Urinary system stone disease is common among urological diseases. Stone diseases are a common health problem in our country. In recent years, there has been an increase in the incidence of stone disease due to nutritional problems and a sedentary lifestyle. Stone surgeries, which were previously open, are now performed with endoscopic (closed) methods with the advancement of technology. We perform almost all of our surgeries with the laser method.

As a laser, we frequently use the holmium laser technique in the treatment of benign prostate enlargement (BPH) (HOLEP method). The same technology is a method that we have used for a long time in the treatment of kidney stones. In this article, I will talk about holmium laser application in the treatment of urinary system stone disease in the light of our own experience.

What is holmium laser / what does it mean?

Holmium laser is an advanced laser system of a high-tech product used in the treatment of benign prostate enlargement (BPH) and urinary tract stones in urology. With this system, bits of stones can be broken. The stones are turned into powder and excreted in the urine.

We use the 100 Watt holmium laser system that we use in the treatment of benign prostate enlargement (BPH) in our surgeries. The power of laser devices used in the treatment of kidney stones is usually between 10-30 Watts. With the high power holmium laser system, large stones can be broken in a very short time. Short operation time and high success rate are very important advantages. It is a very effective system compared to the pneumatic stone crushing system used before.

Where is the holmium laser used in urology?

Holmium laser is a type of laser frequently used in urology. Among urological diseases, it is often used in the treatment of the following diseases:

• Benign prostate enlargement (HOLEP surgery)
• Treatment of kidney stones
• Treatment of renal pelvis and ureter stones
• Treatment of bladder stones
• Treatment of urethral stones

What are the advantages/benefits of laser stone surgery?

Laser stone surgery has many advantages over open surgery. For this reason, the use of lasers in stone surgeries has become very common. We can list these advantages as follows;

• Stones are easier to break
• The operation time is shorter
• There is no surgical incision
• There is no bleeding
• Infection is less
• The hospital stay is short. Most patients are discharged the same day.
• Pain is less
• Patients start their daily lives earlier
• Complications are less

What are the complications of laser stone surgery?

Complications of urinary system stone surgeries using holmium laser are extremely few and insignificant. These rare complications are:

• There may be mild pain
• Urinary tract infection
• Bleeding
• Stone path formation
• Inability to urinate
• Urethral and ureteral injuries can be seen very rarely.
• In the late stages, urethra and ureteral strictures may develop.

How much does laser stone removal surgery cost?

It is not correct to say a clear price for holmium breakage of urinary system stones with this system. Because many factors are effective here. Conditions such as the size of the stone, its location, whether the patient has any other disease (heart, lung, etc.), are important in determining the price of the hospital where the surgery will be performed.

Who is the holmium laser suitable for and not suitable for?

Stone breaking with holmium laser is suitable for all stones smaller than 3 cm in the kidney. Sometimes a second session may be required if the time is prolonged in large stones.

A second session may be required in patients with too much stone load. This method is difficult to apply in patients with stenosis in the urinary tract. After the stenosis is corrected, the stone can be reached and broken with a laser.

What is the type of anesthesia, the duration of the operation, and the length of stay in the hospital?

The type of anesthesia for laser stone surgery depends on the location of the stone. If the stone is in the lower end of the urethra, bladder and ureter, spinal or general anesthesia is given. General anesthesia is applied in upper ureter and kidney stones. The duration of the operation varies according to the size of the stone. It takes about 45 minutes to 2 hours on average. We usually discharge most of our patients on the same day. Sometimes they stay in the hospital for 1 day. If the patient has internal problems, problems such as infection and bleeding, he may stay in the hospital a little longer.

Is laser use during pregnancy harmful?

It has been reported that laser treatment does not have any negative effects on ureteral stones that do not respond to known treatments during pregnancy. After laser stone surgery, we insert a double J catheter for our patients for a few days so that edema, blood clots or small stone fragments do not block the ureter and cause pain (colic). In this way, the postoperative period can be spent comfortably and pain-free.

How is the pre-operative preparation?

The necessary tests for general or spinal anesthesia are requested from the patients who are decided to have surgery. These tests vary according to the age of the patients and the presence of chronic diseases. Steps to be followed before surgery;

• Patients who use blood thinners such as aspirin 1 week before the surgery are asked to discontinue these drugs (it is not always necessary to discontinue blood thinners in patients who will be treated with holmium laser).
• Patients with urinary tract infections need to be treated with appropriate antibiotics.
• Routine blood tests, chest X-ray and ECG are requested for anesthesia.
• They regularly take the drugs they use for chronic diseases such as heart disease and diabetes.
• Sedative medications may be given to relax patients before surgery.
• Nothing is taken by mouth for at least 5-6 hours before the operation.
• Patients are admitted to the hospital on the day of surgery, necessary consent forms are filled and signed.
• Preventive antibiotics are administered before the operation.

Holmium laser surgery for renal pelvis and kidney stones

Urinary tract stones mostly form in the kidneys. Kidney stones are found in the calyces of the kidney, called the collecting system, and in the renal pelvis. Calisk stones can be numerous and in different sizes. The renal pelvis is the area where the ureters begin at the exit from the kidneys.

In the treatment of kidney stones, there are different treatment options depending on the location and size of the stone and the anatomical structure of the calyces. For large stones, wig-like nephrolithotomy (PCNL) is performed. If renal pelvis stones are large, these stones can also be removed laparoscopically. The methods used in the endoscopic treatment of kidney stones are:

• PCNL (PNL): It is a method applied for stones larger than 2 cm. When the patient is in the supine position, the stone is focused and the stone is reached by entering through a 0.5 cm hole on the back and the stones are broken with a holmium laser.
• RIRS (Retrograde Intrarenal Surgery): Stones located in the inner part of the kidney (calyx) are removed with laser by reaching the stone with flexible URS. This is called retrograde intrarenal surgery (RIRS).
• ECIRS (endoscopic combined intrarenal surgery): Here, two surgeons work simultaneously by entering from both kidney and urinary canal. Kidney access is made with the patient in the supine and slightly turned sideways position. The surgeon on the kidney side does PCNL and the other does URS (RIRS). It is done in complicated stones. It is possible to completely clean the stones completely with this method.

Holmium laser surgery for ureteral stones

The ureters are organs that carry urine between the bladder and the kidney. The ureter normally has stenosis in three regions. These are: the part where the ureter exits the renal pelvis (ureteropelvic region), the middle part of the ureter, and the part where the ureter enters the bladder (ureterovesical junction). Ureteral stones are most commonly found in these three regions of the ureter. These stones can be stones that have fallen from the kidneys or stones that form in the ureter. If the ureteral stones are in the lower ureter, they are entered with a rigid, that is, metallic reterorenoscope (URS), and in the upper parts, with a flexible, that is, bendable ureterorenoscope (flexible URS) device, and the stone is reached.

By sending a laser probe through the URS, the stone is directly seen and broken. These stones are excreted in the urine in very small pieces. The operation takes 30-60 minutes depending on the size of the stone. Because edema and blood clots block the ureter and cause pain after stone removal, we put a double J catheter in some patients at the end of stone breaking with holmium laser. This catheter is removed after 2-3 weeks. If the stone is very small and there is not much damage to the ureter, we usually do not put a catheter.

Laser surgery for bladder and urethral stones

Bladder and urethral stones can be performed with spinal anesthesia. Urethra stones are rare. Most of the time, it appears in the form of stones in the kidney, ureter or bladder falling into the urethra. Patients apply to the physician with complaints of severe pain and inability to urinate as a result of the stone blocking the urethra. Bladder stones occur mostly in older men due to benign prostate enlargement. We break the bladder stones that develop in this way with laser in the same session during the HOLEP surgery. Apart from this, bladder stones are also seen in patients with bladder neck height and urethral stenosis.

Urethra and bladder stones are completely broken with laser. The duration of the operation varies according to the size and number of the stone. We insert a urinary catheter for one day after surgery and discharge our patients on the same day. In some cases, patients stay in the hospital overnight.

In the following cases, a doctor should be called after laser surgery!

After laser surgery, it is generally very comfortable and hassle-free. However, in some cases there may be mild complaints.

• High fever, chills, shivering, nausea, vomiting
• Severe pain
• Serious blood in the urine
• Inability to urinate

What should be considered after the operation?

Patients have a very comfortable post-operative period. Serious complications are not observed. In patients who underwent stone surgery with the endoscopic (closed) method, the urine may be dark and bloody in the early stages. The situation is normal. Sometimes it can take 3-4 weeks. If excessive bleeding occurs, patients should definitely contact their doctor. We recommend our patients to pay attention to the following points;

• Consuming 2-3 liters of fluid per day
• Regular use of painkillers and antibiotics given
• Not using blood thinners such as aspirin
• Not doing excessive sports for 4-6 weeks, not lifting heavy

In summary: Holmium laser is an effective treatment method in the treatment of urinary system stones. The success rate of laser treatment is high and complications are extremely low. Treatment of urinary tract stones with holmium laser is the most advanced technology in this field today. The surgical technique changes according to the location of the stone. Even the hardest stones can be broken with a laser.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY