JU INSIGHT Holmium:YAG Laser with MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery

By: Daniele Castellani, MD, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy; Khi Yung Fong, MBBS, Yong Loo Lin School of Medicine, National University of Singapore; Ee Jean Lim, MD, Singapore General Hospital; Ben Hall Chew, MD, University of British Columbia, Vancouver, Canada; Thomas Tailly, MD, University Hospital of Ghent, Belgium; Esteban Emiliani, MD, Fundación Puigvert, Universidad Autónoma de Barcelona, Spain; Jeremy Yuen-Chun Teoh, MD, S.H. Ho Urology Centre, The Chinese University of Hong Kong, China; Chu Ann Chai, MD, University Malaya, Kuala Lumpur, Malaysia; Chin Tiong Heng, MD, Ng Teng Fong General Hospital, Singapore; William Ong Lay Keat, MD, Penang General Hospital, Malaysia; Yiloren Tanidir, MD, Marmara University School of Medicine, Istanbul, Turkey; Deepak Ragoori, MD, Asian Institute of Nephrology and Urology, Hyderabad, India; Andrea Benedetto Galosi, MD, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy; Abhishek Singh, MD, Muljibhai Patel Urological Hospital, Nadiad, India; Saeed Bin Hamri, MD, Ministry of the National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Olivier Traxer, MD, Sorbonne University, Tenon Hospital, Paris, France; Bhaskar Kumar Somani, University Hospitals Southampton, NHS Trust, United Kingdom; Vineet Gauhar, Ng Teng Fong General Hospital, Singapore | Posted on: 30 Aug 2023

Castellani D, Fong KY, Lim EJ, et al. Comparison between holmium:YAG laser with MOSES technology vs thulium fiber laser lithotripsy in retrograde intrarenal surgery for kidney stones in adults: a propensity score-matched analysis from the FLEXible ureteroscopy outcomes registry. J Urol. 2023;210(2):323-330.

Study Need and Importance

Retrograde intrarenal surgery (RIRS) has become a first-line option for kidney stones up to 2 cm as a minimally invasive appealing procedure due to its low morbidity and excellent stone-free rate (SFR), which have contributed to its wide adoption worldwide (see Figure). This was proven when we published FLEXOR (FLEXible ureteroscopy Outcomes Registry) outcomes which looked at RIRS performed by experts, globally and in a real-world setting. Traditionally, RIRS lithotripsy has been carried out using holmium:YAG laser with 20-W machines. Recently, the availability of high-power lasers has allowed a wider range of pulse energy, frequency, and power settings to improve lithotripsy efficiency. In this study, we compared thulium fiber laser (TFL) and holmium:YAG laser with MOSES technology (HLM) in terms of complications and SFR 3 months after RIRS for renal stones.

Figure. A urologist performing retrograde intrarenal lithotripsy.

What We Found

One-to-one propensity score matching for age, gender, and stone characteristics was performed for a total of 568 patients. There was a higher rate of basket extraction in HLM (89% vs 43%, P < .001). Total operation time and lasing time were similar. We found that 9 patients had sepsis in TFL vs none in HLM. Higher SFR was achieved in TFL (85% vs 56%, P < .001). At multivariable analysis, the use of TFL and ureteral access sheath ≥8F had significantly higher odds of being stone-free, while lasing time, multiple stones, stone diameter, and use of disposable scopes showed significantly lower odds of being stone-free.

Limitations

Our study is limited by its retrospective design, limited use of postoperative CT to assess SFR, lacking data on total laser energy delivered, and long-term follow-up.

Interpretation for Patient Care

The results of this study suggest that the use of TFL in ureteroscopy lithotripsy for kidney stones in daily practice had better stone clearance but a higher rate of infectious complications.