Holmium:YAG laser has been the lithotrite of choice for around 30 years in kidney stone surgery. Lasers have evolved over the years to offer higher power, increased pulse frequencies and longer pulse durations. The drivers for change have been to improve stone ablation and to minimise retropulsion. We report on a new prototype Holmium laser that fires multiple “micro-pulses” in “pulse packets” and discuss the stone phantom ablation rate results utilizing a bench model. The prototype laser demonstrated impressive stone ablation rates in our bench testing across a range of power settings. We will discuss the details of these results supporting that pulse-modulation with packets of micro-pulses are a promising technological development. (Disclaimers: Bench Test results may not necessarily be indicative of clinical performance. The testing was performed by or on behalf of BSC.
Ureteroscopic stone dusting utilizing a high power laser system has become more popular in recent years due to the production of finer debris/remains, lower retropulsion, and shorter operation time (potential to avoid the routine use of post-operative stenting and the use of ureteral access sheaths (UAS)). Typical dusting settings are lower pulse energy (as low as 0.2 J) with higher frequency (up to 80 Hz). This study investigates the best dusting mode to produce a high ablation rate and low retropulsion. The objective of the study was to evaluate the performance of a concept optimal dusting mode. In vitro investigations of Ho:YAG laser-induced stone ablation and retropulsion were performed with a benchtop model in a highly reproducible manner using a hands-free setup and measuring the effects of multiple pulses. A systematic comparison of the performance (ablation and retropulsion) of the concept optimal dusting mode against a reference laser dusting mode was conducted. Within this benchtop test model, the optimal dusting mode had a relatively fast ablation rate while keeping retropulsion low.
Holmium:YAG laser is commonly used as an efficient technology for lithotripsy, breaking urinary stones into small particles (dust) and larger residual fragments (RF). One of the ultimate goals is to create fine dust for real-time aspiration, eliminating the need for mechanical retrieval of RFs. A recent study of stone dust definition suggests a maximum particle size of 250-µm to allow complete aspiration through the working channel of a flexible ureteroscope.
We have evaluated the particle size generation of a concept Holmium:YAG laser utilizing a pulse width modulation technique. This technology delivers numerous low-energy micro-pulses per pulse with long temporal pulse duration to potentially enable finer dust particles, better ablation rate, and reduced retropulsion. Overall, the concept device generates a high percentage of fine dust compared with prior results found in literature.
(Disclaimers: Bench Test results may not necessarily be indicative of clinical performance. The testing was performed by or on behalf of BSC. Data on file. Concept device or technology. Not available for sale. This device is not yet available for sale in the United States).
Although laser lithotripsy is now the preferred treatment option for urolithiasis due to shorter operation time and a better stone-free rate [1], the optimal laser settings for URS (Ureteroscopic lithotripsy) to enable shorter operating times remain unclear. This study aims to identify optimal laser settings for Ho:YAG laser-lithotripsy to maximize the ablation rate while minimizing the retropulsion, as well as to improve the discharge of fragments via the urinary tract. The net result will be an increase in treatment success and patient satisfaction by ameliorating the stone-free rate.
In vitro investigations of Ho:YAG laser-induced stone ablation and retropulsion were performed with a bench top model first introduced by Sroka’s group [2]. A commercial Ho:YAG laser system (Lumenis VersaPulse PowerSuite 100W, Lumenis Ltd., Yokneam, Israel) was used as the laser pulse source, with pulse energy from 0.2 J up to 1.5 J and repetition rate from 5 to 40 Hz. A DOE with two replicate points and two lack-of-fit points was performed on artificial BEGO stones of sample size 14 under reproducible experimental conditions (fiber size: 365 μm, S-LLF365 SureFlex Fiber, Boston Scientific Corporation, San Jose, CA, USA). The best fit to the experimental data was analyzed utilizing the design of experiment software, which can produce the numerical formulas for the response surfaces of ablation rate and retropulsion in terms of laser pulse parameters [3].
The coded numerical formulas for the response surfaces of ablation speed and retropulsion velocity are generated. The coded equation is useful for identifying the relative impact of the factors by comparing their coefficients. Upon examination of the laser ablation of stone phantoms (BEGO), the laser pulse energy is 1.4 times the impact of the frequency, and laser pulse peak power’s impact is the same as the frequency; while for retropulsion, the laser pulse energy is 5.8 times as the impact of the frequency, and laser pulse peak power’s impact is 13 times as the frequency; A series of laser settings for relatively efficient laser lithotripsy were identified in terms of laser pulse energy and peak power.
The laser pulse energy or peak power in reference to frequency has a higher impact coefficient to stone retropulsion as compared to stone ablation in Ho:YAG laser-lithotripsy. The most effective way to reduce stone retropulsion during laser lithotripsy is to reduce the laser pulse peak power (which has the highest impact coefficient in the coded response equation).
Laser lithotripsy is now the preferred treatment option for urolithiasis over Shock wave lithotripsy (SWL) for renal stones smaller than 1.5 cm due to shorter operation times and a better stone-free rates (from the retrospective study by E. B. Cone et al). Nonetheless, the detailed mechanism of calculus disintegration by laser pulse remains relatively unclear. One of the fundamental parameters for laser stone interaction is the ablation threshold. Richard L. Blackmon, et. al. have studied the ablation threshold for Ho: YAG and the thulium fiber lasers (TFL) in terms of the laser energy density. However, an ablation threshold in terms of peak power density would be more universally applicable. In this study, two commercially available Ho: YAG lasers were used as the laser pulse source. The fibers used in the investigation are SureFlexTM fibers, (Models S-LLF273 and S-LLF365) with 273 and 365 μm core diameters, respectively. Calculus phantoms were made of the Bego stone material with various degrees of hardness. These stone phantoms were ablated with the Ho: YAG lasers at different peak power densities. The laser pulse width was measured utilizing a 2 μm photodiode (Thorlabs DET10D), and the laser-induced crater volumes were evaluated with a 3-D digital microscope (Keyence VHX-900F). In this way, we determined the ablation threshold as a function of peak power density for the Bego stone phantoms with 3 different hardness values. Additional investigations of the ablation threshold of other stone types will be conducted in a future study.
In this study we test the hypothesis that nonlinear optical (NLO) multiphoton photoactivation of riboflavin using a focused femtosecond (FS) laser light can be used to induce cross-linking (CXL) and mechanically stiffen collagen as a potential clinical therapy for the treatment of keratoconus and corneal ectasia. Riboflavin-soaked, compressed collagen hydrogels are cross-linked using a FS laser tuned to 760 nm and set to either 100 mW (NLO CXL I) or 150 mW (NLO CXL II) of laser power. FS pulses are focused into the hydrogel using a 0.75 NA objective lens, and the hydrogel is three-dimensionally scanned. Measurement of hydrogel stiffness by indentation testing show that the calculated elastic modulus (E ) values are significantly increased over twofold following NLO CXL I and II compared with baseline values (P<0.05 ). Additionally, no significant differences are detected between NLO CXL and single photon, UVA CXL (P>0.05 ). This data suggests that NLO CXL has a comparable effect to conventional UVA CXL in mechanically stiffening collagen and may provide a safe and effective approach to localize CXL at different regions and depths within the cornea.
Non-linear optical (NLO) imaging using femtosecond lasers provides a non-invasive means of imaging the structural
organization of the eye through the generation of second harmonic signals (SHG). While NLO imaging is able to detect
collagen, the small field of view (FoV) limits the ability to study how collagen is structurally organized throughout the
larger tissue. To address this issue we have used computed tomography on optical and mechanical sectioned tissue to
greatly expand the FoV and provide high resolution macroscopic (HRMac) images that cover the entire tissue (cornea
and optic nerve head). Whole, fixed cornea (13 mm diameter) or optic nerve (3 mm diameter) were excised and either 1)
embedded in agar and sectioned using a vibratome (200-300 um), or 2) embedded in LR White plastic resin and serially
sectioned (2 um). Vibratome and plastic sections were then imaged using a Zeiss LSM 510 Meta and Chameleon
femtosecond laser to generate NLO signals and assemble large macroscopic 3-dimensional tomographs with high
resolution that varied in size from 9 to 90 Meg pixels per plane having a resolution of 0.88 um lateral and 2.0 um axial.
3-D reconstructions allowed for regional measurements within the cornea and optic nerve to quantify collagen content,
orientation and organization over the entire tissue. We conclude that NLO based tomography to generate HRMac
images provides a powerful new tool to assess collagen structural organization. Biomechanical testing combined with
NLO tomography may provide new insights into the relationship between the extracellular matrix and tissue mechanics.
We used optical coherence tomography (OCT) for non-invasive imaging of the anterior segment of the eye for
investigating partial-thickness scleral channels created with a femtosecond laser. Glaucoma is associated with elevated
intraocular pressure (IOP) due to reduced outflow facility in the eye. A partial-thickness aqueous humor (AH) drainage
channel in the sclera was created with 1.7-&mgr;m wavelength femtosecond laser pulses to reduce IOP by increasing the
outflow facility, as a solution to retard the progression of glaucoma. It is hypothesized that the precise dimensions and
predetermined location of the channel would provide a controlled increase of the outflow rate resulting in IOP reduction.
Therefore, it is significant to create the channel at the exact location with predefined dimensions. The aim of this
research has two aspects. First, as the drainage channel is subsurface, it is a challenging task to determine its precise
location, shape and dimensions, and it becomes very important to investigate the channel attributes after the laser
treatment without disturbing the internal anterior structures. Second, to provide a non-invasive, image-based verification
that extremely accurate and non-scarring AH drainage channel can be created with femtosecond laser. Partial-thickness
scleral channels created in five human cadaver eyes were investigated non-invasively with a 1310-nm time-domain OCT
imaging system. Three-dimensional (3D) OCT image stacks of the triangular cornea-sclera junction, also known as
anterior chamber angle, were acquired for image-based analysis and visualization. The volumetric cutting-plane
approach allowed reconstruction of images at any cross-sectional position in the entire 3D volume of tissue, making it a
valuable tool for exploring and evaluating the location, shape and dimension of the channel from all directions. As a
two-dimensional image-based methodology, an image-processing pipeline was implemented to enhance the channel
features to augment the analysis. In conclusion, we successfully demonstrate that our image-based visualization tool is
appropriate for effective investigation and evaluation of femtosecond laser-created, partial-thickness aqueous humor
drainage channels in the sclera.
Photodisruption of femtosecond laser at 1700nm wavelength has been demonstrated
as a potential subsurface surgical method that can be used in trabeculectomy for
glaucoma treatment without causing failure due to scarring at the level of conjunctiva
and underlying tissue [1, 2]. In this study, Fourier domain optical coherence
tomography (FD-OCT) technology is used to demonstrate high speed non-invasive
imaging of high precision photodisruption in human sclera. Photodisruption cavities
of different size in human sclera can reveal itself in its 3D FDOCT image. Transclera
channel cut from back to surface and partial transclera channel are easily identified in
3D OCT image. The whole 3D data set acquired with high speed frequency domain
OCT system permits further quantitative analysis of subsurface phtodisruption
incisions. The preliminary results indicate that high speed frequency domain OCT
system is a good candidate for imaging subsurface photodisruption with femtosecond
laser and its 3D image may provide good guidance during surgical procedures when it
is integrated with laser ablation system.
The reduced outflow rate caused by the increased resistance through trabecular meshwork (TM) has been thought to be the main reason for elevated intraocular pressure (IOP). It has been demonstrated that femtosecond laser pulses tuned to 1.7 μm wavelength can create the partial thickness channel in the sclera in ex vivo human eyes [1] and aqueous outflow can be increased by these channels in porcine eyes [2]. It was also shown that the outflow rate is reduced over time in ex vivo human eyes [3]. Therefore, the control experiment without laser treatment at the same condition was conducted and showed that outflow was reduced by 1.5 ± 0.8 μl/min at 15mmHg and 1.8 ± 1.0 μl/min at 25mmHg. However, the outflow rate increased by 0.26 μl/min at 15mmHg and 0.15 μl/min at 25mmHg after the partial thickness channel was created, meaning the amount of increased outflow rate might be more than measured considering the outflow reduction in control experiment. We suggest that the femtosecond laser created partial thickness channel can increase the outflow rate and delay the progression of glaucoma.
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