1. Multifunctional Use Of "Holmium:Yag Laser" in UrologyBy
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.

2. Technical Specifications of Holmium: Yag Laser
Laser type Pulse Holmium:YAG
Wavelength 2.1 micron
Pulse duration 350 microsecs
Power to tissue Variable Watts
Energy/Pulse 1 J 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

3. Holmium Laser Holmium: Yag Laser
From Sun Microsystems, California, USA
Setting for Stones 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 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

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

6. 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

7. Holmium:YAG For Stone Disease

8. Site & Size of Stones in the Ureter
Left Right Total
Upper 1/3 rd
Middle 1/3 rd
Lower 1/3 rd
Total
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 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

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

11. 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

12. 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)

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. 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

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

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