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Multifunctional Use Of "Holmium:Yag Laser" in Urology

Multifunctional Use Of "Holmium:Yag Laser" in Urology. 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.

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Multifunctional Use Of "Holmium:Yag Laser" in Urology

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  1. Multifunctional Use Of "Holmium:Yag Laser" in Urology 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.

  2. 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 (400mm) Dimensions 79 cm H x 36 cmW x 53 cm D Weight 64 Kg Cost 20W £70000

  3. Holmium Laser Holmium: Yag Laser From Sun Microsystems, California, USA Setting for Stones - 0.05 - 1 Joule/Pulse at 5 Watts Setting for Other Proced.- 1 Joule/Pulse at 15 Watts

  4. 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

  5. HOLMIUM:YAG Laser in Urology Holmium Laser for ureteric Lithotripsy - 114 (79%) Other Procedures With Holmium Laser - 30 (21%)

  6. 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

  7. Holmium:YAG For Stone Disease

  8. 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)

  9. 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

  10. Holmium:YAG For Stone Disease 6 year old with bilateral renal and Right lower ureteric calculi. She underwent Ureteroscopy and holmium laser lithotripsy.

  11. 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

  12. 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)

  13. 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

  14. 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

  15. 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

  16. 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

  17. Holmium for Neoureterocystostomy…. Superstiff guidewire passed through the neo-orifice and pulled down into the bladder with cystoscope

  18. Holmium for Neoureterocystostomy…. Neo-orifice dilated with a balloon catheter to 14 Fr

  19. Holmium for Neoureterocystostomy…. 6F 22cm JJ stent inserted

  20. Complications with Holmium:YAG Laser - Stones 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

  21. Complications with Holmium:YAG Laser - other procedures Early Hemorrhage (PUJ obst.) 1 Hydropneumothorax (Calyc. Divert.) 1 Late Nephrectomy (Stricture) 1 Total 3

  22. 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).

  23. 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

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