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What is the definition of stone dust and how does it compare with clinically insignificant residual fragments? A comprehensive review

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Abstract

Purpose

During endoscopic stone surgery, Holmium:YAG (Ho:YAG) and Thulium Fiber Laser (TFL) technologies allow to pulverize urinary stones into fine particles, ie DUST. Yet, currently there is no consensus on the exact definition of DUST. This review aimed to define stone DUST and Clinically Insignificant Residual Fragments (CIRF).

Methods

Embase, MEDLINE (PubMed) and Cochrane databases were searched for both in vitro and in vivo articles relating to DUST and CIRF definitions, in November 2023, using keyword combinations: “dust”, “stones”, “urinary calculi”, “urolithiasis”, “residual fragments”, “dusting”, “fragments”, “lasers” and “clinical insignificant residual fragments”.

Results

DUST relates to the fine pulverization of urinary stones, defined in vitro as particles spontaneously floating with a sedimentation duration ≥ 2 sec and suited for aspiration through a 3.6Fr-working channel (WC) of a flexible ureteroscope (FURS). Generally, an upper size limit of 250 µm seems to agree with the definition of DUST. Ho:YAG with and without “Moses Technology”, TFL and the recent pulsed-Thulium:YAG (pTm:YAG) can produce DUST, but no perioperative technology can currently measure DUST size. The TFL and pTm:YAG achieve better dusting compared to Ho:YAG. CIRF relates to residual fragments (RF) that are not associated with imminent stone-related events: loin pain, acute renal colic, medical or interventional retreatment. CIRF size definition has decreased from older studies based on Shock Wave Lithotripsy (SWL) (≤ 4 mm) to more recent studies based on FURS (≤ 2 mm) and Percutaneous Nephrolithotomy(PCNL) (≤ 4 mm). RF \(\le\) 2 mm are associated with lower stone recurrence, regrowth and clinical events rates. While CIRF should be evaluated postoperatively using Non-Contrast Computed Tomography(NCCT), there is no consensus on the best diagnostic modality to assess the presence and quantity of DUST.

Conclusion

DUST and CIRF refer to independent entities. DUST is defined in vitro by a stone particle size criteria of 250 µm, translating clinically as particles able to be fully aspirated through a 3.6Fr-WC without blockage. CIRF relates to ≤ 2 RF on postoperative NCCT.

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Data availability

All data is available on reasonable request to the corresponding author.

Abbreviations

SWL:

Extracorporeal shock wave therapy

URS:

Ureteroscopy

PCNL:

Percutaneous nephrolithotomy

FURS:

Flexible URS

Ho YAG:

Holmium:Yttrium–Aluminium-Garnet

TFL:

Thulium fiber laser

RF:

Residual fragments

CIRF:

Clinically insignificant residual fragments

CSRF:

Clinically significant residual fragments

RIRS:

Retrograde intrarenal surgeries

PRISMA:

Preferred reporting items for systematic review and meta-analysis

HS:

Human urinary stones

Cr,Nd, YSSG:

Chromium, Neodynium:yttrium-scandium-gallium-garnet

Cr,Er, YSSG:

Chromium, erbium:YSSG

Cr,Tm,Ho, YSSG:

Chromium,Thulium,Holmium:YSSG

WC:

Working channel

COD:

Calcium oxalate dihydrate

COM:

Calcium oxalate monohydrate

ISO:

International Standardization Organization

WHO:

World Health Organization

DISS:

Direct in-scope suction systems

UAS:

Ureteral access sheath

KUB:

Kidney Ureter Bladder

US:

Ultrasound

ECIRS:

Endosopic Combined Intrarenal Surgery

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Funding

EAU Scholarship Program Grant 2024; AFU Reaserch Grant 2023.

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Authors and Affiliations

  1. GRC No 20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France

    Frederic Panthier & Olivier Traxer

  2. Service d’Urologie, Assistance-Publique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, 4 Rue de la Chine, 75020, Paris, France

    Frederic Panthier & Olivier Traxer

  3. UMR 8006 CNRS-Arts et Métiers ParisTech, PIMM, 151 bd de l‘Hôpital, 75013, Paris, France

    Frederic Panthier & Olivier Traxer

  4. Progressive Endourological Association for Research and Leading Solutions (PEARLS), Paris, France

    Frederic Panthier, Olivier Traxer & Etienne X. Keller

  5. Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland

    Jia-Lun Kwok & Etienne X. Keller

  6. Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore

    Jia-Lun Kwok

  7. Department of Urology, University of Arizona, Tucson, AZ, USA

    David T. Tzou

  8. Department of Urology, University of California-San Diego School of Medicine, La Jolla, CA, USA

    Manoj Monga

  9. Endourology & Urolithiasis Working Group, Young Academic Urologists (YAU), Arnhem, The Netherlands

    Etienne X. Keller

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  1. Frederic Panthier
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Contributions

FPT, EXK, DT, JLK: project development, data collection, data analysis, manuscript writing and editing. MM, OT: project development, manuscript editing.

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Correspondence to Frederic Panthier.

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Conflict of interest

Jia-Lun Kwok, Manoj Monga, and David Tzou have no specific conflicts of interest relevant to this work. Frederic Panthier is a consultant for Dornier MedTech. Etienne Xavier Keller is a speaker and/or consultant for Coloplast, Olympus and Boston Scientific, and has no specific conflicts of interest relevant to this study. Olivier Traxer is a consultant for Boston Scientific, Coloplast, EMS, IPG, Quanta and Rocamed, and has no specific conflicts relevant to this work.

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Panthier, F., Kwok, JL., Tzou, D.T. et al. What is the definition of stone dust and how does it compare with clinically insignificant residual fragments? A comprehensive review. World J Urol 42, 292 (2024). https://doi.org/10.1007/s00345-024-04993-4

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