Introduction: There are many options available to perform a transurethral cystolitholapaxy including ultrasonic, ballistic, pneumonic, laser, and mechanical lithotripsy. Both holmium laser lithotripsy and ultrasonic lithotripsy are commonly used for the treatment of bladder stones. Both have been deemed safe and have been shown to produce less mucosal bleeding when compared to other methods. Recently the thulium laser has been used for the treatment of nephrolithiasis. Proponents suggest that this laser creates smaller stone fragments with greater stone ablation, allowing for shorter operative times and higher stone free rates when compared to the holmium laser. Here we compare the thulium laser and dual action ultrasonic/ballistic lithotripsy for the treatment of bladder stones in a single patient.
Methods: A 76-year-old male presented with two bladder stones of equal size (1.6cm) and Hounsfield units (1300). Both stones were treated transurethrally during a single procedure. The first stone was treated with the thulium laser where a 550-micron fiber was placed through a 28 French resectoscope. A frequency of 8Hz and energy of 18.8kJ was used. The second stone was treated with an Olympus ShockPulse (dual action ultrasonic/ballistic) lithotripter placed through a 24 French nephroscope. The two procedures were evaluated objectively based on time to completion and subjectively based on visualization, mucosal bleeding, and stone retropulsion.
Results: The thulium laser cystolitholapaxy was completed in 29 minutes and 10 seconds, while the ultrasonic/ballistic lithotripsy was completed in 36 minutes and 6 seconds. Both were effective at clearing the stone burden. Subjectively, the thulium laser allowed for less stone retropulsion and greater stone ablation. There was minimal mucosal damage and excellent visualization. The ultrasonic/ballistic lithotripter produced larger stone fragments and significant stone movement, leading to mucosal bleeding with decreased visualization.
Conclusions: A thulium laser cystolitholapaxy may provide shorter operative times, minimal stone movement, decreased mucosal bleeding, and improve visualization when compared to ultrasound/ballistic cytsolitholapaxy. Future prospective or retrospective analysis is needed to make a definitive assessment.