentation (ablation) efficiency of laser lithotripsy along a wide range of pulse energies, frequencies, power settings and different laser fibres, in particular to compare high- with low-frequency lithotripsy using a dynamic and innovative testing procedure free from any human interaction bias. MATERIALS AND METHODS: An automated laser fragmentation testing system was developed. The unmoving laser fibres fired at the surface of an artificial stone while the stone was moved past at a constant velocity, thus creating a fissure. The lithotripter settings were 0.2-1.2 J pulse energies, 5-40 Hz frequencies, 4-20 W power levels, and 200 and 550 μm core laser fibres. Fissure width, depth, and volume were analysed and comparisons between laser settings, fibres and ablation rates were made. RESULTS: Low frequency-high pulse energy (LoFr-HiPE) settings were (up to six times) more ablative than high frequency-low pulse energy (HiFr-LoPE) at the same power levels (P < 0.001), as they produced deeper (P < 0.01) and wider (P < 0.001) fissures. There were linear correlations between pulse energy and fragmentation volume, fissure width, and fissure depth (all P < 0.001). Total power did not correlate with fragmentation measurements. Laser fibre diameter did not affect fragmentation volume (P = 0.81), except at very low pulse energies (0.2 J), where the large fibre was less efficient (P = 0.015). CONCLUSIONS: At the same total power level, LoFr-HiPE lithotripsy was most efficient. Pulse energy was the key variable that drove fragmentation efficiency. Attention must be paid to prevent the formation of time-consuming bulky debris and adapt the lithotripter settings to one's needs. As fibre diameter did not affect fragmentation efficiency, small fibres are preferable due to better scope irrigation and manoeuvrability

Laser fiber and flexible ureterorenoscopy: the safety distance concept

INTRODUCTION The costs of flexible ureterorenoscopes (fURS) and their repair oblige the surgeon to know the proper handling of instruments. There is a lack of evidence in the literature about the safety distance that the laser fiber should have once out from the scope to avoid instrumental damages. MATERIAL AND METHODS We performed an in-vitro observational study. Seven fURS were tested. The distance from the laser fiber tip and the fURS camera was measured at the first appearance on the endoscopic screen and when the fiber was reaching one fourth of the screen. Secondly, to evaluate the impact of the Holmium laser bubble according to the different fiber distances, an assessment of the size and shape of the bubble created at the tip of the fiber with the laser activated was done recording the images with an High Speed Camera. RESULTS The first appearance on the screen of the laser tip is different in different scopes. In all the scopes when observed that when the laser fiber was at \ubc of the screen the bubble was never touching the fURS tip. CONCLUSION Even if there is a big limitation of this study due the impossibility to measure and to evaluate the damage of the fURS tip surface, we observed that when the laser fiber tip reach \ubc of the screen, the bubble generated by the laser activation is never rebounding on the camera of the scope preserving it from laser damages. We can define this position as the "safety distance"

Very first tests on SOLEIL regarding the Zn environment in pathological calcifications made of apatite determined by X-ray absorption spectroscopy

This very first report of a X-ray absorption spectroscopy experiment on Soleil is part of a more large long term study dedicated to ectopic calcifications. Such biological entities composed of various inorganic and/or organic compounds contain also trace elements. In the case of urinary calculi, different papers already published point out that these oligo elements may promote or inhibit crystal nucleation or growth of mineral or organic species involved. By using such tool specific to synchrotron radiation i.e. determine the local environment of oligoelements and thus their occupation site, we contribute to our understanding of the role of trace elements in ectopic calcifications

Évaluation préclinique et clinique d’un outil développé pour la planification opératoire des chirurgies lithiasiques : « Kidney Stone Calculator »

Kidney Stone Calculator (KSC) est un outil que nous avons développé pour mesurer le volume lithiasique total (VLT) et estimer la durée opératoire de lithotritie laser endocorporelle (LLE) au cours de l’urétérorénoscopie souple (URS-S), à partir du scanner abdominopelvien préopératoire non injecté (TDM AP IV-). L’objectif de cette étude était de réaliser une évaluation préclinique et cli-nique de cet outil