Richard L. Blackmon

Comparison of holmium:YAG and thulium fiber laser lithotripsy: ablation thresholds, ablation rates, and retropulsion effects

The holmium:YAG (Ho:YAG) laser lithotriptor is capable of operating at high pulse energies, but efficient operation is limited to low pulse rates (∼10 Hz) during lithotripsy. On the contrary, the thulium fiber laser (TFL) is limited to low pulse energies, but can operate efficiently at high pulse rates (up to 1000 Hz). This study compares stone ablation threshold, ablation rate, and retropulsion for the two different Ho:YAG and TFL operation modes. The TFL (λ = 1908 nm) was operated with pulse energies of 5 to 35 mJ, 500-μs pulse duration, and pulse rates of 10 to 400 Hz. The Ho:YAG laser (λ = 2120 nm) was operated with pulse energies of 30 to 550 mJ, 350-μs pulse duration, and a pulse rate of 10 Hz. Laser energy was delivered through 200- and 270-μm-core optical fibers in contact mode with human calcium oxalate monohydrate (COM) stones for ablation studies and plaster-of-Paris stone phantoms for retropulsion studies. The COM stone ablation threshold for Ho:YAG and TFL measured 82.6 and 20.8 J∕cm(2), respectively. Stone retropulsion with the Ho:YAG laser linearly increased with pulse energy. Retropulsion with TFL was minimal at pulse rates less than 150 Hz, then rapidly increased at higher pulse rates. For minimal stone retropulsion, Ho:YAG operation at pulse energies less than 175 mJ at 10 Hz and TFL operation at 35 mJ at 100 Hz is recommended, with both lasers producing comparable ablation rates. Further development of a TFL operating with both high pulse energies of 100 to 200 mJ and high pulse rates of 100 to 150 Hz may also provide an alternative to the Ho:YAG laser for higher ablation rates, when retropulsion is not a primary concern.

Thulium fiber laser lithotripsy using tapered fibers

The Thulium fiber laser has recently been tested as a potential alternative to the Holmium:YAG laser for lithotripsy. This study explores use of a short taper for expanding the Thulium fiber laser beam at the distal tip of a small‐core fiber.

Probing biological nanotopology via diffusion of weakly constrained plasmonic nanorods with optical coherence tomography

Significance Many diseases are characterized by nanostructural changes in connective fibers and soluble proteins, which can indicate or drive disease progression. Noninvasive methods sensitive to nanotopological changes in 3D tissue models can elucidate biophysical changes associated with disease progression. Nanoparticles probe their environment via their diffusion, which is impacted by the size and connectivity of pores into which they freely diffuse. Here, we show that optical coherence tomography provides depth-resolved imaging of gold nanorods (GNRs) to infer local biological nanotopology. We demonstrate the broad potential of this method by sensing changes in diffusion of GNRs in 3D models of mammary ECM and pulmonary mucus. Biological materials exhibit complex nanotopology, i.e., a composite liquid and solid phase structure that is heterogeneous on the nanoscale. The diffusion of nanoparticles in nanotopological environments can elucidate biophysical changes associated with pathogenesis and disease progression. However, there is a lack of methods that characterize nanoprobe diffusion and translate easily to in vivo studies. Here, we demonstrate a method based on optical coherence tomography (OCT) to depth-resolve diffusion of plasmon-resonant gold nanorods (GNRs) that are weakly constrained by the biological tissue. By using GNRs that are on the size scale of the polymeric mesh, their Brownian motion is minimally hindered by intermittent collisions with local macromolecules. OCT depth-resolves the particle-averaged translational diffusion coefficient (DT) of GNRs within each coherence volume, which is separable from the nonequilibrium motile activities of cells based on the unique polarized light-scattering properties of GNRs. We show how this enables minimally invasive imaging and monitoring of nanotopological changes in a variety of biological models, including extracellular matrix (ECM) remodeling as relevant to carcinogenesis, and dehydration of pulmonary mucus as relevant to cystic fibrosis. In 3D ECM models, DT of GNRs decreases with both increasing collagen concentration and cell density. Similarly, DT of GNRs is sensitive to human bronchial-epithelial mucus concentration over a physiologically relevant range. This novel method comprises a broad-based platform for studying heterogeneous nanotopology, as distinct from bulk viscoelasticity, in biological milieu.

Thulium fiber laser ablation of kidney stones using a 50-μm-core silica optical fiber

Abstract. Our laboratory is currently studying the experimental thulium fiber laser (TFL) as a potential alternative laser lithotripter to the gold standard, clinical Holmium:YAG laser. We have previously demonstrated the efficient coupling of TFL energy into fibers as small as 100-μm-core-diameter without damage to the proximal end. Although smaller fibers have a greater tendency to degrade at the distal tip during lithotripsy, fiber diameters (≤200  μm) have been shown to increase the saline irrigation rates through the working channel of a flexible ureteroscope, to maximize the ureteroscope deflection, and to reduce the stone retropulsion during laser lithotripsy. In this study, a 50-μm-core-diameter, 85-μm-outer-diameter, low-OH silica fiber is characterized for TFL ablation of human calcium oxalate monohydrate urinary stones, ex vivo. The 50-μm-core fiber consumes approximately 30 times less cross-sectional area inside the single working channel of a ureteroscope than the standard 270-μm-core fiber currently used in the clinic. The ureteroscope working channel flow rate, including the 50-μm fiber, decreased by only 10% with no impairment of ureteroscope deflection. The fiber delivered up to 15.4±5.9  W under extreme bending (5-mm-radius) conditions. The stone ablation rate measured 70±22  μg/s for 35-mJ-pulse-energy, 500-μs-pulse-duration, and 50-Hz-pulse-rate. Stone retropulsion and fiber burnback averaged 201±336 and 3000±2600  μm, respectively, after 2 min. With further development, thulium fiber laser lithotripsy using ultra-small, 50-μm-core fibers may introduce new integration and miniaturization possibilities and potentially provide an alternative to conventional Holmium:YAG laser lithotripsy using larger fibers.

Holmium:YAG (λ = 2,120 nm) versus thulium fiber (λ = 1,908 nm) laser lithotripsy

The holmium:YAG laser is currently the most common laser lithotripter. However, recent experimental studies have demonstrated that the thulium fiber laser is also capable of vaporizing urinary stones. The high‐temperature water absorption coefficient for the thulium wavelength (µa = 160 cm−1 at λ = 1,908 nm) is significantly higher than for the holmium wavelength (µa = 28 cm−1 at λ = 2,120 nm). We hypothesize that this should translate into more efficient laser lithotripsy using the thulium fiber laser. This study directly compares stone vaporization rates for holmium and thulium fiber lasers.

Fiber-optic manipulation of urinary stone phantoms using holmium:YAG and thulium fiber lasers

Abstract. Fiber-optic attraction of urinary stones during laser lithotripsy may be exploited to manipulate stone fragments inside the urinary tract without mechanical grasping tools, saving the urologist time and space in the ureteroscope working channel. We compare thulium fiber laser (TFL) high pulse rate/low pulse energy operation to conventional holmium:YAG low pulse rate/high pulse energy operation for fiber-optic suctioning of plaster-of-paris (PoP) stone phantoms. A TFL (wavelength of 1908 nm, pulse energy of 35 mJ, pulse duration of 500 μs, and pulse rate of 10 to 350 Hz) and a holmium laser (wavelength of 2120 nm, pulse energy of 35 to 360 mJ, pulse duration of 300 μs, and pulse rate of 20 Hz) were tested using 270-μm-core optical fibers. A peak drag speed of ∼2.5  mm/s was measured for both TFL (35 mJ and 150 to 250 Hz) and holmium laser (210 mJ and 20 Hz). Particle image velocimetry and thermal imaging were used to track water flow for all parameters. Fiber-optic suctioning of urinary stone phantoms is feasible. TFL operation at high pulse rates/low pulse energies is preferable to holmium operation at low pulse rates/high pulse energies for rapid and smooth stone pulling. With further development, this novel technique may be useful for manipulating stone fragments in the urinary tract.

Enhanced thulium fiber laser lithotripsy using micro-pulse train modulation

The thulium fiber laser (TFL) is currently being studied as an alternative to the conventional holmium:YAG (Ho:YAG) laser for lithotripsy. The diode-pumped TFL may be electronically modulated to operate with variable parameters (e.g., pulse rate, pulse duration, and duty cycle) for studying the influence of pulse train mode on stone ablation rates. The TFL under study was operated at 1908 nm, 35-mJ pulse energy, and 500-μs pulse duration, in a train of 5 micro-pulses, with macro-pulse rates of 10 Hz, compared with conventional TFL operation at 10 to 50 Hz. TFL energy was delivered through 100-μm-core fibers in contact with human uric acid (UA) and calcium oxalate monohydrate (COM) stones. Mass removal rates, optical coherence tomography, and light microscopy were used to analyze the ablation craters. Stone retropulsion and fiber tip degradation studies also were conducted for these laser parameters. TFL operation in micro-pulse train (MPT) mode resulted in a factor of two increase in the ablation rate of 414 ± 94 μg/s and 122 ± 24 μg/s for the UA and COM stones, respectively, compared to 182 ± 69 μg/s and 60 ± 14 μg/s with standard pulse trains delivered at 50 Hz (P<0.05). Stone retropulsion remained minimal (<2 mm after 1200 pulses) for both pulse modes. Fiber burnback was significant for both pulse modes and was higher for COM stones than UA stones. TFL operation in MPT mode results in increased stone ablation rates which, with further optimization, may approach levels comparable to Ho:YAG laser lithotripsy in the clinic.

Hollow steel tips for reducing distal fiber burn-back during thulium fiber laser lithotripsy

Abstract. The use of thulium fiber laser (TFL) as a potential alternative laser lithotripter to the clinical holmium:YAG laser is being studied. The TFL’s Gaussian spatial beam profile provides efficient coupling of higher laser power into smaller core fibers without proximal fiber tip degradation. Smaller fiber diameters are more desirable, because they free up space in the single working channel of the ureteroscope for increased saline irrigation rates and allow maximum ureteroscope deflection. However, distal fiber tip degradation and “burn-back” increase as fiber diameter decreases due to both excessive temperatures and mechanical stress experienced during stone ablation. To eliminate fiber tip burn-back, the distal tip of a 150-μm core silica fiber was glued inside 1-cm-long steel tubing with fiber tip recessed 100, 250, 500, 1000, or 2000 μm inside the steel tubing to create the hollow-tip fiber. TFL pulse energy of 34 mJ with 500-μs pulse duration and 150-Hz pulse rate was delivered through the hollow-tip fibers in contact with human calcium oxalate monohydrate urinary stones during ex vivo studies. Significant fiber tip burn-back and degradation was observed for bare 150-μm core-diameter fibers. However, hollow steel tip fibers experienced minimal fiber burn-back without compromising stone ablation rates. A simple, robust, compact, and inexpensive hollow fiber tip design was characterized for minimizing distal fiber burn-back during the TFL lithotripsy. Although an increase in stone retropulsion was observed, potential integration of the hollow fiber tip into a stone basket may provide rapid stone vaporization, while minimizing retropulsion.

Detachable fiber optic tips for use in thulium fiber laser lithotripsy.

Abstract. The thulium fiber laser (TFL) has recently been proposed as an alternative to the Holmium:YAG (Ho:YAG) laser for lithotripsy. The TFL’s Gaussian spatial beam profile provides higher power transmission through smaller optical fibers with reduced proximal fiber tip damage, and improved saline irrigation and flexibility through the ureteroscope. However, distal fiber tip damage may still occur during stone fragmentation, resulting in disposal of the entire fiber after the procedure. A novel design for a short, detachable, distal fiber tip that can fit into an ureteroscope’s working channel is proposed. A prototype, twist-lock, spring-loaded mechanism was constructed using micromachining methods, mating a 150-μm-core trunk fiber to 300-μm-core fiber tip. Optical transmission measuring 80% was observed using a 30-mJ pulse energy and 500-μs pulse duration. Ex vivo human calcium oxalate monohydrate urinary stones were vaporized at an average rate of 187  μg/s using 20-Hz modulated, 50% duty cycle 5 pulse packets. The highest stone ablation rates corresponded to the highest fiber tip degradation, thus providing motivation for use of detachable and disposable distal fiber tips during lithotripsy. The 1-mm outer-diameter prototype also functioned comparable to previously tested tapered fiber tips.

A review of Thulium fiber laser ablation of kidney stones

The clinical solid-state Holmium:YAG laser lithotripter (λ=2120 nm) is capable of operating at high pulse energies, but its efficient operation is limited to low pulse rates during lithotripsy. The diode-pumped experimental Thulium Fiber Laser (λ=1908 nm) is limited to low pulse energies, but can operate at high pulse rates. This review compares stone ablation threshold, ablation rate, and retropulsion effects for Ho:YAG and TFL. Laser lithotripsy complications also include optical fiber bending failure resulting in endoscope damage and low irrigation rates leading to poor visibility. Both problems are related to fiber diameter and limited by Ho:YAG laser multimode spatial beam profile. This study exploits TFL spatial beam profile for higher power transmission through smaller fibers. A short taper is also studied for expanding TFL beam at the distal tip of a small-core fiber. Stone mass loss, stone crater depths, fiber transmission losses, fiber burn-back, irrigation rates, and deflection through a flexible ureteroscope were measured for tapered fiber and compared with conventional fibers. The stone ablation threshold for TFL was four times lower than for Ho:YAG. Stone retropulsion with Ho:YAG increased linearly with pulse energy. Retropulsion with TFL was minimal at pulse rates < 150 Hz, then rapidly increased at higher pulse rates. TFL beam profile provides higher laser power through smaller fibers than Ho:YAG laser, potentially reducing fiber failure and endoscope damage and allowing greater irrigation rates for improved visibility and safety. Use of a short tapered distal fiber tip also allows expansion of the laser beam, resulting in decreased fiber tip damage compared to conventional fibers, without compromising fiber bending, stone ablation efficiency, or irrigation rates.