OBJECTIVES
To explore the optimal laser settings and treatment strategies for Thulium Fiber Laser (TFL) lithotripsy with the highest treatment efficiency, lowest thermal injury risk, and shortest procedure time.


MATERIALS AND METHODS
An in-vitro kidney model was utilized to assess the efficacy of TFL lithotripsy. Stone ablation experiments were performed on BegoStone phantoms at different combinations of pulse energy (EP ) and frequency (F) to determine the optimal settings. Temperature changes and thermal injury risks were monitored using embedded thermocouples. Experiments were also performed on calcium oxalate monohydrate (COM) stones to validate the optimal settings.


RESULTS
High EP /low F settings demonstrated superior treatment efficiency compared to low EP /high F settings under the same power. Specifically, the optimal settings of 0.8 J/12 Hz resulted in a two-fold increase in treatment efficiency, 39% reduction in energy expenditure per unit of ablated stone mass, 35% reduction in residual fragments, and 36% reduction in total procedure time compared to the 0.2 J/50 Hz for COM stones. Thermal injury risk assessment indicated that 10 W settings with high EP /low F combinations remained below the threshold for tissue injury, while higher power settings (> 10 W) consistently exceeded the safety threshold.


CONCLUSIONS
Our findings suggest that high EP /low F settings, such as 0.8 J/12 Hz, are optimal for TFL lithotripsy in the treatment of COM stones. These settings demonstrated significantly improved treatment efficiency with reduced residual fragments compared to conventional settings while keeping the thermal dose below the injury threshold. This study highlights the importance of using high EP /low F in low power settings, which maximize treatment efficiency and minimizes potential thermal injury. Further studies are warranted to determine the optimal settings of TFL for treating kidney stones with different compositions.

Exploring optimal settings for safe and effective thulium fiber laser lithotripsy in a kidney model.

Objective Low energy and high frequency settings are used in stone dusting for holmium lasers. Such settings may not be optimal for thulium fiber laser (TFL). With the seemingly endless combination of settings, we aim to provide guidance to the practicing urologists and assess the efficiency of the TFL platform in an automated in vitro "dusting model". Materials/Methods Three experimental setups were designed to investigate stone dusting produced by an IPG Photonics TLR-50W TFL system using 200µm fiber and soft BegoStone phantoms. The most popular 10W and 20W dusting settings among endourologist familiar with TFL were evaluated. We directly compared short pulse (SP) vs. long pulse (LP) mode using various combinations of pulse energy (Ep) and frequency (F). Thereafter, we tested the 10W and 20W settings and compared them amongst each other in order to elucidate the most efficient settings at each power. Treatments were performed under the same total laser energy delivered to the stone at four different standoff distances (SD) with a clinically relevant scanning speed of either 1mm/sec or 2mm/sec. Ablation volumes were quantified by optical coherence tomography to assess stone dusting efficiency. Fragment size after ablation at different pulse energies was evaluated by sieving and evaluating under a microscope after treatment. Results Overall, SP provided greater ablation volume when compared to LP. Our dusting efficiency model demonstrated that the maximum stone ablation was achieved at the combination of high energy/low frequency settings (p<0.005) and at a SD of 0.2mm. At all tested pulse energies, no stone phantoms were broken into fragments >1mm. Conclusions During stone dusting with TFL, SP offers superior ablation to LP settings. Optimal dusting at clinically relevant scanning speeds of 1mm/sec and 2mm/sec occurs at high energy/low frequency settings. Thulium lithotripsy with high pulse energy does not result in increased fragment size.

In pursuit of the optimal dusting settings with the Thulium Fiber Laser: an in vitro assessment.

Experts’ recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group

Flexible ureteroscopy (fURS) with laser lithotripsy is currently the gold standard surgical treatment for ureteral and kidney stones with a maximum diameter of 2 cm [...].

New Technologies in Endourology and Laser Lithotripsy: The Need for Evidence in Comprehensive Clinical Settings.

The Annual Collaborating for the Advancement of Interdisciplinary Research (CAIRIBU) Meeting in 2022 highlighted basic, translational, and clinical non-malignant urology research within five main areas affecting the urinary tract: urinary dysfunction due to prostate disease, microbes and infection, bladder function and physiology, neurology and neuromuscular influences and calculi and obstruction. In this paper, we summarize main findings and future directions outlined by CAIRIBU-affiliated scientists who presented as part of the scientific sessions. 

Current research and future directions in non-malignant urologic research - proceedings of the annual CAIRIBU meeting.

Objectives To investigate mechanistically the effects of fiber scanning speed (vfiber) and fiber tip-to-stone standoff distance (SD) on dusting efficiency during Holmium (Ho): YAG laser lithotripsy (LL) Materials and Methods Pre-soaked BegoStone samples (23 × 23 × 4 mm, W x L x H) were treated in water using a clinical Ho:YAG laser in dusting mode (0.2 J pulse energy delivered at 20 Hz frequency) at three different SDs (0.10, 0.25 and 0.50 mm) with vfiber in the range of 0 to 10 mm/s. Stone damage was quantified by optical coherence tomography, bubble dynamics were captured by high-speed imaging, and associated pressure transients were measured using a needle hydrophone. To compare photothermal ablation vs. cavitation in stone dusting, the experiments were further repeated in air (photothermal ablation only), and in water with the fiber tip advanced at a short (0.25 mm) offset distance (OSD) from a ureteroscope to mitigate the bubble collapse toward the stone surface, thus eliminating cavitation-induced damage. Results Compared to the craters produced by a stationary fiber, the damage troughs produced by a scanning fiber after 100 pulses were significantly larger in volume. The optimal vfiber for maximum dusting efficiency was found to be 3.5 mm/s for SD = 0.10 ∼ 0.25 mm, resulting in long (17.5 mm), shallow (0.14 – 0.15 mm) and narrow (0.3 – 0.4 mm) troughs. In contrast, the maximum stone damage was produced at an optimal vfiber of 0.5 mm/s for SD = 0.50 mm, which generates much shorter (2.5 mm), yet deeper (0.35 mm) and wider (1.4 mm) troughs. Greater stone damage was produced in water than in air, especially at vfiber = 0 – 3.5 mm/s. With the scope end placed near the fiber tip, stone damage could be significantly reduced in water by 29% - 58% for SD = 0.10 mm, by 51% - 82% for SD = 0.25 mm, and by 66% - 100 % for SD = 0.50 mm, compared to those produced without the scope. Together, these findings suggest that cavitation plays an indispensable role in stone dusting by scanning treatment. Moreover, under clinically relevant vfiber (1 ∼ 3 mm/s), dusting at SD = 0.5 mm (i.e., non-contact mode) may leverage higher frequency of the laser (e.g., 40 to 120 Hz) to harvest the full potential of cavitation damage while significantly reducing the procedure time, compared to its counterpart at SD = 0.1 mm (i.e., contact mode) that promotes photothermal ablation. Conclusion Dusting efficiency during Ho:YAG LL may be substantially improved by utilizing the optimal combination of vfiber and SD for a given frequency.

The Optimal Combination of Scanning Speed and Fiber-to-Stone Distance for Effective and Efficient Dusting during Holmium: YAG Laser Lithotripsy

To investigate the effects of fiber lateral scanning speed across the stone surface (vfiber) and fiber standoff distance (SD) on dusting efficiency during short pulse holmium (Ho): YAG laser lithotripsy (LL), pre-soaked BegoStone samples were treated in water using 0.2 J/20 Hz at SD of 0.10~0.50 mm with vfiber in the range of 0~10 mm/s. Bubble dynamics, pressure transients, and stone damage were analyzed. To differentiate photothermal ablation vs. cavitation damage, experiments were repeated in air, or in water with the fiber tip at 0.25 mm proximity from the ureteroscope end to mitigate cavitation damage. At SD = 0.10 mm, the maximum dusting efficiency was produced at vfiber = 3.5 mm/s, resulting in long (17.5 mm), shallow (0.15 mm), and narrow (0.4 mm) troughs. In contrast, at SD = 0.50 mm, the maximum efficiency was produced at vfiber = 0.5 mm/s, with much shorter (2.5 mm), yet deeper (0.35 mm) and wider (1.4 mm), troughs. With the ureteroscope end near the fiber tip, stone damage was significantly reduced in water compared to those produced without the ureteroscope. Under clinically relevant vfiber (1~3 mm/s), dusting at SD = 0.5 mm that promotes cavitation damage may leverage the higher frequency of the laser (e.g., 40 to 120 Hz) and, thus, significantly reduces the procedure time, compared to at SD = 0.1 mm that promotes photothermal ablation. Dusting efficiency during short pulse Ho: YAG LL may be substantially improved by utilizing an optimal combination of vfiber, SD, and frequency.

/pdf/the-effects-of-scanning-speed-and-standoff-distance-of-the-24xcv9ga.pdf

The Effects of Scanning Speed and Standoff Distance of the Fiber on Dusting Efficiency during Short Pulse Holmium: YAG Laser Lithotripsy

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The Optimal Combination of Scanning Speed and Fiber-to-Stone Distance for Effective and Efficient Dusting during Holmium: YAG Laser Lithotripsy

The Effects of Scanning Speed and Standoff Distance of the Fiber on Dusting Efficiency during Short Pulse Holmium: YAG Laser Lithotripsy