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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.
Multifunctional Use Of "Holmium:Yag Laser" in Urology
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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 (400m)
Dimensions 79 cm H x 36 cmW x 53 cm D
Weight 64 Kg
Cost 20W £70000
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Holmium: Yag LaserFrom Sun Microsystems, California, USA
Holmium Laser
Setting for Stones - 0.05 - 1 Joule/Pulse at 5 Watts
Setting for Other Proced.- 1 Joule/Pulse at 15 Watts
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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
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Holmium Laser for ureteric
Lithotripsy - 114 (79%)
Other Procedures With
Holmium Laser - 30 (21%)
HOLMIUM:YAG Laser in Urology
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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
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Holmium:YAG For Stone Disease
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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)
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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
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6 year old with bilateral renal and Right lower ureteric calculi.
She underwent Ureteroscopy and holmium laser lithotripsy.
Holmium:YAG For Stone Disease
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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
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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)
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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
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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
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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
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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
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Holmium for Neoureterocystostomy….
Superstiff guidewire passed through the neo-orifice and pulled down into the bladder with cystoscope
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Holmium for Neoureterocystostomy….
Neo-orifice dilated with a balloon catheter to 14 Fr
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Holmium for Neoureterocystostomy….
6F 22cm JJ stent inserted
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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
Complications with Holmium:YAG Laser - Stones
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Early
Hemorrhage (PUJ obst.) 1
Hydropneumothorax (Calyc. Divert.) 1
Late
Nephrectomy (Stricture) 1
Total 3
Complications with Holmium:YAG Laser - other procedures
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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).
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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