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BackTable / Urology / Article
Laser Treatment for Kidney Stone & Upper Tract Tumor Removal
Melissa Malena • Updated Oct 2, 2024 • 34 hits
Laser technology has advanced the treatment of kidney stones and urinary tract tumors, offering a less invasive solution for both conditions. Traditional surgical methods often involve more procedural trauma, longer recovery times, and a higher risk of complications, but laser-based techniques can provide precision and efficiency, allowing for targeted stone fragmentation and tumor removal with minimal impact on surrounding tissues.
Whether it’s treating complex stone formations or addressing small tumors in delicate areas, the integration of laser technology is reshaping urologic care, improving patient outcomes, and reducing procedural risks. However, as a urologist, it’s important to understand when laser is the most appropriate modality and which technique to employ in specific clinical scenarios. Expert surgical urologist Dr. Ben Chew shares his decision-making process for laser treatment of kidney stones and explains how tackling upper tract tumors with laser differs from classic stone removal.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
•Kidney and ureter stones can be removed with laser technology via dusting or fragmentation and basket techniques.
•Dr. Chew recommends fragmentation with a basket and ureteral sheath for stones in the ureter and upper lobe of the kidney, as dusting involves a significant amount of laser energy.
•Upper tract tumors can be targeted via percutaneous nephrolithotomy (PCNL) incision or a flexible scope.
•When removing active tumors, the thulium fiber laser is Dr. Chew’s preferred modality. He emphasizes that relook procedures are recommended six to eight weeks following the initial procedure to remove any remaining tumor tissue.
Table of Contents
(1) Laser Kidney Stone Removal Techniques: Dust vs. Fragmentation & Basket
(2) Treating Upper Tract Tumors with Laser Technology
Laser Kidney Stone Removal Techniques: Dust vs. Fragmentation & Basket
When deciding between dusting or the fragmentation-and-basket technique for laser kidney stone removal, careful consideration of the stone’s location and the surgeon’s familiarity with the methods is crucial. For ureter stones, Dr. Chew prefers the fragmentation technique over dusting, as the latter requires higher laser energy in the sensitive ureter, increasing the risk of complications. For upper pole kidney stones, Dr. Chew recommends fragmenting the stone with a basket and using a ureteral sheath. While not always necessary, the ureteral sheath helps lower intrarenal pressure, reducing patient discomfort and the risk of sepsis. Both the Holmium and thulium fiber lasers are effective for dusting and fragmenting; however, the Holmium laser is optimized for fragmentation, while the thulium fiber laser excels in dusting.
[Dr. Jose Silva]
Let's talk about the kidney stone per se. Dust versus fragmentation and basket. What are your options or what do you feel about it? When do you do one? What are your thoughts?
[Dr. Ben Chew]
I think do what you're comfortable with. I like to basically fragment and basket, especially when I'm in the distal ureter, just because it's so easy to break it up and take all the pieces out. I don't really like dusting too much in the ureter because it just means a lot more laser energy. I think basketing in the distal ureter is the way to go. Even just putting it into the bladder and letting them pee it out, or you can take it out with a cystoscope afterwards. I think that's a good idea.
For the upper pole in the kidney, certainly basketing involves A, basket and B, a ureteral access sheath usually. I don't use the ureteral access sheath all the time, but if I am going to be up there for some time, I like to put it up and to keep the intrarenal pressure down, so we'd get less chance of sepsis, less pain. Then also to try and really keep all that fluid coming out because then it will basically keep it cool as well as prevent sepsis as well too.
Now the Holmium:YAG with Moses will let you do both fragment and dust it as well too. It's really good at fragmenting and is a pretty good duster. Thulium fiber laser is really good at dusting and not quite as good at fragmenting. This is a car that wants to go fast. This is a laser that just wants to dust because of the wavelength of it and the pulse width and just the way it's all delivered, it's really just built to be a dusting machine.
You can try and fragment by lowering the rate a little bit and going higher up on energy. I know that Mantu Gupta does somewhere around 1 joule and 2 hertz. Not too high in energy but basically very low rate so you can control it really easily and that's good for fragmenting. This is the thulium fiber I'm talking about. We all know that 1 joule and 10 hertz on Holmium:YAG works great. Works really well for basically fragmenting and basketing out.
I think it depends on the stone. Some stones are harder to basket out than others, particularly the soft ones where they just really want to just dust into pieces. My best case scenario is basically to make it into chunks with the laser and that's with either laser depending on how hard it is and then use thulium fiber to basically pop dust it. Basically where I sit in the calyx pop dust for 30 to 45 seconds and for that setting, I like to use 0.1 joule and 200 or 0.15 joules and 240 hertz all at low pulse width, short pulse width for the thulium fiber.
For Moses what I would tend to do for that is basically use 0.2 and 80. You can use that just sparingly. I don't really get a feel sometimes of the Moses contact versus Moses distance. Khurshid Ghani, who's much more of an expert Moses than I am, prefers the distance even if you're in the ureter. I've tended to use distance more. I don't know what experience you have with Moses.
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Treating Upper Tract Tumors with Laser Technology
In addition to stone removal, laser technologies such as the Holmium:YAG and thulium fiber lasers can be used to treat upper tract tumors. When targeting an upper tract tumor, the laser can be placed through a percutaneous nephrolithotomy (PCNL) incision or a flexible scope. For either access technique, Dr. Chew emphasizes the importance of avoiding seeding when using a resectoscope in the kidney and practicing caution to avoid potential injury of the segmental artery.
For actively spreading tumors, Dr. Chew exclusively uses thulium fiber lasers and recommends booking patients for a six to eight-week relook as there is a high likelihood of missing a piece of cancerous tissue. In addition to the relook, neuroband imaging is recommended to help locate any remaining tumor fragments.
[Dr. Jose Silva]
In terms of upper tract tumors are you using a flexible, are you going through the back like a PCNL? What do you usually do for that?
[Dr. Ben Chew]
Usually, it's flexible if we need to and we have done some PCNLs as well too. We've done some percutaneous procedures to get some out. I've used to actually use a resectoscope or just get some tissue out if it's really quite large. We've backed off from that a little bit.
I know some places still do that a lot. I don't know. We're always worried about seeding, but you just have to be careful using the resectoscope in the kidney. I've had one bad instance where we resected through basically, I think a segmental artery. Yes, that was not good. Once we put a Foley catheter in there to tamponade it, it stopped it. Once we had to take it off at some point, once we took it off, the patient bled and we had to remove the kidney.
The good news for me was that the tumor was spread all throughout and was really spreading. It's a good thing we took the kidney out but I use flexible. When we do that, I only use thulium fiber for that now. I always rebook them for at least another six-week look, unless it was a really tiny little thing. If it's anything where it's bigger than a small papillary thing, I always book them for a relook at about six to eight weeks. It's inevitable you may have missed something in there as well too, which could be an issue.
I think using adjuvant things like neuroband imaging, things like that can actually be helpful as well too.
Podcast Contributors
Dr. Ben Chew
Dr. Ben Chew is a urologist at University of Britich Columbia and the chair of research of the Endourology Society.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2024, February 20). Ep. 152 – Laser Options for Kidney Stones: A Clinician’s Guide [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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