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By Sunil Shroff, Graham Watson Institute of Urology & Nephrology in association with St. Peter's Hospital, London, UK Sri Ramachandra Medical College &

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Presentation on theme: "By Sunil Shroff, Graham Watson Institute of Urology & Nephrology in association with St. Peter's Hospital, London, UK Sri Ramachandra Medical College &"— Presentation transcript:

1 By Sunil Shroff, Graham Watson Institute of Urology & Nephrology in association with St. Peter's Hospital, London, UK Sri Ramachandra Medical College & Research Institution Sri Ramachandra Hospital, Porur, Madras. Multifunctional Use Of "Holmium:Yag Laser" in Urology

2 Technical Specifications of Holmium: Yag Laser Laser typePulse Holmium:YAG Wavelength2.1 micron Pulse duration350 microsecs Power to tissueVariable 1 - 20 Watts Energy/Pulse1 J - 1.8 J Aiming beam3 milliwatts (red) Beam deliveryLow water quartz fibre (400 m) Dimensions79 cm H x 36 cmW x 53 cm D Weight64 Kg Cost20W £70000

3 Holmium: Yag Laser From Sun Microsystems, California, USA Holmium Laser Setting for Stones -0.05 - 1 Joule/Pulse at 5 Watts Setting for Other Proced.-1 Joule/Pulse at 15 Watts

4 Advantages of Holmium: Yag Laser Combines cutting superiority of Co 2 laser haemostatic superiority of Neodymium: YAG Laser Can be used in contact and non-contact mode Can be used for cutting and for stone work Easy to maintain

5 Holmium Laser for ureteric Lithotripsy-114 (79%) Other Procedures With Holmium Laser-30 (21%) HOLMIUM:YAG Laser in Urology

6 Other Procedures With Holmium Laser Endoureterotomy - Ureteric Strictures8 PUJ Obstruction Retrograde Endopyelotomy6 PUJ Obstruction Antegrade Endopyelotomy1 Ablation of Tumours - Bladder & Kidney5 Ablation of Calyceal Diverticulum 4 Fragmentation of Lower Calyceal Calculi2 Bladder Neck Incision2 Fragmentation of Very hard calculi Calculi1 Excision of Uretheral Caruncle1 Total30

7 Holmium:YAG For Stone Disease

8 Site & Size of Stones in the Ureter Left Right Total Upper 1/3 rd242852 Middle 1/3 rd41216 Lower 1/3 rd133346 Total4173114 Average size of Calculus - 10 x 6 mm. (Range from 6 x 2 mm to 50 x 15 mm)

9 Success with Stones Clearance using Holmium Laser Left (N=41)Right (N=73) Upper 1/3 rd19/24 (79%)21/28 (75%) Middle1/3rd4/4 (100%)11/12 (92%) Lower 1/3rd12/13 (92%)32/33 (97%) Total35/41 (85%)64/73 (88%) Lower calyceal calculi (2) – 100% success - fragmentation and clearance

10 6 year old with bilateral renal and Right lower ureteric calculi. She underwent Ureteroscopy and holmium laser lithotripsy. Holmium:YAG For Stone Disease

11 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

12 Results - Holmium To Cut & Coag. Sustained Improv. PUJ Obstruction5/7 (6 To 12 Months F/U) Ureteric Stricture7/8 (1 Year F/u) (2 On DJ Stent) Calyceal Divert.2/4 (However Only Partial Ablation) BNI2/2 ( 6/12 F/U)

13 Holmium 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

14 Holmium 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

15 Holmium 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

16 Holmium for Neoureterocystostomy…. 0.25 super-stiff guidewire through nephrostomy to upper end of stricture. 6F flexible ureteroscope passed over guidewire Holmium used to rebore through stricture into bladder. Flexible ureteroscope with holmium beam

17 Holmium for Neoureterocystostomy…. Superstiff guidewire passed through the neo- orifice and pulled down into the bladder with cystoscope

18 Holmium for Neoureterocystostomy…. Neo-orifice dilated with a balloon catheter to 14 Fr

19 Holmium for Neoureterocystostomy…. 6F 22cm JJ stent inserted

20 Early Perforation of ureter3 Double J Stent for Obstruction3 Nephrostomy for Obstruction2 Deep venous thrombosis1 Late Ureteric Stricture3 Total12 Complications with Holmium:YAG Laser - Stones

21 Early Hemorrhage (PUJ obst.)1 Hydropneumothorax (Calyc. Divert.)1 Late Nephrectomy (Stricture)1 Total3 Complications with Holmium:YAG Laser - other procedures

22 Conclusion - 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).

23 Conclusion - Holmium To Cut & Coag. 1.Excellent haemostatic properties 2.Use via small calibre ureteroscope 3.End on cutting action of laser under vision - an advantage 4.Control & precision greater with laser 5.Depth of penetration 0.5cm - safe for deeper tissues like intestines 6.Multi-Speciality Laser - hence economical


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