BySunil Shroff, Graham Watson Institute of Urology .ppt

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1、BySunil Shroff, Graham Watson Institute of Urology & Nephrology in association with St. Peters Hospital, London, UKSri Ramachandra Medical College & Research Institution Sri Ramachandra Hospital, Porur, Madras.,Multifunctional Use Of “Holmium:Yag Laser“ in Urology,Technical Specifications of Holmium

2、: Yag Laser,Laser type Pulse Holmium:YAG Wavelength 2.1 micron Pulse duration 350 microsecs Power to tissue Variable 1 - 20 Watts Energy/Pulse 1 J - 1.8 J Aiming beam 3 milliwatts (red) Beam delivery Low water quartz fibre (400mm) Dimensions 79 cm H x 36 cmW x 53 cm D Weight 64 Kg Cost 20W 70000,Hol

3、mium: 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,Advantages of Holmium: Yag Laser,Combines cutting superiority of Co2 laser haemostatic superiority of Neodymium: YAG Laser Ca

4、n be used in contact and non-contact mode Can be used for cutting and for stone work Easy to maintain,Holmium Laser for ureteric Lithotripsy - 114 (79%)Other Procedures With Holmium Laser - 30 (21%),HOLMIUM:YAG Laser in Urology,Other Procedures With Holmium Laser,Endoureterotomy - Ureteric Stricture

5、s 8 PUJ Obstruction Retrograde Endopyelotomy 6 PUJ Obstruction Antegrade Endopyelotomy 1 Ablation of Tumours - Bladder & Kidney 5 Ablation of Calyceal Diverticulum 4 Fragmentation of Lower Calyceal Calculi 2 Bladder Neck Incision 2 Fragmentation of Very hard calculi Calculi 1 Excision of Uretheral C

6、aruncle 1Total 30,Holmium:YAG For Stone Disease,Site & Size of Stones in the Ureter,Left Right TotalUpper 1/3 rd 24 28 52Middle 1/3 rd 4 12 16Lower 1/3 rd 13 33 46Total 41 73 114,Average size of Calculus - 10 x 6 mm. (Range from 6 x 2 mm to 50 x 15 mm),Success with Stones Clearance using Holmium Las

7、er,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,6 year old with bilateral renal and Right lower ureteric calculi.

8、She underwent Ureteroscopy and holmium laser lithotripsy.,Holmium:YAG For Stone Disease,Holmium: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 followe

9、d by stenting,Results - 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),Holmium Laser for impassable PUJ stricture,82 year old male with a perma

10、nent nephrostomy ( for over 5 years ) in a solitary kidney. Nephrostogram showed complete obstruction at PUJ level,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

11、-months,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,Holmium for Neoureterocystostomy.,0.25 super-stiff guidewire through nephrostomy to upper end of strict

12、ure.6F flexible ureteroscope passed over guidewireHolmium used to rebore through stricture into bladder.,Flexible ureteroscope with holmium beam,Holmium for Neoureterocystostomy.,Superstiff guidewire passed through the neo-orifice and pulled down into the bladder with cystoscope,Holmium for Neourete

13、rocystostomy.,Neo-orifice dilated with a balloon catheter to 14 Fr,Holmium for Neoureterocystostomy.,6F 22cm JJ stent inserted,Early Perforation of ureter 3 Double J Stent for Obstruction 3 Nephrostomy for Obstruction 2 Deep venous thrombosis 1Late Ureteric Stricture 3Total 12,Complications with Hol

14、mium:YAG Laser - Stones,Early Hemorrhage (PUJ obst.) 1 Hydropneumothorax (Calyc. Divert.) 1 Late Nephrectomy (Stricture) 1 Total 3,Complications with Holmium:YAG Laser - other procedures,Conclusion - Holmium for Stones,1. Can be used through the smallest semirigid ureteroscopes (6.9F). 2. Can be use

15、d through flexible ureteroscopes. 3. Effective for very hard stones(Disadvantage - not as safe as pulsed dye laser for ureteric wall).,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,