Brian R Matlaga1, Ben Chew2, Brian Eisner3, Mitchell Humphreys4, Bodo Knudsen5, Amy Krambeck4, Dirk Lange2, Michael Lipkin6, Nicole L Miller7, Manoj Monga8, Vernon Pais9, Roger L Sur10, Ojas Shah11. 1. 1 James Buchanan Brady Urological Institute , Johns Hopkins Medical Institutions, Baltimore, Maryland. 2. 2 Department of Urologic Sciences, University of British Columbia , Vancouver, British Columbia. 3. 3 Department of Urology, Massachusetts General Hospital , Boston, Massachusetts. 4. 4 Department of Urology, Mayo Clinic , Indianapolis, Indiana. 5. 5 Division of Urology, Department of Surgery, Ohio State University Medical Center , Columbus, Ohio. 6. 6 Department of Surgery and Urology, Duke University Medical Center , Durham, North Carolina. 7. 7 Department of Urologic Surgery, Vanderbilt University School of Medicine , Nashville, Tennessee. 8. 8 Cleveland Clinic Foundation, Cleveland, Ohio. 9. 9 Department of Urology, Dartmouth Hitchcock Medical Center , Lebanon , New Hampshire. 10. 10 Department of Surgery/Urology, UC San Diego , San Diego, California. 11. 11 Department of Urology, NYU , New York, New York.
Abstract
INTRODUCTION: Ureteroscopic laser lithotripsy is becoming the most commonly utilized treatment for patients with urinary calculi. The Holmium:YAG (yttrium aluminum garnet) laser is integral to the operation and is the preferred flexible intracorporeal lithotrite. In recent years, there has been increasing interest in examining the effect of varying the laser settings on the effectiveness of stone treatment. Herein, we review the two primary laser treatment approaches: dusting and fragmentation with extraction. METHODS: We reviewed PubMed and MEDLINE databases from January 1976 through January 2017. All authors participated in the development of consensus definitions of dusting and fragmentation with extraction. The review protocol adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology. RESULTS: When the Holmium:YAG laser is used to treat stones, there are two parameters that can be adjusted: power (J) and frequency (Hz). In one treatment paradigm, which became termed "fragmentation with extraction," laser settings that relied on high energy and low frequency were used. Another paradigm, which became termed "dusting," utilized low energy and high frequency settings, which had the effect of breaking off exceedingly small fragments from the stone. CONCLUSIONS: Both dusting and fragmentation with extraction approaches to ureteroscopic stone treatment are effective. In fact, there is little evidence that one approach is better than the other. However, each does have relative advantages and disadvantages, which should be considered. Although dusting tends to be associated with shorter procedure times and a lower risk of ureteral damage, this approach may place the patient at increased risk for future stone events should all of the resultant debris not be expelled from the collecting system. The active removal associated with fragmentation with extraction, in contrast, may provide for a more complete initial stone clearance.
INTRODUCTION: Ureteroscopic laser lithotripsy is becoming the most commonly utilized treatment for patients with urinary calculi. The Holmium:YAG (yttrium aluminum garnet) laser is integral to the operation and is the preferred flexible intracorporeal lithotrite. In recent years, there has been increasing interest in examining the effect of varying the laser settings on the effectiveness of stone treatment. Herein, we review the two primary laser treatment approaches: dusting and fragmentation with extraction. METHODS: We reviewed PubMed and MEDLINE databases from January 1976 through January 2017. All authors participated in the development of consensus definitions of dusting and fragmentation with extraction. The review protocol adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology. RESULTS: When the Holmium:YAG laser is used to treat stones, there are two parameters that can be adjusted: power (J) and frequency (Hz). In one treatment paradigm, which became termed "fragmentation with extraction," laser settings that relied on high energy and low frequency were used. Another paradigm, which became termed "dusting," utilized low energy and high frequency settings, which had the effect of breaking off exceedingly small fragments from the stone. CONCLUSIONS: Both dusting and fragmentation with extraction approaches to ureteroscopic stone treatment are effective. In fact, there is little evidence that one approach is better than the other. However, each does have relative advantages and disadvantages, which should be considered. Although dusting tends to be associated with shorter procedure times and a lower risk of ureteral damage, this approach may place the patient at increased risk for future stone events should all of the resultant debris not be expelled from the collecting system. The active removal associated with fragmentation with extraction, in contrast, may provide for a more complete initial stone clearance.
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