Lithotripsy Doctor FAQs

Q: What do you do if the holmium laser does not fragment the stone?
A: Be sure to place the fiber in direct contact with the stone. Increase the energy per pulse if necessary to improve fragmentation. There has not been a stone that the holmium laser cannot fragment.

Q: What fragmentation pattern breaks stones most effectively?
A: Think of the fragmentation technique as "sculpting with the laser." Use the geometry of the stone to determine where to place the fiber to maximize fragmentation.

Q: How can the holmium laser ablate tissue but also break stones without damaging the ureter?
A: The minimal penetration of the laser energy into water or tissue (<0.5 mm) limits its effect. Careful visual positioning of the fiber with appropriate selection of the energy level gives extremely accurate control of the laser.

Q: What is the minimum size of fragments obtained with the holmium laser during lithotripsy?
A: Very tiny pieces of stone can be removed during holmium laser lithotripsy. The debris in the irrigant giving the snowstorm effect with lithotripsy consists of stone "dust." By maximizing this effect, a large volume of stone can be removed without having major fragments to retrieve or to pass.

Q: When treating tumors do you use coagulation or ablation with the holmium laser?
A: Both the coagulative and ablative effects of the laser are used to treat tumors in the urinary tract.

Q: How is the holmium laser different from other surgical lasers?
A: Holmium is very effective for several endoscopic applications. The holmium laser can break any urinary calculus. It can also coagulate or ablate tissue and cut tissue to make an incision. It can treat stones, tumors, strictures and the enlarged prostate effectively with great precision and minimal bleeding.

Holmium Prostatectomy Doctor FAQs

Q: How does HoLAP compare to TURP?

A: HoLAP and TURP provide immediate symptom relief and have similar OR times. The biggest difference is the change in bleeding. Your vision is so much clearer with holmium since there's very little bleeding. I also think clearer view reduces the chance of penetrating the prostate capsule. Certainly, post operatively, the difference is tremendous. Using electrocautery, a lot of patients require bladder irrigation, which keeps them in the hospital. Because we don't have any significant bleeding with holmium, virtually all patients are watched for a couple of hours then released to go home.

Q: How does HoLAP compare to TUMT?

A: HoLAP provides immediate symptom relief and quick catheter removal. TUMT patients have catheters and have symptoms relieved over a longer period of time.

Q: Is it true that HoLAP has a short learning curve?

A: No. HoLAP is very easy to learn. You can go into the OR after watching this webinar. Holmium ablation must have been confused with holmium enucleation, which does have a significant learning curve.

Q: My first few HoLAP cases were relatively bloodless. But recently a patient had an indwelling catheter for several weeks prior to surgery. I saw more blood during the procedure. Was that due to catheter irritation?

A: Yes, there can be more bleeding with catheterized patients. Patients in urinary retention and a catheter experience a tremendous increase in prostate vascularity. What you describe is commonly seen with patients treated with electrosurgery. It's less common to see with holmium because most of the bleeding is at the mucosa level. One of my tricks is to put those patients on a drug called Avodart, a five alpha reductase inhibitor. I typically have the patient use it for a week or two before surgery if they've had retention because it seems to reduce the degree of bleeding.

Another tip is to coagulate blood vessels with holmium. Once you identify the source of the bleeding, position the laser fiber a short distance away and slowly advance the fiber. Keep the aiming beam directed on the area that's bleeding. As you slowly advance, you'll coagulate the area. It's worthwhile to take a second and stop mucosal bleeders so you'll get better visualization.

Q: What is your usual OR time for HoLAP?

A: Around 30 to 45 minutes.

Q: Can prostate ablation be done in the office?

A: My office doesn't have a 220V outlet, so I haven't done any in my office. It's probably possible to do with the new prostatic block anesthesia.

Q: Is the DuoTome fiber single use?

A:Yes, it is.

Q: What is your personal preference, a 12 or 30 scope?

A: My preference is a 30 scope, but I also use a 12. I used a 30 scope for TURPs, so I'm most used to it.

Q: What is the typical prostate vaporization rate?

A:Both holmium and the green light laser ablate about 1 - 2 grams of tissue per minute. The green light rate is affected by fiber degradation and can slow down over time. The holmium rate is affected by laser power. For example, the 100W is faster than the 80W.

Q: Please elaborate on the speed of holmium versus green light ablation. Why does green light 'slow down'?

A: The difference in speed is related to how KTP and holmium work. Holmium vaporizes the water and every cell has water. So holmium starts out and finishes at the same speed. KTP, however, is absorbed by blood in tissue. There can be more blood on the surface of the prostate, so the green light laser can initially vaporize quickly. As you get to less vascular prostatic tissue, green light laser ablation slows down. And because KTP causes deep coagulation, the resulting desiccated tissue is harder, or slower, to vaporize.

Q: What are your concerns about the patient impact of green light laser deep coagulation compared to holmium?

A: I think the result of the deeper coagulation with green light laser is a lot like what we saw with the old Nd:YAG VLAP procedure. A zone of necrotic tissue was formed. We saw in a number of patients that it sometimes took a long time for the tissue to slough. So patients had irritative symptoms for a long time. Or sometimes the tissue did not slough, and that required another surgical treatment to deal with. So that's my concern. My experience with the green light laser has been that patients have more irritative symptoms than they do when treated with holmium.

Q: What are the advantages of HoLEP over TURP?

A: The benefits of HoLEP include shorter catheter time, shorter hospital stay, minimal risk of blood transfusion, the rare need for perioperative bladder irrigation, and quicker return to full activity.

Q: What are the disadvantages of HoLEP?

A: Clinically, there is a higher incidence of stress urinary incontinence for HoLEP (10-15%) as compared to TURP, especially in patients with larger prostates (>100gm). However, this problem is virtually resolved in all patients after 6 weeks. Second, there is a high learning curve for HoLEP (approximately 15 to 20 cases) before the surgeon becomes efficient with this technique. This equates to an investment in time and equipment for the surgeon to learn HoLEP.

Q: Can you use the Holmium laser to coagulate specific bleeding points during HoLEP or HoLAP?

A: Yes, by placing the fiber tip 2-3 mm away from the bleeding point and then activating the laser for 8-10 seconds (this is also known as 'defocusing' the laser beam).

Q: Is the risk of retrograde ejaculation from HoLEP less than TURP?

A: No, since obstructive adenomatous prostate is removed, the incidence of retrograde ejaculation is similar.

Q: How often do you see TURP syndrome with holmium laser prostatectomy?

A: Almost never. The holmium laser coagulates as it cuts tissue, which minimizes fluid absorption. In addition, normal saline, which is more physiologic, is used during holmium laser prostatectomy.

Answers from "Endourologic use of the Holmium Laser" by Dr. Akhil Das and Dr. Demetrius H. Bagley.