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| Flexible ureteroscopic treatment of kidney stones: How do the new laser systems change our concepts? |
Simin Yu,Linhu Liu,Ya Li,Liang Zhou,Jixiang Chen,Hong Li,Kunjie Wang*( )
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Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China
Hospital, Sichuan University, Chengdu, Sichuan, China |
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Abstract Objective: Flexible ureteroscopy (fURS) has become a widely accepted and effective technique for treating kidney stones. With the development of new laser systems, the fURS approach has evolved significantly. This literature review aims to examine the current state of knowledge on fURS treatment of kidney stones, with a particular focus on the impact of the latest laser technologies on clinical outcomes and patient safety. Methods: We conducted a search of the PubMed/PMC, Web of Science Core Collection, Scopus, Embase (Ovid), and Cochrane Databases for all randomized controlled trial articles on laser lithotripsy in September 2023 without time restriction. Results: We found a total of 22 relevant pieces of literature. Holmium laser has been used for intracavitary laser lithotripsy for nearly 30 years and has become the golden standard for the treatment of urinary stones. However, the existing holmium laser cannot completely powder the stone, and the retropulsion of the stone after the laser emission and the thermal damage to the tissue have caused many problems for clinicians. The introduction of thulium fiber laser and Moses technology brings highly efficient dusting lithotripsy effect through laser innovation, limiting pulse energy and broadening pulse frequency. Conclusion: While the holmium:yttrium-aluminum-garnet laser remains the primary choice for endoscopic laser lithotripsy, recent technological advancements hint at a potential new gold standard. Parameter range, retropulsion effect, laser fiber adaptability, and overall system performance demand comprehensive attention. The ablation efficacy of high-pulse-frequency devices relies on precise targeting, which may pose practical challenges.
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Received: 31 January 2023
Available online: 20 April 2024
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Corresponding Authors:
* E-mail address: wangkj@scu.edu.cn (K. Wang).
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| Study | Pt, n | Laser setting | Primary outcome | Secondary outcome | Major conclusion | | Ho:YAG | TFL | Moses 2.0 | Moses 1.0 | | Haas et al., [47] 2023 | ? Pts diagnosed with renal stones, 108 | ? NA | ? 200 μm laser fibers: 0.3-0.8 J; 8-80 Hz | ? 200 μm laser fibers: 0.4-0.8 J; 6-20 Hz | ? NA | ? Ureteroscope time required to adequately fragment stones to 1 mm or less | ? SFR, complications, subjective surgeon measurement of laser performance, Pt related stone quality of life outcomes, and measurements of laser efficiency | ? No significant clinical advantage of TFL over the Ho:YAG with Moses 2.0 | | Ulvik et al., [45] 2022 | ? Pts with renal stones ≥5 mm, 120 | ? 270 μm laser fibers: 0.4-0.8J; 6-20 Hz | ? 200 μm laser fibers: 0.4-0.8J; 6-20 Hz | ? NA | ? NA | ? SFR | ? Operative time and complications | ? Significantly more Pts with renal stones achieved stone-free status and fewer experienced intraoperative complications using TFL compared to Ho:YAG | | Shrestha et al., [52] 2022 | ? Pts with renal stones <2 cm, 120 | ? 270 μm laser fibers
-LP group: 0.5-1.5 J; 15-20 Hz
-HP group: 0.2-1.0 J; 50-80 Hz | ? NA | ? NA | ? NA | ? Lasing duration | ? Total laser energy used, laser energy used to ablate 1 mm3 of stone, operative duration, stone ablation speed, and SFR | ? The total energy used were lower in the LP group than in the HP group with similar lasing duration, operative duration, ablation speed, and SFR for Pts | | Martov et al., [53] 2021 | ? Pts with single renal stone, 174 | ? 365 μm laser fibers: 1 J; 10 Hz | ? 400 μm laser fibers: 1 J; 10 Hz | ? NA | ? NA | ? The ability to effectively treat the stone | ? Total operation and lasering time, the degree of retropulsion, and endoscopic view deterioration | ? SP TFL technology was associated with excellent efficacy and safety ratio | | Karakoyunlu et al., [54] 2021 | ? Pts with renal stones (1-2 cm), 223 | ? 272 μm laser fibers: 0.8-3.0 J; 8-15 Hz | ? NA | ? NA | ? NA | ? The efficacy of different laser devices on lithotripsy | ? The effect of different laser devices and power ranges on perioperative outcomes | ? The 30 W laser device used in RIRS for 1-2 cm kidney stones had shorter operative time, higher SFRs, and lower postoperative pain scores compared with the 20 W device | | Abdelbary et al., [55] 2021 | ? Pts with upper ureteric stones (<1.5 cm and ≤1000 HU), 108 | ? 272 μm laser fibers: 0.8-3.0 J; 8-15 Hz | ? NA | ? NA | ? NA | ? SFR | ? Postoperative complications | ? Ultraslow full-power SWL treatment is more safe and effective compared to laser URS | | Alghamdi et al., [56] 2020 | ? Pts with a single ureteral or renal calculus, 145 | ? 275 μm laser fibers: 1.5 J; 10 Hz | ? NA | ? NA | ? NA | ? Laser efficiency overall operative time | ? Number of stone recovery and SFR | ? Efficiency of the Ho:YAG laser can be positively influenced by different pulse shapes | | Lu et al., [57] 2020 | ? Pts with nephrolithiasis, 200 | ? Case group: 365 μm laser fibers: 1.5-2.2 J; 20 Hz
? Control group: 200 μm laser fibers: 0.8-1.0 J; 20 Hz | ? NA | ? NA | ? NA | ? One-step SFR (postoperative 1 day) and final SFR (postoperative 4 weeks) | ? Operation time, Hb drop and white blood cell increase | ? The fURL combined with 365 μm holmium laser is safer and highly efficacious for the management of nephrolithiasis compared to conventional fURL procedures, especially for those located in lower pole and larger than 2 cm | | Ibrahim et al., [58] 2020 | ? Pts diagnosed with renal stones, 72 | ? 275 μm laser fibers: 0.4-1.0 J; 10-80 Hz | ? NA | ? NA | ? 275 μm laser fibers: 0.4-1.0 J; 10-80 Hz | ? Success rate | ? Operative complications | ? The Moses technology was associated with significantly lower fragmentation and pulverization and procedural time due to the significantly lower retropulsion of stones during laser lithotripsy | | Jiang et al., [59] 2019 | ? Pts with lower calyceal stones with a diameter ≤2 cm, 116 | ? 200 μm laser fibers: 0.2-1.0 J; 3-20 Hz | ? NA | ? NA | ? NA | ? SFR | ? Mean Hb reduction and complications | ? For treating lower calyceal stones of ≤2 cm, the “All-Seeing Needle” micro-PCNL group had shorter operative time than fURS | | Jin et al., [60] 2019 | ? Pts with lower-pole renal calculi (1-2 cm), 220 | ? 200 μm laser fibers: 1.0-1.2 J; 10 Hz | ? NA | ? NA | ? NA | ? Operative time | ? Intraoperative and postoperative complications | ? fURL could be a better alternative surgical method to miniaturized PCNL with similar curative effect and less blood loss and hospital stay | | EL-Nahas et al., [61] 2016 | ? Pts with complete staghorn stones (branching to the three major calyces), without contraindications to PCNL, 70 | ? 500 μm laser fibers: 2 J; 20-30 Hz | ? NA | ? NA | ? NA | ? SFR | ? Complications, blood transfusion, operative time, and Hb deficit | ? Compared with Us-L for intracorporeal lithotripsy of staghorn stones during PCNL, Hp-Hll showed comparable safety and efficacy with a lower Hb deficit but longer operative time | | Li et al., [62] 2015 | ? Pts with middle or distal ureteral stones, 982 | ? 0.8-1.0 J; 10 Hz | ? NA | ? NA | ? NA | ? Mean operative time | ? SFR and complications | ? Ho:YAG laser has advantages in efficacy of stone fragmentation and early SFR compared with pneumatic lithotripsy, with the increased risks of postoperative stricture | | Kumar et al., [63] 2015 | ? Pts with single radiopaque upper ureteric calculus >2 cm, 110 | ? 0.6-1.2 J; 5-15Hz | ? NA | ? NA | ? NA | ? Success rate | ? Retreatment, auxiliary procedure rate, and complications | ? LU has a greater stone clearance rate, comparable operative time, lesser need for auxiliary procedure, and complication rate as compared to URS | | Cimino et al., [64] 2014 | ? Pts with single and primary ureteral stones, 133 | ? 200 μm laser fibers: 0.5-1.0 J; 5-10 Hz | ? NA | ? NA | ? NA | ? Mean operative time | ? Complications | ? LL significantly influences the SFR status after ureteroscopy, allowing a higher SFR when compared to PL | | Ganesamoni et al., [65] 2013 | ? Pts undergoing miniperc for renal calculi of 15 mm to 30?mm, 60 | ? 500 μm laser fibers: 0.5-1.5 J; 6-20 Hz | ? NA | ? NA | ? NA | ? Total operative time | ? Stone fragmentation time, surgeon assessed Likert scores for ease of stone fragmentation | ? LL is associated with lower stone migration and easier retrieval of the smaller fragments it produces | | Razzaghi et al., [66] 2013 | ? Pts with 1-2 cm ureteral calculi, 112 | ? 0.2-1.5 J; 5-10 Hz | ? NA | ? NA | ? NA | ? Mean operation time | ? Complications, immediate and 3-month stone-free status | ? LL is a superior approach for the management of upper ureteral stones compared with pneumatic lithotripsy | | Kassem et al., [67] 2012 | ? Pts with a ureteric stone size of 0.5-2 cm, 80 | ? 550 μm laser fiber: 0.6-1.2 J; 5-15 Hz | ? NA | ? NA | ? NA | ? Early SFR | ? Intraoperative complications | ? Both PL and LL are effective and safe modalities in treating large ureteric stones with minor insignificant differences | | Zhang et al., [68] 2011 | ? Pts diagnosed with renal stones, 257 | ? 0.8-1.2 J; 6-10 Hz | ? NA | ? NA | ? NA | ? Efficiency quotient and cost effectiveness | ? Complications | ? Primary in situ SWL for upper and middle ureteral calculi showed lower complication rates and more cost-effective compared to ureteroscopic holmium laser lithotripsy in Eastern China | | Binbay et al., [69] 2011 | ? Pts with ureteral stones, 87 | ? 550 μm laser fiber: 1.0-1.5 J; 5-12 Hz | ? NA | ? NA | ? NA | ? Operative time | ? SFR and complications | ? Ho:YAG is highly efficient with high success rates, regardless of the stone location compared with pneumatic lithotripsy | | Garg et al., [70] 2009 | ? Pts with ureteral stones, 55 | ? 550 μm laser fibers: 0.2-0.8 J; 3-16 Hz | ? NA | ? NA | ? NA | ? Immediate stone clearance rate | ? Complications | ? Both laser and pneumatic energies are effective and safe for intracorporeal lithotripsy; LL takes more time but provides earlier stone-free status | | Arrabal-Polo et al., [71] 2009 | ? Pts with lithiasis localized in the lumbar ureter, iliac or pelvic regions, 164 | ? 600 μm laser fibers: 1.5-2.5 J; 3-6 Hz | ? NA | ? NA | ? NA | ? Overall success rate | ? Complications | ? Endoscopic lithotripsy with the holmium laser is more effective than ESWL, but for lumbar ureteric calculi ESWL is therapeutically recommended as it is less invasive |
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Summary of included studies.
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Flowchart illustrating literature review. Ho:YAG, holmium:yttrium-aluminum-garnet; TFL, thulium fiber laser.
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| Feature | Moses 1.0 | Moses 2.0 | | First description | ? 2017 | ? 2021 | | Definition | ? A composed pulse mode in which the first pulse generates a vapor cavity and more effectively delivers the second pulse to the target as the energy of the electromagnetic wave is less absorbed by water | ? A new version of this high-power laser that can go up to 120 Hz | | Clinical implication | ? Shorter lasting time and better laser efficacy | ? Faster ablation speed, longer operative time, and higher stone-free rate |
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Differences between Moses 1.0 and Moses 2.0.
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| Study | Technique | Laser setting | Stone location, sizea (cm) | Lasing timea, min | Energya, kJ | SFR, % | | Majdalany et al., 2021 [24] | ? Moses 1.0 | ? 0.5 J/50-80 Hz | ? Renal, 0.94 | ? 5.3 | ? 6.4 | ? 71 | | ? Moses 2.0 | ? 0.5 J/50-120 Hz | ? Renal, 0.94 | ? 7 | ? 12.4 | ? 90 | | Rezakahn Khajeh et al., 2021 [5] | ? Moses 2.0 | ? Debulk: 0.2-0.3 J/ 100-120 Hz | ? Renal, 1.04 | ? 6.9 | ? 12 | ? 82 | | ? Dusting: 0.5 J/80 Hz (Moses distance) | ? Renal, 1.04 | ? 6.9 | ? 12 | ? 82 | | Ulvik et al., 2022 [45] | ? Ho:YAG | ? 0.8 J/20 Hz
? 0.4 J/6 Hz | ? Renal, 1.5
? Ureteric, 0.9 | ? 13
? 13 | ? 4.2
? 4.2 | ? 49
? 100 | | ? TFL | ? 0.8 J/20 Hz | ? Renal, 1.3 | ? 13 | ? 3.5 | ? 86 | | | ? 0.4 J/6 Hz | ? Ureteric, 0.9 | ? 13 | ? 3.5 | ? 100 | | Patil et al., 2022 [72] | ? Holmium laser and Moses mode | ? 0.3-1.2 J/ 20-80 Hz | ? Renal, 1.7 | ? 11.3 | ? 21.9 | ? 78 | | ? TFL | ? 0.1-1.0 J/ 100-250 Hz | ? Renal, 1.8 | ? 9.2 | ? 16.3 | ? 69 | | Knoedler et al., 2021 [18] | ? Holmium laser and Moses mode | ? 0.3-0.8 J/ 8-80 Hz | ? Renal, 13.1 | ? 10.2 | ? 7.7 | ? 34.3 | | ? Ureteric, 7.7 | ? 3.9 | ? 2.1 | ? 75 | | ? Holmium laser and regular mode | ? 0.3-0.8 J/ 8-80 Hz | ? Renal, 14.7
? Ureteric, 6.8 | ? 8.6
? 2.9 | ? 5.4
? 1.5 | ? 61.9
? 93.8 | | Corrales et al., 2021 [46] | ? TFL | ? 0.3-0.6 J/ 50-180 Hz | ? Renal, NA | ? 23 | ? 18.6 | ? NA | | ? 0.2-0.4 J/ 20-55 Hz | ? Ureteric, NA | ? 9.3 | ? 16.3 | ? NA | | Pietropaolo et al., 2021 [73] | ? Moses 1.0 | ? 0.4-0.8 J/20-35 Hz | ? Renal and ureteric, 1.1 | ? NA | ? NA | ? 97.3 | | ? Holmium laser | ? 0.4-0.8 J/12-18 Hz | ? Renal and ureteric, 1.2 | ? NA | ? NA | ? 81.6 |
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