Multifunctional Use Of "Holmium:Yag Laser" in Urology 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.

Technical Specifications of Holmium: 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

Holmium Laser Holmium: Yag Laser From Sun Microsystems, California, USA 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 Can be used in contact and non-contact mode Can be used for cutting and for stone work Easy to maintain

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

Other Procedures With Holmium Laser Endoureterotomy - Ureteric Strictures 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 Caruncle 1 Total 30

Holmium:YAG For Stone Disease

Site & Size of Stones in the Ureter Left Right Total Upper 1/3 rd 24 28 52   Middle 1/3 rd 4 12 16 Lower 1/3 rd 13 33 46 Total 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 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

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

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 followed 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 permanent 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-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 stricture. 6F flexible ureteroscope passed over guidewire Holmium 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 Neoureterocystostomy…. Neo-orifice dilated with a balloon catheter to 14 Fr

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

Complications with Holmium:YAG Laser - Stones Early Perforation of ureter 3 Double J Stent for Obstruction 3 Nephrostomy for Obstruction 2 Deep venous thrombosis 1  Late Ureteric Stricture 3 Total 12

Complications with Holmium:YAG Laser - other procedures Early Hemorrhage (PUJ obst.) 1 Hydropneumothorax (Calyc. Divert.) 1 Late Nephrectomy (Stricture) 1 Total 3

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).

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