By Sunil Shroff, Graham Watson Institute of Urology & Nephrology in association with St....

By

Sunil Shroff, Graham Watson 

Institute of Urology & Nephrology in association with St. Peter's Hospital, London, UK

 Sri Ramachandra Medical College & Research Institution

Sri Ramachandra Hospital, Porur, Madras.

Multifunctional Use Of "Holmium:Yag Laser" in Urology

Technical Specifications of Holmium: Yag Laser

Laser type Pulse Holmium:YAG

Wavelength 2.1 micron

Pulse duration 350 microsecs

Power to tissue Variable 1 - 20 Watts

Energy/Pulse 1 J - 1.8 J

Aiming beam 3 milliwatts (red)

Beam delivery Low water quartz fibre (400m)

Dimensions 79 cm H x 36 cmW x 53 cm D

Weight 64 Kg

Cost 20W £70000

Holmium: Yag LaserFrom Sun Microsystems, California, USA

Holmium Laser

Setting for Stones - 0.05 - 1 Joule/Pulse at 5 Watts

Setting for Other Proced.- 1 Joule/Pulse at 15 Watts

Advantages of Holmium: Yag Laser

• Combines cutting superiority of Co2 laser haemostatic superiority of Neodymium: YAG Laser

• Can be used in contact and non-contact mode• Can be used for cutting and for stone work• Easy to maintain

Holmium Laser for ureteric

Lithotripsy - 114 (79%)

Other Procedures With

Holmium Laser - 30 (21%)

HOLMIUM:YAG Laser in Urology

Other Procedures With Holmium Laser

Endoureterotomy - Ureteric Strictures 8

PUJ Obstruction Retrograde Endopyelotomy 6

PUJ Obstruction Antegrade Endopyelotomy 1

Ablation of Tumours - Bladder & Kidney 5

Ablation of Calyceal Diverticulum 4

Fragmentation of Lower Calyceal Calculi 2

Bladder Neck Incision 2

Fragmentation of Very hard calculi Calculi 1

Excision of Uretheral Caruncle 1

Total 30

Holmium:YAG For Stone Disease

Site & Size of Stones in the Ureter

Left Right Total

Upper 1/3 rd 24 28 52 Middle 1/3 rd 4 12 16 Lower 1/3 rd 13 33 46

Total 41 73 114

Average size of Calculus - 10 x 6 mm.

(Range from 6 x 2 mm to 50 x 15 mm)

Success with Stones Clearance using Holmium Laser

Left (N=41) Right (N=73)

Upper 1/3 rd 19/24 (79%) 21/28 (75%)

Middle1/3rd 4/4 (100%) 11/12 (92%)

Lower 1/3rd 12/13 (92%) 32/33 (97%)

Total 35/41 (85%) 64/73 (88%)

Lower calyceal calculi (2) – 100% success - fragmentation and clearance

6 year old with bilateral renal and Right lower ureteric calculi.

She underwent Ureteroscopy and holmium laser lithotripsy.

Holmium:YAG For Stone Disease

Holmium:YAG For Stone Disease

She dropped another stone after a few months

and at that time was found to have a stricture

at the site of previous stone. She hence

underwent stricturotomy using the holmium

followed by stenting

Results - Holmium To Cut & Coag.

Sustained Improv.

PUJ Obstruction 5/7 (6 To 12 Months F/U)

Ureteric Stricture 7/8 (1 Year F/u)(2 On DJ Stent)

Calyceal Divert. 2/4 (However Only Partial Ablation)

BNI 2/2 ( 6/12 F/U)

Holmium Laser for impassable PUJ stricture

82 year old male with a permanent nephrostomy ( for over 5 years ) in a solitary kidney. Nephrostogram showed complete obstruction at PUJ level

Holmium Laser Stricturotomy & DJ Stenting

Core through stricturotomy through the PUJ using the holmium laser and DJ stent done to get rid of permanent nephrostomy.

Stent changed every 6-months

Holmium for Neoureterocystostomy

 Antegrade nephrostogram showing looped course of ureter in the transplant kidney with 2 cms lower end stricture.

Transplant Ureter with lower end stricture

Holmium for Neoureterocystostomy….

0.25 super-stiff guidewire through nephrostomy to upper end of stricture.

6F flexible ureteroscope passed over guidewire

Holmium used to rebore through stricture into bladder.

Flexible ureteroscope with holmium beam

Holmium for Neoureterocystostomy….

Superstiff guidewire passed through the neo-orifice and pulled down into the bladder with cystoscope

Holmium for Neoureterocystostomy….

Neo-orifice dilated with a balloon catheter to 14 Fr

Holmium for Neoureterocystostomy….

6F 22cm JJ stent inserted

Early

Perforation of ureter 3

Double J Stent for Obstruction 3

Nephrostomy for Obstruction 2

Deep venous thrombosis 1

 Late

Ureteric Stricture 3

Total 12

Complications with Holmium:YAG Laser - Stones

Early

Hemorrhage (PUJ obst.) 1

Hydropneumothorax (Calyc. Divert.) 1

Late

Nephrectomy (Stricture) 1

Total 3

Complications with Holmium:YAG Laser - other procedures

Conclusion - Holmium for Stones

1. Can be used through the smallest semirigid ureteroscopes (6.9F).

2. Can be used through flexible ureteroscopes.

3. Effective for very hard stones

(Disadvantage - not as safe as pulsed dye laser for ureteric wall).

Conclusion - Holmium To Cut & Coag.

1. Excellent haemostatic properties

2. Use via small calibre ureteroscope

3. End on cutting action of laser under vision - an advantage

4. Control & precision greater with laser

5. Depth of penetration 0.5cm - safe for deeper tissues like intestines

6. Multi-Speciality Laser - hence economical