Ureteroscopic lithotripsy by thulium fiber laser versus holmium laser: A single-center prospective randomized study.

Objective: Laser lithotripsy has been the standard of care for lower and mid-ureteric calculi. Thulium fiber laser (TFL) is a new introduction to this field, which has been extensively studied for retrograde intrarenal surgery. We have done a prospective randomized study of ureteroscopic lithotripsy between TFL and holmium: Yttrium-aluminum-garnet (HO: YAG) laser to know the efficacy of stone fragmentation, stone-free rate, and complications. Methodology: A prospective randomized study was done in our hospital from March 2021 to May 2022 on patients planned for ureteroscopic laser lithotripsy. Patients with distal and mid-ureteral stones from 4 mm to 15 mm were included. The laser was used to fragment the stone. All the stones were fragmented from the center to periphery. The setting used was up to 10 W (6-10 Hz, 1J) for TFL and up to 10 W for HO: YAG (5-10 Hz, 0.5-1J). Once the stones were fragmented, they were retrieved until complete visual clearance. Demographic data and stone parameters such as stone size, volume, density, laterality, laser usage time, total operative time, and total energy used were recorded. Operative time, lasering time, retropulsion rate, ablation speed, and visibility score were recorded. Results: Each group had 90 randomized patients. Both the groups had similar kinds of patient and stone profiles. The mean operating time was 18.5 ± 1.5 min (95% confidence interval [CI] 16.2-25.6) in the TFL group, which was shorter than the holmium group 31.6 ± 1.2 min (95% CI 18.4-38.5), and it was statistically significant (P = 0.024,). Lasering time was also statistically significant with less lasering time with TFL group 7.4 ± 1.8 min (95% CI 5.2-10.3) versus holmium group 14.8 ± 1.5 min (95% CI 12.3-18.4) (P = 0.011). Laser efficacy and ablation speed were better in the TFL group compared to the HO: YAG group and were statistically significant. The visual score was better in HO: YAG group compared to the TFL group. Conclusion: TFL is more efficacious and faster than Holmium: Yag laser. Complications were similar between the groups. Stone-free rate was also similar between both the groups.

A multicentric non-randomized prospective observational study on the clinical efficiency of thulium fibre laser in large volume stones (> 1000 mm3).

PURPOSE: Our objective was to analyse the clinical efficiency of TFL in large volume stones during retrograde intrarenal surgery. MATERIALS AND METHODS: Patients with large volume renal stones (> 1000 mm3) operated at two different centres, from May 2020 to April 2021, were enrolled in this study. Retrograde intrarenal surgery was performed using 60W Superpulse thulium fibre laser™ (IPG Photonics, Russia). Demographic data, stone parameters, laser time, and total operating time were recorded, and laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. NCCT KUB was done at 3 months postoperatively to calculate stone-free rate. RESULTS: A total of 76 patients were included and analysed in the study. Mean stone volume was 1753.12 ± 1245.81 (1169.27-2193.25) mm3, mean stone density was 1104.46 ± 313.09 (875.00-1317.00) HU, mean laser time was 537.79 ± 689.89 (21.00-1080.00) sec, mean operating time was 43.38 ± 12.96 (35.00-51.25) min, mean laser efficacy was 20.30 ± 15.5 (8.88-25.57) J/mm3, and mean ablation speed was 1.32 ± 0.7 (0.82-1.64) mm3/sec. A strong positive correlation was found between the stone volume and ablation speed (r = 0.659, p = 0.000), and a moderate negative correlation was found between the stone volume and laser efficacy (J/mm3) (r = - 0.392, p = 0.000). With increasing volume of the stone, J/mm3 decreased significantly and ablation speed increased significantly (p < 0.001). Complications occurred in 21.05% (16/76) patients, most of which were Clavien grades 1-2. Overall SFR is 96.05%. CONCLUSION: Laser efficiency increases at higher stone volumes (> 1000 mm3), as less energy is required to ablate every mm3 of stone.

Durability of current generation flexible ureteroscopes: the experience from a high-volume centre.

Introduction: The aim of this article was to evaluate the durability of current generation fibreoptic flexible ureteroscopes (FURS), analyse factors that influence durability, identify reasons for premature damage of FURS and offer suggestions to expand its life span. Material and methods: A total of 952 retrograde intrarenal surgeries (RIRS) done for upper tract calculi using 8 fibreoptic FURS, namely three Storz Flex X2, one Flex X2S, two Olympus URF- P6, two Olympus URF- P7, between March 2013 and December 2018, were reviewed retrospectively. All procedures were done by two consultants, in a single referral centre. Data relating to stone characteristics and flexible ureteroscopy procedure were retrieved from hospital database. The primary end point was damage of FURS requiring first repair. Results: The average stone burden was 14.59 ±3.37 mm (range 3-22 mm). Ureteral access sheath was used in 95.4% of cases, 36.7% of the cases were pre-stented. Mean ureteroscope durability was 119 procedures and mean ureteroscopy time was 71.99 hours of use before first repair. Prolonged laser usage time and increased usage of accessories had significant negative impact on longevity of FURS (p = 0.002, p = 0.036 respectively). Inadvertent laser fibre misfire and extreme torque caused premature FURS damage, at the end of 35 and 12 procedures respectively. Conclusions: Current generation fibreoptic flexible ureteroscopes have a mean durability of 119 procedures. Anticipation of torque, knowledge of the common reasons for damage and meticulous handling is essential to maximise the durability of FURS.

The clinical efficiency and safety of 60W superpulse thulium fiber laser in retrograde intrarenal surgery.

Introduction: Our aim is to evaluate the clinical efficiency and safety of 60W Thulium fiber laser (TFL) during retrograde intrarenal surgery (RIRS). The performance of the TFL across different ranges of stone volumes and stone densities is assessed. Materials and Methods: Between October 2019 and August 2020, a prospective study was done on 135 patients with < 20 mm renal stones, who underwent RIRS using TFL. Stone parameters, total laser time, total energy delivered (kJ), and fiber burn-back were recorded. Laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. Results: Data of 126 of 135 patients included in the study were analyzed. The mean patient age was 45.04 ± 12.30 years. Mean stone size was 15.19 ± 4.52 mm, and mean stone volume was 1061.85 ± 806.81 mm3. Mean laser time was 19.78 ± 12.32 min. At higher stone volume (>1000 mm3), J/mm3 decreased significantly from 16.18 ± 5.90 to 10.92 ± 3.21 (P < 0.001) and the ablation speed increased significantly (0.77 ± 0.28-1.04 ± 0.28 mm3/s [P < 0.001]). Stone density did not have a significant influence on the laser efficacy [B = -0.31 (-2.45 to 1.82, p=0.771)] or on the ablation speed [B = -0.06 (-0.17 to 0.05, p=0.278)]. Overall SFR was 93.6%. The complication rate was 16.6% (21/126). Out of the 21, 12 patients had hematuria and 9 had fever, which were of Clavien grades 1-2. Conclusion: Superpulse TFL is efficient and safe. The work efficiency increases for larger volume stones. The work efficiency remains the same across different stone densities. No complication more than Clavien grade 2 was encountered.

Occult penile fracture: An atypical presentation.

Penile fracture is a urological emergency. Most cases are under reported due to social stigma. It is caused by rupture of the tunica -albuginea of corpora cavernosa. Here we present an atypical case of penile fracture, with normal physical examination findings. But characteristic history and ultrasonography, led us to penile exploration and timely repair. Delay in diagnosis and treatment could have led to complications. Objective of our case report is to raise suspicion of fracture penis in patients with typical history, even without physical findings with normal appearing penis. This helps in early repair and prevent complications.

Supine percutaneous nephrolithotomy in a 9-month infant.

Treatment of nephrolithiasis in infants is challenging. There are no separate guidelines for the management of renal stones in infants. There is a recent surge in doing PCNL in supine position. Literature is lacking regarding the feasibility and safety of supine PCNL in infants. We report a case of supine PCNL in 9-month-old female baby. We report our case to insist on the feasibility, safety and advantages of supine PCNL even in less than 1 year age group.

Emphysematous pyelonephritis with gas in inferior vena cava.

Emphysematous pyelonephritis (EPN) is a progressive necrotizing infection of the renal parenchyma, collecting system and perinephric tissue. A 36-year female with uncontrolled diabetes, presented with left emphysematous pyelonephritis, with air in the infra-hepatic inferior vena cava (IVC). She was hydrated, treated with intravenous antibiotics, insulin. Percutaneous nephrostomy with Double J stenting was done in modified supine position. Patient was discharged with nephrostomy. Two weeks later, flexible ureterorenoscopy was done and obstructing papillary necrosis removed. Pneumo-vena cava due to emphysematous pyelonephritis is quite rare and careful evaluation is required. Prompt intervention is life saving and obviates the need for nephrectomy.

Bilateral simultaneous RIRS for calculus anuria in a 4 months male baby.

Treatment of pediatric stone disease is a challenge, more so, in the case of infants. Infantile anuria due to calculus disease is rare, as pre-renal causes predominate. Retrograde intrarenal surgery is a less often sorted modality in infants, due to the lingering skepticism regarding handling pediatric ureters and urethra. We hereby present the first case report of bilateral simultaneous RIRS, in a 4 month old male child. With better stone free rates than ESWL and a lesser incidence of major complications, we opted for RIRS in this child, taking advantage of the pre-stented ureter.