Objective: To evaluate using an inanimate model the thermal injury and laser efficiency on high frequency, high energy and its combination in hands of junior and experienced urologists during holmium YAG (Ho:YAG) and Thulium fiber laser (TFL) lithotripsy. Methods: Cyber: Ho 150 WTM and Fiber Dust TFL (Quanta System) with 200µm core-diameter laser fibers (LF) were used in a saline in vitro ureteral model. Each participant (5 junior -5 experienced urologist) performed 32 sessions of 5 minutes lasering (125 mm3 phantom BegoStonesTM), comparing four modes (3J/5Hz (1.5W), 0.3J/20Hz (6W), 1.2 J/5Hz (6W), and 1.2J/20Hz (24W)). Transparent tip and cleaved LF, and digital and fiberoptic ureteroscopes were also compared. Ureteral damage was classified in a scale (0-5) according to the burns and holes seen in the ureteral model’s surface. Results: High-power setting (24W) was associated with higher delivered energy and higher ablation rates in both lasers (p<0.001). For the same power setting (6W), there were no differences in delivered energy nor stone ablation rates. Regardless the settings, higher ablation rate was observed with TFL than with Ho:YAG ((0.5Δmg/s ± 0.33 vs 0.39 Δmg/s ± 0.31, p:0.002) laser. Higher mean ablation rate was found with cleaved tip vs transparent tip (p:0.03) in TFL. For both lasers, higher ureteral damage was observed in the 24W group (p: 0.006) and in the junior urologists (p: 0.03). Between 6W groups, different type of lesions were found and junior urologist have more lesions when high frequency was used, for both Ho:YAG (p=0.05) and TFL (p=0.04). Conclusion: High-power settings have more stone ablation rate and may reduce the operative time; however, more ureteral thermic-related damage is produced. When comparing the same power, higher energy or frequency does not modify the ablation rate. Nonetheless, more ureteral thermic-related thermal damage is observed in high frequency settings in unexperienced hands.

Purpose: To evaluate whether stone dust can be obtained from all prevailing stone composition types using the novel pulsed thulium:YAG (p-Tm:YAG), including analysis of stone particle size after lithotripsy. Methods: Human urinary stones of 7 different compositions were subjected to in vitro lithotripsy using a p-Tm:YAG laser with 270 µm silica core fibers (Thulio^®, Dornier MedTech GmbH^®, Wessling, Germany). A cumulative energy of 1000 J was applied to each stone using one of three laser settings: 0.1 J × 100 Hz, 0.4 J × 25 Hz and 2.0 J × 5 Hz (average power 10 W). After lithotripsy, larger remnant fragments were separated from stone dust using a previously described method depending on the floating ability of dust particles. Fragments and dust samples were then passed through laboratory sieves to evaluate stone particle count according to a semiquantitative analysis relying on a previous definition of stone dust (i.e., stone particles ≤ 250 µm). Results: The p-Tm:YAG laser was able to produce stone dust from lithotripsy up to measured smallest mesh size of 63 µm in all seven stone composition types. Notably, all dust samples from all seven stone types and with all three laser settings had high counts of particles in the size range agreeing with the definition stone dust, i.e., ≤ 250 µm. Conclusion: This is the first study in the literature proving the p-Tm:YAG laser capable of dusting all prevailing human urinary stone compositions, with production of dust particles ≤ 250 µm. These findings are pivotal for the broader future implementation of the p-Tm:YAG in clinical routine.

Background and Objective: The cost of imaging and interventions in the surgical field varies between countries and sometimes within different regions of the same country. Procedural cost takes into account equipment, consumables, operating room, surgical, anesthetic and nursing teams, radiology, medications, and hospital stay. Health care systems therefore face an incredible burden related to investigations and surgical procedures. The aim of this study was to collect costs of imaging and interventions for kidney calculi across different hospitals and health care systems in the world. Methods: An online shared Google spreadsheet was created by the European Association of Urology Young Academic Urology urolithiasis group. The survey consisted of the cost of four radiological imaging (ultrasound of the urinary tract [USS], plain X-ray radiography of the abdomen including kidneys, ureter, and bladder [XRKUB], noncontrast-enhanced computerized tomography [CTKUB], and contrast-enhanced CT with urographic phase [CTU]) and seven interventions (endoscopic laser treatment of renal stones, ureteroscopic treatment or extraction of ureteral stones, percutaneous nephrolithotomy (PCNL), insertion of ureteral stent, diagnostic ureteroscopy, and cystolitholapaxy). A chosen representative from each country collected and collated the data, and this was converted to Euros (€). Key Findings and Limitations: Data were collected from 32 countries, which include Turkey, Armenia, Nepal, Uzbekistan, Brazil, Chile, Qatar, Peru, Israel, Singapore, Thailand, Colombia, Argentina, Saudi Arabia, Asia, North America, 15 countries from the European continent, and the United States. The mean cost of USS, XRKUB, CTKUB, and CTU was 51.3 € (range: 2–160 €), 27.1 € (range: 2.5–187 €), 105.8 € (range: 19–405 €), and 171.5 € (range: 19–674 €), respectively. Similarly, the cost of endoscopic laser treatment of renal stones, ureteroscopic treatment/extraction of ureteral stones, PCNL, insertion of ureteral stent, diagnostic ureteroscopy, and cystolitholapaxy was 1942.6 € (range: 100–7887 €), 1626.8 € (range: 80–9787 €), 2884.6 € (range: 110–12642 €), 631 € (range: 110–2787 €), 861.6 € (range: 3–2667 €), and 876 € (range: 19–3457 €), respectively. Wide differences in cost between countries were found within the study. Conclusions and Clinical Implications: This study highlights the significant economic impact of kidney stone management on health care systems worldwide. There seem to be significant disparities between costs, and this study shows the social and economic inequalities in health care access, which can differ significantly between private and public health care. These results can aid policymakers to address these disparities and perhaps to learn from other health care providers.