A New Technology to Treat Pediatric Urolithiasis: The Thulium Fiber Laser
Christopher Jaeger, MD, Bartley Cilento, MD, MPH, Caleb Nelson, MD, MPH, Michael Kurtz, MD, MPH.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: The Holmium-YAG (Ho:YAG) laser system has been the gold standard for laser lithotripsy for several decades. The Thulium Fiber Laser (TFL) has emerged as an alternative laser lithotripsy technology in recent years with noted technical differences when compared to Ho:YAG resulting in faster stone ablation rates during in vitro studies. The Soltive™ Premium SuperPulsed Laser by Olympus was the first TFL product in the United States to receive regulatory approval in 2019 for treatment of urolithiasis and other soft tissues pathologies. Our center was the first free-standing children’s hospital in the United States to adopt TFL technology in September of 2020. In this video, we show how the TFL can be used to efficiently dust a large bladder stone burden of 2.7cm composed predominantly of brushite in a young pediatric patient. We aim to showcase the TFL technology in use on a pediatric patient for a technology previously only described in the adult Urology literature.
METHODS: The TFL system by Olympus can be used to dust or fragment stones of all types depending on surgeon preference. We commonly dust stones and tend to use settings of 0.05 J/ 400 Hz and 0.1 J/ 200 Hz for soft and hard stones, respectively. For the bladder stones seen in this case, we used a 200-micron fiber through a 9.5 fr Wolf cystoscope. Both bladder stones were dusted predominantly with the hard stone dusting setting. Remaining fragments were irrigated or basketed until visibly stone free.
RESULTS: Cystolithalopaxy with the TFL for the 2.7cm total stone burden in our case was successful and performed without complication. Notably, the majority of the stones were obliterated into very fine dust particles. The total energy used during the case by the laser system was 5.9 kJ encompassing 4 minutes and 59 seconds of laser time. The case duration was 1 hour and 8 minutes. The patient was discharged the same day without a foley catheter. The stone composition was 96% brushite.
CONCLUSIONS: TFL is a novel technology that is capable of efficiently dusting even hard stones such as brushite. Notably, there was minimal retropulsion experienced during the case. In our experience, TFL has the potential of being a more efficient and effective laser lithotripsy technology than Ho:YAG for treatment of pediatric urolithiasis.
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