Introduction/Purpose: The prevalence of renal calculi has tripled from 3.8% in the late 1970s to 11% in 2022 in the United States, making it a growing public health concern. Renal calculi are the most common cause of hematuria and abdominal, flank or groin pain. They affect one in eleven people at some point in their lifetime, with men being more commonly affected than women. The recurrence rate for patients with a previous history of urinary stones can approach 50% at ten years. Urolithiasis is more common in Caucasians than African Americans. The “stone belt region” (Southeast and Southwest United States) has a higher incidence due to the hot weather and relative dehydration in these areas.
Acute management involves IV hydration, analgesia, and antiemetic medications, and smaller stones can often pass on their own. Elective surgical removal may be an option, with different procedures available depending on the size and location of the stones. Laser lithotripsy has become a popular choice among urologists, with the thulium fiber laser (TFL) being a promising new technology for lithotripsy with several advantages compared to the previously used Holmium:yttrium-aluminum-garnet (Ho:YAG) laser. The present study aimed to assess the outcomes and efficiency of the new thulium fiber laser in renal calculi lithotripsy. This is the first study that delves into the efficiency and outcome of the TFL in rural community hospitals.
Methods or Case Description: A retrospective medical chart review was conducted in a rural community hospital. We evaluated all patients who underwent laser ureteroscopy from 2020-2022. The medical record of patients meeting the following criteria were selected for the study: patient who had renal calculi and who underwent laser lithotripsy. Medical record of patients who were excluded from this study were patients who did not have renal calculi treated with laser lithotripsy. The consent of individual participants was not required for this study, as it was conducted using data from medical records that did not include participants’ personally identifiable information. The following items were collected through medical records: age, sex, BMI, stone location, stone size, stone volume, stone score, presence of preoperative stent, presence of hydronephrosis, total procedure time, laser time (min), laser setting used, basket used or not, operator duty cycles, ablation speed, ablation efficiency, fiber size, used of access sheath, length of stay at hospital, need for admission, post-op ER visit, ureteral injuries, complications, post-op stent use, stent duration, 6-week post-op visit, post-op imaging and any residual stones.
Outcomes: The study included 41 patients with renal calculi measuring 10-30 mm and a median age of 55 years. The stones were primarily dusted using settings of 0.5J and 70Hz, with a mean laser ablation speed of 3.98 mm3/sec and ablation efficiency of 0.02J/mm3. Most cases showed good dusting. Seven patients with stones larger than 2 cm were successfully dusted, achieving complete clearance. Intraoperative complication included Grade 1 mucosal ureteral injury in two patients and Grade 3 ureteral injury in one patient. However, all complications healed completely after stenting for 3 weeks. Postoperative imaging (renal ultrasound at six-week post-op) was completed by 31 patients, with 28 showing complete clearance.
Conclusion: In the present study, the findings indicate that TFL has an overall better prognosis and with its capability it can be used in rural community hospitals. This initial series of the use of SP-TFL has shown promising results. This laser doesn’t need high power outlets hence was easy to operate in any operating room in our community hospital. Further prospective comparative trials with long term follow up are needed to establish supremacy over the holmium laser.
