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Flexible
Lithotripters:
Electrohydraulic
Laser
Rigid
lithotripsy (EHL)
lithotripsy
Lithotripters:
Ultrasonic
Ballistic
lithotripsy
lithotripsy
Flexible Lithotripters
Electrohydraulic Lithotripters
EHL was
The
first reported use of EHL outside the Eastern bloc was in 1960, when a modified
version of Yutkins invention, the Urat-1, was used to fragment bladder calculi
(Rouvalis, 1970)
The
Unlike
in SWL the shockwave is not focused, so the stone must be placed where the
shockwave is generated.
Electrohydraulic Lithotripters
Subsequent improvements in the EHL generator allowed the surgeon more control
over energy discharge, pulse, and duration.
Denstedt and Clayman (1990) demonstrated that EHL works equally well in a
normal saline solution, eliminating the hazard of irrigating the upper urinary tract
with a hypotonic solution.
Electrohydraulic Lithotripters
Advantages:
Probe flexibility, especially the smaller probes such as the 1.9 Fr.
Electrohydraulic Lithotripters
Disadvantages:
Ureteral Perforation (the risk of perforation is greater with higher energies, such
as in treatment of a hard stone)
Retrograde propulsion of calculi and fragments can occur during EHL and is
more pro- nounced than with holmium:YAG lithotripsy
Electrohydraulic Lithotripters
Technique:
The EHL fiber tip should be positioned 2 to 5 mm distal to the end of the
ureteroscope
The goal of the treatment is to create fragments that can be removed with
grasping forceps or a basket device or fragments that are likely to pass
spontaneously.
After 50 to 60 seconds of firing, the insulation at the tip of the probe may peel
away and at this time a new probe should be used
Laser Lithotripsy
The
laser was developed in 1960 and the first medium used was the ruby.
In
1968, Mulvaney and Beck reported that although the ruby laser could effectively
fragment urinary calculi it generated excessive heat and was not appropriate for clinical
use.
The
first widely available laser lithotrite was the pulsed-dye laser, which employed a
coumarin green dye as the liquid laser medium.
The
holmium laser wavelength is 2140 nm in the pulsed mode and pulse duration of the
holmium laser ranges from 250 to 350 sec.
The
holmium
Laser Lithotripsy
Advantage:
The holmium laser is one of the safest, most effective, and most versatile intracorporeal lithotripters.
The ability of the holmium laser to fragment all stones regardless of composition is
a clear advantage.
The holmium laser is more compact than the coumarin laser, requires minimal
maintenance,and is ready for use 1 minute after it is turned on.
Laser Lithotripsy
Disadvantage:
The holmium laser is the initial high cost of the device and the cost of the laser
fibers.
Laser Lithotripsy
Rigid Lithotripters
Ballistic Lithotripters
Ballistic
The
Swiss LithoClast, introduced in the early 1990s, was the first ballistic lithotrite.
Following
There
Ballistic Lithotripters
Advantage:
Ballistic Lithotripters
Disadvantage:
Teichman and associates (1998b) reported that fragments larger than 4 mm are
produced by all types of endoscopic lithotrites, with the exception of the
holmium:YAG laser.
Ballistic Lithotripters
Technique:
The ballistic lithotripter should be activated only when there is a clear view of the
stone and the probe position can be identified.
The goal of ballistic lithotripsy in the ureter is to generate fragments that are small
enough to permit spontaneous passage (<2 mm).
Ultrasonic Lithotripters
Mulvaney first reported the use of ultrasound vibrations to break renal calculi in 1953.
The ultrasound probe works by applying electrical energy to excite a piezoceramic plate
in the ultrasound transducer.
Ultrasonic lithotripsy is more efficient during PNL, owing to the greater flow of irrigant
through the larger diameter ultrasonic probes that can be used.
The size, density, and surface structure of the calculus appear to be more important.
Ultrasonic Lithotripters
Advantage:
Ultrasonic Lithotripters
Disadvantage:
The rigid nature of ultrasonic probes and their small diameter limit the appeal of this
technology in treatment of ureteral stones.
Ultrasonic Lithotripters
Technique:
When ultrasonic lithotripsy is applied during PNL the stone should first be trapped
between the probe and the urothelium.
When ureteral stones are treated the ureter may need to be dilated to allow passage
of the offset rigid ureteroscope.
The first combination device brought to the clinical market was the Lithoclast Ultra
(Boston Scientific, Natick, MA) which relied on a combination handpiece.
Pietrow and associates (2003) reported, the stone clearance times were significantly better
for the combination device than for the conventional ultrasonic lithotripters.
Kim and associates (2007) find that the stone penetration time for the Cyberwand was
almost twice as rapid as it was for the Lithoclast Ultra.
Conclusion
The holmium laser has become the mainstay of ureterorenoscopic lithotripsy by virtue
of its ability to fragment all stones.
As well, the use of small-diameter fibers allows access to all areas of the ureter and
intrarenal collecting system.
However, for patients with complex, large-volume calculi undergoing PNL, the
combination devices will permit more efficient fragmentation of the stone.
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