Presentation on theme: "Multifunctional Use Of "Holmium:Yag Laser" in Urology"— Presentation transcript:
1Multifunctional Use Of "Holmium:Yag Laser" in Urology BySunil Shroff, Graham Watson Institute of Urology & Nephrology in association withSt. Peter's Hospital, London, UKSri Ramachandra Medical College & Research InstitutionSri Ramachandra Hospital, Porur, Madras.
2Technical Specifications of Holmium: Yag Laser Laser type Pulse Holmium:YAGWavelength 2.1 micronPulse duration 350 microsecsPower to tissue Variable WattsEnergy/Pulse 1 J JAiming beam 3 milliwatts (red)Beam delivery Low water quartz fibre (400mm)Dimensions 79 cm H x 36 cmW x 53 cm DWeight 64 KgCost 20W £70000
3Holmium Laser Holmium: Yag Laser From Sun Microsystems, California, USASetting for Stones Joule/Pulse at 5 WattsSetting for Other Proced.- 1 Joule/Pulse at 15 Watts
4Advantages of Holmium: Yag Laser Combines cutting superiority of Co2 laser haemostatic superiority of Neodymium: YAG LaserCan be used in contact and non-contact modeCan be used for cutting and for stone workEasy to maintain
5HOLMIUM:YAG Laser in Urology Holmium Laser for uretericLithotripsy (79%)Other Procedures WithHolmium Laser (21%)
6Other Procedures With Holmium Laser Endoureterotomy - Ureteric Strictures 8PUJ Obstruction Retrograde Endopyelotomy 6PUJ Obstruction Antegrade Endopyelotomy 1Ablation of Tumours - Bladder & Kidney 5Ablation of Calyceal Diverticulum 4Fragmentation of Lower Calyceal Calculi 2Bladder Neck Incision 2Fragmentation of Very hard calculi Calculi 1Excision of Uretheral Caruncle 1Total
8Site & Size of Stones in the Ureter Left Right TotalUpper 1/3 rdMiddle 1/3 rdLower 1/3 rdTotalAverage size of Calculus - 10 x 6 mm.(Range from 6 x 2 mm to 50 x 15 mm)
9Success 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
10Holmium:YAG For Stone Disease 6 year old with bilateral renal and Right lower ureteric calculi.She underwent Ureteroscopy and holmium laser lithotripsy.
11Holmium: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
12Results - 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)
13Holmium 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
14Holmium 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
15Holmium 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
16Holmium for Neoureterocystostomy…. 0.25 super-stiff guidewire through nephrostomy to upper end of stricture.6F flexible ureteroscope passed over guidewireHolmium used to rebore through stricture into bladder.Flexible ureteroscope with holmium beam
17Holmium for Neoureterocystostomy…. Superstiff guidewire passed through the neo-orifice and pulled down into the bladder with cystoscope
18Holmium for Neoureterocystostomy…. Neo-orifice dilated with a balloon catheter to 14 Fr
19Holmium for Neoureterocystostomy…. 6F 22cm JJ stent inserted
20Complications with Holmium:YAG Laser - Stones EarlyPerforation of ureter 3Double J Stent for Obstruction 3Nephrostomy for Obstruction 2Deep venous thrombosis 1 LateUreteric Stricture 3Total
21Complications with Holmium:YAG Laser - other procedures EarlyHemorrhage (PUJ obst.) 1Hydropneumothorax (Calyc. Divert.) 1LateNephrectomy (Stricture) 1Total
22Conclusion - 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).
23Conclusion - Holmium To Cut & Coag. 1. Excellent haemostatic properties2. Use via small calibre ureteroscope3. End on cutting action of laser under vision - an advantage4. Control & precision greater with laser5. Depth of penetration 0.5cm - safe for deeper tissues like intestines6. Multi-Speciality Laser - hence economical