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Intracorporeal Lithotripsy
its inefficiency at treating cystine stones prevented its popularisation.
Table 1: Summary of Available Intracorporeal Lithotriptors
This laser is based on a wavelength of 504nm, pulsed at 1µs, with
fibres of 200–320µm; overall stone-free rates are quoted at 84–90%.
5
Lithotriptor Technique Stone Resistant Thermal
Contact Stones Injury
Other lasers that have been described in treating stones include the
Ballistic Projectile fired Yes None No
thullium and the neodymium: YAG (Nd-YAG) lasers. A modification of
onto metal rod
the holmium laser is the development of the frequency-doubled,
by pressurised air
Electrokinetic Magnetic core Yes None No
projected onto metal
The first laser to be used was the
rod by electromagnetic
acceleration
pulsed-dye laser, which was
Electrohydraulic Shock wave generated No None Yes
introduced in the 1980s; however, the
under water through (<1mm)
coaxial probe;
high cost of coumarin dye and its ‘microexplosions’
Ultrasonic High-frequency Yes Calcium Yes
inefficiency at treating cystine stones
vibration of oxalate
prevented its popularisation.
metal probe; monohydrate
aspiration of
fragments
Laser (Ho:YAG) Solid-state laser Yes None Yes
double-pulse Nd-YAG (FREDDY) laser; this induces generation of a
Ho:Yag = holmium yttrium–aluminium–garnet.
plasma bubble, collapse of which generates a shock wave that
produces stone fragmentation.
16
The use of lasers also depends on the of which makes it difficult to reach true economic conclusions.
theatre staff being adequately trained, as unlike the other energy Nevertheless, depending on the country of purchase, currently the
modalities this type carries a small but real risk of injury to the user(s). holmium laser machine costs around US$70,000, the LithoClast
Furthermore, the theatre must be appropriately modified, consistent
with safe medical practice. These costs should be considered when
initially investing in this technology, along with the relatively high cost
The use of lasers also depends on the
of disposables.
theatre staff being adequately trained,
Economics as unlike the other energy modalities
There is a paucity of data in the literature directly comparing
this type carries a small but real risk of
modalities of intracorporeal lithotripsy, with most available studies
comparing ESWL with PCNL or ureteroscopy (mostly in association injury to the user(s).
with laser lithotripsy). Lotan and Pearle highlight the difficulties in
translating economic conclusions across different countries and
healthcare systems.
17
For example, in an economic survey by Master 2 around US$50,000 and the portable Stonebreaker around
Chandhoke, charges for extracorporeal lithotripsy varied from US$373 US$10,000; the cost of a laser fibre (US$250–500) is significantly
to US$9,924, and for ureteroscopy from US$491 to US$8,108.
18
In higher than that of an EHL probe (US$200). These figures will
another study across different countries, the cost of ureteroscopy and obviously affect local practice based on financial circumstances.
stone fragmentation ranged from US$160 in Germany to US$926 in
the UK, US$1,685 in Italy and US$4,773 in the US.
19
There are Conclusion
numerous variables such as patient factors (stone location, size, etc.), A range of energy modalities has been described for intracorporeal
need for hospitalisation, equipment costs (initial cost of machine, renal tract stone treatment. Deciding which modality to use where
further disposables, maintenance, ancillary staff) and indirect costs, all depends on user preference and regional health economics. ■
1. Denstedt JD, Eberwein PM, Singh RR, The Swiss Lithoclast: A evaluation of a new pneumatic intracorporeal lithotripter, BJUI, 13. Leveillee RJ, Lobik L, Intracorporeal lithotripsy: which modality
new device for intracorporeal lithotripsy, J Urol, 1992;148: 2007;100(3):629–32. is best?, Curr Opin Urol, 2003;13:249–53.
1088–90. 8. Auge BK, Lallas CD, Pietrow PK, et al., In vitro comparison of 14. Breda A, Ogunyemi O, Leppert JT, et al., Flexible ureteroscopy
2. Keeley FXJ, Pillai M, Smith G, et al., Electrokinetic lithotripsy: standard ultrasound and pneumatic lithotrites with a new and laser lithotripsy for single intrarenal stones 2 cm or
safety, efficacy and limitations of a new form of ballistic combination intracorporeal lithotripsy device, Urology, greater—is this the new frontier?, J Urol, 2008;179(3).
lithotripsy, BJUI, 1999;84(3):261–3. 2002;60:28–32. 15. Watson GM, Wickham JE, Initial experience with a pulsed dye
3. Menezes P, Kumar PV, Timoney AG, A randomized trial 9. Kuo RL, Paterson RF, Siqueira TMJ, et al., In vitro assessment of laser for ureteric calculi, Lancet, 1986;14(1):1357–8.
comparing lithoclast with an electrokinetic lithotripter in the lithoclast ultra intracorporeal lithotripter, J Endourol, 16. Marguet CG, Sung JC, Springhart WP, et al., In vitro
management of ureteric stones, BJUI, 2000;85(1):22–5. 2004;18(2):153–6. comparison of stone retropulsion and fragmentation of the
4. De Sio M, Autorino R, Damiano R, et al., Comparing two 10. Kim SC, Matlaga BR, Tinmouth WW, et al., In vitro assessment frequency doubled, double pulse Nd:YAG laser and the
different ballistic intracorporeal lithotripters in the management of a novel dual probe ultrasonic intracorporeal lithotriptor, holmium:yag laser, J Urol, 2005;173(5):1797–1800.
of ureteral stones, Urol Int, 2004;72(Suppl. 1):52–4. J Urol, 2007;177(4):1363–5. 17. Lotan Y, Pearle MS, Economics of stone management, Urol Clin
5. Noor Bucholz NP, Intracorporeal lithotripters: selecting the 11. Raney AM, Electrohydraulic ureterolithotripsy, Urology, North Am, 2007;34(3):443–53.
optimum machine, BJUI, 2002;89(2):157–61. 1978;12:284–5. 18. Chandhoke PS, When is medical prophylaxis cost-effective for
6. Manohar T, Ganpule A, Desai M, Comparative evaluation of 12. Elashry OM, DiMeglio RB, Nakada SY, et al., Intracorporeal recurrent calcium stones?, J Urol, 2002;168(3):937–40.
Swiss LithoClast 2 and holmium:YAG laser lithotripsy for electrohydraulic lithotripsy of ureteral and renal calculi using 19. Bensalah K, Pearle M, Lotan Y, Cost-effectiveness of medical
impacted upper-ureteral stones, J Endourol, 2008;22(3):443–6. small caliber (1.9F) electrohydraulic lithotripsy probes, J Urol, expulsive therapy using alpha-blockers for the treatment of
7. Rané A, Kommu SS, Kandaswamy SV, et al., Initial clinical 1996;156(5):1581–5. distal ureteral stones, Eur Urol, 2008;53(2):411–18.
EUROPEAN UROLOGICAL REVIEW 83
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