2017 oulu lisl v1 for pdt.ppt [kompatibilitätsmodus] · repulsion result max. pendulum deviation...
TRANSCRIPT
1
CAMPUS GROSSHADERN
Laser-Forschungslabor
Laser assisted stone fragmentation
Ronald Sroka
Oulu – Summerschool 2017
ECBO 2015 - Sroka 2/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline
ECBO 2015 - Sroka 3/23
Urinary Stones
increased expulsion of stone promotors- Calcium- Oxalic acid- Cystine
reduction of stone inhibitors- Citrate- Magnesium
changed acid content- strongly acidic urine (uric acid diathesim)
- strongly alkalin urine (renal illness, RTA)
ECBO 2015 - Sroka 4/23
Urinary Stones
hyperexcretion+
supersaturation
crystallisation
ECBO 2015 - Sroka 5/23
Diagnostic
CTx-rayECBO 2015 - Sroka 6/23
Therapy ESUT Report
57% URS:
intracorporealLithotripsy
PneumaticLithotripsy
70%
Laserlithotripsy24%
Electrohydraulic Lithotripsy
6%
survey of trends and strategies of endourologic stone-therapy
(ESUT Endourological Stone Management Questionnaire) Kauer et al, Eur. Urol. 2005
2
ECBO 2015 - Sroka 7/23
Laser ESWL
SFR:
SFR:
SFR:
SFR:
SFR:
SFR:
50-84%
83-100%
95-100%
45-80%
45-64%
73-100%
Stone-free-rate
ECBO 2015 - Sroka 8/23
Equipment Semirigid URS
- OD 7,5 - 12 Ch
- Workchanel: 5 - 8 Ch
Flexible URS- OD: 6,5 - 7,5 Ch
- Workchanel: 3,6 Ch
- Flexion: → 360°
Endourologic tools- forceps
- dormia
- catheter
treatment options- pneumatic
- ultrasound
- electrohydraulic
- laser
ECBO 2015 - Sroka 9/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline Disruption - Fragmentation
Irradiance[W/cm²]
Irradiation[J/cm²]
Time [s]
<70°C100°C
>>150°C
<40°C
ECBO 2015 - Sroka 11/23
Dynamic of an vapor bubble
expanding phase
collapsing phasemax
Ho:YAG in watert(sequence) = 1ms
Verdaasdonk et al 2007; Proc SPIE 64350S
ECBO 2015 - Sroka 12/23
Bubble dynamic
Cavitation
Shockwave induced by collapse
oscillation
3
ECBO 2015 - Sroka 13/23
Optic breakthrough (LIB)
Optical breakthrough: 1011 W/cm2
laser induced breakdown (LIB)
- ionisation- Electrons get accelerated by laser field- Ionisation-avalanche (plasma)- Optical penetration decreases significantly (plasmashielding)
ECBO 2015 - Sroka 14/23
Laser pulse in waterVapour bubble Shock wavePressure wave
v(shock) >> v(pressure)
ECBO 2015 - Sroka 15/23
Shock wave front
High pressure high speed
x
p
ECBO 2015 - Sroka 16/23
High energy shockwave
Transmission / Reflexion at boundary to tissue or water
Tension and pressure within the stone structure
Fragmentation
Photomechanic process
ECBO 2015 - Sroka 17/23
Photothermal Ablation
∆t > 100μsP = 106 W/cm2
Photomechanic Ablation
∆t = 1ns-100μsP > 108 W/cm2
Mechanic vs Thermal
ECBO 2015 - Sroka 18/23
Photothermal destruction
Moses effect
Absorption by stone water
Expansion / vaporisationwater jet
destruction
4
ECBO 2015 - Sroka 19/23
Laser parameter0.5 GW / m²
stone properties
IonisationPlasma creating
10-9 s 15.000 K1020 Elektrons / cm³
Stochastic process
Heating of heavy particles due t impulse
10-8 s
Thermal circumference
Of the volume (200 m/s)10-8 - 10-4 s
Shock wave5 %
Shock < 30 %
Secondary shock wave
water - Jet10-4 s
Fragmentation
Cavitation10 %
Stochastic processECBO 2015 - Sroka 20/23
Mechanisms
2-10µs-laser pulse 250-1000µs-laser pulse
photomechanic photothermal
ECBO 2015 - Sroka 21/23
Laser safed operation process at the urology, ed AG Hofstetter Thieme 2003
Ureter Stone
Stone bed afterlaserlithotripsy
stone after 62shock waves(FLPD, 594nm, 150mJ)
Stone after 84shock waves(FLPD, 594nm, 150mJ)
Before laserlithotripsy
ECBO 2015 - Sroka 22/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline
ECBO 2015 - Sroka 23/23
core diameter 200-600µm
Light emission:
in air and water
Verdaasdonk et al 2007; Proc SPIE 64350S
Fibres
ECBO 2015 - Sroka 24/23
Fibre tip damage
angled side-firing
random process
Verdaasdonk et al 2007; Proc SPIE 64350S
5
ECBO 2015 - Sroka 25/23
Deflection angled fibre tip (45°)
Verdaasdonk et al 2007; Proc SPIE 64350S
Ray-tracingcalculation
Emissionin air
Deformation of bubble3-beam deflection
ECBO 2015 - Sroka 26/23
Fiber burn
Laser type Ep [mJ] Fiber burn off [µm / pulse]
Ho:YAGdcore = 365 µm
500 3,6 ± 0,3800 11,7 ± 0,5
FREDDYdcore = 273 µm
_120 14,1 ± 1,5
_160 25,2 ± 2,0
FLPDdcore = 300 µm
100 9,5 ± 1,3150 16,9 ± 1,7
ECBO 2015 - Sroka 27/23
Verdaasdonk et al 2007; Proc SPIE 64350S
Thermal impact bare fibre tip
Bubble – shock wave Temperature profil
ECBO 2015 - Sroka 28/23Verdaasdonk et al 2007; Proc SPIE 64350S
Thermal impact angled fibre tip (45°)
Bubble – shock wave Temperature profil
ECBO 2015 - Sroka 29/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline
ECBO 2015 - Sroka 30/23
Schematic diagram of the forces involved in the equation of motion of the pendulum experiment:
F Stokes frictionFback restore forcem mass of the pendulumr radius of the lead balls deflectionL length of pendulumΘ deflection angleηH2O viscosity of water
Repulsion set-up
Experimental set-up, measurements and evaluation were previously described
Sroka R et al. Lasers Med Sci. 2012 May;27(3):637-43
6
ECBO 2015 - Sroka 31/23
Stone repulsion - pendulum test
xmax: maximum deflectionv0: start speed
20cm/s = 0,72km/h; 5cm/s = 0,18km/h
Laser type Ep [mJ] xmax [cm] v0 [cm / s]
Ho:YAGdKern = 365 µm
800 0,94 ± 0,38 6,1 ± 2,5
1200 1,61 ± 0,42 10,5 ± 2,7
FREDDYdKern = 273 µm
_120 3,19 ± 0,26 17,0 ± 1,4
_160 3,63 ± 0,29 19,4 ± 1,5
FLPDdKern = 300 µm
100 2,11 ± 0,41 14,2 ± 2,8
150 2,67 ± 0,42 17,9 ± 2,8
ECBO 2015 - Sroka 32/23
Fiber burn back result
Fibre burn back is a stochastic processn(LP) >> n(SP) to destroy fibre
Sroka R et al., World J Urol. 2015 Apr;33(4):479-85.
ECBO 2015 - Sroka 33/23
Repulsion result
max. pendulum deviation
high energy per pulseshort pulse durationlarge fibre core diameter
repulsion decreases
reduced energy per pulsesmaller fibre core diameterlonger pulse duration
Sroka R et al., World J Urol. 2015 Apr;33(4):479-85.
ECBO 2015 - Sroka 34/23
Hand-held and motivated fragmentation showed no sign. differences LP vs SP but for 2J-5Hz
Fragmentation hand-held
Bader MJ et al., World J Urol. 2015 Apr;33(4):471-7.
ECBO 2015 - Sroka 35/23
Scope: Are there differences in puls induced craters?
Fibre position: nearly contact, stepping motor drivenvelocity according to repetition rate
Fibre: fresh polishedLaser parameter: 365µm–10W (20Hz-0.5J, 10Hz-1J, 5Hz-2J)
200µm–10W (5Hz-2J, 10Hz-1J)Laser mode: short pulse vs long pulse
20Hz-0.5J (400µs vs 600µs)
10Hz-1J (475µs vs 1220µs)
5Hz-2J (678µs vs 1500µs)
Evaluation: n=10 holes in BEGOS / group
OCT: TELESTO™ OCT Imaging SystemThorlabs GmbH, Dachau/Munich, Germany
lat. res. 15µm / axial res. 5µmCalculation: topology (depth, diameter, area, volume)Statistic: mean, stddev, 1way Anova
Single Pulse Crater
ECBO 2015 - Sroka 36/23
Single Pulse Crater OCT-evaluation
Sroka R et al., World J Urol. 2015 Apr;33(4):479-85.
7
ECBO 2015 - Sroka 37/23
Single Pulse Crater volume
365µm results trend:depth SP < LParea SP > LP volume SP < LP
Sroka R et al., World J Urol. 2015 Apr;33(4):479-85.
ECBO 2015 - Sroka 38/23
Side effects summary
LongPulse ShortPulse
Fibre Burn Back reduced
Repulsion reduced
Fragmentation hand-held no difference
Fargmentation hands-free no difference
Single Pulse Crater no significance
trends depending on fibre diameter (irradiation)
pulse duration
ECBO 2015 - Sroka 39/23
Recommendation
Fragmentation experiments showed no sign. difference
Single Pulse trends may reflect clinical observation
Recommendation
LongPulse reduced side effectsadditional maneuvres could be reducedeffect on soft tissue may be reducedsmaller fragments could be beneficial
ShortPulse fixed urolithrepulsion effects are minimizedfast fragmentation looks promising
ECBO 2015 - Sroka 40/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline
ECBO 2015 - Sroka 41/23
Historic list
Laser Excimer FLPD Alexandrit Ti : Saphir Nd : YAG Ho : YAG
Wellenlänge [nm] 308 504 / 594 755 792 1064 2130
Leistung [mJ / Puls]
30 - 60 30 - 150 70 bis 250 10 - 100 500 - 2000
Pulsdauer [µs] 0.04 1 - 2.5 0.1 - 0.5 0.1 - 0.5 0.01 350
Repetitionsrate[Hz]
1 - 40 1 - 10 1 - 10 1 - 10 k. A. 1 - 15
Laser Excimer FLPD Alexandrit Ti : Saphir Nd : YAGFreddy
Ho: YAG
Wavelength [nm]
308 504 / 594 755 792 1064532
2130
energy/pulse[mJ / Puls]
30 - 60 30 - 150 70 bis 250 10 – 100120-160
500 -2000
Pulsduration[µs]
0.04 1 - 2.5 0.1 - 0.5 0.1 - 0.5 0.011-3
350
Repetition rate [Hz]
1 - 40 1 - 10 1 - 10 1 - 10 k. A. 1 - 15
ECBO 2015 - Sroka 42/23
Clinical available today
company name type
Wavelight Auriga Ho:YAG
Dornier Medilas H20 Ho:YAG
WOM Freddy Nd:YAG / KTP
STORZ Calculase Ho:YAG
Baasel Lithognost FLPD
EMS Ho:YAG
8
ECBO 2015 - Sroka 43/23
Lasers feedback
Laser type Wavelength Parameter tissue-stone-determination
FreDDYFREquency-Double Dual Pulse
Nd:YAG-Laser
(U100plus – WOM)
532nm plus 1064nm E (puls) = 160 mJ
t(puls) = 1,2 µs
Rep.rate = 1-20 Hz
yes
flashlamp-pmped colouring laser
(FLPD)
(Lithognost - Baasel, Wavelight)
5943nm E (puls) = 60-150 mJ
t(puls) = 2,5 µs
Rep.rate = 1-10 Hz
yes
Ho:YAG
AURIGA – WavelightMedilas H20 – DornierCalculase – STORZ
2100nm E (puls) = 0,3–3 J
t(puls) = 200–600 µs
Rep.rate = 1-25 Hz
no
ECBO 2015 - Sroka 44/23
FREDDY-systemFrequency Doubled Dual pulse Nd:YAG
ECBO 2015 - Sroka 45/23
Feedback -Lithotripsy
t (Feedback) 0,8µsafter 2% total energymax. 5% on tissue
ECBO 2015 - Sroka 46/23
Dormiabasket
Lasergestützte Operationsverfahren in der Urologieed. AG Hofstetter Thieme 2003
Lasercatheter Hofstetter
Central lumenLaserfibre 365µm
Left: Stone in DormiabasketRight: LISL
ECBO 2015 - Sroka 47/23
... depends on the stone composites
... depends on build-up of the stones
Calziumoxalatmonohydrat Calziumoxalatdihydrat Struvit Apatit Bruschit Uric acid (green - brown) Cystin Cholesterol
Efficiency
ECBO 2015 - Sroka 48/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline
9
ECBO 2015 - Sroka 49/23
aus: Körperwelten (v. Hagen)
Upper Urinary Tract
ECBO 2015 - Sroka 50/23
Instruments
Advantages:• easy handling
• multiple working instruments
• large lumen of the working channel
Disadvantages:• limited flexibility
• limited possibility of inspection areas
Semirigide or rigide Ureterorenoscope
ECBO 2015 - Sroka 51/23
Instruments
Advantage:• High degree of flexibility
(270°/90°)
possible inspection of
lower renal calix
Disadvantage:• complex orientation
• special instruments required
• mechanically sensitive
• handling
Flexible Ureterorenoscopes
ECBO 2015 - Sroka 52/23
Interaction guide-wire
Freddy120mJ, 273µm
distance3mm
FLPD120mJ, 300µm
distance0mm
Ho:YAG1200mJ, 600µm
ECBO 2015 - Sroka 53/23
Interaction kidney-catheter
Freddy120mJ, 273µmdistance: 1mm
Ho:YAG800mJ, 365µmdistance: 1mm
FLPD120mJ, 300µmdistance: 1mm
ECBO 2015 - Sroka 54/23
Interaction 3-handed gripping pillars
Ho:YAG1700mJ
Ho:YAG500mJ
Freddy120mJ
FLPD120mJ
10
ECBO 2015 - Sroka 55/23
Interaction ureter tissue
Ho:YAG, FLPD, Freddydistance: 1-2mm
ECBO 2015 - Sroka 56/23
OrientationHo:YAG
ECBO 2015 - Sroka 57/23
Stones
Mechanism
Fibre & Damage
Side Effect Investigations
Clinical Laser
Collateral Damage
Summary
Outline
ECBO 2015 - Sroka 58/23
Cave ...stone repulsion (splitter, catapulting)
individual choice of E(puls) and Hz
damage on tissue
potential of destruction of equipment
Attention
ECBO 2015 - Sroka 59/23
Summary
LISL-effect depends on ...laser and laser parameters
LISL is ...efficient local stone destruction therapy
(with each laser)
efficient in destruction of equipment, too(positive, as well as, negative in terms of use)
ECBO 2015 - Sroka 60/23
Thank You !!