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Laser lithotripsy

From Wikipedia, the free encyclopedia
Laser lithotripsy
SpecialtyUrology
ICD-9-CM98
MeSHD017602

Laser lithotripsy (LL) is a surgical procedure which uses lasers to break down and remove stones from the urinary tract, such as in the kidney, ureter, bladder, or urethra.[1] When it involves a ureteroscopy, the procedure is more specifically called ureteroscopic laser lithotripsy (ULL).[2]

History

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Laser lithotripsy was invented at the Wellman Center for Photo Medicine at Massachusetts General Hospital in the 1980s to remove impacted urinary stones. Optical fibers carry light pulses that pulverize the stone[clarification needed]. Candela[who?] licensed the technology and released the first commercial laser lithotripsy system.[3][better source needed]

Today, laser lithotripsy is recommended in current urological guidelines, such as those of the American Urological Association (AUA) or the European Association of Urology (EAU), as a standard treatment for the endoscopic management of urinary stones.[4][5] The choice of laser type, fibre size, and energy settings is adjusted individually according to stone size, composition, and location. The use of holmium lasers for endoscopic stone treatment is also explicitly recommended in current guidelines, while thulium laser systems are increasingly included as alternative options.[6]

Procedure

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The procedure is part of Endourology, a subspecialty of urology focused on minimally invasive techniques within the urinary tract. A urologist inserts a scope into the urinary tract to locate the stone. The scope may be a cystoscope, ureteroscope, renoscope or nephroscope. An optical fiber is inserted through the working channel of the scope, and laser light is directly emitted to the stone. The stone is fragmented and the remaining pieces are collected in a "basket" or washed out of the urinary tract, along with the finer particulate "dust".[7] The procedure is most commonly performed under general anesthesia, although local anesthesia may be feasible in selected cases.[8] It is widely available in most hospitals in the world.

Comparison with extracorporeal shockwave therapy

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Laser lithotripsy has been evaluated against extracorporeal shockwave therapy (ESWT), finding both to be safe and effective.[9][10] ESWT may be safer for small stones (<10 mm), but less effective for 10–20 mm stones.[9] A 2013 meta-analysis found LL can treat larger stones (> 2 cm) with good stone-free and complication rates.[11]

Holmium laser lithotripsy had superior initial success and re-treatment rate compared to ESWT in a 2013 trial.[12] While ESWT is limited to the non-invasive fragmentation of urinary stones, laser-based endoscopic techniques are more versatile, as they can be used not only for lithotripsy but also for soft tissue applications, including the endoscopic treatment of benign prostatic hyperplasia (BPH) and other intraluminal urological procedures.[13]

Lasers

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Pulsed dye lasers have been used with fiber diameters of 200–550 microns[14] for lithotripsy of biliary and urinary stones.[15]

Initially 504 nm dye lasers were used, then holmium lasers were studied in the 1990s.[citation needed]

Holmium:YAG (Ho:YAG) lasers are a type of solid-state laser; they have a wavelength of 2,100 nm (infrared) and are used for medical procedures in urology and other areas. Ho:YAG lasers have been considered the "gold-standard laser for lithotripsy" since the mid-1990s.[7] Ho:YAG laser machines are loud, contain fragile components including lenses and mirrors, consume a large amount of electricity, and usually require a dedicated power source.[7]

They have qualities of CO2 and Nd:YAG lasers, with ablative and coagulation effects.[16] Holmium laser use results in smaller fragments than those produced by 320- or 365-micron pulsed-dye lasers, as well as electrohydraulic and mechanical methods.[17]

More recently, thulium fiber lasers (TFL) have increasingly been used for laser lithotripsy. The frequency of TFLs increased during the start of the 21st century.[7] TFLs have several advantages compared to Ho:YAG lasers, including a four times lower ablation threshold, a near single-mode beam profile, and higher pulse rates.[18] In contrast to other laser settings - particularly fragmentation-oriented techniques that generate larger fragments requiring basket extraction - dusting techniques produce fine dust and small stone fragments that can often be evacuated spontaneously via urine flow or irrigation.[19] This may reduce the need for basket use, which can prolong the procedure depending on stone location and increase the use of additional disposable instruments. In addition, dusting approaches are associated with reduced retropulsion, higher stone-free rates, and shorter overall procedure times compared to conventional Ho:YAG systems.[20] TFL devices are also smaller and lighter than comparable Ho:YAG devices, and use just 10% of the electricity that a Ho:YAG laser would, potentially allowing for the use of multiple laser devices on a single circuit.[7]

Several clinical studies and meta-analyses have demonstrated the effectiveness as well as advantages of TFL.[21][22] In a prospective, randomized trial by Øyvind Ulvik et al. (2022), 120 patients undergoing ureteroscopic lithotripsy were randomized to TFL or Ho:YAG.[23] The stone-free rate was 92 % in the TFL group versus 67 % in the Ho:YAG group, operative time was shorter with TFL (49 min vs 57 min), and intraoperative bleeding occurred in 5 % of TFL cases compared with 22 % of Ho:YAG cases.[24] While Ho:YAG lasers currently remain the guideline-recommended reference standard, TFL is increasingly being adopted in clinical practice and is being progressively incorporated into contemporary guidelines as an alternative treatment option.[25][26][27]

See also

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References

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  1. ^ "Laser Lithotripsy | Winchester Hospital".
  2. ^ Tu, Hin Yu Vincent; Matsumoto, Edward (1 April 2015). "Mp80-12 Cost Analysis of Ureteral Stenting After Uncomplicated Ureteroscopic Laser Lithotripsy for Urolithiasis: A Decision Model Analysis". The Journal of Urology. 193 (45): e1023–e1024. doi:10.1016/j.juro.2015.02.2848.
  3. ^ "Research Discoveries". Wellman Center for Photomedicine. Retrieved 30 April 2011.{{cite web}}: CS1 maint: deprecated archival service (link)
  4. ^ "Surgical Management of Kidney and Ureteral Stones: AUA Guideline (2025) - American Urological Association". www.auanet.org. Retrieved 2026-05-20.
  5. ^ "EAU Guidelines on Urolithiasis - GUIDELINES - Uroweb". uroweb.org. Retrieved 2026-05-20.
  6. ^ "EAU Guidelines on Urolithiasis - GUIDELINES - Uroweb". uroweb.org. Retrieved 2026-05-20.
  7. ^ a b c d e Giusti, Guido; Pupulin, Matheus; Proietti, Silvia (19 August 2022). "Which Is the Best Laser for Lithotripsy? The Referee Point of View". European Urology Open Science. 44: 20–22. doi:10.1016/j.euros.2022.07.014. PMC 9420467. PMID 36043189.
  8. ^ Pearle, Margaret S.; Matlaga, Brian R.; Antonelli, Jodi A.; Chi, Thomas; Hsi, Ryan S.; Kim, Sennett K.; Kirkby, Erin; Knudsen, Bodo; Koo, Kevin; Maalouf, Naim M.; Pais, Vernon M.; Paris, Ann; Penniston, Kristina L.; Scotland, Kymora B.; Souter, Lesley H. (February 2026). "Surgical Management of Kidney and Ureteral Stones: AUA Guideline (2026). Part II: Evaluation and Treatment of Patients With Kidney and/or Ureteral Stones". The Journal of Urology. 215 (2): 124–131. doi:10.1097/JU.0000000000004843. ISSN 1527-3792. PMID 41263322.
  9. ^ a b Kumar A, Vasudeva P, Nanda B, Kumar N, Das MK, Jha SK (Nov 18, 2014). "A Prospective Randomized Comparison Between Shock Wave Lithotripsy and Flexible Ureterorenoscopy for Lower Caliceal Stones ≤2 cm: A Single-Center Experience". J. Endourol. 29 (5): 575–579. doi:10.1089/end.2013.0473. PMID 25203489.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Cecen K, Karadag MA, Demir A, Bagcioglu M, Kocaaslan R, Sofikerim M (Sep 24, 2014). "Flexible Ureterorenoscopy versus Extracorporeal Shock Wave Lithotripsy for the treatment of upper/middle calyx kidney stones of 10-20 mm: a retrospective analysis of 174 patients". SpringerPlus. 3 (1): 557. doi:10.1186/2193-1801-3-557. PMC 4190185. PMID 25332859.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Aboumarzouk OM, Monga M, Kata SG, Traxer O, Somani BK (Oct 2012). "Flexible ureteroscopy and laser lithotripsy for stones >2 cm: a systematic review and meta-analysis". J. Endourol. 26 (10): 1257–63. doi:10.1089/end.2012.0217. PMID 22642568.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Khalil M (Apr 2013). "Management of impacted proximal ureteral stone: Extracorporeal shock wave lithotripsy versus ureteroscopy with holmium: YAG laser lithotripsy". Urol. Ann. 5 (2): 88–92. doi:10.4103/0974-7796.110004. PMC 3685752. PMID 23798864.
  13. ^ Sánchez-Puy, Antoni; Bravo-Balado, Alejandra; Diana, Pietro; Baboudjian, Michael; Piana, Alberto; Girón, Irene; Kanashiro, Andrés K.; Angerri, Oriol; Contreras, Pablo; Eisner, Brian H.; Balañà, Josep; Sánchez-Martín, Francisco M.; Millán, Félix; Palou, Joan; Emiliani, Esteban (June 2022). "New Generation Pulse Modulation in Holmium:YAG Lasers: A Systematic Review of the Literature and Meta-Analysis". Journal of Clinical Medicine. 11 (11): 3208. doi:10.3390/jcm11113208. ISSN 2077-0383. PMC 9181640. PMID 35683595.
  14. ^ Grasso M, Bagley DH (Feb 1994). "Endoscopic pulsed-dye laser lithotripsy: 159 consecutive cases". J. Endourol. 8 (1): 25–7. doi:10.1089/end.1994.8.25. PMID 8186779.
  15. ^ Grasso M, Bagley D, Sullivan K (October 1991). "Pulsed dye laser lithotripsy--currently applied to urologic and biliary calculi". J. Clin. Laser Med. Surg. 9 (5): 355–9. doi:10.1089/clm.1991.9.355. PMID 10150133.
  16. ^ Chun SS, Razvi HA, Denstedt JD (Winter 1995). "Laser prostatectomy with the holmium: YAG laser". Tech. Urol. 1 (4): 217–21. PMID 9118394.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Teichman Joel M.H. (January 1998). "Holmium:YAG lithotripsy yields smaller fragments than lithoclast, pulsed dye laser or electrohydraulic lithotripsy". J. Urol. 159 (1): 17–23. doi:10.1016/s0022-5347(01)63998-3. PMID 9400428.
  18. ^ Hardy, L.A; Wilson, C.R.; Irby, P.B.; Fried, N.M. (2014). "Rapid vaporization of kidney stones, ex vivo , using a Thulium fiber laser at pulse rates up to 500 Hz with a stone basket". In Choi, Bernard; Kollias, Nikiforos; Zeng, Haishan; Kang, Hyun Wook; Wong, Brian J. F.; Ilgner, Justus F.; Tearney, Guillermo J.; Gregory, Kenton W.; Marcu, Laura; Mandelis, Andreas; Morris, Michael D. (eds.). Photonic Therapeutics and Diagnostics X. Vol. 8926. pp. 89261H. CiteSeerX 10.1.1.819.6910. doi:10.1117/12.2037263. S2CID 121794649. {{cite book}}: |journal= ignored (help)
  19. ^ Kronenberg, Peter; Somani, Bhaskar (2018-05-17). "Advances in Lasers for the Treatment of Stones-a Systematic Review". Current Urology Reports. 19 (6): 45. doi:10.1007/s11934-018-0807-y. ISSN 1534-6285. PMC 5958148. PMID 29774438.
  20. ^ Ulvik, Øyvind; Æsøy, Mathias Sørstrand; Juliebø-Jones, Patrick; Gjengstø, Peder; Beisland, Christian (July 2022). "Thulium Fibre Laser versus Holmium:YAG for Ureteroscopic Lithotripsy: Outcomes from a Prospective Randomised Clinical Trial". European Urology. 82 (1): 73–79. doi:10.1016/j.eururo.2022.02.027. hdl:11250/3010970. ISSN 1873-7560. PMID 35300888.
  21. ^ Tang, Xiaoyu; Wu, Shaojie; Li, Zhilong; Wang, Du; Lei, Cheng; Liu, Tongzu; Wang, Xinghuan; Li, Sheng (February 2024). "Comparison of Thulium Fiber Laser versus Holmium laser in ureteroscopic lithotripsy: a Meta-analysis and systematic review". BMC Urology. 24 (1): 44. doi:10.1186/s12894-024-01419-6. ISSN 1471-2490. PMC 10875760. PMID 38374098.
  22. ^ Chua, Michael E.; Bobrowski, Adam; Ahmad, Ihtisham; Kim, Jin Kyu; Silangcruz, Jan Michael; Rickard, Mandy; Lorenzo, Armando; Lee, Jason Y. (April 2023). "Thulium fibre laser vs holmium: yttrium-aluminium-garnet laser lithotripsy for urolithiasis: meta-analysis of clinical studies". BJU International. 131 (4): 383–394. doi:10.1111/bju.15921. ISSN 1464-4096. PMID 36260370.
  23. ^ Ulvik, Øyvind; Æsøy, Mathias Sørstrand; Juliebø-Jones, Patrick; Gjengstø, Peder; Beisland, Christian (July 2022). "Thulium Fibre Laser versus Holmium:YAG for Ureteroscopic Lithotripsy: Outcomes from a Prospective Randomised Clinical Trial". European Urology. 82 (1): 73–79. doi:10.1016/j.eururo.2022.02.027. hdl:11250/3010970. ISSN 1873-7560. PMID 35300888.
  24. ^ Ulvik, Øyvind; Æsøy, Mathias Sørstrand; Juliebø-Jones, Patrick; Gjengstø, Peder; Beisland, Christian (July 2022). "Thulium Fibre Laser versus Holmium:YAG for Ureteroscopic Lithotripsy: Outcomes from a Prospective Randomised Clinical Trial". European Urology. 82 (1): 73–79. doi:10.1016/j.eururo.2022.02.027. hdl:11250/3010970. ISSN 1873-7560. PMID 35300888.
  25. ^ "Surgical Management of Kidney and Ureteral Stones: AUA Guideline (2025) - American Urological Association". www.auanet.org. Retrieved 2026-05-20.
  26. ^ Ulvik, Øyvind; Æsøy, Mathias Sørstrand; Juliebø-Jones, Patrick; Gjengstø, Peder; Beisland, Christian (July 2022). "Thulium Fibre Laser versus Holmium:YAG for Ureteroscopic Lithotripsy: Outcomes from a Prospective Randomised Clinical Trial". European Urology. 82 (1): 73–79. doi:10.1016/j.eururo.2022.02.027. hdl:11250/3010970. ISSN 1873-7560. PMID 35300888.
  27. ^ "EAU Guidelines on Urolithiasis - GUIDELINES - Uroweb". uroweb.org. Retrieved 2026-05-20.
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