Endoscopic lithotripsy and the FREDDY laser: initial experience

BACKGROUND AND PURPOSE: The frequency-doubled double-pulse neodymium:YAG (FREDDY) laser has been developed for endoscopic lithotripsy and combines the characteristics of solid and dye lasers with a thin flexible optical fiber enabling it to be used with flexible ureterorenoscopy. Furthermore, it is less expensive and easier to maintain than other lasers. Our goal was to evaluate its efficacy and role in the ureteroscopic treatment of urinary stones. PATIENTS AND METHODS: We used a FREDDY laser in 26 patients (29 stones). For 4 stone cases, this was the first line of treatment; for the remaining cases, this was the second line of treatment, following SWL in 23 cases and nephrolithotomy in 2 cases. The mean stone size was 9 mm, with a range of 6 to 15 mm. There were 13 renal and 16 ureteral stones. The absence of residual fragments at 3-month postoperative radiography was considered to reflect successful treatment. RESULTS: Twenty-six stones were treated with satisfactory results. Within 3 months, 18 patients were stone free (69%), and 72.4% of the stones (21/29) had been treated completely. Fragments of 8 stones still remained in 8 patients. Of these stones, 5 were >10 mm and persisted at 3 months. Fragmentation was ineffective for 2 cystine stones and poor for 1 calcium oxalate monohydrate stone. Hospitalization, on average, was 1.5 days with a range of 1 to 3 days. A ureteral perforation was observed in the case of an impacted ureteral stone. CONCLUSIONS: Because of the wavelengths used, endoscopic FREDDY laser lithotripsy is an effective and harmless method. This laser can be used as a therapeutic tool because of its moderate cost and ability to be used with flexible ureterorenoscopy. However, it is important to be aware of the FREDDY laser's limited fragmentation capabilities for cystine stones and its inability to treat tissue lesions such as urinary-tract stenosis and tumors.     

输尿管镜下钬激光碎石术治疗上尿路结石梗阻致急性肾功能衰竭的体会

目的探讨输尿管镜下钬激光碎石术治疗上尿路结石梗阻致急性肾功能衰竭的疗效。方法2005年4月至2007年8月对25例上尿路结石梗阻致急性肾功能衰竭（血肌酐大于500μmol／L）患者行输尿管镜检查并行钬激光碎石术。结果25例患者肌酐恢复正常或接近正常，18例输尿管结石一次取净，5例经体外冲击波碎石后结石排出，2例碎石后肾盂残留小结石经121服排石药自行排出。结论对上尿路结石梗阻致急性肾功能衰竭患者，输尿管镜检查辅以钬激光碎石创伤小、疗效好，并可同时处理双侧输尿管结石。     

Comparison of pneumatic and Holmium laser ureteroscopic lithotripsy for upper third ureteral stones

ObjectiveTo evaluate the outcomes of ureteroscopic lithotripsy with pneumatic lithotripter and Holium:Yttrium-Aluminum-Garnet (Ho:YAG) laser in the management of upper third ureteral stones.Materials and methodsPatients who underwent ureteroscopic lithotripsy with pneumatic lithotripter or Ho:YAG laser for upper third ureteral stones were retrospectively reviewed. Patients with urinary tract infection, radiolucent stones, loss of follow-up, concurrent middle or lower third ureteral stones or acute renal failure were excluded. Patient age, stone size and burden (based on KUB or computerized tomography), stone upward migration, double J stent insertion rate, stone free rate and secondary intervention rate for residual stones were compared in both groups.ResultsThere were 158 patients with 178 upper third ureteral stones (135 in pneumatic lithotripsy group and 43 in Ho:YAG laser lithotripsy group) meeting the study criteria. Patients' age, gender, stone laterality, stone size and burden were similar in both groups. The Ho:YAG laser lithotripsy group had better stone free rate, less double J stent insertion rate and less secondary intervention rate as compared with pneumatic lithotripsy (53.4% vs. 40.1%; 72.1% vs. 91.9%; 25% vs. 48.5% respectively, all p < 0.05). In patients with stones larger than 10 mm, Ho:YAG laser lithotripsy had significantly lower upward migration rate, lower double J stent insertion rate, higher stone free rate and less secondary intervention rate.ConclusionsHo:YAG laser lithotripsy is superior to pneumatic lithotripsy in the management of upper third ureteral stones in terms of double J stent insertion rate, stone free rate and secondary intervention rate for stones of all sizes. For stones larger than 10 mm, laser lithotripsy results in less stone upward migration.     

A comparison of the FREDDY and holmium lasers during ureteroscopic lithotripsy

BACKGROUND AND OBJECTIVE: Two laser devices that are used today in endoscopic treatment of renal and ureteral calculi are the frequency-doubled double-pulse neodynium:YAG (FREDDY) and Holmium:YAG lasers. The mechanism of action of these lasers differs, thus conferring potentially different safety and efficacy profiles. The in vitro efficacy of these lasers in treating urinary stones has been explored, but to our knowledge no study compares the in vivo efficacy. The purpose of this study is to compare the stone-free and complication rates of the FREDDY and holmium lasers. STUDY DESIGN/MATERIALS AND METHODS: Subjects were included in the study (from January 2004 to September 2006) if they had adequate documentation of stone size and location, postoperative stone burden, and perioperative complications. Stone-free status was determined based on intraoperative findings and postoperative imaging. Complications included bleeding, ureteral perforation, any intraoperative event necessitating termination of the procedure, ureteral stricture, hydronephrosis, and admission to the hospital with a diagnosis related to the procedure. RESULTS: Sixty patients with adequate follow-up were identified. Thirty patients were treated with FREDDY and 30 patients with Holmium laser. Fisher's exact test was employed for statistical analysis. There was no significant difference in the average stone size between the FREDDY and Holmium groups, which were 6.7 mm and 6.1 mm, respectively. Stone-free rates in the FREDDY and Holmium groups were 76.7% and 93.3%, respectively, P = 0.149. The complication rates were 17.4% in the FREDDY group and 10% in the Holmium group, P = 0.667. CONCLUSION: The complication and stone-free rates did not significantly differ between the FREDDY and Holmium lasers, though there was a trend toward a higher stone-free rate and lower complication rate with the holmium laser. Holmium laser may be more effective than the FREDDY laser in fragmenting calcium oxalate monohydrate stones. The device and laser fiber costs were comparable.     

ESWL与输尿管镜碎石联合处理上尿路结石

目的：探讨对部分上尿路结石采用ESWI．与输尿管镜碎石联合处理的方法。方法：对70例上尿路结石患者采用ESWI。与输尿管镜下钬激光碎石（URS）联合交替治疗。其中输尿管结石48例,。肾结石22例。结果：结石总排净率为91．4％00（64／70）,其中输尿管结石排净率为95．8％（46／48）,肾结石排净率为81．8％（18／22）。3例治疗失败,其中1例输尿管结石因输尿管狭窄无法入镜;另2例肾结石,1例因交替治疗次数过多中途停止治疗,1例因结石硬度过大ESWI,不佳,均改为PCNL术。结论：ESW[。与URS联合交替进行的疗法处理上尿路结石,避免了创伤性治疗,扩大了ESWI,治疗范围,降低了URS手术难度,缩短了URS操作时间,提高了结石排净率,患者创伤微小、恢复快、并发症少,是治疗上尿路结石,特别是部分复杂性上尿路结石较理想的方法之一。     

输尿管镜下钬激光治疗合并息肉的输尿管上段阴性结石（附60例报告）

目的探讨输尿管镜下钬激光治疗合并息肉的输尿管上段阴性结石的疗效。方法2008年1-12月采用输尿管镜下钬激光（美国科以人公司PowerSuite 20 W激光系统,光纤500μm）治疗合并息肉的输尿管上段阴性结石60例。经尿道输尿管镜直视下到达结石部位,采用钬激光腔内碎石治疗,同时消融息肉。结果手术时间15-70 min,平均21 min。60例息肉均一次治疗成功;除4例上段结石被冲入肾盂外,其余56例均单次原位碎石成功。术中未发生输尿管黏膜撕脱、输尿管穿孔、输尿管黏膜隧道等严重并发症。术后仅有轻微血尿,无低热、肾区疼痛等不适。60例随访3-12个月,平均5个月,均未发现结石残留及输尿管狭窄。结论输尿管镜下钬激光治疗合并息肉的输尿管上段阴性结石安全,疗效满意。     

输尿管镜钬激光碎石术治疗输尿管结石（附677例报告）

目的探讨输尿管镜钬激光碎石术治疗输尿管结石的疗效。方法回顾性分析2003年6月～2012年6月应用输尿管镜钬激光碎石术治疗输尿管结石677例的临床资料。B超测量结石长径7—53mm,平均13．2mm。并发尿路感染39例,行积极抗感染后再手术,急性肾功能衰竭38例行急诊手术,其余患者常规术前准备后手术。结果一次碎石成功率92．9％（629／677）,其中上、中、下段结石一次碎石成功率分别为79．2％（80／101）、89．3％（183／205）、98．7％（366／371）,上段〈中段〈下段（X2=5．670,P=0．017,X2=26．025,P=0．000）。手术时间10～90min,（33．4±14．6）min。术后住院时间1～21d,中位数5d。27例中转开放手术。19例一次碎石失败留置双J管加行ESWL治愈。术中并发症包括输尿管穿孔36例,输尿管撕脱伤1例。569例获随访3～6个月,平均4．8月,无输尿管狭窄等并发症。结论输尿管镜钬激光碎石术治疗输尿管结石安全、高效,尤其适用于ESWL失败或结石被包裹和中下段输尿管结石的患者。熟练掌握输尿管镜钬激光操作技巧可以减少并发症。     

双频双脉冲激光与钬激光碎石术治疗上尿路结石的比较

目的：评价双频双脉冲激光与钬激光碎石术治疗上尿路结石的临床疗效。方法：采用U-100激光蹿石术治疗上尿路结石123例，其中肾及输尿管上段结石54例，中下段输尿管结石69例．鹿角状结石12例（平均径线3．6cm）；采用钬激光碎石术治疗上尿路结石246例．其中肾及输尿管上段结子亍135例，下段输尿管结石111例，鹿角状结行35例（平均径线4．2cm）。并对两组临床疗效、并发症进行比较。结果：1例肾结石经U-100激光碎石未成功，采用钬激光碎石。U-100激光和钬激光结石总体清除率分别为88．7％（109／123）和91．6％（225／246）（P〉0．05）；中、下段输尿管结石上移率分别为2％（3／123）和5％（12／246）（P〉0．05）。鹿角状结石平均手术时间，钬激光为（63．8&#177;24．8）min．U100激光为（86．5&#177;35．5）min（P=0．06）。钬激光组发牛输尿管穿孔2例。结论：U-100激光是上尿路结石安全、有效的治疗方式。     

2μm激光联合气压弹道碎石治疗肉芽包裹输尿管结石

目的 探讨输尿管镜下2μm激光联合气压弹道碎石治疗肉芽包裹输尿管结石的安全性和有效性.方法 2007年6月至2010年3月收治肉芽包裹性输尿管结石38例.男20例,女18例.平均年龄47(21～76)岁.左侧17例,右侧21例.肾积水中度24例,重度14例.肾盂分离平均3.8(2.1～7.2)cm.输尿管硬镜下,先用2 μm激光汽化切除结石下方炎性肉芽,显露结石,再用EMS碎石清石系统碎石,统计分析碎石率、排石率和并发症.结果 原位碎石成功35例(92%).碎石时间平均(23.0±6.5)min;术中出血量平均(7.0±4.5)ml;术后住院时间平均(5.2±0.6)d.2例结石上移至肾盂,留置支架管后辅以ESWL碎石,1例输尿管狭窄置镜失败改开放手术.术后1个月复查,结石排净32例(86%),平均随访8(3～15)个月,未出现输尿管狭窄,尿路感染等并发症.结论 输尿管镜下2 μm激光联合气压弹道碎石治疗肉芽包裹输尿管结石安全、高效,可作为这类病例的首选治疗手段.     

Intracorporeal Lithotripsy with the Swiss Lithoclast

Background: In addition to currently available modalities of intracorporeal lithotripsy (ultrasonic, electrohydraulic, and laser), a new ballistic lithotriptor known as the Swiss Lithoclast has recently gained attention. This study reports our experience with the Swiss Lithoclast in the endoscopic management of urinary calculi.
Methods: A total of 51 patients with urinary calculi were treated with the Swiss Lithoclast; one patient with a renal calculus, 28 with ureteral calculi, and 22 with lower urinary tract (bladder, urethra and Kock pouch) calculi.
Results: The Lithoclast successfully fragmented 94% of the calculi, independent of stone composition. Complete failure of fragmentation was not encountered. In six of the 10 upper ureteral calculi, stone fragments were pushed up into the calyces. Adjunctive extracorporeal shock wave lithotripsy for residual fragments was performed in six cases. The stone-free rate at one and three months was 84% and 88%, respectively. There were no intraoperative or long-term complications directly related to the use of this device.
Conclusion: The Swiss Lithoclast is a safe and effective means of intracorporeal lithotripsy. Although suitable for mid and lower ureteral stones, the device has a risk of stone push-up in patients with upper ureteral stones.     

Surgical management of urinary calculi

Shock wave lithotripsy is the cornerstone of the modern management of urinary calculi and is the preferred treatment for most small renal stones. Percutaneous lithotripsy is preferred for large stones and in combination with ESWL for staghorn calculi. Upper ureteral stones should be pushed back to the kidney for ESWL, if possible; otherwise they should be treated in situ. Lower ureteral stones are preferentially managed with ureteroscopy, but ESWL may also be used. A variety of methods of power lithotripsy are available: ultrasound, electrohydraulic lithotripsy, and pulsed dye laser lithotripsy. Only 1% to 2% of stone patients require open surgery; it is an important judgment to identify these patients to avoid inappropriate use of newer techniques in cases where success is unlikely. It is apparent that modern management of the patient with a urinary calculus requires access to all methods of stone removal. The surgeon and internist should not forget that the goal is to remove the stone safely, efficaciously, and economically.     

输尿管镜钬激光碎石术治疗急性肾后性肾功能衰竭21例

目的探讨输尿管镜钬激光碎石术治疗急性肾后性肾功能衰竭的安全性和效果。方法回顾性分析21例因输尿管结石所致急性肾后性肾功能衰竭患者的临床资料,探讨急诊采用输尿管镜钬激光碎石并置管引流的治疗效果。结果21例患者均急诊成功解除尿路梗阻。手术时间为35．110min,平均68．5min,住院时间9—32d,平均16．5d。无输尿管穿孔、断裂或粘膜撕脱等并发症发生,无中转开放手术。随访1—3个月,所有患者血肌酐均恢复正常,复查超声或KUB＋IVP,无结石残留。结论输尿管镜钬激光碎石治疗因输尿管结石致肾后性急性肾功能衰竭安全有效,并发症发生率低。一旦明确由于输尿管结石引起的急性肾后性肾功能衰竭,我们推荐首选输尿管镜钬激光碎石及置管引流术。     

组合式输尿管软镜钬激光碎石术治疗肾和输尿管上段结石的疗效分析

目的 探讨组合式输尿管软镜钬激光碎石术治疗肾和输尿管上段结石的临床效果.方法 选取2013年11月至2015年12月本院泌尿外科采用组合式输尿管镜联合钬激光碎石术治疗的70例肾和输尿管上段结石患者进行回顾性分析,其中输尿管上段结石患者28例,肾结石42例,在全麻或者脊麻下进行手术治疗.结果 70例患者,手术时间45～ 88 min,平均手术时间(61.4-12.8)min,排石时间2～14d,平均排石时间(8.4±3.9)d,术后72h疼痛程度(VAS)评分2～7分,平均VAS评分(4.04±1.36)分,一次性手术成功碎石62例患者,碎石成功率88.57％(62/70).28例输尿管上段结石患者的手术时间、平均排石时间、术后疼痛发作程度VAS评分均显著的低于肾结石患者(P＜0.05);输尿管上段结石患者的碎石成功率92.86％(26/28)略高于肾结石患者的85.71％(36/42),但差异无统计学意义(P＞0.05).结论 组合式输尿管软镜钬激光碎石术治疗肾和输尿管上段结石具有较好的临床效果及安全性.     

Staging lymphadenectomy in patients with localized high risk prostate cancer: comparison of the laparoendoscopic single site (LESS) technique with conventional multiport laparoscopy

Background

Laser lithotripsy is an established endourological modality. Ho:YAG laser have broadened the indications for ureteroscopic stone managements to include larger stone sizes throughout the whole upper urinary tract. Aim of current work is to assess efficacy and safety of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral calculi in different locations.

Methods

88 patients were treated with ureteroscopic Ho:YAG laser lithotripsy in our institute. Study endpoint was the number of treatments until the patient was stone-free. Patients were classified according to the location of their stones as Group I (distal ureteric stones, 51 patients) and group II (proximal ureteral stones, 37). Group I patients have larger stones as Group II (10.70 mm vs. 8.24 mm, respectively, P = 0.020).

Results

Overall stone free rate for both groups was 95.8%. The mean number of procedures for proximal calculi was 1.1 ± 0.1 (1–3) and for distal calculi was 1.0 ± 0.0. The initial treatment was more successful in patients with distal ureteral calculi (100% vs. 82.40%, respectively, P = 0.008). No significant difference in the stone free rate was noticed after the second laser procedure for stones smaller versus larger than 10 mm (100% versus 94.1%, P = 0.13). Overall complication rate was 7.9% (Clavien II und IIIb). Overall and grade-adjusted complication rates were not dependant on the stone location. No laser induced complications were noticed.

Conclusions

The use of the Ho:YAG laser appears to be an adequate tool to disintegrate ureteral calculi independent of primary location. Combination of the semirigid and flexible ureteroscopes as well as the appropriate endourologic tools could likely improve the stone clearance rates for proximal calculi regardless of stone-size.

     

A comparison of holmium:YAG laser with Lithoclast lithotripsy in ureteral calculi fragmentation

PURPOSE: Among various intracorporeal lithotriptors, Lithoclast (EMS, Switzerland) has become the widely used tool for the treatment of urinary stones. Recently, the holmium:YAG laser has been used with a wide range of potential urological applications, including intracorporeal lithotripsy of urinary calculi. The purpose of the present study is to compare Lithoclast with holmium:YAG laser lithotripsy in ureteral calculi fragmentation. METHODS: Out of 51 patients with ureteral calculi, 26 underwent Lithoclast lithotripsy and 25 holmium:YAG lithotripsy using a 8/9.8F rigid ureteroscope. There were no changes to the ureteroscopes, video monitors, baskets or irrigation devices during the study period. RESULTS: There were no differences in patient age, sex, stone size and location of stones between these groups. The immediate stone-free rates were 96.0% in the holmium:YAG group and 73.1% in the Lithoclast group (P < 0.05). The 3-month stone-free rates were 96.0% and 84.6%, respectively (P = 0.350). The mean operation time and mean period of postoperative hospitalization in the holmium:YAG group (49.8 min and 1.0 days, respectively) were shorter than those of the Lithoclast counterpart (76.9 min and 2.5 days, respectively). Post-treatment complications, such as ureteral perforation, were encountered in only two patients who underwent Lithoclast. CONCLUSIONS: Holmium:YAG lithotripsy was associated with shorter operation time and postoperative hospitalization period. These data also suggest that holmium:YAG lithotripsy was safe and more effective than Lithoclast lithotripsy in the aspect of immediate stone free rate. We believe that holmium:YAG laser is an excellent treatment modality for managing ureteral calculi.     

PercSys型输尿管管路封堵器在输尿管镜钬激光碎石治疗输尿管结石中的应用

目的探讨PercSys型输尿管管路封堵器在输尿管镜钬激光碎石治疗输尿管结石的价值和安全性。方法2011年9月～2012年5月,83例单侧输尿管结石（下段12例,中段21例,上段50例）,Wolf F8.0/9.8输尿管镜在斑马导丝引导下进入输尿管见到结石后,于输尿管镜工作通道内放置PercSys型输尿管管路封堵器,封堵叶片完全超越结石后操作体外手柄使叶片折叠成球状防止结石上移,科医人钬激光完全粉碎结石至直径1～2mm碎片后松开封堵器,拔除封堵器后留置双J管。所有患者术后留置双J管2周。术后4周复查泌尿系彩超或上尿路螺旋CT平扫,残留结石直径〉3mm为有意义的结石残留。结果所有患者均通过输尿管镜工作通道成功放置输尿管管路封堵器并行钬激光碎石。放置管路封堵器时间1～3min,碎石时间3～10min。术中未发生输尿管穿孔或输尿管黏膜撕脱,术后无发热及菌血症发生。术后第4周复查泌尿彩超或泌尿系螺旋CT,除5例输尿管上段有较大碎石漂移人肾盏未排空外,其余78例无结石残留,结石清除率为93．9％（78／83）。所有封堵器均未发生封堵折叠和松开退出不成功机械故障。结论PercSys型输尿管管路封堵器操作简单、方便,可对输尿管结石产生有效封堵,预防输尿管结石碎石术中结石漂移。     

输尿管硬镜下钬激光碎石取石术治疗输尿管上段结石112例

【摘要】〓目的〓探讨输尿管硬镜下钬激光碎石取石术治疗输尿管上段结石的临床效果及安全性。 方法〓应用输尿管硬镜下钬激光碎石取石术治疗112例输尿管上段结石患者。男63例,女49例,年龄18~87岁(46.7±13.6岁),左侧61例,右侧46例,双侧5例。结石长径0.7~2.2 cm(1.2±0.5 cm)。26例合并输尿管息肉,31例曾行体外冲击波碎石术,所有患侧肾脏均合并不同程度肾积水。 结果〓手术成功率88.4%(99/112),手术时间15~80 min(33.6±16.8 min),术后住院天数3~14天(4.7±2.1天)。所有患者均无严重肉眼血尿、输尿管穿孔、粘膜撕裂、输尿管镜石街形成等并发症。3例患者出现畏寒、高热,其中1例发展为尿源性脓毒血症,予以积极抗感染治疗后,症状逐渐缓解。结论〓输尿管硬镜下钬激光碎石取石术治疗输尿管上段结石是安全,有效的治疗方法。     

应用拦石网输尿管镜下钬激光碎石术治疗输尿管上段结石

目的 探讨应用拦石网输尿管镜下钬激光碎石术治疗输尿管上段结石的临床疗效.方法 回顾性分析输尿管镜下拦石网配合钬激光碎石术治疗58例输尿管上段结石患者的临床资料.男36例,女22例,平均47.2岁.结石横径为3～23 mm,纵径为3～25mm.结果 本组单次碎石成功率93.1%(54/58).2例结石上移入肾内,1例因输...     

输尿管软镜钬激光碎石术治疗输尿管上段结石

目的 总结输尿管软镜结合钬激光治疗输尿管上段结石的疗效及并发症,探讨手术技巧.方法 38 例输尿管上段结石患者接受输尿管软镜钬激光碎石治疗,先使用8/9.8 F 输尿管硬镜探查患侧输尿管,置入导丝后留置输尿管软镜鞘,引入输尿管软镜,钬激光碎石,并使用套石篮套取出较大的结石碎屑.结果 35 例患者一期顺利碎石,3 例因输尿管狭窄难以置入输尿管软镜鞘,留置输尿管内支架2 周后再次手术成功.手术时间31~56 min,平均42 min.术后7 例患者发热,无其他严重并发症.术后1 个月拔除内支架,2 周后复查KUB,结石清除率92.1%.结论 输尿管软镜结合钬激光是处理输尿管上段结石的有效手段,即便输尿管结石进入肾内,也可一期处理,避免了额外的体外碎石操作.     

The cost analysis of flexible ureteroscopic lithotripsy in 302 cases

The objective of this study was to audit the cost of flexible ureterorenoscopic lithotripsy. The data for 302 consecutive flexible ureteroscopic lithotripsy (FURSL) procedure undertaken in our department for renal stone treatment were collected retrospectively. The costs associated with performing FURSL, including the cost of ancillary equipment were analyzed. This includes the cost of the initial purchase of the ureterorenoscopes and the holmium laser equipment. The cost of flexible ureterorenoscopy for each lithotripsy procedure (for a total of 302 FURSL) was $118. Additional cost of ancillary equipment including laser device, ureteral acces sheath and stone retrival catheter were $156, $231 and $611, respectively. In this series, the costs of the ancillary equipment including laser exceeded the purchase and maintenance of the flexible ureteroscope. The cost of disposables rather than flexible ureteroscope itself should be considered in planning the budget.