Urolithiasis management- icl.

Contoso
Pharmaceuticals
Intracorporeal
Lithotripsy
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai page 1

Contoso
Pharmaceuticals
Moderators:
Professors:
• Prof. Dr.G. Sivasankar,M.S., M.Ch.,
• Prof. Dr.A. Senthilvel,M.S., M.Ch.,
Asst Professors:
• Dr.J. Sivabalan,M.S., M.Ch.,
• Dr. R. Bhargavi,M.S., M.Ch.,
• Dr.S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam,M.S., M.Ch.,
• Dr. D.Tamilselvan,M.S., M.Ch.,
• Dr. K. Senthilkumar,M.S., M.Ch.
Dept of Urology, GRH and KMC,Chennai.
2

CAMPBELL-
NON
LOWERPOLE
RENAL
CALCULUS
3
DEPT OF UROLOGY,GRH ANDKMC,CHENNAI.

CAMPBELL-
LOWERPOLE
RENAL
CALCULUS
4

EAU GUIDELINES
URETERIC STONE
5

ENERGY SOURCES
1. Flexible Lithotrites
Laser lithotripsy
Electrohydraulic lithotripsy
2. Rigid Lithotrites
Ballistic lithotripsy
Ultrasonic lithotripsy
6

ELECTRO HYDRAULIC LITHOTRIPSY
7

ELECTROHYDRAULIC LITHOTRIPSY
Based on intracorporeal electric
discharge.
A controlled, very fast electric
discharge centered at the tip of the
probe generates a spark plasma.
This expanding plasma and later the
collapse of a cavitation bubble
create sharp rising shock waves which
disintegrate the stone in seconds.
8

EHL PROBES
9

EHL SETUP
10

EHL TECHNIQUE
1.6- and 1.9-Fr flexible probes should be used.
Fiber tip should be positioned 2 to 5 mm distal to the end of the ureteroscope to
protect the lens system.
Before activation, the stone must be clearly visible.
The probe is placed approximately 1 mm from the stone surface, a distance
allowing maximum shock wave emission.
Initially, low voltage (50 to 60 V) and short intermittent or single pulses are used to
enhance safety.
The generator output is increased as needed to fragment the stone.
11

12

Advantage:
1. Probe flexibility
2. Less expensive
Disadvantage:
1. Damage to ureteral mucosa and
perforation (EHL Vs PL 17.6% Vs 2.6%)
2. Retrograde propulsion of calculi
3. Smooth calculi not easily fragmented.
13

LASER LITHOTRIPSY
14

LASER
Light
Amplification by
Stimulated
Emission of
Radiation
An Atom is Stimulated to Emit Radiation and is used
for Light Amplification
15

LASER PRINCIPLE
16

RUBY LASER
First laser to develop
Continuous wave laser
Excess heat generation
Stone vapourised beyond its melting
point.
Not clinically used.
17

PULSED DYE LASER
First widely clinically available laser
lithotrite.
Coumarin green dye is the liquid lasing
medium.
Could not fragment Calcium oxalate
monohydrate and cysteine stones.
Needed eye protection.
Coumarin dye is toxic and disposing it is
difficult.
18

YAG AND DOPING
19

ND:YAG (NEODYMIUM DOPED YAG)
20

HOL:YAG (HOLMIUM DOPED YAG)
Solid state pulsed laser system
Wave length 2140 nm.
Pulse duration 250-350 microsec
Highly absorbed in water
Zone of thermal injury 0.5-1.0 mm
Lithotripsy by photothermal mechanism
causing stone vaporization.
21

HOL:YAG (HOLMIUM DOPED YAG)
Advantages
Flexible fiber
Safer and efficient than EHL
All stones can be fragmented
Weak shock wave hence less retropulsion
Disadvantages
High initial cost of device and cost of
laser fibers
Failure of fiber damages the
ureteroscope
22

PULSE ENERGY
23

PULSE ENERGY HOL:YAG
Measured in Joules
Ranges from 0.2 J to 6.0 J
For URS, typically ranges from 0.2 J to 2.0 J
Higher PE produces larger fragments ideal for stone retrieval devices.
Lower PE produces smaller fragments ideal for spontaneous removal. (Dusting)
24

PULSE FREQUENCY
25

PULSE FREQUENCY HOL:YAG
Measured in Hz
Number of pulses emitted per second.
By keeping the PE constant, and increasing the frequency, fragmentation rate can be
increased.
No increase in retropulsion with increasing frequency.
26

PULSE WIDTH
27

PULSE WIDTH
Duration of single optical pulse emitted from the fiber tip.
For Hol:YAG, traditionally, single fixed SP (Short pulse) mode ranging from 150 to
350 microsec.
Next gen systems with LP (Long pulse) mode delivers ranging from 500 to 1300
microsec.
2 Joules 2 Joules
28

LONG PULSE ADVANTAGES
Decreased stone retropulsion
Reduces laser fiber tip degradation (Burnback)
More efficient lithotripsy
29

LASER SETTINGS
30

LASER POWER
POWER (WATTS) = PULSE ENERGY (JOULES) X FREQUENCY (HERTZ)
2 Joules
4 Joules
1 SECOND
X 3 Hz = 6 watts
X 3 Hz = 12 watts
31

LITHOTRIPSY OUTCOMES
32

LASER FIBER - COMPONENTS
33

LASER FIBER CORE
Ranges from 150 – 1000 micrometer
Larger 550-100 micrometer cores for
rigid instruments
Smaller 240-270 micrometer sizes for
flexible ureteroscopy.
Less than 240 micrometer size more
prone for failures.
34

TRUE DIAMETER –
20O MICROMETER REALLY 200 MICROMETER?
Fibers are not really 200 micrometer
overall.
Cook HLF S200 has 200 micrometer core
and with cladding 374 micrometer.
Flexiva 200 fiber core itself is 240
micrometer and true diameter is 443
micrometer with cladding.
35

FIBER FLEXIBILITY
240 -270 micrometer fiber core - 30-60 degree deflection loss
200 micrometer fiber core - 20-30 degree deflection loss
For maximal deflection - 200 micrometer should be used.
But 200 micrometer fibers are not robest as 240-270 micrometer fibers.
36

BALL TIPPED FIBER –
ACCUTRAC™ AND FLEXIVA™ TRACTIP™
Allows easy passage of fiber through
the flexible ureteroscope by sliding
easily.
Can be inserted into the flexible scope
even in deflected position, which is not
advisable for flat fibers.
Useful for lower pole calculi.
Ball effect is provided only during first
insertion due to burn back.
Not reusable.
37

FIBER BURN BACK
High pulse energy results in rapid burn
back.
0.6-1 J vs 0.2-0.3J.
Hard stones leads to more burn back.
Longer pulse duration decreases fiber
burn back.
38

ECONOMICS –
SINGLE USE FLEXI OR SINGLE USE FIBER
LithoVue™ TracTip™
39

PAINTING
When:
Best for soft stones
How:
Place fiber in contact with stone, brush
back and forth across the stone, ablating
layer by layer
40

CHIPPING
When:
Best for harder stones
How:
Place fiber in contact with edge of the
stone and hold steady as small chips
fragment off.
41

POP CORNING
When:
Best for group of 3-4 mm fragments in a
non dilated calyx
How:
Place fiber near stone, but not in contact
with the urothelium.
Deliver intermittent laser bursts causing
movement of stones and fine
fragmentation.
42

POPCORN TECHNIQUE
43

FRAGMENTING
When:
Best for single stones
How:
Place fiber in contact with stone, pin
against the urothelium.
Focus fiber on one point until the stone
breaks.
44

LASER SETUP
45

DUSTING
Produces smaller fragments
Avoids routine use of UAS, and thus
reduces risk of ureteral trauma
Shorter operation time
Avoids routine postoperative
stenting
Able to offer treatment in cases of
failed UAS insertion
Requires next-generation laser
system (high capital equipment cost)
May not be suitable for hard stones
Stone-free rate may depend on
surgeon skill
Concern for fragment drainage in
certain patients (eg, spinal cord
injury)
May result in no fragment for analysis
A
D
V
A
N
T
A
G
E
S
D
I
S
A
D
V
A
N
T
A
G
E
S
46

FRAGMENTATION AND STONE RETRIEVAL
Uses low-power laser system
(low capital equipment cost)
Ability to extract complete stone in
noncomplicated cases
Suitable for hard stones
Able to send fragments for composition
analysis
Produces larger fragments
Longer operation time
Higher disposable costs
Risk of ureteral injury from using
UAS
Routine ureteral stenting if using
access sheath
A
D
V
A
N
T
A
G
E
S
D
I
S
A
D
V
A
N
T
A
G
E
S
47

MOSES TECHNOLOGY
48

HOL:YAG VS THULIUM
49

ANTI RETROPULSION DEVICES
1. Stone Cone
2. Accordian Device
3. XenX
4. Basket devices
5. Balloon devices
6. Backstop gel
50

STONE CONE
Made of nitinol
Consists of a wire and a radio-opaque
carrying catheter.
Once beyond the stone, removal of the
catheter allows spiraling of the wire
proximal to the stone.
51

BASKET DEVICES
Stones can be grasped by baskets and
then fixed in place.
Followed by stone fragmentation.
Care should be taken not to fire on the
baskets as nitinol can be cut through by
lasers.
52

ACCORDION DEVICE
53

XENX DEVICE – NITINOL MESH
54

BASKET DEVICES
55

SPECIAL BASKETS
LITHOCATCH LESLIE PARACHUTE
56

PASSPORT BALLOON
Inflatable balloon
Inflated beyond the stone.
57

BACKSTOP GEL
58

BALLISTIC LITHOTRIPSY
59

LITHOCLAST
Developed in 1990s
Uses a tank of compressed air or
hospital air lines.
Fires a projectile against a metal probe
with a pressure of 3 atm at a rate of 12
cycles/sec
Uses solid probe.
60

LMA STONE BREAKER
Improved portability.
Used CO2 cartridge which can be
replaced.
Each cartridge contains gas for 80-100
discharges.
Easy portability.
No need for electricity or compressor
cylinder.
Efficiency decreases as air in cartridge
decreases.
61

SWISS LITHOBREAKER
Based on electrokinetic mechanism.
Electromagnetic impulses created by rechargeable batteries move the probe
to produce the ballistic effect.
Consistent shocks compared to LMA Stonebreaker.
62

LITHOVAC
Combination of suction-pneumatic probe setup developed by Swiss lithoclast.
Improvement noted in stone retropulsion.
Frequent clogging decreased the potential for widespread use.
Modified version used in Swiss Lithoclast master.
63

LITHOVAC
64

FLEXPROBE
Can be used in flexible ureteroscopes
using Swiss pneumatic lithotripter.
65

ULTRASONIC LITHOTRIPSY
66

ULTRASONIC LITHOTRIPTER
67

PRINCIPLE
Electric current passing through a piezo ceramic plate produces vibrations in the
ultrasonic range.
Vibrations are in the range of 23-25 kHz, which are transmitted to a metal probe
that contacts the stone.
Probe should be in contact with stone for fragmentation.
Rapid vibrations produce small stone fragments, suctionable enough through the
probe lumen.
Suction capability also cools the piezoelectric elements from overheating.
Deflection of the probe should be avoided.
68

COMBINATION LITHOTRIPSY
69

SWISS LITHOCLAST MASTER
70

SWISS LITHOCLAST MASTER
First Dual probe lithotrite
Pneumatic air driven probe attached
coaxially within a hollow ultrasound
probe with suction capacity.
Individual or combination energy
discharge is possible.
Have become goldstandard for
percutaneous lithotripsy.
200% improvement in lithotripsy speed.
71

LITHOCLAST MASTER - DISADVANTAGES
Decreased suction effect due to pneumatic probe with in the hollow probe.
Retropulsion associated with pneumatic lithotripsy.
Unwieldy due to size.
Multipart handpiece associated with complexity of setup.
Multiple connections to suction and multifunction generator.
72

CYBERWAND
Similar dual energy device.
Both probes hollow.
Inner probe 8.3Fr connected to
handpiece produces Ultrasound
vibrations (21kHz).
Outer 11.5Fr move freely. Pushed
distally by the sliding probe and
brought back into position with a spring
coil.
73

CYBERWAND - DISADVANTAGES
No significant differences when compared with Lithoclast select or LMA stone breaker.
Probe failures
Suction clogging
Smaller inner lumen reducing suction capabilities.
Significantly louder than other devices.
One study suggested hearing protection to avoid long term hearing loss when
activated more than 90 minutes daily.
74

URETRON
75

URETRON
Single probe ultrasound mechanism.
Dual mode foot pedal activation for soft and hard stones.
Improved stone clearance than counterparts.
1. Improved pulse management and vibration control
2. Improved suction mechanism.
76

URETRON
Dual function Foot switch
Blue foot pedal is optimized for the
fragmentation of large and hard calculi.
Yellow pedal can be used to dust softer
stones into small debris, which can be
suctioned out through the probe channel.
Frequency control technology
Many ultrasonic lithotripters depend on
amplitude and added mechanical
energy to weaken the structure of a
stone.
UreTron uses frequency control to
fragment calculi—a highly efficient,
atraumatic approach.
77

SHOCKPULSE-SE
78

SHOCKPULSE-SE
Single probe ultrasound mechanism.
Similar to CyberWand.
Piezoelectric elements produce 21 kHz vibration.
Freemass element and spring action causes ballistic energy of the same probe.
Better stone removal compared to counterparts.
79

SHOCKPULSE-SE
Standard ultrasonic vibration 21 kHz
Ballistic vibration 300 Hz
80

SWISS LITHOCLAST TRILOGY
81

SWISS LITHOCLAST TRILOGY
Single probe model
Uses ultrasonic and electromagnetic energy.
Ultrasonic frequency 24 kHz
Ballistic frequency upto 12 Hz
Either similar to or better than ShockPulse-SE
82

EAU SUMMARY OF EVIDENCE
83

EAU RECOMMENDATIONS – URS AND RIRS
84

THANK YOU
85

Urolithiasis management- icl.

More Related Content

What's hot

Similar to Urolithiasis management- icl.

More from GovtRoyapettahHospit

Recently uploaded

Urolithiasis management- icl.