Introduction: To demonstrate the versatility of the Thulium Laser Fiber (TLF) in the treatment of a simultaneous ureteral tumor, a ureteral stone, and a kidney stone.
Methods: A 44-year-old female patient was evaluated after an episode of right pyelonephritis. Past medical history was positive for morbid obesity (BMI 50.5), hypertension, and depression. She denied gross hematuria or weight loss. Family history was negative for malignancy. She had a history of multiple ureteral stents and six previous ureteroscopies/laser lithotripsy. She quit smoking 7 years ago but was still drinking alcoholic beverages (2 drinks/week). Ultrasound demonstrated right kidney hydronephrosis and two stones (1.5cm in the proximal ureter and 1.2cm in the lower pole). A CT-Scan confirmed previous results. Ureteroscopy incidentally showed a distal ureteral tumor with papillary projections. Specimens were collected for pathology. For tumor ablation, we used TFL combined with a 200µm fiber, and settings to 1.0J, 10 Hz, and 10W of power. We continued with the same fiber to treat the ureteral stone, settings adjusted to 0.2J, 40 Hz, 8W. Next, a flexible ureteroscope was used to treat kidney stones. The ablation prevented the use of an access sheath. After stone repositioning, we continued using the same 200µm fiber, but with different settings: 0.3J, 120Hz, 36W. After stones treatment, a complete survey showed no additional tumors. Finally, a ureteral stent was placed.
Results: The pathology report revealed a benign urothelium, submucosal inflammation, and reactive changes.
The Ho:YAG is the gold standard for most urological endoscopic procedures, but the TFL is a new technology, with numerous advantages over the Ho:YAG.
The TFL offers a wider range of settings. Due to the electronic modulation, the pulse frequency in TFL can vary from 5 to 2400Hz and energy from 0.025 to 6J. TFL also allows smaller fibers (50 to 150µm), good precision, less retropulsion, and less back burn.
Although the thermal threshold for ureteral lesions has been reported to be 42°C - ~20W with TFL -, less than 10W in power is recommended. Aiming for resection and hemostasis, we recommend a "high energy & low frequency" to ablate ureteral tumors. On the other side, stone treatment is best contemplated with "low energy & high frequency".
The problem with temperature is less significant when inside the pelvicalyceal system, and power up to 30-36W is acceptable.
Conclusions: The goal of the video is to demonstrate how the TFL system can be adapted to manage three different but simultaneous endoscopic scenarios.