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Advances in laser technology and fibre-optic delivery systems in lithotripsy

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From Nature Reviews Urology

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Abstract

The flashlamp-pumped, solid-state holmium:yttrium–aluminium–garnet (YAG) laser has been the laser of choice for use in ureteroscopic lithotripsy for the past 20 years. However, although the holmium laser works well on all stone compositions and is cost-effective, this technology still has several fundamental limitations. Newer laser technologies, including the frequency-doubled, double-pulse YAG (FREDDY), erbium:YAG, femtosecond, and thulium fibre lasers, have all been explored as potential alternatives to the holmium:YAG laser for lithotripsy. Each of these laser technologies is associated with technical advantages and disadvantages, and the search continues for the next generation of laser lithotripsy systems that can provide rapid, safe, and efficient stone ablation. New fibre-optic approaches for safer and more efficient delivery of the laser energy inside the urinary tract include the use of smaller-core fibres and fibres that are tapered, spherical, detachable or hollow steel, or have muzzle brake distal fibre-optic tips. These specialty fibres might provide advantages, including improved flexibility for maximal ureteroscope deflection, reduced cross section for increased saline irrigation rates through the working channel of the ureteroscope, reduced stone retropulsion for improved stone ablation efficiency, and reduced fibre degradation and burnback for longer fibre life.

Key points

  • The holmium:yttrium–aluminium–garnet (YAG) laser is currently the gold standard for laser lithotripsy during flexible ureteroscopy because it can be used to effectively treat all stone compositions.

  • The frequency-doubled, double-pulse YAG (FREDDY) laser has been tested as a more compact and efficient solid-state laser than the initial dye lasers for short-pulse lithotripsy, but the FREDDY laser is not effective for all stone compositions.

  • The erbium:YAG laser has been tested for efficient ablation of urinary stones, but a suitable mid-infrared optical fibre delivery system is not available for this procedure.

  • The thulium fibre laser (TFL) is the most promising alternative to holmium for lithotripsy owing to its use of a more suitable TFL wavelength, smaller fibres, and potential for using a smaller, less expensive laser system; however, clinical studies are needed to assess this new technology.

  • TFL promotes the development of novel miniature fibre-optic delivery systems, including tapered, ball tip, hollow steel tip fibres, and muzzle brake fibre-optic tips, which can reduce both fibre burnback or degradation and stone retropulsion without sacrificing laser ablation rates.

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Fig. 1: Water absorption coefficient as a function of laser wavelength in the mid-infrared spectrum.
Fig. 2: Comparison of lasers for lithotripsy.
Fig. 3: Fibre-optic tip designs.

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Authors and Affiliations

  1. Department of Physics and Optical Science, University of North Carolina at Charlotte, Charlotte, NC, USA

    Nathaniel M. Fried

  2. McKay Department of Urology, Carolinas Medical Center, Charlotte, NC, USA

    Nathaniel M. Fried & Pierce B. Irby

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N.M.F. researched data for the article and wrote the manuscript. P.B.I. contributed to the discussion of content and reviewed and edited the manuscript before submission.

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Correspondence to Nathaniel M. Fried.

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N.M.F. is a consultant for IPG Medical Corporation (Marlborough, Massachusetts, USA) and is currently funded by a research grant from the National Institutes of Health (Bethesda, Maryland, USA). P.B.I. declares no competing interests.

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Fried, N.M., Irby, P.B. Advances in laser technology and fibre-optic delivery systems in lithotripsy. Nat Rev Urol 15, 563–573 (2018). https://doi.org/10.1038/s41585-018-0035-8

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